{"Treatment": ["The tendon is repaired without complication."], "Others": ["During the case, the resident inadvertently cuts a flexor tendon.", "The attending tells the resident that the patient will do fine, and there is no need to report this minor complication that will not harm the patient, as he does not want to make the patient worry unnecessarily.", "He tells the resident to leave this complication out of the operative report."]}
{"Examination and Results": ["Pure tone audiometry shows a sensorineural hearing loss of 45 dB."], "Treatment": ["He received this first course of neoadjuvant chemotherapy 1 week ago."]}
{"Patient Personal Background": ["He has type 2 diabetes mellitus and osteoarthritis of the hips.", "Prior to admission, his medications were insulin and naproxen."], "Examination and Results": ["His temperature is 38\u00b0C (100.4\u00b0F), pulse is 93/min, and blood pressure is 125/85 mm Hg.", "Examination shows mottled, reticulated purplish discoloration of the feet.", "Laboratory studies show:\nHemoglobin count 14 g/dL\nLeukocyte count 16,400/mm3\nSegmented neutrophils 56%\nEosinophils 11%\nLymphocytes 31%\nMonocytes 2%\nPlatelet count 260,000/mm3\nErythrocyte sedimentation rate 68 mm/h\nSerum\nUrea nitrogen 25 mg/dL\nCreatinine 4.2 mg/dL\nRenal biopsy shows intravascular spindle-shaped vacuoles."], "Treatment": ["He was also started on aspirin, clopidogrel, and metoprolol after the coronary intervention."]}
{"Patient Symptoms": ["Pelvic examination shows mucopurulent discharge from the cervical os and left adnexal tenderness."], "Examination and Results": ["Her temperature is 39.1\u00b0C (102.3\u00b0F), pulse is 126/min, respirations are 28/min, and blood pressure is 80/50 mm Hg.", "There is blood oozing around the site of a peripheral intravenous line.", "Laboratory studies show:\nPlatelet count 14,200/mm3\nFibrinogen 83 mg/mL (N = 200\u2013430 mg/dL)\nD-dimer 965 ng/mL (N < 500 ng/mL)\nWhen phenol is applied to a sample of the patient's blood at 90\u00b0C, a phosphorylated N-acetylglucosamine dimer with 6 fatty acids attached to a polysaccharide side chain is identified."]}
{"Patient Personal Background": ["He has iron deficiency anemia and ankylosing spondylitis.", "Current medications include ferrous sulfate, artificial tear drops, and indomethacin.", "His vital signs are within normal limits."], "Patient Symptoms": ["He has also been sneezing multiple times a day during this period.", "He had a similar episode 1 year ago around springtime."], "Examination and Results": ["Visual acuity is 20/20 without correction.", "Physical examination shows bilateral conjunctival injection with watery discharge.", "The pupils are 3 mm, equal, and reactive to light.", "Examination of the anterior chamber of the eye is unremarkable."], "Others": ["He works as an elementary school teacher."]}
{"Patient Personal Background": ["He has a 5-year history of untreated hypertension.", "He has smoked 1 pack of cigarettes daily for the past 5 years and started abusing cocaine 2 weeks before his emergency room visit."], "Patient Symptoms": ["The pain radiates to the epigastric area.", "The patient is diaphoretic and in marked distress."]}
{"Patient Personal Background": ["He has a history of diabetes and peripheral artery disease."], "Patient Symptoms": ["Physical examination shows abdominal tenderness and right flank tenderness."], "Examination and Results": ["His blood pressure is 160/90 mm Hg.", "An ultrasound shows dilation of the right ureter and renal pelvis."]}
{"Patient Personal Background": ["He has hypertension and asthma.", "Current medications include atorvastatin, lisinopril, and an albuterol inhaler."], "Patient Symptoms": ["He appears pale and diaphoretic."], "Examination and Results": ["His pulse is 114/min and blood pressure is 130/88 mm Hg.", "An ECG shows ST-segment depressions in leads II, III, and aVF.", "Laboratory studies show an increased serum troponin T concentration.", "At the time of discharge, echocardiography shows a left ventricular ejection fraction of 58%."], "Treatment": ["The patient is treated for acute coronary syndrome and undergoes percutaneous transluminal coronary angioplasty."]}
{"Patient Personal Background": ["She has been utilizing oral contraceptive pills (OCPs) for the past 8 years, but asks to switch to an intrauterine device (IUD)."], "Examination and Results": ["Her vital signs are: blood pressure 118/78 mm Hg, pulse 73/min and respiratory rate 16/min.", "She is afebrile.", "Physical examination is within normal limits."]}
{"Patient Personal Background": ["She has no history of serious illness and takes no medications."], "Examination and Results": ["She appears well.", "A photograph of the nails is shown."]}
{"Patient Personal Background": ["She says she has not experienced vaginal discharge, bleeding, or fluid leakage, and is currently taking no medications.", "She has had little prenatal care and uses condoms inconsistently.", "Her sexually transmitted infections status is unknown."], "Examination and Results": ["On physical examination, her blood pressure is 110/70 mm Hg, heart rate is 86/min, and temperature is 37.6\u00b0C (99.7\u00b0F).", "A confirmatory test is then performed in the mother to confirm the diagnosis of HIV."], "Treatment": ["As part of the patient\u2019s workup, she undergoes a series of rapid screening tests that result in the administration of zidovudine during delivery.", "The infant is also given zidovudine to reduce the risk of transmission."]}
{"Patient Personal Background": ["He had a myocardial infarction 3 years ago.", "He has hypertension, diabetes mellitus, and chronic bronchitis.", "He has smoked half a pack of cigarettes for the past 45 years.", "Vital signs are within normal limits."], "Patient Symptoms": ["During this period, he also has excessive night sweats and shortness of breath on exertion.", "Over the past 3 months, he has had a 5.6-kg (12-lb) weight loss."], "Examination and Results": ["The spleen is palpated 6 cm below the left costal margin.", "Laboratory studies show:\nHemoglobin 6.4 g/dL\nMean corpuscular volume 85 \u03bcm3\nLeukocyte count 5,200/mm3\nPlatelet count 96,000/mm3\nA blood smear is shown.", "Bone marrow aspiration shows extensive fibrosis and a few scattered plasma cells.", "A JAK 2 assay is positive."]}
{"Patient Personal Background": ["He has no history of serious medical illness and takes no medications."], "Patient Symptoms": ["He has had intermittent tingling sensations on both cheeks over this time period."], "Examination and Results": ["Audiometry shows bilateral sensorineural hearing loss.", "Genetic evaluation shows a mutation of a tumor suppressor gene on chromosome 22 that encodes merlin."]}
{"Patient Symptoms": ["He currently has no complaints and claims to be \u201cas fit as a fiddle.\u201d The physical examination findings are unremarkable, except for a mid-systolic murmur heard in the 2nd left intercostal space that radiates to the carotids on auscultation."], "Examination and Results": ["The physician instructs the patient to stand from a supine position with the stethoscope still placed on his chest."], "Others": ["He currently has no complaints and claims to be \u201cas fit as a fiddle.\u201d The physical examination findings are unremarkable, except for a mid-systolic murmur heard in the 2nd left intercostal space that radiates to the carotids on auscultation."]}
{"Others": ["After a detailed study of the virus and its life cycle, he proposes a theory: Initially, a host cell is co-infected with 2 viruses from the same virus family.", "Within the host cell, concomitant production of various genome segments from both viruses occurs.", "Ultimately, the different genome segments from the viruses are packaged into a unique and novel virus particle.", "The newly formed virus particle is both stable and viable and is a new strain from the virus family that caused the outbreak of infection."]}
{"Patient Personal Background": ["Her past medical history is significant for recurrent abdominal pain due to cholelithiasis.", "Her father died at the age of 60 with some form of abdominal cancer."], "Patient Symptoms": ["She also complains of a dull pain in her back with nausea and vomiting several times.", "Her pain has no relation with food."], "Examination and Results": ["Her temperature is 37\u00b0C (98.6\u00b0F), respirations are 15/min, pulse is 67/min, and blood pressure is 122/98 mm Hg.", "Physical exam is unremarkable.", "However, a CT scan of the abdomen shows a calcified mass near her gallbladder."]}
{"Patient Personal Background": ["He was diagnosed with asthma when he was 3 years old and has since been on treatment for the condition."], "Patient Symptoms": ["He is currently on a \u03b2-agonist inhaler because of exacerbation of his symptoms.", "He has observed that his symptoms are more prominent in springtime, especially when the new flowers are blooming.", "His mother has a backyard garden and whenever he goes out to play there, he experiences chest tightness with associated shortness of breath."], "Treatment": ["He is currently on a \u03b2-agonist inhaler because of exacerbation of his symptoms.", "He has been advised to take more precaution during this seasonal change and to stay away from pollen.", "He is also being considered for an experimental therapy, which attenuates the activity of certain mediators which cause his asthmatic attack."], "Diagnosis": ["He was diagnosed with asthma when he was 3 years old and has since been on treatment for the condition."], "Others": ["The targeted mediator favors the class switching of antibodies.", "A reduction in this mechanism will eventually reduce the exaggerated response observed during his asthmatic attacks, even when exposed to an allergen."]}
{"Patient Symptoms": ["Diagnostic evaluation fails to discover an exact etiology of the boy's symptoms and the episode is classified as a brief resolved unexplained event (BRUE)."], "Diagnosis": ["Diagnostic evaluation fails to discover an exact etiology of the boy's symptoms and the episode is classified as a brief resolved unexplained event (BRUE)."], "Others": ["The risk profile for BRUE in infants remains largely unknown.", "The pediatrician who saw the boy in the emergency department is trying to identify risk factors for BRUE.", "She is aware of several confounders, including age, socioeconomic background, and family history of medical illness.", "She recruits 75 infants under 1 year of age with BRUE and 75 infants without BRUE of the same age, socioeconomic background, and family history of medical illness.", "She then compares the two groups with regard to history of feeding problems and history of recent upper respiratory infection."]}
{"Patient Personal Background": ["The patient has no past medical history.", "He has smoked 10 cigarettes per day for the past 7 years and occasionally drinks alcohol."], "Patient Symptoms": ["The pain is sharp, severe, increases when lying down, and improves with leaning forward.", "The pain also radiates to his shoulders and neck."], "Examination and Results": ["He presents with vital signs: blood pressure 110/70 mm Hg, regular radial pulse of 95/min, and temperature 37.3\u00b0C (99.1\u00b0F).", "On physical exam, a scratching sound of to-and-from character is audible over the left sternal border at end-expiration with the patient leaning forward.", "His chest X-ray is normal and ECG is shown in the picture."]}
{"Patient Symptoms": ["He was found on the floor in front of his apartment.", "He is somnolent but responsive when aroused.", "On physical examination, an alcoholic smell and slurred speech are noted.", "His pupils are normal."], "Examination and Results": ["His pulse is 64/min, respiratory rate is 15/min, and blood pressure is 120/75 mm Hg.", "Neurological exam shows diminished deep tendon reflexes bilaterally and an ataxic gait.", "Blood alcohol concentration is 0.04%.", "An ECG shows no abnormalities."]}
{"Patient Personal Background": ["She has a remote history of breast cancer in her 60s that was treated with radiation and chemotherapy.", "She also reports a history of extensive travel to Africa and a 30-pack-year history of smoking."], "Patient Symptoms": ["She recently observed an enlargement of her axillary lymph nodes, which she examines on a weekly basis."], "Examination and Results": ["On physical exam, several axillary lymph nodes are palpable with a large non-tender palpable mass in her right axilla measuring 10 x 8 cm.", "Fine-needle aspiration demonstrates what the pathologist describes as \"a centroblastic and immunoblastic cell presence, suspicious for non-Hodgkin\u2019s lymphoma (NHL)\u2013diffuse large B cell variant\"."]}
{"Patient Personal Background": ["She was born by cesarean section to a G1P1 woman with no prior medical history and had a normal APGAR score at birth."], "Patient Symptoms": ["In addition, she seems to have less energy compared to other babies and appears listless throughout the day."], "Examination and Results": ["Physical exam reveals a high-pitched holosystolic murmur that is best heard at the lower left sternal border."], "Others": ["Her parents say that she has never been observed to turn blue."]}
{"Patient Personal Background": ["The patient has asthma that is treated with an albuterol inhaler.", "The patient has smoked one pack of cigarettes daily for the past 10 years."], "Patient Symptoms": ["During this period, the patient has had headaches, muscle aches, joint pain, fever, and chills."], "Examination and Results": ["Her temperature is 38\u00b0C (100.4\u00b0F).", "Physical examination shows slight wheezes throughout both lung fields.", "Laboratory studies and urinalysis are positive for polysaccharide antigen.", "Bronchoalveolar lavage using silver/PAS-staining shows macrophages filled with a dimorphic fungus with septate hyphae."], "Others": ["Ten days ago, she was hiking with her family in Mississippi.", "Her mother has a lung disease treated with methotrexate."]}
{"Patient Symptoms": ["One week into the hospitalization, he develops a fever and purulent cough."], "Examination and Results": ["His vitals include: heart rate 88/min, respiratory rate 20/min, temperature 38.4\u00b0C (101.1\u00b0F), and blood pressure 110/85 mm Hg.", "On physical examination, he has basal crackles on the right side of the chest.", "Chest radiography shows a new consolidation on the same side."]}
{"Patient Personal Background": ["He has asthma and eczema.", "He uses a glucocorticoid inhaler and an albuterol inhaler but has missed his medications for the past week while on vacation."], "Patient Symptoms": ["He appears uncomfortable."], "Examination and Results": ["His temperature is 36\u00b0C (96.8\u00b0F), pulse is 120/min, respirations are 40/min, and blood pressure is 100/80.", "Expiratory and inspiratory wheezing is heard throughout both lung fields.", "There are moderate intercostal and subcostal retractions and a decreased inspiratory to expiratory ratio.", "His temperature is 36\u00b0C (96.8\u00b0F), pulse is 150/min, respirations are 22/min, and blood pressure is 100/70."], "Treatment": ["Nebulized albuterol and ipratropium treatments and intravenous methylprednisolone are given in the emergency department for a presumed asthma exacerbation.", "Magnesium sulfate is administered."], "Diagnosis": ["Nebulized albuterol and ipratropium treatments and intravenous methylprednisolone are given in the emergency department for a presumed asthma exacerbation."], "Others": ["One hour later, the child is limp and lethargic."]}
{"Examination and Results": ["The patient's neutrophils are examined in the laboratory and they fail to react during the nitroblue tetrazolium test."]}
{"Patient Symptoms": ["His mother reports that his cough has worsened over the last few hours.", "He has a frequent barking cough and a hoarse voice when he speaks."], "Examination and Results": ["The patient's blood pressure is 118/78 mm Hg, pulse is 90/min, respiratory rate is 35/min, and temperature is 38.3\u00b0C (101.1\u00b0F).", "On physical examination, the boy is sitting and leaning forward in apparent respiratory distress with suprasternal and intercostal retractions.", "Auscultation reveals inspiratory stridor without wheezing."]}
{"Patient Personal Background": ["She is very surprised as she has been taking oral contraceptives regularly.", "Her current anti-TB regimen includes rifampin, isoniazid, pyrazinamide, and ethambutol."], "Examination and Results": ["After performing a complete physical examination and a screening test for pregnancy, her gynecologist informs her that she is pregnant."], "Treatment": ["Her current anti-TB regimen includes rifampin, isoniazid, pyrazinamide, and ethambutol."]}
{"Patient Personal Background": ["He is normally in daycare; however, he has been home for the past 3 days."], "Patient Symptoms": ["His mother noted bloody stools and decreased oral intake of food and water over the last 24 hours.", "The next day, he complains of lower extremity weakness and tingling."], "Examination and Results": ["On physical exam his temperature is 102.2\u00b0F (39\u00b0C), blood pressure is 140/90 mmHg, pulse is 120/min, respirations are 22/min and O2 saturation is 99% on room air.", "He has dry mucous membranes.", "On abdominal exam you note diffuse tenderness to palpation without rebound or guarding.", "There are no masses, hepatosplenomegaly, and bowel sounds are hyperactive.", "Ultrasound of the right lower quadrant is negative for appendicitis.", "Stool is guaiac positive.", "On repeat exam, lower extremity strength is 3/5 with diminished patellar deep tendon reflexes."], "Treatment": ["He receives 15mg/kg acetaminophen and fluids are started."]}
{"Patient Personal Background": ["He was born at 38 weeks' gestation by cesarean section because of breech presentation.", "The pregnancy was complicated by oligohydramnios."], "Examination and Results": ["Examination shows concavity of the medial border of the left foot with a skin crease just below the ball of the great toe.", "The lateral border of the left foot is convex.", "The heel is in neutral position.", "Tickling the lateral border of the foot leads to correction of the deformity.", "The remainder of the examination shows no abnormalities.", "X-ray of the left foot shows an increased angle between the 1st and 2nd metatarsal bones."]}
{"Patient Symptoms": ["Physical examination shows a distended abdomen and right upper quadrant tenderness with normal bowel sounds."], "Examination and Results": ["She is 163 cm (5 ft 4 in) tall and weighs 91 kg (200 lb); her BMI is 34 kg/m2.", "Her temperature is 38.5\u00b0C (101.3\u00b0F).", "Laboratory studies show:\nLeukocyte count 14,000/mm3\nSerum\nTotal bilirubin 1.1 mg/dL\nAST 32 U/L\nALT 40 U/L\nAlkaline phosphatase 68 U/L\nAbdominal ultrasonography is performed, but the results are inconclusive.", "Cholescintigraphy shows the intrahepatic bile ducts, hepatic ducts, common bile duct, and proximal small bowel."]}
{"Examination and Results": ["A cardiac catheterization is performed and measurements of the left ventricular volume and pressure at different points in the cardiac cycle are obtained.", "The patient's pressure-volume loop (gray) is shown with a normal pressure-volume loop (black) for comparison."]}
{"Patient Personal Background": ["Five weeks ago, she was hospitalized and received intravenous antibiotics for treatment of bacterial meningitis while visiting relatives in Guatemala."], "Patient Symptoms": ["She also has a 1-month history of progressive fatigue."], "Examination and Results": ["Her temperature is 39.4\u00b0C (102.9\u00b0F), pulse is 130/min, and blood pressure is 105/70 mm Hg.", "Examination shows pallor and scattered petechiae and ecchymoses.", "Laboratory studies show a hemoglobin concentration of 9.0 g/dL, a leukocyte count of 1,100/mm3 with 30% segmented neutrophils, and a platelet count of 20,000/mm3 ."], "Others": ["Blood cultures grow coagulase-negative staphylococci."]}
{"Patient Symptoms": ["He has had a 3.2-kg (7-lb) weight loss during this time.", "Physical examination shows bilateral pitting pedal edema."], "Examination and Results": ["An endoscopy shows prominent rugae in the gastric fundus.", "Biopsy shows parietal cell atrophy."]}
{"Patient Personal Background": ["The patient is a known IV drug abuser but otherwise has an unknown past medical history.", "He currently attends a methadone clinic."], "Patient Symptoms": ["He was brought in by staff from the homeless shelter when they found him unresponsive."], "Examination and Results": ["His temperature is 99.5\u00b0F (37.5\u00b0C), blood pressure is 97/48 mmHg, pulse is 140/min, respirations are 29/min, and oxygen saturation is 98% on room air.", "Serum:\nNa+: 139 mEq/L\nCl-: 100 mEq/L\nK+: 6.3 mEq/L\nHCO3-: 17 mEq/L\nGlucose: 589 mg/dL\n\nThe patient is given treatment.", "His laboratory values are seen below."], "Treatment": ["After treatment, his temperature is 99.5\u00b0F (37.5\u00b0C), blood pressure is 117/78 mmHg, pulse is 100/min, respirations are 23/min, and oxygen saturation is 98% on room air."], "Others": ["Initial laboratory values are shown below."]}
{"Patient Symptoms": ["His left knee was swollen a few weeks ago, but now with both joints affected, he has difficulty walking and feels frustrated.", "He also has back pain which makes it extremely difficult to move around and be active during the day.", "He says his pain significantly improves with rest.", "He also suffers from dandruff for which he uses special shampoos."], "Examination and Results": ["Physical examination is notable for pitting of his nails."]}
{"Patient Symptoms": ["The weakness is more noticeable when climbing stairs and combing hair.", "The weakness improves after brief exercise.", "She also has bladder incontinence for the past 4 weeks and was given an anticholinesterase agent with no improvement."], "Treatment": ["She also has bladder incontinence for the past 4 weeks and was given an anticholinesterase agent with no improvement."]}
{"Examination and Results": ["His weight is in the 10th percentile.", "Laboratory results for the HIV are negative by PCR."], "Diagnosis": ["He is being evaluated for an immunodeficiency disease."]}
{"Others": ["The novel drug was previously tested in a small population and is now undergoing a larger phase 3 trial in preparation for FDA approval."]}
{"Patient Symptoms": ["Noticeably the patient remains unable to complete tasks involving verbal repetition."], "Examination and Results": ["Subsequent neurologic exam finds that the patient is fluent while speaking and is able to comprehend both one and two step instructions."], "Treatment": ["After acute treatment with tissue plasminogen activator (tPA), the patient is able to recover most of his speech."]}
{"Patient Personal Background": ["She says she has always been \"large\" and was constantly targeted by her classmates and coworkers for being so.", "She has tried numerous diet plans, exercise regimens, and cosmetic products with little to no effect.", "She has a family history of type 2 diabetes mellitus and a menstrual cycle that occurs every 45 days."], "Patient Symptoms": ["Her main concern at the moment is her acne and unwanted facial hair on her upper lip, for which she often visits a local spa."], "Examination and Results": ["Recently, she underwent a glucose tolerance test that showed a plasma glucose level of 160 mg/dL (8.9 mmol/L) after 2 hours of a 75 g dose of oral glucose.", "Her pulse is 72/min and the blood pressure is 138/80 mm Hg.", "On physical examination, her height is 160 cm (5 ft 3 in) and her weight is 85 kg (187 lb), and she has severe inflammatory acne over the cheeks and forehead and dark coarse hairs on the back."]}
{"Patient Personal Background": ["Past medical history is significant for type 2 d\u0456\u0430b\u0435tes mellitus for 2 \u0443\u0435\u0430r\u0455, inconsistently managed with m\u0435tform\u0456n \u0430nd gl\u0456m\u0435\u0440\u0456r\u0456d\u0435."], "Patient Symptoms": ["\u041d\u0435 also \u0441om\u0440l\u0430\u0456n\u0455 of \u0440\u0435r\u0455\u0456\u0455t\u0435nt \u0440\u0430\u0456n in his legs wh\u0456\u0441h is not relieved by over-the-counter analgesics."], "Examination and Results": ["\u041en physical \u0435\u0445\u0430m\u0456n\u0430t\u0456on, th\u0435r\u0435 \u0456\u0455 d\u0435\u0441r\u0435\u0430\u0455\u0435d \u0455\u0435n\u0455\u0430t\u0456on to pain in both lower l\u0456mbs, but deep t\u0435ndon r\u0435fl\u0435\u0445\u0435\u0455 \u0430r\u0435 \u0456nt\u0430\u0441t.", "\u041d\u0456\u0455 v\u0456t\u0430l \u0455\u0456gn\u0455 include: blood \u0440r\u0435\u0455\u0455ur\u0435 122/84 mm \u041dg, t\u0435m\u0440\u0435r\u0430tur\u0435 36.7\u00b0C (98.1\u00b0F), and r\u0435\u0455\u0440\u0456r\u0430tor\u0443 r\u0430t\u0435 10/m\u0456n.", "His ankle-brachial pressure index (ABPI) on the right side is 1.1."]}
{"Patient Personal Background": ["He was born at 38 weeks gestation to a 36-year-old gravida 3 via vaginal delivery.", "The pregnancy was complicated by gestational diabetes.", "The patient\u2019s mother received routine prenatal care and declined first trimester screening.", "She subsequently underwent a quadruple screen at 15 weeks gestation that demonstrated decreased maternal serum alpha-fetoprotein (AFP), increased beta-hCG, decreased unconjugated estriol, and increased inhibin A.", "Her last ultrasound prior to onset of labor demonstrated an amniotic fluid index (AFI) of 28 cm.", "The patient\u2019s two older siblings are both healthy.", "The patient\u2019s temperature is 97.8\u00b0F (36.6\u00b0C), blood pressure is 58/37 mmHg, pulse is 166/min, and respirations are 38/min."], "Patient Symptoms": ["The patient has urinated multiple times since birth but has not yet passed meconium.", "His abdomen is firm and distended with hypoactive bowel sounds."], "Examination and Results": ["On physical exam, the patient is in moderate distress.", "His abdomen is firm and distended with hypoactive bowel sounds."]}
{}
{"Patient Personal Background": ["The patient has a past medical history of obesity and type II diabetes on metformin.", "Her last child was born four years ago, and she has had five spontaneous vaginal deliveries."], "Patient Symptoms": ["She now soaks one super absorbent tampon every two hours for five days each cycle.", "Her cycles have also become irregular, with intermenstrual bleeding for the last two months.", "She now experiences significant dysmenorrhea, requiring 400 mg ibuprofen every four hours for the majority of each menses.", "In addition, she reports new onset mild dyspareunia with intercourse and a \u201cheavy feeling\u201d in her pelvis.", "She has also noticed increased urinary frequency but denies bowel changes."], "Examination and Results": ["At this office visit, temperature is 98.5\u00b0F (36.9\u00b0C), blood pressure is 137/84 mmHg, pulse is 87/min, and respirations are 14/min."]}
{"Patient Personal Background": ["The officer state that the man has been arrested multiple times for public alcohol intoxication, but recently became homeless."], "Patient Symptoms": ["On exam, the man is behaving erratically.", "He appears confused and has a slurred speech.", "On gait exam, the patient is ataxic and cannot stand without support for more than a few seconds."], "Examination and Results": ["His vitals are all within normal limits.", "Labs return with the following values: Na 140, K 4, Cl 106, BUN 8, Cr 2.", "His ABG has pH 7.3, PaCO2 13mm, PaO2 130mm, HCO3 7.", "Blood salicylate levels return as normal."], "Others": ["His urinalysis is shown in Figure 1."]}
{"Others": ["The study enrolled a total of 3,000 subjects, 1,500 in each study arm.", "Follow-up was conducted at 45 days post-MI.", "The following are the results of the trial:\nEndpoints Medication 1 Medication 2 P-Value\nPrimary: death from cardiac causes 134 210 0.03\nSecondary: hyperkalemia 57 70 0.4\nWhat is the number needed to treat (NNT) for the primary endpoint of death from cardiac causes?"]}
{"Patient Personal Background": ["He has an 8-year history of type 2 diabetes mellitus.", "He has smoked two packs of cigarettes daily for 34 years.", "His only medication is metformin."], "Patient Symptoms": ["He reports that he started exercising regularly 2 months ago and that his right calf cramps when he uses the incline feature on the treadmill, forcing him to take frequent breaks.", "The pain completely disappears after resting for a few minutes.", "There is no pain in the back."], "Examination and Results": ["His pulse is 82/min, and blood pressure is 170/92 mm Hg.", "Straight leg raise test elicits pallor and tingling pain in the right foot.", "His muscle strength is normal.", "Femoral pulses are palpable; right pedal pulses are absent."]}
{"Patient Personal Background": ["She has no history of serious medical illness.", "She has had an uncomplicated pregnancy.", "Her last ultrasound at 22 weeks' gestation was normal."], "Patient Symptoms": ["On admission, fetal heartbeats cannot be detected by fetal doppler monitor."], "Examination and Results": ["Ultrasound shows decreased amniotic fluid levels and no evidence of fetal movement, respiration, or heart activity.", "Physical examination shows no signs of life.", "The placenta is unremarkable."], "Others": ["The patient gives birth to a 2296 g (5 lb 1 oz) male infant.", "There are no visible malformations."]}
{"Patient Symptoms": ["Despite therapy, his shortness of breath continues to worsen and his oxygen saturation decreases to the point where ICU transfer and intubation are required."], "Examination and Results": ["Respiratory viral panel returns positive for influenza A and the patient is started on a standard five day course of oseltamivir.", "Chest radiograph shows bilateral infiltrates."], "Treatment": ["Respiratory viral panel returns positive for influenza A and the patient is started on a standard five day course of oseltamivir."], "Diagnosis": ["Clinical criteria are consistent with development of Acute Respiratory Distress Syndrome (ARDS)."], "Others": ["After several weeks of supportive therapy, the patient improves with lung function returning to near normal."]}
{}
{"Patient Personal Background": ["He has had no recent changes to his medication regimen, which includes hydrochlorothiazide, lisinopril, and amlodipine."], "Examination and Results": ["His temperature is 98.0\u00b0F (36.7\u00b0C), blood pressure is 174/111 mmHg, pulse is 70/min, respirations are 12/min, and oxygen saturation is 98% on room air.", "The patient's cardiopulmonary and abdominal exams are unremarkable.", "Laboratory values are ordered as seen below."]}
{"Patient Symptoms": ["Examination shows jaundice of the skin and scleral icterus."], "Examination and Results": ["Urinalysis shows an elevated concentration of bilirubin and a low concentration of urobilinogen."]}
{"Patient Symptoms": ["Two weeks later, the patient develops vomiting, mild crampy abdominal pain, and watery, nonbloody diarrhea."], "Treatment": ["Treatment with galantamine is initiated."]}
{"Patient Personal Background": ["He resides in an inpatient psychiatric facility where he has been successfully treated with haloperidol for the past several months."], "Patient Symptoms": ["These symptoms started slowly about 2 weeks ago and have become more pronounced, but they do not seem to bother the patient."], "Examination and Results": ["His physical exam and vitals are within normal limits."]}
{"Patient Personal Background": ["He says this started during summer workouts leading up to this season."], "Patient Symptoms": ["He denies having any rash anywhere else on his body."], "Examination and Results": ["The blood pressure is 123/78 mm Hg, pulse is 67/min, respiratory rate is 15/min, and temperature is 38.1\u00b0C (98.7\u00b0F).", "Physical examination reveals an erythematous, well-demarcated patch with peripheral scale on the left thigh, pubic region, and perineum.", "There is no apparent scrotal involvement with the rash."]}
{"Treatment": ["Risperidone therapy is initiated."]}
{"Patient Symptoms": ["She also says she has been nauseous for the past 3 hours and has vomited twice.", "The patient mentions she has had heavy menstrual bleeding for the past few days."], "Examination and Results": ["Her blood pressure is 95/80 mm Hg and her temperature is 40.0\u00b0C (104.0\u00b0F).", "On physical examination, the patient appears diaphoretic.", "A pelvic examination reveals a tampon in her vagina."]}
{"Patient Personal Background": ["The patient's father states that they returned early from a 6-week roadtrip in Mexico because of these symptoms.", "His immunizations are up-to-date.", "He appears pale."], "Patient Symptoms": ["One week ago, he experienced abdominal pain, vomiting, and bloody diarrhea that have since subsided.", "His temperature is 38.4\u00b0C (101.1\u00b0F), pulse is 130/min, respirations are 35/min, and blood pressure is 95/50 mm Hg.", "Examination shows scleral icterus."], "Examination and Results": ["His temperature is 38.4\u00b0C (101.1\u00b0F), pulse is 130/min, respirations are 35/min, and blood pressure is 95/50 mm Hg.", "The abdomen is soft and nontender; there is no rebound or guarding.", "Bowel sounds are hyperactive.", "Laboratory studies show:\nHemoglobin 8.5 g/dL\nMean corpuscular volume 94 \u03bcm3\nLeukocyte count 18,000/mm3\nPlatelet count 45,000/mm3\nProthrombin time 12 sec\nPartial thromboplastin time 34 sec\nSerum\nUrea nitrogen 28 mg/dL\nCreatinine 1.6 mg/dL\nBilirubin\nTotal 2.5 mg/dL\nDirect 0.1 mg/dL\nLactate dehydrogenase 1658 U/L\nA blood smear shows schistocytes."], "Treatment": ["His parents have been giving him oral rehydration solution."], "Others": ["The remainder of the examination shows no abnormalities."]}
{"Patient Personal Background": ["She has been visiting the same dentist since childhood and for the past 2 years has had at least 2 visits for dental caries.", "She eventually admitted to him that she regularly induces vomiting by putting her fingers down her throat.", "She says she has been doing this for the last few years and purging at least once a week."], "Patient Symptoms": ["More recently, she has been inducing emesis more often and even looked into diuretics as she feels that she is gaining more and more weight compared to her \u2018skinny friends\u2019."], "Examination and Results": ["Her BMI is at the 50th percentile for her age and sex."]}
{"Patient Personal Background": ["She returned from Indonesia 2 weeks ago, where she spent the summer with her grandparents."], "Patient Symptoms": ["Her symptoms began one week ago, when she had several days of low-grade fever and constipation.", "Her temperature is 39.3\u00b0C (102.8\u00b0F)."], "Examination and Results": ["Examination shows diffuse abdominal tenderness and mild hepatosplenomegaly.", "There is a faint salmon-colored maculopapular rash on her trunk and abdomen."]}
{"Patient Symptoms": ["At a party shortly afterward she experiences facial flushing, nausea, tachycardia, dyspnea, headache, and abdominal cramps after consuming alcohol."]}
{"Patient Personal Background": ["She takes folic acid, iron, and vitamin D supplementation."], "Patient Symptoms": ["She complains of increased fatigability, but is otherwise well."], "Examination and Results": ["Her vital signs are as follows: blood pressure, 110/70 mm Hg; heart rate, 86/min; respiratory rate, 13/min; and temperature, 36.6\u2103 (97.9\u2109).", "The physical examination is unremarkable."]}
{"Patient Symptoms": ["During the physical, the patient mentions some discomfort in his abdomen and pelvis and during a records review it is noted that he has not passed urine in the PACU, step-down unit, or since arriving on the med-surg floor."], "Examination and Results": ["On the med-surg floor, his temperature is 36.8\u00b0C (98.2\u00b0F), the heart rate is 98/min, the respiratory rate is 15/min, the blood pressure is 100/75 mm Hg, the oxygen saturation is 90%.", "His heart has a regular rate and rhythm and his lungs are clear to auscultation bilaterally.", "His incision site is clean, dry, and intact with an appropriate level of swelling and erythema.", "A bladder scan is inconclusive due to body habitus."], "Treatment": ["He had undergone a successful hernia surgery 14 hours ago.", "Before the surgery, he was pre-treated with atropine, scopolamine, and morphine and recovered well in the PACU after the surgery."], "Others": ["There were no complications in the step-down unit and the patient continued to recover.", "On physical exam, he is a well-developed, obese man."]}
{"Patient Personal Background": ["He is a competitive swimmer and has had 8 sexual partners in the past year.", "He intermittently uses barrier protection."], "Patient Symptoms": ["He reports that he noticed a white film on his tongue and the sides of his mouth 2 days ago while brushing his teeth.", "The film was easily brushed off.", "He also complains of a bitter metallic taste in his mouth but otherwise denies pain, burning, dysphagia, or hoarseness."], "Examination and Results": ["On exam, he is well-appearing and in no acute distress.", "His oral examination demonstrates patches of white pseudomembranes that can be wiped away to reveal erythematous mucosa."], "Others": ["He is otherwise healthy and takes no medications."]}
{"Patient Personal Background": ["He could not recall any precipitating event except for an amateur weight-lifting competition that he participated in 2 months ago.", "Past medical history is significant for non-small cell lung cancer that was diagnosed and successfully treated."], "Patient Symptoms": ["The pain is described as a dull, constant ache that is worse at night."], "Examination and Results": ["Physical exam was unremarkable except for some point tenderness along the lumbosacral area."], "Others": ["A PET scan 1 year ago demonstrated no recurrence."]}
{"Patient Symptoms": ["He has not had bowel movements in the past 24 hours.", "He appears ill. His temperature is 37.8\u00b0C (100\u00b0F) and pulse is 122/min."], "Examination and Results": ["Examination shows a distended abdomen.", "There is tenderness to palpation in the lower abdomen; guarding and rebound tenderness are present.", "Bowel sounds are decreased.", "An x-ray of the abdomen shows dilated loops of bowel."], "Treatment": ["The surgeon recommends an emergency laparotomy."], "Others": ["He has been accompanied by his 14-year-old brother.", "The parents are away visiting friends and cannot be reached."]}
{"Patient Personal Background": ["He was born at 38 weeks' gestation via normal vaginal delivery.", "He has been latching on and breastfeeding well since birth.", "His mother has a history of Graves' disease and underwent near-total thyroidectomy in the second trimester of her pregnancy after her symptoms could not be controlled with antithyroid drugs.", "She is currently receiving L-thyroxine therapy."], "Patient Symptoms": ["He appears irritable."], "Examination and Results": ["He weighed 3005 g (6 lb, 10 oz) at birth and currently weighs 2835 g (6 lb, 4 oz).", "The patient's temperature is 38.9\u00b0C (102\u00b0F), pulse is 176/min, and respirations are 42/min.", "Examination shows a diaphoretic infant with a paucity of subcutaneous fat.", "There is swelling of the neck at the midline."]}
{"Patient Symptoms": ["She is accompanied by her partner, who reports that she had been complaining of black and tarry stools for the past several days."], "Examination and Results": ["Vital signs are temperature 37 degrees celsius, heart rate 141 beats per minute, blood pressure 90/60, respiratory rate 20, and oxygen saturation 99% on room air.", "On physical examination, she has splenomegaly and a positive fluid wave.", "The remainder of her examination is within normal limits.", "Subsequent emergent upper endoscopy reveals bleeding from the submucosal veins in the lower 1/3 of the esophagus, but no gastric bleed."], "Treatment": ["The patient is stabilized with intravenous fluids, and her blood pressure improves.", "In the endoscopy suite she also receives IV octreotide."]}
{"Patient Personal Background": ["He feels well and currently drinks 5 glasses of wine each night.", "Medications include atenolol and lisinopril."], "Examination and Results": ["On physical exam, temperature is 98.1 deg F (36.7 deg C), blood pressure is 151/82 mmHg, pulse is 71/min, and respirations are 14/min.", "He has spider angiomata on his chest; no asterixis, jaundice, ascites, or peripheral edema is noted.", "Screening ultrasound reveals a new liver nodule, and follow up CT demonstrates a 2 cm right hepatic lobe lesion with enhancement in the arterial phase.", "No hypodense attenuation is seen on the venous or delayed phase."]}
{"Patient Personal Background": ["His past medical history is significant for alcoholic liver cirrhosis."], "Patient Symptoms": ["The patient\u2019s wife says that he has been sleeping much more than usual for the past 5 days.", "On physical examination, the patient is altered and not responsive to commands.", "Oriented x 0."], "Examination and Results": ["His bowel and bladder habit have not changed.", "His vital signs include: pulse 76/min, respiratory rate 15/min, temperature 38.0\u00b0C (100.4\u00b0F) and blood pressure 122/75 mm Hg.", "The abdomen is significantly distended.", "Shifting dullness is present and a positive fluid wave can be elicited.", "Hyperreflexia and asterixis are noted.", "Laboratory findings are significant for the following:\nLaboratory test\nSodium 140 mEq/L\nPotassium 3.5 mEq/L\nChloride 97 mEq/L\nGlucose 90 mg/dL\nAmmonia 100 \u00b5g/dL (ref: 19-60 \u00b5g/dL)\nArterial blood gas\npH 7.4\npCO2 40 mm Hg\npO2 90 mm Hg\nHCO3 26 mEq/L\nAn abdominal ultrasound shows surface nodularity compatible with cirrhosis but no other changes aside from ascites.", "An upper GI endoscopy is performed which shows gastric varices with no signs of active bleeding.", "An MRI of the brain is insignificant."]}
{"Patient Symptoms": ["The patient was the front seat unrestrained driver in a head on collision.", "The patient is currently complaining of chest pain.", "Physical exam is notable for an uncomfortable young man with bruising over his chest wall."], "Examination and Results": ["The patient\u2019s echocardiogram (ECG) is notable only for sinus tachycardia.", "His temperature is 99.5\u00b0F (37.5\u00b0C), blood pressure is 107/58 mmHg, pulse is 120/min, respirations are 17/min, and oxygen saturation is 98% on room air.", "Initial workup demonstrates that the patient\u2019s pulmonary capillary wedge pressure and troponins are elevated."], "Treatment": ["The patient is given 2 liters of Ringer lactate solution and morphine."]}
{"Patient Personal Background": ["He recently started melatonin and magnesium supplementation in hopes of improving his sleep.", "Medical history is significant for alcohol use disorder that required multiple hospital admissions for management of acute pancreatitis and cirrhosis.", "He states that he occasionally injects heroin intravenously."], "Patient Symptoms": ["He reports that his symptoms began approximately 1 week ago and he has noticed episodes of diarrhea."], "Examination and Results": ["Temperature is 100\u00b0F (37.8\u00b0C), blood pressure is 105/70 mmHg, pulse is 92/min, and respirations are 17/min.", "Physical examination is significant for scleral icterus, hepatomegaly, ascites, and diffuse abdominal tenderness.", "Laboratory testing is significant for leukocytosis and metabolic acidosis.", "Ascitic fluid analysis demonstrates a polymorphonuclear cell count of 280 cells/mm^3, serum-ascites albumin gradient of 1.3 g/dL, and a culture positive for Escherichia coli sensitive to cefotaxime and ceftriaxone.", "Physical examination is unchanged.", "Laboratory testing is significant for a serum sodium of 131 mEq/L and creatinine of 1.8 mg/dL (it was 0.9 mg/dL on admission).", "Urine studies are significant for a low urine sodium level, without evidence of blood or protein."], "Treatment": ["A paracentesis is performed and he is admitted into the hospital to receive intravenous cefotaxime and albumin."], "Others": ["On hospital day 2, the nurse reports that the patient is oliguric in the setting of constant fluid intake.", "Since the hospital admission, he has not been started on any new medications."]}
{"Patient Personal Background": ["She has not changed her diet or exercise habits."], "Patient Symptoms": ["She noticed a 6.8 kg (15 lb) unintentional weight loss over the preceding several months.", "She also reports feuding with her boyfriend over the temperature of their shared apartment, as she always feels warmer than he does.", "She also exhibits a fine tremor in her hands when her arms are outstretched."], "Examination and Results": ["The vital signs include: heart rate 110/min and blood pressure 146/78 mm Hg.", "The physical exam is notable for warm and slightly moist skin.", "The urine pregnancy test is negative."]}
{"Patient Personal Background": ["He works as an office manager and has no known exposure to melanocytotoxic chemicals.", "He has been sexually active with three female partners over the past year and uses condoms inconsistently.", "He is 183 cm (6 ft) tall and weighs 80 kg (176 lb); BMI is 23.9 kg/m2.", "One month ago, his hemoglobin A1C was 7.8%."], "Patient Symptoms": ["He first noticed the symptoms after returning from a business trip last week in the Bahamas.", "The rash initially started as a single lesion on his upper back but since then has extended to his shoulders."], "Examination and Results": ["His temperature is 37.2\u00b0C (99\u00b0F), pulse is 78/min, and blood pressure is 130/84 mm Hg."], "Others": ["While he was there, he visited a couple of beaches and went hiking with some coworkers.", "A photograph of the rash is shown."]}
{"Patient Symptoms": ["She is only able to verbalize two word sentences and has generalized developmental delay."], "Examination and Results": ["When she was born it was noticed that she had a high pitched mewing cry and subsequent physical exam revealed microcephaly, prominent epicanthal folds, and a holosystolic murmur best heard in the left 5th intercostal space near the sternum."]}
{"Patient Personal Background": ["Menopause occurred at 52 years of age.", "She has hypertension, hypercholesterolemia, and diabetes.", "Medications include atorvastatin, hydrochlorothiazide, metformin, and aspirin.", "She is sexually active with her husband."], "Patient Symptoms": ["She has had no fever, abdominal pain, or diarrhea."], "Examination and Results": ["Her temperature is 37\u00b0C (98.6\u00b0F), pulse is 95/min, respirations are 12/min, and blood pressure is 155/65 mm Hg.", "Pelvic exam demonstrates a 4 x 3 cm firm, immobile erythematous mass on the right inner vaginal wall."], "Others": ["Her last Pap smear 1 year ago was normal."]}
{"Patient Personal Background": ["He has had diabetes mellitus for 2 years which is not well controlled with medications."], "Patient Symptoms": ["There is swelling and tenderness over the first, second, and third metacarpophalangeal joints of both hands."], "Examination and Results": ["His hand radiograph is shown.", "Lab studies show a transferrin saturation of 88% and serum ferritin of 1,200 ng/mL."]}
{"Patient Symptoms": ["He then develops progressive respiratory failure and is admitted to the neonatal ICU."], "Examination and Results": ["A single loud S2 heart sound is appreciated as well as a machine-like murmur at the left upper sternal border.", "Radiography shows an enlarged \"egg-shaped\" heart."], "Treatment": ["The newborn is then taken for a atrial septostomy to alleviate the condition pending definitive surgical correction."]}
{"Patient Symptoms": ["The patient is unconscious and cannot provide any further history.", "On physical examination, the patient is diaphoretic and unresponsive.", "Extremities are pale and cool."], "Examination and Results": ["Vitals show a temperature of 37-0\u00b0C (98.6\u00b0F), blood pressure of 85/55 mm Hg, pulse of 115/min, respirations of 19/min, and oxygen saturation of 92% on room air.", "There is a 3-inch long penetrating wound between the 3rd and 4th intercostal space on the left side of the chest, which is bleeding profusely.", "Transthoracic echocardiography reveals a full thickness penetrating injury to the right ventricular free wall.", "There are no apparent injuries to any coronary arteries or major branches."], "Treatment": ["The patient is intubated and aggressive fluid resuscitation is initiated, including a blood transfusion."]}
{}
{"Patient Personal Background": ["He has well-controlled hypertension and diabetes but has otherwise been healthy.", "He does not smoke but drinks socially with his friends."], "Examination and Results": ["Physical exam reveals enlarged nodules that are not tender to palpation.", "A biopsy is obtained showing a characteristic change in chromosome 18."]}
{"Patient Personal Background": ["She is concerned about cancer because her uncle died of metastatic melanoma 1 year ago.", "She has no history of serious illness and does not take any medication.", "She has been working in a law firm for the past 20 years and travels to the Carribean regularly with her husband."], "Examination and Results": ["Examination of her skin shows no abnormal moles or warts."]}
{"Patient Personal Background": ["The patient\u2019s past medical history is positive for diverticulosis.", "She takes no medication."], "Patient Symptoms": ["The daughter reports that her mother has recently been having difficulty combing her hair in the mornings."], "Examination and Results": ["Her blood pressure is 120/70 mm Hg, heart rate is 75/min, respiratory rate is 14/min, and temperature is 37.6\u00b0C (99.7\u00b0F).", "On physical examination, the patient\u2019s neck is stiff and she also has bilateral shoulder tenderness; muscle strength is intact."], "Others": ["The patient\u2019s family history is significant for an ischemic stroke in her father."]}
{"Patient Personal Background": ["She is sexually active with her husband and does not use contraception."], "Patient Symptoms": ["The patient also reports episodic pelvic and back pain accompanied by painful diarrhea for 5 years.", "She has about one such episode on average per month for 4\u20136 days.", "She has taken ibuprofen for the pain, which has provided some relief."], "Examination and Results": ["Analysis of her husband's semen has shown normal sperm counts during this time.", "Vital signs are within normal limits.", "Pelvic and bimanual examinations are normal; rectal examination is unremarkable.", "A hysterosalpingogram 6 months prior showed normal results."], "Treatment": ["Menses have occurred at regular 29-day intervals since menarche at the age of 14 years and last for 7 days."]}
{"Patient Personal Background": ["The patient has been previously hospitalized for a tricuspid valve replacement surgery 1 year ago and takes aspirin daily.", "The medical history is also relevant for myocardial infarction 3 years ago and hypertension for the past 10 years, for which he takes lisinopril."], "Patient Symptoms": ["She states that her husband developed a fever and began feeling weak 3 days ago, but has refused medical help.", "He has been unable to go to work because of his symptoms."], "Examination and Results": ["His blood pressure is 140/80 mm Hg, the pulse is 82/min, the respirations are 18/minute, and the temperature is 37.2\u00b0C (98.9\u00b0F).", "On examination, several hemorrhages are noted on the nail beds of several fingers."]}
{"Patient Personal Background": ["She is sexually active with her husband.", "She uses a combined oral contraceptive pill."], "Patient Symptoms": ["She also reports frequent episodes of crampy pelvic pain that starts one day before menses and lasts for 7 days.", "Her symptoms are not relieved with pain medication."], "Examination and Results": ["Her vital signs are within normal limits.", "Physical examination shows rectovaginal tenderness.", "Cervical and urethral swabs are negative.", "Transvaginal ultrasonography shows no abnormalities."], "Others": ["Menses occur at regular 28-day intervals and last 5 days.", "Her last menstrual period was 2 weeks ago."]}
{"Patient Personal Background": ["The patient has no active complaints and says he feels healthy; however, he does not exercise regularly and lives a sedentary lifestyle.", "He is employed as an administrative position at a local college, and is seated at a desk most of the day.", "His father had a heart attack at age 54 and his mother is still alive with no health concerns.", "He does not smoke, only drinks socially, and does not use drugs.", "Today, his blood pressure is 130/90 mm Hg, pulse is 84/min, and respiratory rate is 14/min."], "Examination and Results": ["Physical examination reveals an obese male with no significant findings."], "Others": ["He is concerned about his health after a colleague recently had a heart attack."]}
{"Patient Symptoms": ["On arrival, she is lethargic and incoherent.", "She has severe facial lacerations and is in respiratory distress."], "Examination and Results": ["Her pulse is 130/min, respirations are 29/min, and blood pressure is 90/58 mm Hg.", "Pulse oximetry on room air shows an oxygen saturation of 70%.", "Examination shows multiple facial lacerations.", "There is dullness to percussion and decreased breath sounds over the left lung base.", "Abdominal examination shows diffuse tenderness with no guarding or rebound.", "Bowel sounds are normal.", "Her hemoglobin concentration is 12.1 g/dL.", "An x-ray of the chest shows a fractured left second rib, depression of the left mainstem bronchus, deviation of the nasogastric tube to the right, and a widened mediastinum."], "Others": ["The remainder of the examination shows no abnormalities."]}
{"Patient Personal Background": ["She denies having similar symptoms in the past or starting any new medications or illicit drugs.", "She is currently 10 weeks pregnant and is closely followed by her obstetrician."], "Patient Symptoms": ["She finds it difficult initiating sleep, occasionally has palpitations, and feels fatigued."], "Examination and Results": ["Her temperature is 98.6\u00b0F (37\u00b0C), blood pressure is 125/70 mmHg, pulse is 105/min, and respirations are 18/min.", "On physical exam, the patient is mildly diaphoretic.", "The skin is warm and the thyroid gland is diffusely enlarged with thyroid bruits.", "Laboratory studies are significant for a thyroid-stimulating hormone level of 0.01 \u00b5U/mL (normal is 0.5-5.0 \u00b5U/mL) and an elevated free thyroxine (FT4) that is inappropriate for her pregnancy."]}
{"Patient Personal Background": ["She immigrated to the US from Uganda 6 weeks ago."], "Patient Symptoms": ["Abdominal examination shows diffuse tenderness with no guarding or rebound."], "Examination and Results": ["The liver is firm and palpable 3 cm below the right costal margin, and the spleen is palpable just below the left costal margin.", "Her leukocyte count is 12,800/mm3 (12% eosinophils).", "Stool culture shows several oval-shaped eggs with lateral spines.", "Microscopic examination of a liver biopsy specimen shows granulomatous inflammation with periportal fibrosis."]}
{"Patient Symptoms": ["She has central cyanosis without signs of respiratory distress or signs of heart failure."], "Examination and Results": ["An echocardiogram reveals severe pulmonary outflow obstruction, right ventricular hypertrophy, a ventricular septal defect, and an overriding of the aorta."], "Treatment": ["An elective primary surgical repair is planned at 4 months of age."]}
{"Patient Personal Background": ["Her husband says that she usually drinks one to two glasses of wine weekly.", "Her only current medication is oxycodone for pain."], "Patient Symptoms": ["She is unarousable during the day, but then is awake and impulsive during the night, requiring frequent reorientation.", "She is distressed and oriented to person but not to place or time."], "Examination and Results": ["Her vital signs are within normal limits.", "Neurologic examination shows inattentiveness but no focal deficits.", "Urine dipstick is normal."], "Treatment": ["Her only current medication is oxycodone for pain."]}
{"Patient Symptoms": ["Her caretakers state that the patient\u2019s gait suddenly became ataxic, and she became less responsive than her normal non-verbal baseline."], "Examination and Results": ["Her temperature is 98.5\u00b0F (36.9\u00b0C), blood pressure is 125/68 mmHg, pulse is 90/min, respirations are 15/min, and oxygen saturation is 99% on room air.", "Physical exam is notable for an unremarkable HEENT exam with normal facial features and no signs of airway compromise.", "Neurological exam is remarkable for new onset spasticity.", "The patient has 3+ reflexes and a positive Babinski sign.", "Musculoskeletal exam is only notable for symmetric swelling and deformities of the patient\u2019s hands bilaterally.", "Additionally, there is a \"clunk\" when posterior force is applied to the head while anterior force is applied to the cervical spine."]}
{"Patient Symptoms": ["On arrival, he has rapid, shallow breathing and appears anxious."], "Examination and Results": ["His pulse is 135/min, respirations are 30/min and shallow, and palpable systolic blood pressure is 80 mm Hg.", "Examination shows no active external bleeding.", "There is a 2.5-cm single stab wound to the left chest at the 4th intercostal space at the midclavicular line.", "Cardiovascular examination shows muffled heart sounds and jugular venous distention.", "Breath sounds are normal."], "Treatment": ["He is intubated and mechanically ventilated.", "Infusion of 0.9% saline is begun."]}
{"Patient Personal Background": ["He has a 10-year history of hypertension that remains poorly controlled on maximum doses of lisinopril, hydrochlorothiazide, and amlodipine.", "His past medical history is otherwise unremarkable.", "He has no smoking history, drinks alcohol occasionally, and denies any illicit drug use.", "His father required a kidney transplant in his forties."], "Patient Symptoms": ["He is asymptomatic at his office visit and denies any new complaints."], "Examination and Results": ["The physical exam is notable for palpable flank masses bilaterally.", "Laboratory studies show a creatinine of 2.5."], "Others": ["The physician orders a renal ultrasound, and the results are shown."]}
{"Patient Personal Background": ["She has no previous medical history and does not recall anything that could have provoked these symptoms."], "Patient Symptoms": ["She says that the chest pain is worse when she breathes or coughs.", "Furthermore, on the way to the hospital she noticed that there were specks of blood on a tissue that she coughed into."], "Examination and Results": ["On presentation her temperature is 99\u00b0F (37.2\u00b0C), blood pressure is 107/65 mmHg, pulse is 102/min, respirations are 21/min, and O2 saturation is 91% on room air.", "Further testing shows a large filling defect in the pulmonary vessels, and the patient is started on an appropriate treatment intravenously."], "Treatment": ["After drug administration, the effects of the drug are monitored using a standard blood test."], "Others": ["Surprisingly, the test results come back within normal parameters."]}
{"Examination and Results": ["A urethral smear shows gram negative diplococci within white blood cells.", "The organism grows well when cultured on Thayer-Martin agar."], "Treatment": ["The patient is prescribed a course of ceftriaxone and the infection resolves without further complication."], "Others": ["One year later, the patient returns with the same infection."]}
{"Patient Symptoms": ["He reported significant neck pain to emergency responders, but otherwise denies weakness, numbness or tingling in his extremities."], "Examination and Results": ["His vitals on presentation to the ED are HR 90, BP 140/80, RR 20, SpO2 98%."]}
{"Patient Symptoms": ["He is concerned about abnormal discharge from both nipples over the past 3 months.", "The fluid is white, and he wonders if it could be milk.", "On further review of systems, he endorses a diminished sexual drive."], "Diagnosis": ["The physician suspects that one of the patient's medications may be the culprit for these symptoms."]}
{"Patient Personal Background": ["He had previously been well.", "He was born at 38 weeks' gestation via uncomplicated vaginal delivery and weighed 3.1 kg (6 lb 13 oz).", "The mother has no medical insurance and did not receive prenatal care.", "The newborn's 4-year-old brother has sickle cell disease."], "Patient Symptoms": ["Examination shows jaundice."], "Examination and Results": ["The abdomen is mildly distended.", "The liver is palpated 1 cm below the right costal margin and the spleen tip is palpated just below the left costal margin."]}
{"Patient Symptoms": ["He says he has also noticed hand tremors, which increase at rest and decrease with focused movements."], "Examination and Results": ["On examination, the patient does not swing his arms while walking and has a shortened, shuffling gait."], "Treatment": ["An antiviral drug is prescribed which alleviates the patient\u2019s symptoms."]}
{"Examination and Results": ["Examination shows absent deep tendon reflexes bilaterally."]}
{"Patient Symptoms": ["She was found wandering next to the highway.", "The patient was unable to answer questions and collapsed in transit."], "Examination and Results": ["Her vitals are: temperature, 33.0\u00b0C (91.4\u00b0F); pulse, 40/min; respirations,12/min; blood pressure, 80/50 mm Hg; and oxygen saturation, 85% on room air.", "Physical examination shows decorticate posturing, incomprehensible speech, eyes opening to pain, dry hair, coarse and waxy skin, and non-pitting edema around the face and all extremities.", "Electrocardiogram shows sinus bradycardia."]}
{"Patient Personal Background": ["His past medical history is significant for hypertension that is well-controlled with lisinopril."], "Patient Symptoms": ["He notes that this is particularly obvious when he is mowing his lawn or climbing the stairs in his home."], "Examination and Results": ["His vital signs are as follows: T 37.6 C, HR 88, BP 136/58, RR 18, SpO2 97% RA.", "Physical examination is significant for an early diastolic blowing, decrescendo murmur heard best at the left sternal border, a midsystolic murmur heard best at the right upper sternal border, and a late diastolic rumbling murmur heard best at the apex on auscultation.", "In addition, an S3 heart sound is also present.", "Bounding pulses are palpated at the radial arteries bilaterally."]}
{"Patient Personal Background": ["Her family members describe her as being very impulsive and frequently acting to manipulate people\u2019s feelings.", "The patient denies any history of smoking, alcohol use, or recreational drug use."], "Patient Symptoms": ["She says that her attempt was a result of a fight with her boyfriend and that she slit her wrists in an attempt to keep him from breaking up with her.", "Since she was admitted to the hospital, she has spit at several staff members and alternated between sobbing and anger."], "Others": ["In the past, she has had many turbulent relationships, both romantic and in her family life."]}
{"Patient Personal Background": ["The patient reports no pain in his lower abdomen or groin, no constipation, and states that he enjoys his usual diet.", "He denies any use of alcohol, tobacco, or illicit drugs.", "He has returned to work as a cruise ship attendant."], "Examination and Results": ["Preoperative workup included chest radiography which demonstrated an opacification in his right middle lobe.", "The patient agrees to undergo computed tomography (CT) of his chest without contrast for further evaluation.", "The radiologist reports an 8 mm nodule in the patient's peripheral right middle lobe that has regular margins and appears calcified.", "One year later, the patient obtains another chest CT without contrast that reports the nodule size as 10 mm with similar characteristics."]}
{"Patient Personal Background": ["He has been trying to conceive for over 2 years with his wife and previous evaluation of his wife's fertility revealed no abnormalities."], "Examination and Results": ["Physical exam reveals a tall man with long extremities, sparse body hair, gynecomastia, and small testes.", "Laboratory studies reveal increased serum follicle-stimulating hormone concentration and an increased estradiol:testosterone ratio.", "Genetic studies reveal a cytogenetic abnormality."]}
{"Patient Personal Background": ["The patient has a past medical history notable only for obesity and asthma."], "Patient Symptoms": ["Physical exam is notable for an inability of the patient to bear weight on his left leg and limited range of motion of the left hip."], "Examination and Results": ["His temperature is 98\u00b0F (36.7\u00b0C), blood pressure is 124/65 mmHg, pulse is 128/min, respirations are 14/min, and oxygen saturation is 99% on room air.", "Physical exam is notable for an inability of the patient to bear weight on his left leg and limited range of motion of the left hip."]}
{"Patient Personal Background": ["He works as a pharmacy technician."], "Patient Symptoms": ["He has had up to 4 bowel movements per day.", "Several times he noticed mucoid strings with the stool.", "He has abdominal bloating.", "Over the past month, has had a 3.2-kg (7-lb) weight loss.", "He has not had fever, cough, or bloody stools.", "He had a painful rash on his lower extremity 3 weeks ago that resolved spontaneously."], "Examination and Results": ["His temperature is 37.3\u00b0C (98.8\u00b0F), pulse is 85/min, and blood pressure is 115/77 mm Hg.", "The abdomen is soft and nontender.", "His hemoglobin concentration is 11.9 g/dL, MCV is 79 fL, ferritin is 106 ng/dL, and platelet count is 410,000/mm3; serum concentrations of glucose, creatinine, and electrolytes are within the reference range."]}
{"Patient Personal Background": ["He was diagnosed with hepatitis C 3 years ago but refused treatment.", "There is no family history of serious illness.", "His only medication is a calcium supplement.", "He emigrated from India 15 years ago."], "Patient Symptoms": ["His wife states that he has been unable to recall his birthday or her name.", "He is confused and oriented only to person."], "Examination and Results": ["He appears ill. His temperature is 38.3\u00b0C (100.9\u00b0F), pulse is 101/min, and blood pressure is 104/68 mm Hg.", "Examination shows scleral icterus and spider angiomas.", "There are fine tremors of the hands bilaterally.", "The abdomen is distended and shifting dullness is present.", "There is diffuse tenderness to palpation with no guarding.", "Bowel sounds are absent.", "Laboratory studies show:\nHemoglobin 12.6 g/dL\nLeukocyte count 13,900/mm3\nPlatelet count 342,000/mm3\nSerum\nAlbumin 2.6 g/dL\nTotal bilirubin 2.56 mg/dL\nAlkaline phosphatase 54 U/L\nAST 17 U/L\nALT 44 U/L\nParacentesis is performed.", "Ascitic fluid analysis shows an albumin concentration of 0.8 g/dL, glucose concentration of 62 mg/dL, and a leukocyte count of 1900/mm3 with 60% neutrophils."], "Treatment": [], "Others": ["He has been treated twice in the past year for acute pancreatitis."]}
{"Patient Symptoms": ["She has had a runny nose and a low-grade fever for the past 2 days, with some hoarseness and a rough-sounding cough that started this afternoon.", "This evening she began making some high-pitched sounds when taking breaths, and she seemed to be having some trouble breathing.", "She has an occasional barking cough."], "Examination and Results": ["She is alert and does not appear to be in acute distress.", "She has a temperature of 38.0\u00b0C (100.4 \u00b0F), with a respiratory rate of 50/min and O2 saturation of 97%.", "There is audible inspiratory stridor that worsens when she starts to cry during the examination.", "Her pharynx is mildly erythematous with normal tonsils and no exudate.", "A frontal X-ray of the upper chest airways is obtained (shown in the image)."]}
{"Patient Personal Background": ["Her past medical history is unknown and this is her first time seeing a doctor.", "She states she is otherwise healthy and review of systems is notable for episodic hand pain that is worse in the winter as well as a chronic and severe cough with dyspnea which she attributes to her smoking."], "Patient Symptoms": ["It has persisted for the past several years but has been getting worse.", "She states she is otherwise healthy and review of systems is notable for episodic hand pain that is worse in the winter as well as a chronic and severe cough with dyspnea which she attributes to her smoking."], "Examination and Results": ["Her temperature is 97.7\u00b0F (36.5\u00b0C), blood pressure is 174/104 mmHg, pulse is 80/min, respirations are 22/min, and oxygen saturation is 92% on room air.", "Physical exam is notable for a young appearing woman with coarse breath sounds.", "Laboratory studies and urinalysis are ordered and currently pending."]}
{"Patient Personal Background": ["He has a 20-year history of poorly-controlled type 2 diabetes mellitus.", "Current medications include metformin and insulin."], "Patient Symptoms": ["Examination shows conjunctival pallor and bounding pulses."], "Examination and Results": ["His pulse is 105/min.", "Laboratory studies show:\nHemoglobin 8.6 g/dL\nMean corpuscular volume 90 \u03bcm3\nReticulocyte count 0.5%\nSerum\nFerritin 325 ng/mL\nUrea nitrogen 45 mg/dL\nCreatinine 2.2 mg/dL\nThe patient is prescribed a drug to treat the cause of his current symptoms."], "Treatment": []}
{"Patient Personal Background": ["His past medical history is significant for obesity, sleep apnea, and type 2 diabetes that is well controlled on metformin.", "He also has gastroesophageal reflux disease for which he occasionally takes antacids."], "Patient Symptoms": ["He says that these symptoms came on rapidly but does not recall anything that may have triggered the episode.", "He has never experienced these symptoms before.", "On presentation he is found to have fast, shallow breathing and abdominal pain that is poorly localized."]}
{"Others": ["She has identified a drug that selectively inhibits phosphate release by the myosin head."]}
{"Patient Symptoms": ["He does not make eye contact and sits very close to his mother."], "Examination and Results": ["Physical examination shows a grade 3/6 holosystolic murmur at the cardiac apex.", "Neurological examination shows decreased strength in the right lower leg with normal strength in the other extremities.", "Fundoscopic examination shows several multinodular, calcified lesions in the retina bilaterally.", "A photograph of his skin findings is shown."]}
{"Patient Personal Background": ["His past medical history is notable for diabetic nephropathy, hypertension, dyslipidemia, depression, and morbid obesity.", "He also is currently being treated for an outbreak of genital herpes."], "Patient Symptoms": ["He endorses diffuse abdominal tenderness."], "Examination and Results": ["His temperature is 99.0\u00b0F (37.2\u00b0C), blood pressure is 184/102 mmHg, pulse is 89/min, respirations are 18/min, and oxygen saturation is 98% on room air.", "Physical exam is notable for an obese man in no acute distress.", "A CT scan of the abdomen with contrast is performed and is unremarkable."], "Treatment": ["The patient is admitted to the observation unit for monitoring of his pain."], "Others": ["Notably, the patient's abdominal pain improves after an enema and multiple bowel movements.", "The patient's evening laboratory values are ordered and return as seen below."]}
{"Patient Personal Background": ["He is a former construction worker, and worked in a steel mill when he was in high school.", "He is an active smoker with a 36-pack-year smoking history."], "Patient Symptoms": ["He presents with a 1-year history of worsening shortness of breath and weight loss."], "Examination and Results": ["The blood pressure is 130/78 mm Hg, pulse rate is 90/min, respiratory rate is 17/min, and the BMI is 31 kg/m2.", "The patient is afebrile and the oxygen saturation at rest is 95% on room air.", "The pulmonary examination reveals a mildly prolonged expiratory phase, and no wheezing or crackles are auscultated.", "A pulmonary function test is recommended for the patient, and 2 weeks later he returns with a report that shows an FEV1/FVC ratio of 60% and FEV1 of 50% of the predicted value.", "The lung volumes show a total lung capacity of 110% of predicted value, a residual volume of 115% of predicted value, and a DLCO of 60% of predicted value."]}
{"Patient Personal Background": ["He is otherwise fine and denies recent travel or trauma.", "Medical history is unremarkable and he does not take any medications.", "He does not smoke cigarettes or drinks alcohol.", "Allergies include peanuts, dust, and pollen.", "Childhood asthma runs in the family."], "Patient Symptoms": ["He states that the symptoms come in episodes at the end of the workday and last a few hours.", "He also mentions that he is fatigued all the time."], "Examination and Results": ["Chest X-ray reveals diffuse haziness in both lower lung fields.", "A PPD skin test is negative."], "Others": ["His job includes taking care of various types of birds."]}
{"Patient Personal Background": ["She underwent menopause ten years prior.", "She has a past medical history of hypertension and diabetes mellitus."], "Patient Symptoms": ["In the immediate postoperative period, the patient develops left-sided flank pain and oliguria."], "Examination and Results": ["On physical examination, her uterus is uniformly enlarged.", "Ultrasound reveals a thickened endometrial stripe and tissue biopsy reveals neoplastic endometrial cells.", "Serum creatinine is found to be 1.4 mg/dl whereas it was 1.0 mg/dl prior to the operation.", "Renal ultrasound is normal.", "Urinalysis is notable for hematuria."], "Treatment": ["A workup for metastatic disease is negative and the gynecologist recommends a laparoscopic hysterectomy.", "During the procedure, the surgeon ligates multiple vessels in order to remove the entire uterus."]}
{"Patient Symptoms": ["He also says he frequently sweats profusely at night and has a recurring low-grade fever, for which he takes acetaminophen."], "Examination and Results": ["His temperature is 37.1\u00baC  (98.8\u00baF), pulse is 76/min, blood pressure is 116/78 mm Hg, and respiratory rate is 13/min.", "On physical examination, he has generalized pallor.", "Bilateral cervical lymphadenopathy is present.", "Examination of his abdomen reveals non-tender hepatosplenomegaly in the right upper quadrant."], "Diagnosis": ["Laboratory evaluation confirms the diagnosis of Hodgkin\u2019s lymphoma."], "Others": ["The patient denies any symptoms like cough, breathlessness, or gastrointestinal symptoms."]}
{"Patient Personal Background": ["A week prior to her symptoms, she had traveled to Brazil where she spent most of the evenings hiking.", "She did not use any mosquito repellents.", "There is no personal or family history of chronic or congenital diseases.", "Medications include iron supplementation and a multivitamin.", "She received all of the recommended childhood vaccinations.", "She does not drink alcohol or smoke cigarettes."], "Patient Symptoms": ["Early in the 1st trimester, she had fevers and headaches for 1 week.", "She also experienced myalgias, arthralgias, and a pruritic maculopapular rash."], "Examination and Results": ["The IgM and IgG titers for toxoplasmosis were negative."], "Others": ["The symptoms resolved without any medications."]}
{"Patient Personal Background": ["Patient has no significant past medical history and takes no medications.", "Her last two pregnancies ended with spontaneous abortions before the 10th week of gestation.", "No significant family history."], "Examination and Results": ["Her vital signs include: blood pressure 130/90 mm Hg, pulse 58/min, respiratory rate 11/min, and temperature 36.8\u2103 (98.2\u2109).", "GCS is 14/15.", "Physical examination shows 3+ deep tendon reflexes and increased muscle tone in the left upper and lower extremities.", "Laboratory findings are significant for the following:\nPlatelet count 230,000/mm3\nFibrinogen 3.5 g/L\nActivated partial thromboplastin time  70 s\nThrombin time 34 s\n A non-contrast CT of the head is performed and shown in the picture."]}
{"Diagnosis": ["While there, he delivers a baby who he suspects has congenital hypothyroidism, most likely caused by inadequate maternal iodine intake."]}
{"Patient Symptoms": ["She denies any cough, shortness of breath, hemoptysis, weight loss, fatigue, fevers, or night sweats over the last several months."], "Examination and Results": ["Her temperature is 97.0\u00b0F (36.1\u00b0C), blood pressure is 120/81 mmHg, pulse is 82/min, respirations are 15/min, and oxygen saturation is 98% on room air.", "An initial chest radiograph is unremarkable."]}
{"Patient Personal Background": ["Past medical history is significant for hypertension and atrial fibrillation.", "Medications are lisinopril, metoprolol, and warfarin."], "Patient Symptoms": ["The son reports that the patient was in her usual state of health until she complained of chest palpitations.", "This startled her while she was climbing down the stairs and lead to a fall."], "Examination and Results": ["Temperature is 99\u00b0F (37.2\u00b0C), blood pressure is 152/96 mmHg, pulse is 60/min, respirations are 12/min, and pulse oximetry is 98% on room air.", "On physical examination, she is disoriented and at times difficult to arouse, the left pupil is 6 mm and non-reactive to light, and the right pupil is 2 mm and reactive to light.", "A right-sided visual field defect is appreciated on visual field testing.", "There is 1/5 strength on the right upper and lower extremity; as well as 5/5 strength in the left upper and lower extremity.", "A computerized tomography (CT) scan of the head is shown."]}
{"Examination and Results": ["A complete blood count, serum creatinine, and serum electrolyte concentrations are within the reference ranges.", "A bone marrow biopsy shows 6% monoclonal plasma cells.", "Further analysis shows that class I major histocompatibility molecules are downregulated in these monoclonal plasma cells."], "Others": ["The proliferation of these monoclonal plasma cells is normally prevented by a class of immune cells that lyse abnormal cells without the need for opsonization, priming, or prior activation."]}
{"Patient Personal Background": ["She has a 5-year history of hyperlipidemia controlled with fluvastatin."], "Patient Symptoms": ["She feels that the muscles in her shoulders and hips have been getting weaker and sometimes feel sore.", "She now has difficulty getting up from chairs, climbing stairs, and combing her hair.", "She has also noticed new difficulty with swallowing solid foods, but has no trouble with liquids."], "Examination and Results": ["Vital signs are within normal limits.", "Neurologic examination shows moderate weakness in the arm abductors and hip flexors bilaterally.", "Deep tendon reflexes are 2+ bilaterally."], "Others": ["Her maternal uncle died at age 26 from Duchenne's muscular dystrophy and her mother has Hashimoto's thyroiditis."]}
{"Patient Symptoms": ["He states that he was resting at home when he noticed he had difficulty reading.", "Currently, he is also starting to see double, and is seeing two images on top of each other.", "Earlier today, he felt ill with nausea, vomiting, and watery diarrhea, which he attributed to food he had eaten at a picnic the day before.", "When asked which foods he ate, he lists potato salad, a hamburger, deviled eggs, and pickles made by his neighbor.", "He also heard that his friend who went to the picnic with him has developed similar symptoms and was seen in another hospital earlier."], "Examination and Results": ["While in the emergency room, the patient\u2019s temperature is 98.4\u00b0F (36.9\u00b0C), pulse is 75/min, blood pressure is 122/84 mmHg, and respirations are 13/min.", "Cranial nerve exam is notable for fixed pupillary dilation, and difficulty depressing both eyes."]}
{"Patient Personal Background": ["The patient was delivered vaginally at 38 weeks' gestation.", "Pregnancy and delivery were uncomplicated."], "Patient Symptoms": ["The mother has noticed that the girl's stools have become pale over the past week.", "Examination shows scleral icterus and jaundice."], "Examination and Results": ["She appears healthy.", "Vital signs are within normal limits.", "She is at the 50th percentile for length and at the 60th percentile for weight.", "The liver is palpated 2 cm below the right costal margin.", "Cardiopulmonary examination shows no abnormalities.", "Neurologic examination shows no focal findings."], "Treatment": ["She was breastfed since birth but her parents switched her to formula feeds recently after reading on the internet that breastfeeding could be the cause of her current symptoms."]}
{"Patient Personal Background": ["His only medication is a multivitamin supplement."], "Patient Symptoms": ["He appears fatigued.", "While measuring the patient's blood pressure, the nurse observes a spasm in the patient's hand."], "Examination and Results": ["Physical examination shows a well-healing surgical wound on the neck."], "Treatment": ["3 days ago, he underwent a total thyroidectomy for treatment of papillary thyroid cancer."], "Diagnosis": ["3 days ago, he underwent a total thyroidectomy for treatment of papillary thyroid cancer."]}
{"Patient Personal Background": ["Her last menstrual period was 16 years ago."], "Patient Symptoms": ["She describes the pain as 'crampy'.", "She also says she has suffered from mild constipation for the past few years."], "Examination and Results": ["The patient denies any recent weight change or urinary symptoms.", "Her body temperature is 37.8\u00b0C (100.0\u00b0F), pulse is 102/min, respiratory rate is 16/min, and blood pressure is 133/87 mm Hg.", "On physical examination, tenderness to palpation in the left lower quadrant is present."]}
{"Patient Personal Background": ["His past medical history is notable for diabetes, coronary artery disease, and hypertension, and he has a 40 pack-year smoking history."], "Patient Symptoms": ["He states that for the past month he has been unable to engage in sexual intercourse with his wife despite having appropriate sexual desire.", "He also endorses deep and burning buttock and hip pain when walking, which is relieved by rest.", "The patient states that he does not have erections at night or in the morning."], "Examination and Results": ["Physical exam is notable for weak lower extremity and femoral pulses."]}
{}
{"Examination and Results": ["He isolates a group of cells that are shown by flow cytometry to be positive for the cell surface marker CD8."], "Treatment": ["He then mixes this cell population with a group of infected cells, crosslinks extracellular interactions, and immunoprecipitates the CD8 protein."], "Others": ["He identifies a protein bound to CD8 that is composed of two chains from an adjacent cell."]}
{"Patient Symptoms": ["He states that he is worried about his heart, as his father died at age 62 from a heart attack.", "He reports that his chest pain worsens with large meals and spicy foods and improves with calcium carbonate."], "Examination and Results": ["He denies dyspnea on exertion and an ECG is normal."]}
{"Patient Personal Background": ["Her past medical history is unremarkable.", "She reports a 20-pack-year smoking history and is currently a daily smoker."], "Patient Symptoms": ["She also notes having occasional palpitations, nervousness, sweating, and heat intolerance."], "Examination and Results": ["Physical examination shows an anxious, trembling woman.", "She has eyelid retraction bilaterally, with an inability to fully close her eyes.", "Her extraocular motility is limited on upgaze.", "There is no thyromegaly, and no thyroid nodules are noted.", "Laboratory studies reveal a thyroid-stimulating hormone level of 0.1 \u03bcU/mL and total T4 of 42 \u03bcg/dL.", "Thyroid-stimulating immunoglobulin is positive.", "CT scan of the orbits shows proptosis and marked enlargement of the extraocular muscle with sparing of the tendons."]}
{"Patient Personal Background": ["A detailed history reveals that there has been no history of urinary incontinence during the day since the boy was 4 years of age, but that he has never been dry at night continuously for 1 week."], "Examination and Results": ["On physical examination, the boy\u2019s vital signs are stable.", "His neurologic and abdominal examinations are completely normal."], "Others": ["There is no history of urinary tract infections, urgency, frequency, or hesitancy."]}
{"Examination and Results": ["At autopsy, examination of the spinal cord shows unilateral atrophy of the neurons in the area indicated by the arrow."]}
{"Patient Personal Background": ["Past medical history is noncontributory.", "She takes a multivitamin with iron and folate every day and has been receiving regular prenatal care and the pregnancy is progressing normally."], "Patient Symptoms": ["She also complains of headaches and difficulty moving her neck."], "Examination and Results": ["On examination, an erythematous rash is seen on her right arm, as shown in the accompanying photograph.", "Her obstetric examination is normal.", "Ultrasound of the fetus is reassuring with a normal heartbeat and no gross abnormalities."], "Others": ["Further questioning reveals that she had a tick bite on her arm while gardening a few days ago.", "A specimen is collected to test for Lyme disease."]}
{"Patient Personal Background": ["She has only had one menstrual period in the last four months and has never been pregnant.", "She smokes a pack of cigarettes every day and does not take any medications."], "Patient Symptoms": ["The weakness has been progressive to the point where she cannot climb stairs and stand from a sitting position."], "Examination and Results": ["Her temperature is 98\u00b0F (36.7\u00b0C), blood pressure is 160/100 mmHg, pulse is 70/min, and respirations are 15/min.", "She is obese with a significant pannus.", "Abdominal striae are present.", "Her laboratory workup is notable for the following:\n\nSerum:\nNa+: 142 mEq/L\nCl-: 102 mEq/L\nK+: 3.9 mEq/L\nHCO3-: 25 mEq/L\nBUN: 20 mg/dL\nGlucose: 314 mg/dL\nCreatinine: 1.1 mg/dL\nCa2+: 10.1 mg/dL\nAST: 9 U/L\nALT: 8 U/L\n24-hour urinary cortisol: 470 \u00b5g (< 300 \u00b5g)\nSerum cortisol 30 \u00b5g/mL (5-23 \u00b5g/dL)\nSerum adrenocorticotropin-releasing hormone (ACTH) 2 pg/mL (> 5 pg/mL)\n\nA 48-hour high dose dexamethasone suppression trial shows that her serum cortisol levels do not decrease."]}
{"Examination and Results": ["Physical examination shows decreased sensation to light touch in all distal extremities.", "Knee and ankle deep tendon reflexes are decreased."], "Treatment": ["Her last cycle of chemotherapy with vincristine was 1 week ago."]}
{"Examination and Results": ["A CT scan of the urinary tract shows areas of bladder wall thickening.", "Cystoscopy shows several sessile masses with central necrosis arising from the bladder wall.", "A biopsy specimen of the bladder masses shows moderately differentiated urothelial cells with abundant mitotic figures and nuclear atypia."]}
{"Patient Personal Background": ["Her birth weight was normal.", "Her father reports he had a short stature during his teenage years; he is currently 177 cm (5 ft 10 in) tall."], "Patient Symptoms": ["She feels well overall, but is concerned because all of her friends are taller than her."], "Examination and Results": ["She is at the 2ndpercentile for height and 35th percentile for weight.", "Breast development is Tanner stage 2.", "Pubic and axillary hair is absent.", "An x-ray of the left hand and wrist shows a bone age of 11 years."]}
{"Patient Symptoms": ["Two weeks ago, he had a sore throat that resolved spontaneously."], "Examination and Results": ["His temperature is 37\u00b0C (98.6\u00b0F), pulse is 107/min, and blood pressure is 94/67 mm Hg.", "Examination shows pitting edema of the upper and lower extremities as well as periorbital edema.", "The abdomen is mildly distended."]}
{"Patient Personal Background": ["The patient\u2019s medical history is unremarkable, and he is currently working reduced hours at his job as an accountant."], "Examination and Results": ["Physical examination reveals confluent scaly patches, plaques, and generalized erythroderma along the torso and lower extremities (see image).", "There is also a solid skin lesion with a diameter greater than 1 cm."], "Others": ["The dermatologist suspects a malignancy and orders a biopsy."]}
{"Patient Personal Background": ["She works at an accountant's office and reports difficulty in concentrating on her work.", "She is married and frequently fights with her husband."], "Patient Symptoms": ["During this period, she has found it difficult to relax.", "She states that her head is full of worries.", "She has been working longer shifts because one of her coworkers is on vacation and reports feeling more tired than usual.", "The patient states that in order to deal with her stress, she goes shopping.", "While shopping, she steals small trivial items and feels immediately relieved thereafter.", "Her husband is concerned about her behavior, but she is unable to stop shoplifting.", "She reports feeling anxious."], "Examination and Results": ["Her vital signs are within normal limits.", "On mental status examination, she is oriented to person, place, and time.", "Physical examination shows no abnormalities."], "Others": ["She discards the objects she steals and has feelings of shame and guilt about her actions."]}
{"Patient Symptoms": ["Initially, the patient was noted to be behaving inappropriately including using foul language and grabbing people unexpectedly.", "This has progressed to a worsening of his memory and trouble caring for himself.", "When he is engaged in conversation, he exhibits word finding difficulty and is rather inattentive."], "Examination and Results": ["His temperature is 98.1\u00b0F (36.7\u00b0C), blood pressure is 162/103 mmHg, pulse is 83/min, respirations are 13/min, and oxygen saturation is 98% on room air.", "Physical exam is notable for an elderly man who laughs inappropriately at times and who is a poor historian."]}
{"Patient Personal Background": ["His birth history is insignificant, and his immunizations are up to date."], "Patient Symptoms": ["She notes that he is eating less and is more cranky than usual."], "Examination and Results": ["Vital signs include: temperature is 37.8\u00b0C (100.0\u00b0F), pulse is 98/min, and respiratory rate is 16/min.", "The rash features thin-walled, fluid-filled blisters that rupture easily.", "Fluid samples from the lesions are sent for analysis to a microbiology lab.", "The results reveal an infection by the gram-positive bacterium Staphylococcus aureus."], "Diagnosis": ["The patient is diagnosed with staphylococcal scalded skin syndrome."]}
{"Patient Symptoms": ["He also reports that he has had 3 episodes of watery diarrhea per day for the last 2 days.", "He appears slightly pale."], "Examination and Results": ["His temperature is 38.0\u00b0C (100.4\u00b0F), pulse is 65/min, respirations are 15/min, and blood pressure is 140/78 mm Hg.", "Diffuse crackles are heard over bibasilar lung fields.", "Laboratory studies show:\nHemoglobin 13.8 g/dL\nLeukocyte count 16,000/mm3\nPlatelet count 150,000/mm3\nSerum\nNa+ 131 mEq/L\nCl-\n102 mEq/L\nK+ 4.7 mEq/L\nHCO3- 26 mEq/L\nUrea nitrogen 18 mg/dL\nCreatinine 1.2 mg/dL\nAn x-ray of the chest shows patchy infiltrates in both lungs."]}
{"Examination and Results": ["Both the ovaries are enlarged and have multiple thin-walled, septated cysts with clear content."]}
{"Patient Personal Background": ["The patient lives with her son and his family and her son reports that other members of the family have had similar symptoms during the past week but that he has not had any symptoms."], "Examination and Results": ["The result of a polymerase chain reaction test confirms that the woman is infected with a virus that has a helical capsid and a segmented genome."]}
{"Patient Personal Background": ["His psychiatric history is significant for major depression with psychotic features.", "He was diagnosed after his wife died from pancreatic cancer four years earlier.", "He lives alone in his apartment and has no children.", "He does not possess a firearm at home but has access to weapons at a local hunting club.", "He takes sertraline and olanzapine.", "He does not smoke or drink alcohol."], "Patient Symptoms": ["Today, he feels well but still wakes up frequently at night and cannot sleep through the night."], "Treatment": ["He takes sertraline and olanzapine."], "Diagnosis": ["His psychiatric history is significant for major depression with psychotic features."], "Others": ["Three years ago, he deliberately overdosed on sleeping pills.", "The patient currently denies suicidal thoughts or thoughts of self-harm."]}
{"Patient Personal Background": ["He returned from a camping trip 1 week ago.", "He attends a daycare center."], "Patient Symptoms": ["During this period, he has had severe itching and was not able to sleep well.", "He has also had fever, headache, and some muscle pain.", "Five days ago, he had a runny nose which subsided with over-the-counter medications."], "Examination and Results": ["The patient is at the 55th percentile for height and at the 50th percentile for weight.", "His temperature is 38.2\u00b0C (100.7\u00b0F), pulse is 97/min, and blood pressure is 96/60 mm Hg.", "Examination of the skin shows several macules, papules, and crusted lesions over his face, trunk, and extremities.", "There are a few fluid-filled vesicles over his abdomen and back.", "There is no cervical lymphadenopathy."]}
{"Patient Personal Background": ["He has a history of major depressive disorder and seasonal allergies.", "His mother has a history of anxiety.", "He drinks 5 beers on the weekends.", "Current medications include amitriptyline and diphenhydramine."], "Patient Symptoms": ["The patient does not respond to questions and repeatedly says, \"\"The government is following me everywhere.\"\"", "He is not oriented to place or time.", "After the examination, the patient starts screaming and tries to bite the physician."], "Examination and Results": ["His temperature is 37.9\u00b0C (100.2\u00b0F), pulse is 115/min, respirations are 24/min, and blood pressure is 160/89 mm Hg.", "He is diaphoretic.", "Neurologic examination shows dilated pupils bilaterally and diffuse hyperreflexia.", "His feet are cold, and capillary refill time is 3 seconds.", "Urine toxicology screening is positive for ethyl glucuronide."]}
{"Patient Personal Background": ["His past medical history is notable for schizophrenia and asthma and he currently takes albuterol as well as another medication whose name he does not remember."], "Patient Symptoms": ["He reports that his neck started \u201clocking\u201d three hours ago.", "He is now unable to move it."], "Examination and Results": ["His temperature is 99.0\u00b0F (37.2\u00b0C), blood pressure is 130/90 mmHg, pulse is 105/min, and respirations are 18/min.", "On physical examination, the patient appears anxious and diaphoretic.", "He speaks in full sentences and is oriented to person, place, and time.", "The patient\u2019s neck is flexed and rotated to the right approximately 40 degrees.", "The right sternocleidomastoid and trapezius are firm and contracted.", "Extraocular movements are full and intact."]}
{"Examination and Results": ["Physical examination shows hepatosplenomegaly.", "A venous blood sample obtained for routine screening tests is milky.", "After refrigeration, a creamy supernatant layer appears on top of the sample.", "Genetic analysis shows a mutation in the apolipoprotein C-II gene (APOC2) on chromosome 19."]}
{"Patient Personal Background": ["Six months ago, he underwent a Roux-en-Y gastric bypass to treat obesity.", "He underwent a total thyroidectomy to treat a Hurthle cell lesion 4 days ago.", "He has smoked 1 pack of cigarettes daily for 22 years.", "His only current medication is a multivitamin supplement."], "Patient Symptoms": ["His abdominal discomfort is worse shortly after meals.", "He has also had progressive perioral numbness and upper-extremity muscle cramping for the past 24 hours.", "He appears fatigued.", "Physical examination shows a well-healing surgical wound on the neck."], "Examination and Results": ["His temperature is 36\u00b0C (96.8\u00b0F), pulse is 72/min, respirations are 20/min, and blood pressure is 130/70 mm Hg.", "While measuring the patient's blood pressure, the nurse observes spasm of the patient's hand.", "The abdomen is mildly tender to palpation with well-healed laparoscopic incisional sites.", "The remainder of the examination shows no abnormalities."], "Others": ["His mother died of lung cancer at age 68."]}
{"Patient Personal Background": ["He prefers watching television rather than going out and playing with other kids.", "The patient was delivered healthy and is fully immunized.", "The medical history is unremarkable, and he takes no medications.", "He has no siblings."], "Patient Symptoms": ["The mother mentions that her boy is always tired, and seems to be getting worse.", "Furthermore, he has had frequent episodes of constipation since birth."], "Examination and Results": ["The pulse is 90/min, the blood pressure is 110/75 mm Hg, and the respiratory rate is 15/min.", "He is in the bottom 10th percentile for height and weight according to his age.", "The remainder of the physical examination is unremarkable.", "He recently had a urinalysis that showed elevated urinary calcium excretion."], "Others": ["Except for frequent cravings for salty foods, the boy eats a regular diet.", "His father is a banker and his mother is a librarian."]}
{"Patient Personal Background": ["His mother reports intermittent episodes of jaundice with joint and bone pain since he was 5 months old."], "Patient Symptoms": ["The child is clutching his abdomen and crying about pain in his belly."], "Examination and Results": ["At presentation, the patient\u2019s vital signs are within normal limits.", "Physical examination reveals slight jaundice and pale conjunctiva.", "The spleen is tender and easily palpable.", "After a complete blood count with differential and an abdominal ultrasound, the patient is found to have sickle-cell disease with splenic infarct."], "Treatment": ["A partial splenectomy is performed.", "After the operation, the physician provides vaccines against Neisseria meningitidis, Haemophilus influenzae, and Streptococcus pneumoniae."], "Diagnosis": ["After a complete blood count with differential and an abdominal ultrasound, the patient is found to have sickle-cell disease with splenic infarct."], "Others": ["The picture shows a slide obtained from the resected portion of the patient\u2019s spleen."]}
{"Patient Personal Background": ["She has a history of hypertension, for which she takes hydrochlorothiazide (HCTZ), but she has no other medical problems.", "Family history is significant for her grandmother having systemic lupus erythematosus."], "Patient Symptoms": ["She says the dryness has become so severe that she has difficulty swallowing food.", "On physical exam, she has tender parotid glands bilaterally and dries mucous membranes."], "Examination and Results": ["The vital signs include: blood pressure 118/76 mm Hg, heart rate 78/min, and respiratory rate 15/min.", "On physical exam, she has tender parotid glands bilaterally and dries mucous membranes.", "The presence of serum anti-Ro and anti-La autoantibodies is confirmed at high titers."]}
{"Patient Personal Background": ["Past medical history is significant for hypertension and hyperlipidemia.", "He takes chlorthalidone and atorvastatin.", "Family history is noncontributory.", "He has smoked 20\u201330 cigarettes daily for the past 26 years."], "Patient Symptoms": ["He reports feeling ill for the past 3 weeks."], "Examination and Results": ["Anti-glomerular basement membrane serologies are positive."]}
{"Patient Personal Background": ["Current medications include trimethoprim-sulfamethoxazole, dolutegravir, and tenofovir-emtricitabine."], "Patient Symptoms": ["His temperature is 38.5\u00b0C (101.3\u00b0F).", "Physical examination shows nuchal rigidity.", "Kernig and Brudzinski signs are present."], "Examination and Results": ["A lumbar puncture is performed and shows an opening pressure of 32 cm H2O (N: < 20).", "The pathogen isolated from the cerebrospinal fluid (CSF) can be cultured on Sabouraud agar."]}
{"Patient Personal Background": ["She has a history of hypertension and gastroesophageal reflux.", "She does not smoke or drink alcohol.", "Current medications include ramipril and pantoprazole.", "The patient appears healthy and well nourished."], "Patient Symptoms": ["For the past six days, she has had a burning pain in her upper right back and chest.", "She cannot recall any recent injury and has no prior history of back pain."], "Examination and Results": ["Her temperature is 36.9\u00b0C (98.42\u00b0F), pulse is 76/min, and blood pressure is 145/92 mm Hg.", "Examination shows a long erythematous rash covered with multiple clear vesicles and crusty lesions extending from her back to below her right breast."]}
{"Diagnosis": ["It is determined that patients have a 4-year asymptomatic period prior to developing clinical symptoms from this adrenal cancer."], "Others": ["A new screening test is developed, and the cancer can now be detected 2 years prior to developing clinical symptoms.", "A new observational case-control study of screened and unscreened patients measures the median 5-year survival of patients who decline medical and surgical treatment.", "The screened population has statistically better outcomes."]}
{"Patient Personal Background": ["He has been working in the glass manufacturing industry for 20 years."], "Patient Symptoms": ["The shortness of breath started a year ago and is exacerbated by physical activity."], "Examination and Results": ["His vital signs include: heart rate 72/min, respiratory rate 30/min, and blood pressure 130/80 mm Hg.", "On physical exam, there are diminished respiratory sounds on both sides.", "On the chest radiograph, interstitial fibrosis with reticulonodular infiltrate is found on both sides, and there is also an eggshell calcification of multiple adenopathies."]}
{"Patient Symptoms": ["The patient recently lost her husband in a car accident and is still extremely shocked by the event."], "Examination and Results": ["On physical examination, her blood pressure is 105/67 mm Hg, the heart rate is 96/min and regular, breathing rate is 23/min, and the pulse oximetry is 96%.", "An S3 heart sound and rales in the lower right and left lung lobes are heard.", "A 12-lead ECG shows no significant findings.", "Echocardiography shows an enlarged left ventricle and left atrium."], "Treatment": ["The patient is stabilized and informed about the diagnosis and possible treatment options."]}
{"Patient Personal Background": ["The staff recognizes him as a local homeless man with a long history of alcoholism."], "Patient Symptoms": ["He was found unconscious on the street.", "He smells of alcohol."], "Examination and Results": ["At the hospital, his pulse is 95/min, the blood pressure is 110/70 mm Hg, the respirations are 20/min, and the oxygen saturation is 98% on room air.", "On physical exam, the unconscious man is covered in bloody vomit with small clots and food particles.", "A digital exam reveals black tarry stool in the rectal vault."], "Treatment": ["The patient is given oxygen, IV fluids, and an NG-tube is placed and set to intermittent suction.", "Labs are sent and the patient is prepared for a procedure."]}
{"Patient Symptoms": ["Two weeks ago, she had a sore throat that resolved without treatment."], "Examination and Results": ["Physical examination shows 1+ pitting edema of the lower legs and ankles.", "Urinalysis shows numerous RBCs and 3+ proteinuria.", "Her antistreptolysin O titer is elevated."]}
{"Patient Personal Background": ["His past medical history is unknown."], "Patient Symptoms": ["He was found down in the middle of the street."], "Examination and Results": ["His temperature is 99.0\u00b0F (37.2\u00b0C), blood pressure is 104/64 mmHg, pulse is 70/min, respirations are 5/min, and oxygen saturation is 91% on room air."], "Treatment": ["The patient is being resuscitated in the trauma bay."]}
{"Patient Personal Background": ["The patient\u2019s previous pregnancies were uncomplicated, and she delivered three healthy babies at full term."], "Patient Symptoms": ["She reports that she feels well and has not experienced any contractions or vaginal bleeding.", "She also reports good fetal movement."], "Examination and Results": ["On the ultrasound, the technician observes a male fetus with likely intrauterine growth restriction (IUGR).", "She also notes microcephaly, convex-rounded feet, and clenched fists with overlapping fingers.", "The technician further notes a medium-sized ventricular septal defect (VSD).", "The amniotic fluid index (AFI) is 26 cm."], "Others": ["The patient declined prenatal screening earlier in the pregnancy for religious reasons but would now like an anatomy ultrasound to ensure the fetus is growing appropriately."]}
{"Patient Symptoms": ["During the evening, the patient becomes irritable.", "He is talking to someone despite nobody being present in the room.", "He is easily agitated and attempts to strike a nurse with a remote control to his TV.", "Subsequently, the patient keeps getting out of bed and trying to walk away despite being a fall risk."], "Treatment": ["He is diagnosed with urosepsis based on urinalysis and culture and started on ceftriaxone and intravenous fluids."], "Diagnosis": ["He is diagnosed with urosepsis based on urinalysis and culture and started on ceftriaxone and intravenous fluids."], "Others": ["By hospital day 3, he is clinically improving."]}
{"Patient Personal Background": ["There is no personal or family history of serious illness.", "Her only medication is a multivitamin."], "Examination and Results": ["A metyrapone stimulation test is performed and the results rule out a diagnosis of adrenal insufficiency."]}
{"Examination and Results": ["One subset of study participants consists of asymptomatic individuals who were diagnosed with GBM after undergoing a screening MRI of the brain.", "Results from the study show that the asymptomatic patients who were diagnosed with screening MRI had an average survival time that was 6 weeks longer than that of the patients who were diagnosed after symptom onset."], "Diagnosis": ["One subset of study participants consists of asymptomatic individuals who were diagnosed with GBM after undergoing a screening MRI of the brain.", "The other subset of study participants was diagnosed with GBM only after they developed symptoms."]}
{"Patient Symptoms": ["On questioning by the paramedics, he reported severe chest pain and mild dyspnea.", "On arrival, he is confused and unable to provide a history."], "Examination and Results": ["His pulse is 93/min, respirations are 28/min, and blood pressure is 91/65 mm Hg.", "Pulse oximetry on room air shows an oxygen saturation of 88%.", "He is able to move his extremities in response to commands.", "He opens his eyes spontaneously.", "Pupils are equal and reactive to light.", "Examination shows multiple bruises over the trunk and extremities.", "There is a 3-cm (1.2-in) wound at the left fifth intercostal space at the midclavicular line.", "There is jugular venous distention.", "Decreased breath sounds and hyperresonance on percussion are noted on the left."]}
{"Examination and Results": ["The scan is found to be positive in 590 of the 600 patients with known PD, and positive in 20 of the 600 patients without PD."], "Others": ["A clinical research study has enrolled 1,200 patients, half of whom have the disease."]}
{"Patient Personal Background": ["The patient was a professional athlete who retired at age 50."], "Patient Symptoms": ["He also notes morning stiffness in his joints that lasts approx.", "50 minutes.", "He denies joint swelling, color changes in his digits, dryness of mucous membranes, and constitutional symptoms such as fever and chills."], "Examination and Results": ["On physical exam, the physician notes several non-tender nodules on the left 1st, 3rd, and 4th distal interphalangeal joints.", "There is also tenderness with palpation at the base of both thumbs.", "The patient\u2019s knees are enlarged, bilaterally, and he has pain and crepitus on passive range of motion."]}
{"Patient Personal Background": ["Past medical history is insignificant."], "Patient Symptoms": ["He has never felt like this before."], "Examination and Results": ["His blood pressure is 125/75 mm Hg, pulse 86/min, respiratory rate 13/min, temperature 36.8\u00b0C (98.2\u00b0F).", "A T2-weighted MRI shows a left C5 hemicord lesion."], "Treatment": ["The patient is treated with cervical immobilization, a course of steroids, and physical therapy."]}
{"Patient Personal Background": ["He is sexually active with one female partner and does not use condoms."], "Patient Symptoms": ["He has also had a burning sensation on urination and increased urinary frequency for the past 3 days.", "He has not had urethral discharge."], "Examination and Results": ["Vital signs are within normal limits.", "Physical examination shows a tender right testicle; lifting it provides relief.", "The penis appears normal, with no discharge at the meatus.", "Laboratory studies show a normal complete blood count; urinalysis shows 3 WBC/hpf.", "A Gram stain of a urethral swab shows polymorphonuclear leukocytes but no organisms.", "Testicular ultrasound shows increased blood flow to the right testicle compared to the left."]}
{"Patient Symptoms": ["He has a 1-month history of multiple bruising that measures 1 cm in diameter each in the hands and feet, and tiny red spots that appeared in the upper and lower extremities without any trauma either.", "He has no prior bleeding history nor any relevant family history."], "Examination and Results": ["The vital signs include: heart rate 190/min, respiratory rate 40/min, blood pressure 99/42 mm Hg, and temperature 36.6 \u00b0C (97.9 \u00b0F).", "His physical exam shows pale skin color, petechiae in the soft palate and in the upper and lower extremities as well as ecchymosis in the back of the hands and feet.", "The complete blood count results are as follows:\nHemoglobin 8.9 g/dL\nHematocrit 41%\nLeukocyte count 10,500/mm3\nNeutrophils 53%\nBands 2%\nEosinophils 1%\nBasophils 0%\nLymphocytes 33%\nMonocytes 2%\nPlatelet count 450,000/mm3\nThe coagulation test results are as follows:\nPartial thromboplastin time (activated) 30.0 sec\nProthrombin time 13.6 sec\nInternational normalized ratio 0.99\nFibrinogen 364.9 mg/dL\nThe blood smear shows hypochromia, poikilocytosis, and large platelets, while a platelet aggregation test with ristocetin is normal.", "The overall bleeding time is increased."]}
{"Examination and Results": ["Vital signs are within normal limits.", "Urinalysis shows cloudy, red urine."]}
{"Patient Personal Background": ["The patient has cryptorchidism as an infant and underwent a successful orchiopexy.", "In addition, he was recently diagnosed with ADHD and is currently on methylphenidate with improvement in his symptoms.", "He has a family history of type I diabetes in his father and breast fibroadenoma in his mother."], "Patient Symptoms": ["He noticed it last month and felt that it has increased slightly in size.", "It is tender to touch but has no overlying skin changes."], "Examination and Results": ["On exam, the patient is at the 82nd percentile for height, 79th percentile for weight, and 80th percentile for BMI.", "He has tanner IV pubic hair.", "Testicular volume is 7 mL on each side, and both testes are smooth and freely mobile.", "Breast exam shows a normal right breast and a 3-centimeter round, firm, and slightly tender discrete mass under the left nipple."], "Others": ["There is no breast discharge."]}
{"Patient Personal Background": ["She is otherwise healthy and takes no medications.", "She denies any recent prolonged travel.", "She experienced a similar episode affecting the opposite leg one year ago and was diagnosed with a thrombus in the right femoral vein.", "On examination, the left leg is erythematous and swollen."], "Patient Symptoms": ["She reports that she developed painful left-sided leg swelling and redness earlier in the day."], "Examination and Results": ["Passive dorsiflexion of the left ankle elicits pain in the left calf.", "Ultrasound of the leg reveals a thrombus in the left popliteal vein.", "A genetic workup reveals that she has an inherited condition."], "Diagnosis": ["On examination, the left leg is erythematous and swollen."]}
{"Patient Personal Background": ["He had been living independently but came to live with his daughter temporarily after he complained that he was unable to perform some of his daily activities.", "He has hypertension treated with amlodipine."], "Patient Symptoms": ["He has left the front door wide open and tap water running on multiple occasions.", "He does not sleep well and wakes up 6\u20137 times during the night.", "He does not leave his room and rarely makes conversation with his daughter.", "He says that he used to enjoy playing the piano but has not played for several months.", "Attention and concentration are impaired.", "He is very concerned about his memory lapses."], "Examination and Results": ["Vital signs are within normal limits.", "Mental status examination shows orientation to person, place, and time and psychomotor retardation.", "Short- and long-term memory is impaired.", "Neurologic examination shows no focal findings.", "Serum concentration of electrolytes, thyroid-stimulating hormone, and vitamin B12 are within the reference range."], "Others": ["He has a blunted affect."]}
{"Patient Symptoms": ["He appears markedly pale and lethargic."], "Examination and Results": ["Examination shows a 6-cm, nonmobile mass in the left upper quadrant that crosses the midline.", "24-hour urine collection shows elevated homovanillic acid and vanillylmandelic acid."], "Treatment": ["The physician recommends the established standard treatment, which is initiation of neoadjuvant chemotherapy followed by surgical resection, if possible."], "Diagnosis": ["Further evaluation including biopsy confirms the diagnosis of intermediate-risk neuroblastoma."], "Others": ["After a thorough discussion of the risks and benefits of chemotherapy, the likelihood of unresectability without neoadjuvant treatment, and the prognosis without it, the patient's parents steadily refuse chemotherapy because they do not want their son to suffer the side effects.", "They prefer to take their son home for supportive care only."]}
{"Others": ["In order to do so, they biochemically charge a Lys-tRNA with valine instead of lysine and insert the tRNA into the cell.", "They design an mRNA sequence that contains only codons for lysine."]}
{"Patient Personal Background": ["He has required escalating doses of oral morphine, but is now having dose limiting side-effects."], "Treatment": ["His pain management team recommends using a medication that can reduce his opioid need through interaction with the NMDA-receptor."]}
{"Patient Personal Background": ["He is an amateur tennis player who practices on weekends.", "He denies any trauma during his practice sessions."], "Patient Symptoms": ["He says that the pain often worsens when he tries to sleep on his left side.", "Although he tried several pain medications, none of the pain medications helped.", "The range of motion was limited to the left side."], "Examination and Results": ["On examination of the shoulder joint, severe tenderness was present localized to the greater tuberosity of the left shoulder joint along with biceps tendon tenderness over the bicipital groove.", "An X-ray of the joint showed narrowing of the acromiohumeral space with sclerosis and spurring of the acromion.", "Routine blood test results are normal except for the rheumatoid factor, which is positive."]}
{"Patient Personal Background": ["She states that menses began at age of 13 and has been regular until two months ago.", "She denies sexual activity, and urine pregnancy test is negative.", "She says that she has been very stressed with school and has recently been binge eating."], "Patient Symptoms": ["She says that she has been very stressed with school and has recently been binge eating."], "Examination and Results": ["On exam, she appears well-nourished with a BMI of 21 kg/m^2, but you note that she has enlarged cheeks bilaterally and has calluses on the dorsum of her hands."]}
{"Patient Personal Background": ["He has no past medical history; the physical exam is unremarkable."], "Patient Symptoms": ["He reports that, about once per month for the past 8 or 9 months, he's had episodes of \"feeling like my chest is going to explode.\"", "During these episodes, he also feels shortness of breath, feels shakiness throughout his arms and legs, and sweats so heavily that he needs to change his shirt.", "He is unsure of any clear precipitating factors but thinks they may occur more often around important exams or when big school projects are due.", "He shares that, as these episodes continue to recur, he has had mounting anxiety about having one when he is in class or at a restaurant.", "As a result, he is leaving the house less and less."], "Examination and Results": ["He has no past medical history; the physical exam is unremarkable."]}
{"Patient Personal Background": ["The mother had no prenatal care."], "Examination and Results": ["Examination of the stillborn shows a small pelvis, shallow intergluteal cleft, and club feet.", "An x-ray shows the absence of the sacrum and lumbar vertebrae."]}
{"Examination and Results": ["They decide to stratify their results by CD4+T-lymphocyte count at the time of diagnosis.", "Among patients with CD4+ cell counts below 200/mm3, cART adherence was a significant predictor of DLBCL risk (RR = 0.52, p = 0.01).", "However, among patients with CD4+ cell counts above 200/mm3, no relationship was found between DLBCL risk and cART adherence (RR = 0.96, p = 0.36)."], "Treatment": ["Among patients with CD4+ cell counts below 200/mm3, cART adherence was a significant predictor of DLBCL risk (RR = 0.52, p = 0.01).", "However, among patients with CD4+ cell counts above 200/mm3, no relationship was found between DLBCL risk and cART adherence (RR = 0.96, p = 0.36)."], "Diagnosis": ["Among patients with CD4+ cell counts below 200/mm3, cART adherence was a significant predictor of DLBCL risk (RR = 0.52, p = 0.01).", "However, among patients with CD4+ cell counts above 200/mm3, no relationship was found between DLBCL risk and cART adherence (RR = 0.96, p = 0.36)."]}
{"Others": ["In addition, the secreted factors help activate macrophages to produce mediators such as NO, which are capable of destroying the invading pathogen.", "Furthermore, activation of the macrophages by the secreted factor eventually leads to the formation of a tubercle."]}
{"Patient Symptoms": ["His mother says he has been increasingly irritable recently.", "His vocabulary consists of 50 words and he does not use sentences.", "He refers to himself by name but is unable to name body parts or count to three."], "Examination and Results": ["Physical examination shows pale conjunctivae and abdominal tenderness.", "Peripheral blood smear shows small, pale red blood cells with basophilic stippling."]}
{"Patient Personal Background": ["All participants were interviewed about their prenatal consumption of folic acid using standardized questionnaires."], "Examination and Results": ["The study ultimately found that folic acid supplementation was associated with lower rates of ASD in offspring (OR = 0.3, p < 0.01)."], "Diagnosis": ["The researchers retrospectively surveyed 200 mothers with children diagnosed with ASD during the first 4 years of life and 200 mothers with healthy children."], "Others": ["A 94% response rate was obtained from the surveys."]}
{"Examination and Results": ["For one of the subjects, he notices that the subject is eliminating 0.5 mg of the drug every 4 hours."], "Others": ["His duty as a member of the team is to collect serum samples of the subjects every 4 hours and send them for analysis of serum drug levels.", "He is also supposed to collect, document and analyze the data."]}
{"Patient Symptoms": ["She has felt weaker lately and has lost some weight."], "Examination and Results": ["Her BUN at her last visit 4 months ago was 45 mg/dL, and her creatinine was 2.0 mg/dL."], "Others": ["She denies any urinary issues."]}
{"Patient Personal Background": ["He has had 2 children from a previous marriage and has been tested for causes of male infertility.", "She has had prior abdominal surgery as well as a family history of endocrine abnormalities."], "Examination and Results": ["Based on this history, a panel of tests are obtained and treatment is started."], "Treatment": ["This treatment will be administered intermittently one week before her normal menstrual cycle."]}
{"Examination and Results": ["Renal ultrasound shows bilateral dilation of the renal pelvis.", "A voiding cystourethrography shows retrograde flow of contrast into the ureters during micturition."]}
{"Patient Personal Background": ["He had recently lost his job and his house was about to begin foreclosure.", "His adult children were concerned for his well being and called the police requesting a welfare check.", "A review of his medical records reveals that he was previously in good health."], "Patient Symptoms": ["He was found unresponsive in his gurague.", "There were several empty bottles of vodka around him and one half empty container of antifreeze.", "On physical exam his speech is slurred and he has difficulty following commands."], "Examination and Results": ["Upon arrival to the ED he regains consciousness.", "His blood pressure is 135/85 mmHg, heart rate 120/min, respiratory rate 22/min, and temperature 36.5\u00b0C (97.7\u00b0F).", "His abdomen is diffusely tender to palpation with no rebound tenderness.", "Initial laboratory tests show an elevated serum creatinine (Cr) of 1.9 mg/dL, and blood urea nitrogen (BUN) of 29 mg/dL."]}
{"Patient Symptoms": ["Treatment with oral antibiotics and topical combination therapy with benzoyl peroxide and retinoid has not completely resolved her symptoms."], "Examination and Results": ["Examination shows oily skin with numerous comedones, pustules, and scarring over the face and upper back."], "Treatment": ["Treatment with oral antibiotics and topical combination therapy with benzoyl peroxide and retinoid has not completely resolved her symptoms.", "Long-term therapy is started with combined oral contraceptive pills."]}
{"Patient Symptoms": ["She presented with a lump in her neck 2 weeks ago."], "Examination and Results": ["On examination, a thyroid nodule was present; the nodule was fixed, immobile, and non-tender.", "Ultrasound showed a hypoechoic nodule with a size of 2 cm.", "Histological examination of a fine needle biopsy was performed and cytological examination reported a likely suspicion of neoplasia.", "CT scan is performed to check for any lesions in the bones and/or lungs, common metastatic sites in this condition."], "Treatment": ["Treatment with radioiodine therapy is planned after near-total thyroidectomy."]}
{"Patient Personal Background": ["He recently returned from a tour of the world where he visited Thailand, Ethiopia, and Brazil.", "Otherwise his past medical history is unremarkable."], "Patient Symptoms": ["He also says his right eyelid has been painlessly swelling and is starting to block his vision from that eye."], "Examination and Results": ["On presentation, his temperature is 102\u00b0F (38.8\u00b0C), blood pressure is 126/81 mmHg, pulse is 125/min, and respirations are 13/min.", "Physical exam reveals a nontender swelling of the right eyelid, lymphadenopathy, and an indurated red patch with surrounding erythema and local swelling on his left leg."]}
{}
{"Patient Personal Background": ["Her chart demonstrates no other medical problems and vaccinations/boosters up to date."], "Examination and Results": ["On arrival to the emergency department, her vitals are T: 36 deg C, HR: 110 bpm, BP: 100/60, RR: 12, SaO2: 99%.", "A FAST and abdominal CT are promptly obtained which are demonstrated in Figures A and B, respectively."], "Treatment": ["Bystanders call paramedics and she is subsequently taken to the nearest hospital.", "The splenectomy is successfully performed with removal of the damaged spleen (Figure C)."], "Diagnosis": ["The patient is diagnosed with a Grade V splenic laceration and is immediately brought to the OR for emergent splenectomy."]}
{"Others": ["It is believed that, in addition to the commonly found \u0394F508 mutation, a novel mutation in this gene is found in a particular population under study."]}
{"Patient Personal Background": ["Her past medical, family, and social histories are all non-contributory."], "Patient Symptoms": ["The patient is quite anxious about the implications of this diagnosis."], "Examination and Results": ["Her physical examination is within normal limits.", "Her vital signs do not show any abnormalities at this time."]}
{"Treatment": ["Darunavir has been particularly efficacious in recent patients; however, some have experienced an increased incidence of hyperglycemia.", "A new drug called DN501 is developed with the same mechanism of action as darunavir but fewer side effects."], "Others": ["Darunavir has been particularly efficacious in recent patients; however, some have experienced an increased incidence of hyperglycemia.", "A new drug called DN501 is developed with the same mechanism of action as darunavir but fewer side effects."]}
{"Patient Personal Background": ["He has smoked one pack of cigarettes daily for 20 years.", "He has worked as a fruit picker for the past 25 years.", "His current medications include captopril and metformin."], "Examination and Results": ["Examination of the oral cavity shows a single ulcer near the vermillion border."]}
{"Examination and Results": ["Endometrial cells obtained from study participants are plated on growth media and the distribution of cell cycle phase is measured with flow cytometry.", "Drug X, which is known to activate cyclin-dependent kinase 4, is administered to all the cells, and the distribution of cell cycle phase is measured again 1 hour later."], "Treatment": ["Drug X, which is known to activate cyclin-dependent kinase 4, is administered to all the cells, and the distribution of cell cycle phase is measured again 1 hour later."]}
{"Patient Personal Background": ["His past medical history is significant for human immunodeficiency virus (HIV) diagnosed 10 years ago with which he admits to not always being compliant with his antiretroviral medication.", "The patient reports a 20-pack-year smoking history but no alcohol or recreational drug use."], "Patient Symptoms": ["He also says he has been having intermittent fevers and severe night sweats which require a change of bed sheets the next day.", "A review of systems is significant for a 6 kg (13.2 lb) unintentional weight loss over the past 2 months."], "Examination and Results": ["The vital signs include: temperature 37.8\u2103 (100.0\u2109) and blood pressure 120/75 mm Hg.", "On physical examination, there are multiple non-tender swollen lymph nodes averaging 2 cm in diameter that is palpable in the anterior and posterior triangles of the neck bilaterally.", "Axillary and inguinal lymphadenopathy is present on the right side.", "The spleen size is 16 cm on percussion.", "Laboratory studies show the following:\nHemoglobin 9 g/dL\nMean corpuscular volume 88 \u03bcm3\nLeukocyte count 18,000/mm3\nPlatelet count 130,000/mm3\n    Serum creatinine 1.1 mg/dL\nSerum lactate dehydrogenase 1,000 U/L\nAn excisional biopsy of a superficial axillary lymph node on the right is performed and a histopathologic analysis confirms the most likely diagnosis."], "Diagnosis": [], "Others": ["A cardiopulmonary exam is unremarkable."]}
{"Examination and Results": ["Parameters such as patient demographic, type of implant, number of wires used, fracture union rate, and potential complications were thoroughly recorded and analyzed in all the patients, with a mean duration of patient follow-up of 16 months.", "Union was achieved in all patients with a mean duration of 90 days, and there were no complications found in patients included in the study."], "Others": ["The authors were satisfied with their findings and, due to the prospective nature of their research, submitted their study to a journal as a cohort study (which they noted in the study title as well).", "However, the journal editor returned the article, suggesting that it should be submitted as a case series instead."]}
{"Patient Symptoms": ["She has seemed more confused lately and is unable to verbalize her symptoms."], "Examination and Results": ["Her temperature is 102\u00b0F (38.9\u00b0C), blood pressure is 117/65 mmHg, pulse is 110/min, respirations are 19/min, and oxygen saturation is 95% on room air.", "Physical exam is notable for a right upper quadrant mass that elicits discomfort when palpated.", "Ultrasound is notable for pericholecystic fluid and gallbladder wall thickening without any gallstones."]}
{"Patient Personal Background": ["She has no significant past medical history but reports a family history of diabetes in her mother.", "She states that she has been undergoing a difficult divorce over the past few months."], "Patient Symptoms": ["She states that she has never had an episode like this before."], "Examination and Results": ["The patient is found to have a blood glucose level of 35 mg/dL.", "Hgb A1c was found to be 5.1%.", "C-peptide level was found to be decreased."], "Treatment": ["The patient returned to her baseline after glucose replacement."]}
{"Patient Personal Background": ["He has no family history of prostate disease."], "Patient Symptoms": ["He is frustrated that he has to wake up 2 or 3 times per night to urinate even though he tried reducing the amount of water he consumes before bed and made some other dietary changes without any improvement."], "Examination and Results": ["Physical examination is negative for any suprapubic mass or tenderness, and there is no costovertebral angle tenderness."], "Others": ["He does not complain of any pain during urination."]}
{"Patient Personal Background": ["Current medications include aspirin, which she takes almost daily for headaches."], "Examination and Results": ["Her temperature is 37.4\u00b0C (99.3\u00b0F) and her blood pressure is 150/90 mm Hg.", "Physical examination shows costovertebral tenderness to percussion bilaterally.", "Laboratory studies show a hemoglobin concentration of 10.2 g/dL and serum creatinine concentration of 2.4 mg/dL.", "Urine studies show:\nUrine\nProtein\n3+\nRBC > 16/hpf\nWBC 2/hpf\nThere are no casts or dysmorphic RBCs visualized on microscopic analysis of the urine."]}
{"Patient Personal Background": ["Her medications include folic acid and a multivitamin.", "She has smoked one pack of cigarettes daily for 15 years."], "Patient Symptoms": ["She has had spotting during the last 3 days."], "Examination and Results": ["Her temperature is 37\u00b0C (98.6\u00b0F), pulse is 110/min, and blood pressure is 89/65 mm Hg.", "Pelvic examination shows a dilated cervical os and a uterus consistent in size with an 11-week gestation.", "Ultrasonography shows an embryo of 4 cm in crown-rump length and no fetal cardiac activity."]}
{"Patient Symptoms": ["She develops type I hypersensitivity-mediated histamine release, resulting in pruritic wheals on the skin."], "Diagnosis": ["She develops type I hypersensitivity-mediated histamine release, resulting in pruritic wheals on the skin."]}
{"Patient Personal Background": ["The past year the child has been admitted to the hospital 3 times with pneumonia.", "Her parents are also concerned that she has not gained much weight due to her frequent hospital visits.", "She was born at 39 weeks gestation via spontaneous vaginal delivery and is up to date on all vaccines and is meeting all developmental milestones."], "Patient Symptoms": ["For the past 1 week, the child has been experiencing thick purulent cough and says that her chest feels \u2018heavy\u2019.", "Her stools have been loose and foul-smelling over the past week."], "Examination and Results": ["On physical exam, the temperature is 39.1\u00b0C (102.4\u00b0F).", "She appears lethargic and uncomfortable.", "Crackles are heard in the lower lung bases, with dullness to percussion.", "A small nasal polyp is also present on inspection."]}
{"Patient Personal Background": ["He is a non-smoker and does not drink alcohol.", "He denies any use of illicit drugs.", "The vital signs are as follows: heart rate 98/min, respiratory rate 16/min, temperature 37.6\u00b0C (99.68\u00b0F), and blood pressure 132/70 mm Hg."], "Patient Symptoms": ["He says that he finds it difficult to walk a few blocks and has to rest.", "He also complains of a cough for the past 3 months, which is dry and hacking in nature."], "Examination and Results": ["The physical examination is significant for inspiratory crackles over the lung bases.", "An echocardiogram shows a normal ejection fraction.", "A chest radiograph is performed and shown below."], "Treatment": ["The medical history is relevant for an idiopathic arrhythmia for which he takes amiodarone daily."]}
{"Patient Personal Background": ["The mother has HIV and received triple antiretroviral therapy during pregnancy."], "Examination and Results": ["Her HIV viral load was 678 copies/mL 1 week prior to delivery.", "Apgar scores were 7 and 8 at 1 and 5 minutes respectively.", "Physical examination of the newborn shows no abnormalities."], "Others": ["Labor was uncomplicated."]}
{"Patient Personal Background": ["The patient was diagnosed with diabetes 5 years ago and is compliant with her medications.", "The medical history is otherwise unremarkable."], "Patient Symptoms": ["She says that the shortness of breath is worse on exertion and improves with rest.", "While she could previously walk to the nearby store for her groceries, she now has to drive because she gets ''winded'' on the way."], "Examination and Results": ["The physical examination reveals gross ascites and visibly engorged periumbilical veins.", "Bilateral pitting edema is noted around the ankles.", "The finger-prick blood glucose level is 100 mg/dL."]}
{"Patient Personal Background": ["Menses have occurred at regular 28-day intervals since menarche at the age of 12 years and last for 5 to 6 days.", "She is sexually active with two male partners and uses condoms inconsistently."], "Patient Symptoms": ["The pain occurs a few hours before her menstrual period and lasts for 2 days."], "Examination and Results": ["Vital signs are within normal limits.", "Physical examination shows no abnormalities."], "Treatment": ["She has been taking ibuprofen, which has provided some relief."]}
{"Patient Personal Background": ["Five weeks ago, the patient was in Mexico, where he went on several spelunking expeditions with friends."], "Patient Symptoms": ["His parents report that he has been experiencing flu-like symptoms for one week prior to hospital admission."], "Examination and Results": ["Autopsy of brain tissue suggests a viral infection."], "Others": ["The patient ultimately becomes comatose and dies."]}
{"Examination and Results": ["He undergoes a skin biopsy and is found to have an absence of melanocytes in the epidermis."]}
{"Patient Personal Background": ["His past medical history is significant for hypercholesterolemia, well managed with rosuvastatin, and hypertension, well managed with hydrochlorothiazide.", "His current medications also include aspirin."], "Patient Symptoms": ["Three years after the initial diagnosis, the patient presents with swollen cervical and axillary lymph nodes, unintentional weight loss of 4.5 kg (approx.", "10 lb), and \u201crib pain\u201d on his right side."], "Examination and Results": ["He has no complaints.", "The patient is afebrile, and his vital signs are within normal limits.", "Physical examination is unremarkable.", "His laboratory tests are significant for the following:\nWBC 29,500/mm3\nHematocrit 26.1%\nHemoglobin 9.1 g/dL\nPlatelet count 298,000/mm3\nA peripheral blood smear and differential shows 92% small normocytic lymphocytes.", "On physical examination, there is palpable, firm, non-tender cervical and axillary lymphadenopathy bilaterally.", "He also has moderate splenomegaly, which, when palpated, elicits pain."], "Diagnosis": ["The patient\u2019s diagnosis in confirmed by bone marrow biopsy and flow cytometry."], "Others": ["At his last annual visit, his physical and laboratory tests were unremarkable.", "He is monitored through regular follow-up visits."]}
{"Examination and Results": ["Laboratory studies show:\nSerum\nNa+ 136 mEq/L\nK+ 3.2 mEq/L\nCl- 115 mEq/L\nMg2+ 1.4 mEq/L\nUrine\npH 7.0\nArterial blood gas analysis on room air shows a pH of 7.28 and a HCO3- concentration of 14 mEq/L."]}
{"Patient Personal Background": ["He reports that he graduated from college last month and returned 3 days ago from a 2 week vacation to Vietnam and Cambodia.", "The patient has a past medical history of asthma managed with albuterol as needed.", "He is sexually active with both men and women, and he uses condoms \u201cmost of the time.\u201d On physical exam, the patient\u2019s temperature is 102.5\u00b0F (39.2\u00b0C), blood pressure is 112/66 mmHg, pulse is 105/min, respirations are 12/min, and oxygen saturation is 98% on room air."], "Patient Symptoms": ["For the past 2 days, he has developed a worsening headache, malaise, and pain in his hands and wrists."], "Examination and Results": ["He has tenderness to palpation over his bilateral metacarpophalangeal joints and a maculopapular rash on his trunk and upper thighs.", "Tourniquet test is negative."]}
{"Patient Personal Background": ["She has no history of any serious illness.", "She does not use illicit drugs.", "Current medications include norepinephrine, ceftriaxone, and acetaminophen."], "Examination and Results": ["She appears well.", "Her temperature is 37.5\u00b0C (99.5\u00b0F), heart rate is 96/min, and blood pressure is 85/55 mm Hg.", "Examination of the back shows costovertebral tenderness bilaterally.", "Examination of the thyroid gland shows no abnormalities.", "Laboratory studies show:\n  Hospital day 1 Hospital day 3\nLeukocyte count 18,500/mm3 10,300/mm3\nHemoglobin 14.1 mg/dL 13.4 mg/dL\nSerum\nCreatinine 1.4 mg/dL 0.9 mg/dL\nFasting glucose 95 mg/dL 100 mg/dL\nTSH   1.8 \u00b5U/mL\nT3, free   0.1 ng/dL\nT4, free   0.9 ng/dL\nRepeat blood cultures are negative."], "Treatment": ["Her blood cultures are positive for Escherichia coli, for which she has been receiving appropriate antibiotics since admission.", "Current medications include norepinephrine, ceftriaxone, and acetaminophen."]}
{"Examination and Results": ["Blood pressure in the upper limb is 140/90 mm Hg and lower limbs are 110/70 mm Hg.", "There is a brachiofemoral delay in the pulse.", "Auscultation shows a loud S1, loud S2, and S4.", "There is a presence of an ejection systolic murmur in the interscapular area.", "Chest X-ray reveals the notching of the ribs."]}
{"Patient Personal Background": ["He underwent a total knee arthroplasty of his left knee joint 4 months ago.", "He has hypertension and osteoarthritis.", "Current medications include glucosamine, amlodipine, and meloxicam."], "Patient Symptoms": ["Examination shows a tender, swollen left knee joint; range of motion is limited by pain."], "Examination and Results": ["His temperature is 38.1\u00b0C (100.6\u00b0F), pulse is 97/min, and blood pressure is 118/71 mm Hg.", "Analysis of the synovial fluid confirms septic arthritis, and the prosthesis is removed."], "Treatment": [], "Diagnosis": []}
{"Patient Personal Background": ["He has had diabetes mellitus for 15 years, for which he takes metformin and gliclazide."], "Patient Symptoms": ["On examination, he is ill-appearing, and he has a tender liver edge that is palpable approx.", "Percussion and movement worsens the pain."], "Examination and Results": ["His vital signs include a temperature of 38.3\u00b0C (101.0\u00b0F), pulse of 85/min, and blood pressure of 110/70 mm Hg.", "2 cm below the right costal margin.", "Abdominal ultrasonography is shown.", "Stool is negative for Entamoeba histolytica antigen."]}
{"Patient Symptoms": ["The patient complains that he has experienced a loss of sensation in his toes and fingertips, which has caused him to injure himself often."], "Examination and Results": ["Examination of his face reveals skin that is thick and contains many lesions."]}
{"Patient Personal Background": ["His only medication is a multivitamin."], "Patient Symptoms": ["During this period, he has had recurrent episodes of low-grade fever lasting for 7 to 10 days, and an 8-kg (18-lb) weight loss."], "Examination and Results": ["Physical examination shows nontender, right axillary, cervical, and inguinal lymphadenopathy.", "His serum calcium concentration is 15.1 mg/dL and parathyroid hormone (PTH) concentration is 9 pg/mL.", "A lymph node biopsy shows granuloma formation and large CD15-positive, CD30-positive cells with bilobed nuclei."]}
{"Patient Personal Background": ["He recently traveled to Guatemala.", "He feels well but has not seen a physician in several years, and his immunization records are unavailable."], "Examination and Results": ["Physical examination shows no abnormalities."]}
{"Patient Symptoms": ["She reports that the child develops severe sunburns every time the infant is exposed to sunlight.", "She has applied copious amounts of sunscreen to the infant but this has not helped the problem."], "Examination and Results": ["On examination, there are multiple areas of reddened skin primarily in sun exposed areas.", "The child\u2019s corneas appear irritated and erythematous."]}
{"Patient Personal Background": ["His past medical history is notable for gout for which he takes allopurinol.", "He runs 4 times per week and eats a balanced diet of mostly fruits and vegetables.", "He does not smoke and drinks a glass of wine with dinner."], "Patient Symptoms": ["He first noticed a firm mass on the anterior aspect of his neck approximately 4 months ago.", "The mass is painless and has not increased in size since then.", "He has also noticed occasional fatigue and has gained 10 pounds in the past 4 months despite no change in his diet or exercise frequency."], "Examination and Results": ["His temperature is 97.8\u00b0F (36.6\u00b0C), blood pressure is 127/72 mmHg, pulse is 87/min, and respirations are 19/min.", "On exam, he has a firm, symmetric, and stone-firm thyroid."], "Others": ["He denies any prior thyroid disorder.", "His family history is notable for medullary thyroid cancer in his maternal uncle."]}
{"Diagnosis": ["For study purposes, the researchers labeled incident cases at the initial occurrence of SLE diagnosis in the hospital database, while prevalent cases were those that were coded as harboring SLE at any time, with patients maintaining their diagnosis until death."], "Others": ["These estimates were not only based on hospital discharges, but also on physician billing codes."]}
{"Patient Symptoms": ["She has had progressive shortness of breath over the last year with an intermittent non-productive cough.", "In addition, she complains of difficulty raising her arms to brush her hair."], "Examination and Results": ["Her temperature is 99.6\u00b0F (37.6\u00b0C), pulse is 80/min, blood pressure is 130/85 mmHg, respirations are 18/min, and oxygen saturation is 95% on room air.", "Neurologic exam shows 4/5 strength in the deltoid muscles bilaterally.", "Diffuse dry crackles are heard on lung auscultation.", "A faint erythematous rash is noted on the malar cheeks, periorbital areas, lateral proximal thighs, and the elbows."]}
{"Patient Personal Background": ["He has been taking over-the-counter cough medications, but they have not helped much.", "There is no past history of any specific medical disorder.", "His father died of lung cancer at the age of 54 years."], "Patient Symptoms": ["He adds that he expectorated bloody sputum the previous night.", "He denies breathlessness but mentions that he frequently experiences fatigue after little physical exertion."], "Examination and Results": ["His temperature is 37.0\u00b0C (98.6\u00b0F), the pulse rate is 82/min, the blood pressure is 118/80 mm Hg, and the respiratory rate is 18/min.", "Auscultation of his chest reveals the presence of localized rhonchi over the interscapular region.", "A plain radiograph of the chest shows a coin-like opacity in the right lung."], "Diagnosis": ["Further diagnostic evaluation confirms the diagnosis of small cell carcinoma of the lung."]}
{"Patient Personal Background": ["He drinks 5-6 beers on the weekend and has a 20 pack-year smoking history.", "He denies any family history of cancer."], "Patient Symptoms": ["He says that the pain \u201ccomes and goes\u201d throughout the day and usually lasts 20-30 minutes per episode.", "He can point to the spot 1-2 inches above the umbilicus where he feels the pain.", "He denies any feeling of regurgitation or nighttime cough but endorses nausea.", "He reports that he used to eat three large meals per day but has found that eating more frequently improves his pain.", "He has gained four pounds since his past appointment three months ago.", "The patient denies any diarrhea or change in his stools."], "Examination and Results": ["On physical exam, he is tender to palpation above the umbilicus.", "Bowel sounds are present.", "A stool guaiac test is positive."], "Treatment": ["He tried a couple pills of ibuprofen with food over the past couple days and thinks it helped.", "The patient undergoes endoscopy with biopsy to diagnose his condition."], "Others": ["He has no past medical history."]}
{"Patient Personal Background": ["The patient is in kindergarten and doing well in school.", "She is learning to read and is able to write her first name.", "The patient\u2019s past medical history is significant for moderate persistent asthma, which has required three separate week-long courses of prednisone over the last year and recently diagnosed myopia.", "The patient\u2019s mother is 5\u20197\u201d, and the patient\u2019s father is 5\u201910\u201d."], "Patient Symptoms": ["The patient\u2019s mother is concerned that the patient is a picky eater and often returns home from school with most of her packed lunch uneaten."], "Examination and Results": ["The patient\u2019s weight and height are in the 55th and 5th percentile, respectively, which is consistent with her growth curve.", "On physical exam, the patient has a low hairline and a broad chest.", "Her lungs are clear with a mild expiratory wheeze.", "The patient\u2019s abdomen is soft, non-tender, and non-distended.", "She has Tanner stage I breast development and pubic hair."], "Diagnosis": ["The patient\u2019s past medical history is significant for moderate persistent asthma, which has required three separate week-long courses of prednisone over the last year and recently diagnosed myopia."], "Others": ["Her teacher has no concerns."]}
{"Patient Personal Background": ["The decision is made to stop the statin and return to the clinic in 2 weeks to assess any changes in symptoms."], "Patient Symptoms": ["He complains of pain in his legs and general weakness.", "On physical exam, he has full range of motion of his extremities but complains of pain."], "Examination and Results": ["On physical exam, he has full range of motion of his extremities but complains of pain.", "His blood pressure is 126/84 mm Hg and heart rate is 74/min."], "Treatment": ["The decision is made to stop the statin and return to the clinic in 2 weeks to assess any changes in symptoms."], "Others": ["After stopping the statin, his muscular symptoms resolve."]}
{"Examination and Results": ["A portion of the specimen is cut and stained with hematoxylin and eosin.", "The remainder is analyzed and is found to contains type II collagen and chondroitin sulfate."]}
{"Patient Symptoms": ["Lung examination shows bilateral rales.", "Abdominal examination shows a distended abdomen and intact abdominal surgical incisions."], "Examination and Results": ["Computed tomography shows a small bowel perforation.", "Her temperature is 37.3\u00b0C (99.1\u00b0F), pulse is 76/min, and blood pressure is 111/50 mm Hg.", "She is responsive to painful stimuli.", "Lung examination shows bilateral rales.", "Abdominal examination shows a distended abdomen and intact abdominal surgical incisions.", "The remainder of the physical examination shows no abnormalities."], "Treatment": ["The patient is prepared for emergent exploratory laparotomy.", "She is sedated with midazolam, induced with propofol, intubated, and maintained on nitrous oxide and isoflurane for the duration of the surgery.", "The ventilator is set at an FiO2 of 50%, tidal volume of 1000 mL, respiratory rate of 12/min, and positive end-expiratory pressure of 2.5 cm H2O."], "Diagnosis": ["Computed tomography shows a small bowel perforation.", "A single perforation in the terminal ileum is diagnosed intraoperatively and successfully repaired."], "Others": ["The patient is transferred to the intensive care unit."]}
{"Patient Symptoms": ["He is thin and diaphoretic with pinpoint pupils, poor dentition, and track marks on his arms and legs."], "Examination and Results": ["On physical exam, temperature is 100.6 deg F (38.1 deg C), blood pressure is 109/56 mmHg, pulse is 94/min, and respirations are 18/min.", "A high-pitched systolic murmur is heard, loudest in the left sternal border and with inspiration.", "One of the blood cultures drawn 12 hours ago returns positive for Staphylococcus aureus."], "Treatment": ["He is admitted to the hospital and started on broad-spectrum antibiotics."]}
{"Patient Personal Background": ["He has not seen a doctor since he became uninsured 2 years ago."], "Examination and Results": ["His temperature is 38.3\u00b0C (100.9\u00b0F).", "Abdominal examination shows mild, diffuse tenderness throughout the lower quadrants.", "The liver is palpated 2\u20133 cm below the right costal margin, and the spleen is palpated 1\u20132 cm below the left costal margin.", "His CD4+ T-lymphocyte count is 49/mm3 (N \u2265 500 mm3).", "Blood cultures grow acid-fast organisms.", "A PPD skin test shows 4 mm of induration."]}
{"Examination and Results": ["Two weeks ago, she had a routine Pap smear that showed atypical squamous cells.", "Colposcopy shows an area of white discoloration of the cervix with application of acetic acid solution."], "Diagnosis": ["Biopsy of this area shows carcinoma-in-situ."]}
{"Examination and Results": ["In a pilot study of 50 patients, the imaging test detected the presence of CMV retinitis in 50% of the patients.", "An ophthalmologist slit lamp examination, which was performed for each patient to serve as the gold standard for diagnosis, confirmed a diagnosis of CMV retinitis in 20 patients that were found to be positive through imaging, as well as 1 patient who tested negative with the device."], "Diagnosis": ["An ophthalmologist slit lamp examination, which was performed for each patient to serve as the gold standard for diagnosis, confirmed a diagnosis of CMV retinitis in 20 patients that were found to be positive through imaging, as well as 1 patient who tested negative with the device."]}
{"Patient Personal Background": ["She has no past psychiatric history and she denies hearing voices or seeing objects.", "No significant past medical history.", "Although she has lived in the same community for years, she says she usually keeps to herself and does not have many friends.", "She holds a regular job at the local hardware store and lives alone."], "Patient Symptoms": ["She vaguely explains that the necklace is to mask her scent from the moles tracking her."]}
{"Examination and Results": ["Digital rectal exam was positive for a slightly enlarged prostate but did not detect any additional abnormalities of the prostate or rectum.", "The patient\u2019s serum PSA was measured to be 6 ng/mL.", "Image A shows a transabdominal ultrasound of the patient."]}
{"Patient Personal Background": ["He finds his work as a computer programmer rewarding and looks forward to coming into the office every day.", "His past medical history is noncontributory."], "Patient Symptoms": ["However, he often falls asleep during meetings even though he usually gets a good night sleep and has limited his exposure to alcohol and caffeine in the evening.", "The patient returns one month later to report no changes to his condition."], "Examination and Results": ["His vital signs are within normal limits.", "Physical examination is unremarkable.", "The sleep journal reveals that the patient is getting sufficient sleep and wakes up rested.", "The questionnaire reveals that the patient does not snore nor does he stop breathing during his sleep.", "A sleep study reveals mean sleep latency of 6 minutes."], "Treatment": ["The primary care provider recommends keeping a sleep journal and provides a questionnaire for the patient\u2019s wife."]}
{"Patient Personal Background": ["He has hypertension treated with enalapril.", "The patient has smoked a pack of cigarettes daily for the past 20 years.", "Vital signs are within normal limits."], "Patient Symptoms": ["The patient reports that he first noticed the swelling several weeks ago, but it is not always present."], "Examination and Results": ["Physical examination shows a 10-cm, soft, cystic, nontender right scrotal mass that transilluminates.", "The mass does not increase in size on coughing and it is possible to palpate normal tissue above the mass.", "There are no bowel sounds in the mass, and it does not reduce when the patient is in a supine position.", "Examination of the testis shows no abnormalities."]}
{"Patient Personal Background": ["His past medical history is significant for type 2 diabetes mellitus and hypertension for the past 25 years."], "Examination and Results": ["Clinical examination shows the presence of wound dehiscence in the lower 3rd of the sternal region.", "The wound surface shows the presence of dead necrotic tissue with pus.", "Computed tomography (CT) of the thorax shows a small fluid collection with fat stranding in the perisurgical soft tissues."], "Treatment": ["He recently had a triple coronary artery bypass graft 3 weeks ago."]}
{}
{"Patient Personal Background": ["He does not have any complaints.", "He says that he has tried to keep himself healthy and active by jogging and gardening since his retirement at age 50.", "He adds that he spends his mornings in the park and his afternoons in his garden.", "He has no significant medical history.", "The patient denies any smoking history and drinks alcohol occasionally."], "Examination and Results": ["On physical examination, the following lesion is seen on his scalp (see image)."]}
{"Patient Symptoms": ["At a routine well-child examination 4 months later, the physician notices that he has persistent head lag."], "Examination and Results": ["On examination, he has blue eyes, pale skin, blonde hair, and generalized hypotonia.", "His serum prolactin level is markedly elevated."], "Treatment": ["He is started on a special diet and the hyperphenylalaninemia resolves."]}
{"Patient Symptoms": ["She further expresses her concerns about the possibility of contracting tuberculosis as one of the patients under her care is being treated for tuberculosis.", "At a follow-up appointment 3 months later the patient presents with fatigue.", "She has also been experiencing occasional dizziness, weakness, and numbness in her feet."], "Examination and Results": ["A PPD skin test is done and reads 11 mm on day 3.", "Chest X-ray demonstrates a cavitary lesion in the right upper lobe.", "Physical exam is positive for conjunctival pallor.", "Lab work is significant for a hemoglobin level of 10 g/dL and mean corpuscular volume of 68 fl."], "Treatment": ["The standard anti-tuberculosis medication regimen is started."]}
{"Patient Symptoms": ["She is feeling well but is concerned because her brother was recently diagnosed with hereditary hemochromatosis.", "Today, she denies fever, chills, joint pain, or skin hyperpigmentation."], "Examination and Results": ["Her temperature is 37.0\u00b0C (98.6\u00b0F), pulse is 85/min, respirations are 16/min, and blood pressure is 123/78 mm Hg.", "Her physical examination is normal.", "Her serum iron, hemoglobin, ferritin, and AST and ALT concentrations are normal."], "Others": ["All first-degree relatives were encouraged to undergo genetic screening for any mutations associated with the disease.", "Gene screening will involve a blood specimen."]}
{"Patient Personal Background": ["Her menstrual cycles are 28\u201330 days apart with 3\u20135 days of vaginal bleeding.", "Her last menses ended 9 days ago."], "Patient Symptoms": ["The pain is in her right lower quadrant (RLQ), which is also where it began.", "She has had no nausea or vomiting despite eating a snack 2 hours ago.", "She had a similar episode last month which resolved on its own."], "Examination and Results": ["Her blood pressure is 125/75 mm Hg, the pulse is 78/min, the respirations are 15/min, and the temperature is 37.2\u00b0C (99.0\u00b0F).", "Abdominal examination shows moderate pain on direct pressure over the RLQ which decreases with the release of pressure."]}
{"Patient Personal Background": ["The patient states he was at a barbecue around noon.", "Lunch was arranged as a buffet without refrigeration."], "Patient Symptoms": ["Within 2 to 3 hours, he had abdominal pain with 3 episodes of watery diarrhea."], "Examination and Results": ["On exam, vital signs are T 99.1, HR 103, BP 110/55, RR 14.", "Abdominal exam is significant for pain to deep palpation without any rebounding or guarding.", "There is no blood on fecal occult testing (FOBT)."]}
{"Patient Personal Background": ["He has a history of major depressive disorder and had an ischemic stroke 4 months ago.", "Current medications are aspirin and sertraline."], "Patient Symptoms": ["He is lethargic and disoriented.", "While in the waiting room, he has a generalized, tonic-clonic seizure."], "Examination and Results": ["His pulse is 78/min, and blood pressure is 135/88 mm Hg.", "Physical examination shows moist oral mucosa, normal skin turgor, and no peripheral edema.", "Laboratory studies show a serum sodium of 119 mEq/L and an elevated serum antidiuretic hormone concentration."]}
{"Patient Personal Background": ["She states that she has always had an irrational and excessive fear of dogs but has been able to avoid it for most of her life while living in the city."], "Patient Symptoms": ["When she sees her neighbors walking their dogs outside, she is terrified and begins to feel short of breath.", "Recently, she has stopped picking up her children from the bus stop and no longer plays outside with her children in order to avoid seeing any dogs."]}
{"Patient Symptoms": ["The patient was found unconscious with a large metal spike protruding from his abdomen by a coworker who was unable to estimate the amount of time the patient went without medical aid.", "Upon arrival to the ER, the patient was unconscious and unresponsive.", "The patient remained sedated after surgery and continued to have relatively stable vital signs until his third day in the intensive care unit, when he experiences an oxygen desaturation of 85% despite being on a respirator with 100% oxygen at 15 breaths/minute."], "Examination and Results": ["His vital signs are BP: 80/40, HR: 120 bpm, RR: 25 bpm, Temperature: 97.1 degrees, and SPO2: 99%.He is taken to the operating room to remove the foreign body and control the bleeding.", "Although both objectives were accomplished, the patient had an acute drop in his blood pressure during the surgery at which time ST elevations were noted in multiple leads.", "On auscultation air entry is present bilaterally with the presence of crackles.", "A 2/6 systolic murmur is heard.", "Readings from a Swan-Ganz catheter display the following: central venous pressure (CVP): 4 mmHg, right ventricular pressure (RVP) 20/5 mmHg, pulmonary artery pressure (PAP): 20/5 mmHg.", "Pulmonary capillary wedge pressure (PCWP): 5 mm Hg."], "Treatment": ["His vital signs are BP: 80/40, HR: 120 bpm, RR: 25 bpm, Temperature: 97.1 degrees, and SPO2: 99%.He is taken to the operating room to remove the foreign body and control the bleeding.", "Although both objectives were accomplished, the patient had an acute drop in his blood pressure during the surgery at which time ST elevations were noted in multiple leads.", "This resolved with adequate fluid resuscitation and numerous blood transfusions."], "Others": ["A chest x-ray is shown as Image A.", "The patient dies soon after this episode."]}
{"Patient Personal Background": ["He is a 60 pack-year smoker, worked as a shipbuilder 30 years ago, and recently traveled to Ohio to visit family."], "Examination and Results": ["Chest radiograph shows increased bronchovascular markings, reticular parenchymal opacities, and multiple pleural plaques.", "Labs are unremarkable except for a slight anemia."]}
{"Patient Personal Background": ["His past medical history is significant for prediabetes, which he controls with exercise and diet.", "He has a 30-pack-year smoking history."], "Patient Symptoms": ["He reports having shortness of breath over the last 6 months, but he has felt worse since he contracted a cold that has been traveling around his office.", "Today, he reports body aches, headache, and fever along with this chronic cough."], "Examination and Results": ["His blood pressure is 130/85 mmHg, pulse rate is 90/min, temperature is 36.9\u00b0C (98.5\u00b0F), and respiratory rate is 18/min.", "Physical examination reveals diminished breath sounds bilateral, a barrel-shaped chest, and measured breathing through pursed lips.", "A chest X-ray reveals a flattened diaphragm and no signs of consolidation.", "Pulmonary function testing reveals FEV1/FVC ratio of 60%."]}
{"Others": ["He and his wife have three unaffected daughters."]}
{"Patient Symptoms": ["The patient reports that he noticed a decrease in his hearing approximately 10 years ago.", "His wife says that he watches television at an elevated volume and appears to have trouble understanding what is being said to him, especially when there is background noise.", "He states that he also experiences constant ear ringing and episodes of unsteadiness."], "Examination and Results": ["On physical examination, the outer ears are normal and otoscopic findings are unremarkable.", "The patient is unable to repeat the sentence said to him on whisper testing.", "When a vibrating tuning fork is placed in the middle of the patient's forehead, it is heard equally on both ears.", "When the vibrating tuning fork is placed by the ear and then on the mastoid process, air conduction is greater than bone conduction."]}
{"Patient Personal Background": ["He wears soft contact lenses and has not removed them for 2 days."], "Examination and Results": ["Ophthalmologic examination shows a deep corneal ulcer, severe conjunctival injection, and purulent discharge on the right."], "Treatment": ["Treatment with topical ciprofloxacin is initiated."]}
{"Patient Symptoms": ["She said that about a year ago, she had trouble with her vision, and that it eventually recovered in a few days."], "Examination and Results": ["On physical exam, bilateral internuclear ophthalmoplegia, hyperreflexia in both patella, and bilateral clonus, are noted.", "A magnetic resonance imaging (MRI) study was done (Figure 1)."]}
{"Patient Personal Background": ["The course of her pregnancy has been unremarkable and she has no significant co-morbidities.", "The BMI is 25.6 kg/cm2 and she has gained 3 kg (6.72 lb) during the pregnancy."], "Patient Symptoms": ["She is concerned about the results of a dipstick test she performed at home, which showed 1+ glucose.", "She does not know  if her liquid consumption has increased, but she urinates more frequently than before."], "Examination and Results": ["The blood pressure is 110/80 mm Hg, the heart rate is 82/min, the respiratory rate is 14/min, and the temperature is 36.6\u2103 (97.9\u2109).", "The lungs are clear to auscultation, the heart sounds are normal with no murmurs, and there is no abdominal or costovertebral angle tenderness."]}
{"Patient Personal Background": ["Pregnancy and delivery were uncomplicated.", "He was diagnosed with eczematous dermatitis at 3 months old."], "Patient Symptoms": ["His height and weight are below the 5th percentile."], "Examination and Results": ["Immunologic evaluation shows a defect in activated regulatory T cells.", "A genetic analysis shows a mutation in the FOXP3 gene."]}
{"Patient Personal Background": ["He has smoked 1 pack of cigarettes daily for 37 years.", "He has a 12-year history of drinking 6 to 8 beers daily."], "Patient Symptoms": ["He describes the stools as bulky, foul-smelling, and difficult to flush.", "He also has a 4-month history of recurrent dull upper abdominal pain that usually lasts for a few days, worsens after meals, and is not relieved with antacids.", "He has had a 10-kg (22-lb) weight loss in the past 4 months."], "Examination and Results": ["He is 160 cm (5 ft 3 in) tall and weighs 52 kg (115 lb); BMI is 20 kg/m2.", "His vital signs are within normal limits.", "Abdominal examination shows mild epigastric tenderness without rebound or guarding.", "Bowel sounds are normal."], "Others": ["He has no personal or family history of serious illness.", "The remainder of the examination shows no abnormalities."]}
{"Patient Personal Background": ["In the past, he has had significant sun exposure including multiple blistering sunburns."], "Patient Symptoms": ["He notes a pink bump that has rapidly developed on his forehead over the last month."], "Examination and Results": ["The physical examination reveals a 2 cm dome-shaped plaque with a central keratin plug (as shown in the image).", "Excisional biopsy of the lesion reveals an exophytic nodule with central invagination, full of keratin.", "Keratinocyte atypia is minimal."]}
{"Patient Personal Background": ["His past medical history is notable for hypercholesterolemia and hypertension.", "He takes simvastatin and losartan."], "Patient Symptoms": ["He reports a 2-month history of exertional chest pain that commonly arises after walking 5 or more blocks.", "He describes the pain as dull, burning, non-radiating substernal pain."], "Examination and Results": ["His temperature is 98.9\u00b0F (37.2\u00b0C), blood pressure is 150/85 mmHg, pulse is 88/min, and respirations are 18/min.", "On exam, he is well-appearing and in no acute distress.", "S1 and S2 are normal.", "No murmurs are noted.", "An exercise stress test is performed to further evaluate the patient\u2019s pain."]}
{"Patient Personal Background": ["His past medical history is notable for iron deficiency anemia, osteoarthritis, and paraneoplastic Lambert-Eaton syndrome.", "He has a 40 pack-year smoking history."], "Patient Symptoms": ["However, he reports that he recently developed multiple \u201cspots\u201d all over his body.", "He denies any overt bleeding from his gums or joint swelling."], "Examination and Results": ["His temperature is 98.5\u00b0F (36.9\u00b0C), blood pressure is 130/70 mmHg, pulse is 115/min, and respirations are 20/min.", "On examination, a rash is noted diffusely across the patient\u2019s trunk and bilateral upper and lower extremities.", "Results from a complete blood count are shown below:\nHemoglobin: 11.9 mg/dl\nHematocrit: 35%\nLeukocyte count: 5,000/mm^3\nPlatelet count: 20,000/mm^3\n\nThe oncologist would like to continue chemotherapy but is concerned that the above results will limit the optimal dose and frequency of the regimen."], "Treatment": ["He has responded well to etoposide and cisplatin with plans to undergo radiation therapy."]}
{"Patient Personal Background": ["During his annual physical, he reports that he has been taking over the counter pain medications, but that no amount of analgesics can relieve his constant pain."], "Patient Symptoms": ["During his annual physical, he reports that he has been taking over the counter pain medications, but that no amount of analgesics can relieve his constant pain."], "Examination and Results": ["Laboratory results reveal that his renal function has deteriorated when compared to his last office visit 2 years ago.", "Serum creatinine is 2.0 mg/dL, and urinalysis shows 1+ proteinuria.", "There are no abnormalities seen on microscopy of the urine.", "A renal biopsy shows eosinophilic infiltration and diffuse parenchymal inflammation."]}
{"Patient Personal Background": ["The patient has a past medical history of COPD and a 44-pack-year smoking history.", "The patient has been admitted before for a similar presentation."], "Patient Symptoms": ["The patient says he feels as if he is unable to take a deep breath.", "The patient claims he is still short of breath."], "Examination and Results": ["His temperature is 98.7\u00b0F (37.1\u00b0C), blood pressure is 177/118 mmHg, pulse is 123/min, respirations are 33/min, and oxygen saturation is 80% on room air.", "Physical exam reveals bilateral wheezes and poor air movement.", "His oxygen saturation is 80%."], "Treatment": ["The patient is started on 100% oxygen, albuterol, ipratropium, magnesium, and prednisone."]}
{"Patient Personal Background": ["He has hypertension treated with enalapril.", "He has smoked 1 pack of cigarettes daily for 60 years."], "Patient Symptoms": ["He says that the pain is sharp, radiates to his left side, and has a burning quality.", "He has had a cough occasionally productive of blood-streaked sputum for the past 2 months.", "He has had 3.2-kg (7.0-lb) weight loss in that time.", "He is now unable to walk without assistance and has had constipation and difficulty urinating for the past 2 weeks.", "He is unable to lie recumbent due to severe pain."], "Examination and Results": ["His temperature is 37\u00b0C (98.6\u00b0F), pulse is 75/min, and blood pressure is 150/80 mm Hg.", "He is oriented to person, place, and time.", "Neurologic examination shows 3/5 strength of the lower extremities.", "Deep tendon reflexes are hyperreflexive.", "Babinski sign is present bilaterally.", "Sensory examination shows decreased sensation to pinprick below the T4 dermatome.", "An x-ray of the chest shows multiple round opacities of varying sizes in both lungs."]}
{"Patient Personal Background": ["The patient reports that he has had a fear of flying since being a teenager.", "He went on a family vacation 15 years ago, and during the flight there was turbulence and a \u201crough landing\u201d.", "Since then he has avoided flying.", "He did not go to his cousin\u2019s wedding because it was out of the country.", "He also was unable to visit his grandmother for her 80th birthday.", "The last time his job asked him to meet a client out of state, he drove 18 hours instead of flying.", "Two years ago he promised his fianc\u00e9 they could fly to Florida."], "Patient Symptoms": ["Upon arrival at the airport, he began to feel dizzy, lightheaded, and refused to go through security.", "He recognizes that his fear is irrational."], "Examination and Results": ["During the clinic visit, the patient appears anxious and distressed."], "Others": ["He is upset that it is affecting his relationship with his wife.", "Additionally, his current job may soon require employees in his sales position to fly to meet potential clients.", "He is embarrassed to have a conversation with his manager about his fear of flying."]}
{"Examination and Results": ["A skin biopsy is performed, which shows an epidermal basement membrane with immunoglobulin G (IgG) antibodies and linear immunofluorescence."]}
{"Patient Personal Background": ["She does not have friends and spends most of the time reading by herself.", "She states that she likes reading and feels more comfortable on her own."], "Patient Symptoms": ["Her father says that she comes up with excuses to avoid family dinners and other social events.", "Her affect is flat."], "Examination and Results": ["On mental status examination, her thought process is organized and logical.", "Her affect is flat."]}
{"Patient Symptoms": ["During this period, he has had generalized malaise and a cough productive of moderate amounts of green sputum.", "For the past 10 days, he has had fever, a sore throat, and generalized aches; these symptoms initially improved, but worsened again over the past 5 days."], "Examination and Results": ["His temperature is 38.7\u00b0C (101.7\u00b0F), pulse is 109/min, respirations are 27/min, and blood pressure is 100/70 mm Hg.", "Pulse oximetry on room air shows an oxygen saturation of 93%.", "There are decreased breath sounds and crackles heard over the upper right lung field.", "His hemoglobin concentration is 13.3 g/dL, leukocyte count is 15,000/mm3, and platelet count is 289,000/mm3.", "An x-ray of the chest shows a right upper-lobe infiltrate."]}
{"Patient Symptoms": ["His breathlessness worsens while walking, climbing the stairs, and lying flat on his back.", "He also finds it difficult to sleep well at night, as he often wakes up to catch his breath."], "Examination and Results": ["His pulse is 98/min and blood pressure is 114/90 mm Hg.", "On examination, he has mild respiratory distress, distended neck veins, and bilateral pitting edema is evident on the lower third of his legs.", "His respiratory rate is 33/min, SpO2 is 93% in room air, and coarse crepitations are heard over the lung bases.", "On auscultation, the P2 component of his second heart sound is heard loudest at the second left intercostal space, and an S3 gallop rhythm is heard at the apex."], "Treatment": ["Medication is prescribed for his symptoms which changes his cardiac physiology as depicted with the dashed line recorded post-medication."]}
{"Patient Personal Background": ["Past medical history and family history are insignificant."], "Patient Symptoms": ["He also complains of abdominal pain and constipation for the same duration.", "On further questioning, he reports that he has lost 8 pounds in the last 2 weeks."], "Examination and Results": ["His temperature is 37.3\u00b0 C (99.2\u00b0 F), respirations are 21/min, pulse is 63/min, and blood pressure is 99/70 mm Hg.", "On physical examination, he is a tired-appearing, thin male.", "He has a bronze discoloration to his skin, but he denies being outside in the sun or any history of laying in tanning beds."]}
{"Patient Personal Background": ["The obstetrician is worried that the child may have been infected due to the mother's haphazard use of her anti-retroviral medications."]}
{"Patient Personal Background": ["He was diagnosed with chronic obstructive pulmonary disease (COPD) the previous year and since then has been on a short-acting \u03b2-agonist to help alleviate his symptoms.", "Since his diagnosis, he has quit smoking, a habit which he had developed about 30 years ago.", "He used to smoke about 2 packs of cigarettes daily."], "Patient Symptoms": ["Today, he has come in with an increase in his symptoms.", "He tells his physician that he has been having a fever for the past 3 days, ranging between 37.8\u00b0\u201339\u00b0C (100\u00b0F\u2013102.2\u00b0F).", "Along with this, he has a persistent cough with copious amounts of greenish-yellow sputum.", "He has also been having difficulty breathing."], "Examination and Results": ["On examination, his temperature is 38.6\u00b0C (101.5\u00b0F), the respirations are 22/min, the blood pressure is 110/80 mm Hg, and the pulse is 115/min.", "Slight crackles and respiratory wheezes are prominent in the lower lung fields.", "His FEV1 is 57% of his normal predicted value."], "Treatment": ["He is started on oxygen and a dose of oral prednisone."]}
{"Patient Symptoms": ["His headaches tend to occur in the morning and are associated with nausea and vomiting."], "Examination and Results": ["His temperature today is 37.5\u00b0C (98.5\u00b0F).", "An MRI of the brain shows bilateral ventricular enlargement and enlargement of the subarachnoid space."], "Treatment": ["One month ago, the patient was admitted to the hospital because of fever, irritability, and neck rigidity, and he was successfully treated with antibiotics."]}
{"Patient Symptoms": ["Physical examination shows bilateral saccadic eye movement in all directions and brief, involuntary muscle contractions of the trunk and limbs."], "Examination and Results": ["Physical examination shows bilateral saccadic eye movement in all directions and brief, involuntary muscle contractions of the trunk and limbs.", "There is an ill-defined, nontender mass in the upper right abdomen."], "Treatment": ["He undergoes surgical resection of the tumor."]}
{"Examination and Results": ["Average baseline LDL levels for each group were identical.", "Statistical analysis reports a p-value of 0.052."], "Treatment": ["The group receiving statin A exhibited an 11 mg/dL greater reduction in LDL in comparison to the statin B group."]}
{"Patient Personal Background": ["Other medical history reveals that she has had 3 past spontaneous abortions at < 10 weeks of gestational age but has never been diagnosed with any diseases.", "She drinks socially but has never smoked or used drugs.", "She has never taken any medications except for over the counter analgesics and antipyretics.", "Physical exam shows that the cord-like lesion is tender, thick, and hardened on palpation."], "Patient Symptoms": ["She says that she has had multiple such lesions previously."], "Examination and Results": ["In addition, she has a lacy mottled violaceous rash on multiple extremities."]}
{"Patient Personal Background": ["Past medical history is insignificant."], "Patient Symptoms": ["The patient denies dyspnea, fatigue, and syncope."], "Examination and Results": ["Her temperature is 37.0 degrees C, blood pressure is 115/75 mm Hg, pulse is 76/min, and respiratory rate is 16/min.", "Transthoracic echocardiography reveals a large, pedunculated tumor in the left atrium."]}
{"Patient Personal Background": ["She was born at 39 weeks via spontaneous vaginal delivery, has met all developmental milestones and is fully vaccinated.", "Past medical history is significant for mild allergies to pet dander and ragweed, as well as a severe peanut allergy.", "She also has asthma.", "She normally carries both an emergency inhaler and EpiPen but forgot them today."], "Patient Symptoms": ["On physical examination, the patient has severe edema over her face and an audible stridor in both lungs."], "Examination and Results": ["The vital signs include: blood pressure 112/87 mm Hg, heart rate 111/min, respiratory rate 25/min, and temperature 37.2\u00b0C (99.0\u00b0F).", "On physical examination, the patient has severe edema over her face and an audible stridor in both lungs."], "Others": ["Family history is noncontributory."]}
{"Examination and Results": ["On microscopic examination, the biopsy sample shows uniform squamous cells in layers."], "Treatment": ["He obtains a biopsy from the mainstem bronchus of a patient."]}
{"Patient Symptoms": ["She has severe facial acne and dense black hairs on her upper lip, beneath her hairline anterior to her ears, and the back of her neck."], "Examination and Results": ["Ultrasound reveals bilateral enlarged ovaries with multiple cysts."]}
{"Patient Symptoms": ["He states that he first noticed the lesion last year, but he believes that it has been slowly growing in size."], "Examination and Results": ["Dermatopathology determines that the lesion contains neoplastic cells of melanocytic origin."], "Diagnosis": ["Dermatopathology determines that the lesion contains neoplastic cells of melanocytic origin."]}
{"Patient Personal Background": ["She has hypertension and hyperlipidemia.", "Her medications prior to admission were hydrochlorothiazide and atorvastatin."], "Patient Symptoms": ["During the fall she sustained a right-sided subdural hematoma."], "Examination and Results": ["Vital signs are within normal limits.", "Physical and neurologic examinations show no abnormalities.", "Laboratory studies show:\nSerum\nNa+ 130 mEq/L\nK+ 4.0 mEq/L\nCl- 103 mEq/L\nHCO3- 24 mEq/L\nUrea nitrogen 14 mg/dL\nCreatinine 1.1 mg/dL\nOsmolality 270 mOsmol/kg H2O\nUrine\nSodium 45 mEq/L\nOsmolality 326 mOsmol/kg H2O\nA CT scan of the head shows an unchanged right-sided subdural hematoma."]}
{"Patient Symptoms": ["The mother states that she noticed the bleeding today, which appeared as brown discharge with clots in the patient\u2019s diaper.", "She does mention that the patient has been limping and complaining of left leg pain since a fall 2 months ago."], "Examination and Results": ["On physical exam, there are multiple 2-3 cm hyperpigmented patches on the patient\u2019s trunk.", "There is bilateral enlargement of the breasts but no pubic hair.", "The vaginal orifice is normal and clear with an intact hymen.", "A plain radiograph of the left lower leg shows patchy areas of lytic bone and sclerosis within the femoral metaphysis."], "Others": ["The mother denies frequent nosebleeds or easy bruising.", "She also denies any known trauma."]}
{"Examination and Results": ["Cardiac catheterization shows occlusion that has caused a 50% reduction in the diameter of the left circumflex artery."]}
{"Examination and Results": ["Examination of the lower extremities shows no redness or swelling.", "When the child stands on his right leg, his left leg drops and his pelvis tilts towards the left.", "Sensation to light touch is normal in both legs."]}
{"Examination and Results": ["Physical examination shows a well-appearing toddler with a palpable left-sided abdominal mass that does not cross the midline.", "A CT of the abdomen shows a large, necrotic tumor on the left kidney.", "Histological examination of the kidney mass shows primitive blastemal cells and immature tubules and glomeruli."]}
{"Patient Personal Background": ["His father received a renal transplant in his 20s."], "Patient Symptoms": ["His mother says they have to speak at a higher volume for him to understand them.", "He also complains of having difficulty reading his favorite books because he is not able to see the words clearly."], "Examination and Results": ["The vital signs are within normal limits.", "The physical examination shows no abnormalities.", "Laboratory studies show:\nSerum\nUrea nitrogen 15 mg/dL\nCreatinine 1.0 mg/dL\nUrine\nBlood 1+\nProtein 1+\nRBC 15\u201317/hpf\nWBC 1\u20132/hpf\nThe audiometry shows bilateral high-frequency sensorineural hearing loss.", "The ophthalmologic examination shows anterior lenticonus."]}
{"Patient Personal Background": ["She has never had a period and is anxious that she is not \u201ckeeping up\u201d with her friends.", "The patient is a competitive ice skater and has never been sexually active.", "Her mother has a history of migraine headaches, and her older sister has a history of bipolar disorder.", "Both underwent menarche at age 15."], "Patient Symptoms": ["She has never had a period and is anxious that she is not \u201ckeeping up\u201d with her friends.", "Review of systems reveals that she has also been getting headaches every few months over the last year with some photosensitivity and nausea each time."], "Examination and Results": ["At this visit, the patient\u2019s temperature is 98.6\u00b0F (37.0\u00b0C), pulse is 70/min, blood pressure is 118/65 mmHg, and respirations are 13/min.", "Her body mass index is 23.8 kg/m^2.", "Cardiopulmonary and abdominal exams are unremarkable.", "Both breasts are Tanner IV with no expressable discharge.", "Pelvic and axillary hair growth is also Tanner IV.", "The patient is unable to tolerate a full pelvic exam, but the part of the vaginal canal that is examined is unremarkable.", "Laboratory studies are ordered and are below:\n\nSerum:\nNa+: 139 mEq/L\nK+: 4.1 mEq/L\nCl-: 100 mEq/L\nHCO3-: 24 mEq/L\nUrea nitrogen: 12 mg/dL\nGlucose: 73 mg/dL\nCreatinine: 0.9 mg/dL\nCa2+: 9.7 mg/dL\nMg2+: 1.7 mEq/L\nAST: 11 U/L\nALT: 11 U/L\nFollicle Stimulating Hormone (FSH): 16.2 mIU/mL (4.7-21.5 mIU/ml)\nEstrogen: 240 pg/mL (64-357 pg/mL)\n\nAbdominal ultrasound is performed and shows a normal uterus and ovaries."], "Treatment": ["Ibuprofen relieves her symptoms."]}
{"Patient Personal Background": ["He has had similar episodes in the past when he also had to be rushed to the hospital."], "Examination and Results": ["Physical examination shows body temperature is 37.2\u00b0C (98.9\u00b0F), pulse rate is 100/min, respiratory rate is 28/min and blood pressure is 110/60 mm Hg.", "Also, it shows decreased breath sounds on both sides, the peak expiratory flow rate is 200 L/min and SpO2 is 89% on room air.", "An arterial blood gas analysis shows the following:\npH 7.48\nPaO2 59 mm Hg\nPaCO2 26 mm Hg\nHCO3- 26 mEq/L\nAfter administering oxygen by mask, the man\u2019s PaO2 increases to 75 mm Hg."], "Treatment": ["The man is given an initial treatment with nebulization using an inhaled short-acting \u03b2-agonist."]}
{"Patient Symptoms": ["A physical exam on admission reveals scleral icterus and a flapping tremor of the wrists during extension.", "The next morning on rounds, he complains of eleven episodes of diarrhea and near-constant flatulence overnight."], "Examination and Results": ["A physical exam on admission reveals scleral icterus and a flapping tremor of the wrists during extension."], "Treatment": ["The patient is admitted to the hospital and his treatment is started after appropriate investigation."], "Others": ["Past medical records are unavailable."]}
{"Patient Personal Background": ["His medical history is notable for poorly controlled hypertension and hyperlipidemia.", "He takes enalapril, hydrochlorothiazide, aspirin, and atorvastatin.", "He has a 40 pack-year smoking history and drinks 3-4 beers per day.", "His diet consists primarily of fast food."], "Patient Symptoms": ["He reports a 4-day history of steady right lower quadrant pain.", "He has had one small bowel movement in 4 days.", "Normally he has a bowel movement once a day."], "Examination and Results": ["His temperature is 101.8\u00b0F (38.8\u00b0C), blood pressure is 160/95 mmHg, pulse is 90/min, and respirations are 16/min.", "Relevant findings included multiple small, pedunculated polyps which were removed, multiple colonic mucosal outpouchings, and no other masses."], "Others": ["A review of the patient\u2019s medical record reveals colonoscopy results from 1 year ago."]}
{"Patient Personal Background": ["Past medical history is significant for hypertension and a hemorrhagic stroke 6 years ago, which was treated surgically."], "Patient Symptoms": ["The patient\u2019s eldest daughter says that he couldn\u2019t move his arm during the episode.", "After admission, the patient gets increasingly worse and loses consciousness."], "Examination and Results": ["A noncontrast CT of the head shows a subarachnoid hemorrhage (SAH).", "Several days later, a repeat CT of the head shows an enlarging aneurysm in a different vessel in the brain."], "Treatment": ["The patient is taken to the operating room, where the SAH evacuated, and the vessel is repaired."], "Others": ["Postoperatively, the patient is unresponsive.", "The patient\u2019s daughter is asked to consent to a non-emergent, life-saving operation since the patient is in a comatose state.", "She does not consent to the operation even though the physician stresses it would be life-saving.", "Upon further discussion, the physician finds out that the patient was abusive and neglectful to his children, and the daughter wants \u201cto live in peace.\u201d The patient has no written advanced directive."]}
{}
{"Patient Symptoms": ["On physical examination, the patient is unconscious with a GCS of 9/15 and is cyanotic."], "Examination and Results": ["The patient\u2019s vitals are as follows: blood pressure 80/40 mm Hg, heart rate 111/min, respiratory rate 39/min, and temperature 37.1\u00b0C (98.8\u2109).", "There are open fractures of the left femur and left tibia, a likely shoulder dislocation, multiple contusions on the limbs and thorax, and a puncture wound on the left side of his chest.", "There are no breath sounds on the left side and there is hyperresonance to percussion on the left."], "Treatment": ["Preparations are made for an emergency needle thoracostomy to be performed to treat this patient\u2019s likely tension pneumothorax."], "Diagnosis": ["Preparations are made for an emergency needle thoracostomy to be performed to treat this patient\u2019s likely tension pneumothorax."]}
{"Examination and Results": ["The researchers collect data through interviewer-administered questionnaires (for behavioral and sociodemographic data) as well as through clinical and serological evaluation/screening methods for HIV and other sexually transmitted infections."], "Others": ["An additional aim is to evaluate the association between HIV acquisition and certain sociodemographic factors."]}
{"Examination and Results": ["Examination shows pale conjunctivae.", "His hemoglobin concentration is 8.3 g/dL and mean corpuscular volume is 72\u03bcm3.", "Colonoscopy shows a 2.3-cm polypoid mass in the ascending colon.", "A photomicrograph of a biopsy specimen of the lesion is shown."]}
{"Patient Symptoms": ["Her pain is not improved by over the counter analgesics."], "Examination and Results": ["Laboratory analysis is notable for a calcium level of 11.5 mg/dL, creatinine level of 2.0 mg/dL, and blood urea nitrogen level of 30 mg/dL.", "Large eosinophilic casts are seen on renal biopsy."]}
{"Patient Personal Background": ["Past medical history includes diabetes, congestive heart failure, and incontinence.", "She is currently taking metformin, lisinopril, hydrochlorothiazide, metoprolol, and oxybutynin."], "Patient Symptoms": ["She could not get up without assistance and complained of severe pain in her right hip and buttock.", "The nurse who evaluated her tried to stand her up, but when the patient tried to stand on her right leg, she dropped her left hip and lost her balance."], "Examination and Results": ["The nurse then recognized that her patient had a foreshortened right leg fixed in the adducted position and a large swelling in her right buttock.", "Physical exam confirmed the nurse\u2019s findings.", "Radiographs proved the presence of a right posterior hip dislocation without fractures."], "Others": ["At the receiving hospital, the patient was confused and, though she knew her name, she couldn\u2019t remember the date and insists to leave the hospital immediately to see her family."]}
{"Patient Personal Background": ["She is healthy with no prior history of significant illness.", "She exercises 3-4 times a week and eats a plant-based diet with no carbonated drinks."], "Patient Symptoms": ["When asked if anything is bothering her, she reports that she has been having recurring episodes of sneezing, congestion, and itchy eyes for the past year.", "She denies any fever, sick contacts, cough, headaches, chest pain, urinary symptoms, or constipation/diarrhea during these episodes."], "Treatment": ["She is told to take a medication to alleviate her symptoms as needed."]}
{"Patient Symptoms": ["Although she has not had any recent changes in her daily routines, she also complains of increasing fatigue, muscle weakness, and weight loss."], "Examination and Results": ["She has a blood pressure of 126/77 mm Hg, respiratory rate of 14/min, and heart rate of 88/min.", "Physical examination reveals regular heart and lung sounds.", "Anti-U1 RNP antibodies and increased creatinine kinase were found in her serum."]}
{"Patient Personal Background": ["During high school, the patient went through similar episodes of low mood and poor sleep.", "At that time, she would repeatedly engage in binge eating and purging behavior, for which she was referred to therapy."], "Patient Symptoms": ["During this time, she has also has had low energy and has lost interest in playing the guitar."], "Treatment": ["Her physician offers to prescribe a medication for her current symptoms."], "Others": ["There is no evidence of suicidal ideation."]}
{"Patient Personal Background": ["He has hypertension and type 2 diabetes mellitus.", "Current medications include glyburide, hydrochlorothiazide, and enalapril."], "Patient Symptoms": ["He reports that his vision has progressively improved over the past 6 months and he no longer needs the glasses he used while driving."], "Examination and Results": ["Examination shows 20/20 vision bilaterally.", "Fundoscopy shows a few microaneurysms of retinal vessels."]}
{"Patient Personal Background": ["Past records show that this patient has been in the ER 7 times in the past year with similar symptoms."], "Patient Symptoms": ["She does not recall trauma to the arm.", "She also complains of diarrhea and nausea.", "She is sexually active with one male partner and admits to having pain during intercourse."], "Examination and Results": ["There is vague and diffuse tenderness to palpation in all four abdominal quadrants.", "No erythema or edema is noted on the right arm.", "The fecal occult test is negative."]}
{"Patient Personal Background": ["The patient has a history of severe meningoencephalitis at the age of 17 requiring four days in the intensive care unit.", "During that episode, he reported seeing monkeys in his hospital room."], "Patient Symptoms": ["He is accompanied by his mother who reports that the patient recently experienced a 5-day episode of minimal sleep and unusual levels of energy.", "The patient admits to spending $2,000 of his parent\u2019s money, without asking, on a down payment for a motorcycle.", "The patient\u2019s medical history is notable for multiple month-long episodes in the past 2 years of feeling sad, sleeping more than usual, being uninterested in his hobbies, and feeling constantly tired and guilty.", "He states that he feels sad and guilty about what happens."], "Examination and Results": ["On exam, he is a well-appearing, cooperative male in no acute distress.", "He is alert and oriented with a normal affect."], "Others": ["The episode resolved after 5 days, at which point the patient felt guilty and upset.", "He denies suicidal ideation."]}
{"Patient Personal Background": ["She was diagnosed with ulcerative colitis 1 year ago but has had difficulty complying with her drug regimen."], "Patient Symptoms": ["Examination shows a distended, rigid abdomen and hypoactive bowel sounds."], "Examination and Results": ["Her temperature is 38.2\u00b0C (100.8\u00b0F), pulse is 120/min, and blood pressure is 92/56 mm Hg.", "Examination shows a distended, rigid abdomen and hypoactive bowel sounds."], "Treatment": ["Fluid resuscitation is initiated."]}
{"Patient Symptoms": ["He felt a sudden difficulty in breathing and called for the ward nurse.", "He says that he is unable to take deep breaths and has a sharp pain on the right side of his chest with each inspiration.", "He experiences pain in his right calf on dorsiflexion."], "Examination and Results": ["He has been confined to bed for the past 5 days and is under observation.", "His temperature is 37.5\u00b0C (99.8\u00b0F), the pulse is 111/min, the respirations are 31/min, and the blood pressure is 85/55 mm Hg.", "There are no other prominent findings on physical examination.", "His chest X-ray does not show anything significant.", "The ECG reveals sinus tachycardia."]}
{"Patient Personal Background": ["The patient is a retired banking executive and was active as a triathlete until the age of 60.", "He does not smoke and drinks 2-3 alcoholic beverages per day.", "His family history is notable for normal pressure hydrocephalus in his mother and Alzheimer dementia in his father."], "Patient Symptoms": ["Approximately 6 months ago, she started noticing that he was walking more slowly than usual.", "He has fallen more than 6 times in the past month, and she is worried that he will sustain a serious injury if he does not stop falling."], "Examination and Results": ["His temperature is 97.8\u00b0F (36.6\u00b0C), blood pressure is 131/81 mmHg, pulse is 68/min, and respirations are 19/min.", "On exam, his movements appear slowed and forced.", "He shuffles his feet when he walks.", "Tone is increased in his upper and lower extremities bilaterally."]}
{"Patient Personal Background": ["He is exclusively breastfed."], "Examination and Results": ["His mother says that he has not yet begun to walk.", "He is at the 20th percentile for length, 10th percentile for weight, and 50th percentile for head circumference.", "Physical examination shows erosion of the enamel on the lingual surface of the incisors and carious molars.", "He has frontal bossing.", "His wrists are widened, his legs appear bowed, and there is beading of the ribs."]}
{"Patient Symptoms": ["The patient is in acute distress and cannot provide history due to disorientation.", "On examination, his sclera and skin are icteric.", "On abdominal examination, the patient moans with deep palpation to his right upper quadrant."], "Examination and Results": ["Temperature is 38.7\u00b0C (101.6\u00b0F), blood pressure is 80/50 mm Hg, pulse is 103/min, respiratory rate is 22/min, and BMI is 20 kg/m2.", "Laboratory test\nComplete blood count\nHemoglobin 14.5 g/dL\nMCV 88 fl\nLeukocytes 16,500/mm3\nPlatelets 170,000/mm3\nBasic metabolic panel\nSerum Na+ 147 mEq/L\nSerum K+ 3.8 mEq/L\nSerum Cl- 106 mEq/L\nSerum HCO3- 25 mEq/L\nBUN 30 mg/dL\nSerum creatinine 1.2 mg/dL\nLiver function test\nTotal bilirubin 2.8 mg/dL\nAST 50 U/L\nALT 65 U/L\nALP 180 U/L\nThe patient is treated urgently with intravenous fluid, dopamine, and broad spectrum antibiotics.", "On ultrasound of the abdomen, the common bile duct is dilated."], "Treatment": ["The patient\u2019s blood pressure improves to 101/70 mm Hg."]}
{"Patient Personal Background": ["Over the past 2 years, she has had five urinary tract infections."], "Examination and Results": ["Her blood pressure is 150/88 mm Hg.", "Physical examination shows bilateral, nontender upper abdominal masses.", "Serum studies show a urea nitrogen concentration of 29 mg/dL and a creatinine concentration of 1.4 mg/dL.", "Renal ultrasonography shows bilaterally enlarged kidneys with multiple parenchymal anechoic masses."]}
{"Patient Personal Background": ["She has a past medical history significant for sarcoidosis which was recently diagnosed 6 months ago and is currently being treated."], "Patient Symptoms": ["She reports that the pain started 2 weeks ago and is localized to the left hip and groin.", "The pain has been getting progressively more intense."], "Examination and Results": ["Her temperature is 98.1\u00b0F (36.7\u00b0C), blood pressure is 122/78 mm Hg, pulse is 80/min, respirations are 13/min, and oxygen saturation is 98% on room air.", "Physical exam is notable for pain with manipulation without restriction of range of motion of the hip."]}
{"Patient Personal Background": ["The patient states that he just arrived in the United States to live with his wife, with whom he is monogamous."], "Patient Symptoms": ["The patient denies painful urination or urethral discharge, but admits that 10 days ago he \u201cfelt like he had a fever\u201d and the right side of his face was swollen and painful."]}
{"Patient Personal Background": ["Pregnancy has been complicated by gestational diabetes.", "Pregnancy and delivery of her first child were uncomplicated.", "Current medications include insulin, folic acid, and a multivitamin."], "Patient Symptoms": ["The patient reports severe pelvic pain.", "Ten minutes later, the patient has dizziness."], "Examination and Results": ["Vital signs are within normal limits.", "The cervix is 100% effaced and 10 cm dilated; the vertex is at -1 station.", "The fetal heart rate is reactive with no decelerations.", "Her pulse is 68/min, respirations are 16/min, and blood pressure is 90/60 mm Hg."], "Treatment": ["Epidural anesthesia is performed and the patient's symptoms improve.", "Intravenous fluid resuscitation is begun."]}
{"Patient Personal Background": ["Her medical history includes asthma and sickle cell disease.", "She takes hydroxyurea, uses oxycodone as needed for pain, and an albuterol inhaler as needed for shortness of breath."], "Patient Symptoms": ["She is accompanied by her son, who states that the patient had just returned home an hour ago from walking the dog when suddenly the patient stated she felt \u201cstrange.\u201d When her son asked her what was wrong, her speech was slurred and her \"face looked funny.\u201d The son quickly called an ambulance.", "The paramedic upon arrival noted that the patient had left-sided facial droop.", "She has trouble articulating her words, and her speech is garbled."], "Examination and Results": ["The patient\u2019s temperature is 97\u00b0F (36.1\u00b0C), blood pressure is 145/72 mmHg, pulse is 93/min, and respirations are 14/min with an oxygen saturation of 96% on room air.", "On physical examination, a left-sided facial droop is appreciated."], "Treatment": ["She is put on 2 L of oxygen by nasal cannula."], "Others": ["Labs are obtained and pending."]}
{"Patient Symptoms": ["Soon after hospitalization, he develops respiratory distress with crackles present bilaterally on physical examination."], "Examination and Results": ["Soon after hospitalization, he develops respiratory distress with crackles present bilaterally on physical examination.", "Autopsy reveals heavy, red lungs and histology is shown in Image A."], "Treatment": ["The patient does not respond to mechanical ventilation and 100% oxygen and quickly dies due to respiratory insufficiency."]}
{"Patient Personal Background": ["He has a history of several episodes of mild bone pain in the past treated with over the counter analgesics."], "Patient Symptoms": ["On physical examination, the child is icteric with nonspecific pain in his hands.", "His hands are swollen, tender, and warm."], "Examination and Results": ["There is no chest pain, abdominal pain, fever, or hematuria.", "A complete metabolic panel and complete blood count with manual differential are performed:\nTotal bilirubin\n8.4 mg/dL\nWBC\n9,800/mm3\nHemoglobin \n6.5 g/dL\nMCV 82.3 fL\nPlatelet count  465,000/mm3\nReticulocyte 7%\nPeripheral blood smear shows multiple clumps of elongated and curved cells and erythrocytes with nuclear remnant."], "Others": ["The patient's hemoglobin electrophoresis result is pictured below."]}
{"Patient Personal Background": ["He was diagnosed with heart failure 1 year ago.", "He reports that he has been taking low-dose aspirin and digoxin regularly for 1 year, and verapamil was recently added to prevent his frequent migraine headaches."], "Examination and Results": ["An electrocardiogram is performed urgently and shows paroxysmal atrial tachycardia with block.", "Suspecting digitalis toxicity, the emergency medicine physician sends blood to the lab for a serum digoxin level, which is 3.7 ng/mL (therapeutic range: 0.8\u20132 ng/mL)."], "Treatment": ["He reports that he has been taking low-dose aspirin and digoxin regularly for 1 year, and verapamil was recently added to prevent his frequent migraine headaches."], "Others": ["During his last visit to his primary care physician, he was doing well and the lab results were normal."]}
{"Patient Personal Background": ["He has acute myeloid leukemia and is currently receiving chemotherapy."], "Patient Symptoms": ["On arrival, his temperature is 37\u00b0C (98.6\u00b0F), pulse is 63/min, respirations are 10/min, and blood pressure is 100/70 mm Hg.", "He does not respond to any commands, but does groan.", "Painful stimuli cause him to open his eyes and withdraw all extremities."], "Examination and Results": ["On arrival, his temperature is 37\u00b0C (98.6\u00b0F), pulse is 63/min, respirations are 10/min, and blood pressure is 100/70 mm Hg.", "The pupils are equal and sluggish.", "There are multiple bruises over the face, trunk, and right upper and lower extremities.", "There is a 4-cm (1.6-in) laceration over his right cheek.", "There are decreased breath sounds over the right lung base.", "There is tenderness to palpation over the left chest wall.", "Cardiac examination shows no abnormalities.", "The abdomen is soft and shows diffuse tenderness to palpation with no guarding or rebound.", "There is swelling of the right elbow and wrist.", "The right lower extremity is shorter than the left lower extremity.", "There are 2 lacerations around 2 cm (0.8 in) each on the right leg.", "The right knee is swollen."], "Diagnosis": ["He has acute myeloid leukemia and is currently receiving chemotherapy."]}
{"Others": ["Due to the cumulative effects of diabetes, various health screenings and vaccinations are routinely recommended."]}
{"Patient Personal Background": ["Past medical history is negative for any neurological and cardiovascular problems."], "Patient Symptoms": ["Consciousness is regained after cardiopulmonary resuscitation."], "Examination and Results": ["Physical examination reveals a prominent A wave on the jugular venous pulse and a double apical impulse.", "There are no audible murmurs.", "An S4 is present."], "Others": ["There is no history of injury."]}
{"Patient Personal Background": ["The patient does not smoke cigarettes but reportedly drinks 2 glasses of wine daily.", "He has multiple sexual partners and history regarding the contraceptive use is unavailable."], "Patient Symptoms": ["According to the attendants, he has complained of recurrent headaches for the past 2 weeks."], "Examination and Results": ["There is no history of fever, head trauma, or a seizure disorder.", "The patient\u2019s vitals include: blood pressure 137/88 mm Hg, temperature 37.2\u00b0C (99.0\u00b0F).", "On physical examination, he is obtunded.", "He grimaces on pain and localizes in response to pain in both upper extremities.", "Pupils are bilateral 3-mm in diameter and equally round and reactive.", "Laboratory tests are within normal limits.", "An MRI of the brain with contrast is shown in the exhibit (see image).", "A brain biopsy is performed that reveals perivascular clusters of lymphocytes."]}
{"Patient Personal Background": ["She is gravida 1, para 0 with an estimated gestational age of 19 weeks.", "She says that the murmur was found in her childhood, and the doctor at that time placed her under observation only.", "However, she has been lost to follow-up and has not had proper follow up in years."], "Patient Symptoms": ["Currently, she complains of dizziness and occasional dyspnea on exertion which has gradually increased during her pregnancy.", "Prior to her pregnancy, she did not have any symptoms."], "Examination and Results": ["The vital signs are as follows: blood pressure 125/60 mm Hg, heart rate 81/min, respiratory rate 13/min, and temperature 36.7\u00b0C (98.0\u00b0F).", "Her examination is significant for acrocyanosis and a fixed splitting of S2 and grade 3/6 midsystolic murmur best heard over the left upper sternal border."]}
{"Patient Personal Background": ["He denies taking any medications or illicit drugs and states he is generally healthy."], "Patient Symptoms": ["The patient states that he has not felt well for the past 24 hours and his symptoms are no longer tolerable.", "Physical exam is notable for rhinorrhea, lacrimation, and piloerection.", "During the exam, he begins actively vomiting."], "Examination and Results": ["His temperature is 99.3\u00b0F (37.4\u00b0C), blood pressure is 122/88 mmHg, pulse is 107/min, respirations are 19/min, and oxygen saturation is 99% on room air.", "Physical exam demonstrates an ill appearing young man.", "The patient\u2019s pupils are dilated and reactive to light.", "During placement of an ultrasound guided IV, multiple scars are noted in the antecubital fossa, and it is noted that it is very difficult to place an IV in this patient."]}
{"Patient Personal Background": ["She and her husband recently bought a new house in the area."], "Patient Symptoms": ["She reports blacking out and waking up outside the house with a bandage on her arm.", "The patient says she has tried to enter the house several times over the last several months but can not bring herself to cross the threshold for fear of more spiders."], "Others": ["While cleaning the house, they discovered a nest of spiders.", "Her husband says that she began screaming and ran out of the house, breaking a window, and cutting her arm.", "She wants to overcome her extreme and irrational fear."]}
{"Patient Personal Background": ["He has long-standing hypertension, coronary artery disease, and hypercholesterolemia.", "Current medications include aspirin, carvedilol, enalapril, and atorvastatin."], "Patient Symptoms": ["He reports that these symptoms seem to worsen with each fall.", "Initially, he could not remember directions to his home but now cannot remember recent conversations or appointments he has made.", "He often repeats questions that he asked shortly before."], "Examination and Results": ["Examination shows a bruise over the left temple and an unsteady gait.", "On mental status examination, he is oriented to place and person only.", "Short-term memory is impaired; he can recall 0 out of 5 objects after 10 minutes.", "Long-term memory is intact.", "Muscle strength is decreased in the left lower extremity.", "The Babinski sign is present on the left."], "Others": ["He has no delusions or hallucinations.", "A CT scan of the head is shown."]}
{"Examination and Results": ["On examination, the cervix is 100% effaced and 10 cm dilated.", "After 5 minutes of pushing, there is a prolonged deceleration of the fetal heart rate to 90/min."], "Treatment": ["A decision to perform an episiotomy is made to expedite vaginal delivery.", "The anesthesiologist locates the ischial spines by palpating the posterolateral vaginal sidewall and administers an anesthetic.", "Three minutes later, pinching the posterior vulva does not provoke pain."]}
{"Patient Personal Background": ["She has not been compliant with antiretroviral or prophylactic medication."], "Patient Symptoms": ["On evaluation, the patient is in moderate respiratory distress.", "After 30 minutes, the patient develops severe respiratory distress."], "Examination and Results": ["The temperature is 38.8\u00b0C (102.0\u00b0F), the blood pressure is 124/82 mm Hg, the pulse is 96/min, and the respiratory rate is 20/min.", "Pulse oximetry is 92% on 4 L oxygen by nasal cannula.", "Her CD4 count is 180 cells/\u03bcL.", "Repeat vital signs show: temperature 38.3\u00b0C (101.0\u00b0F), blood pressure 80/50 mm Hg, pulse 104/min, respiration rate 32/min and pulse oximetry 85% on nasal cannula.", "The trachea deviates to the left.", "Breath sounds are absent on the right side and the neck veins are distended.", "Telemetry shows sinus tachycardia."], "Treatment": ["IV antibiotics and glucocorticoids are administered."]}
{"Patient Symptoms": ["Physical examination shows tenderness to palpation over the left adnexa and rebound tenderness in the left lower quadrant."], "Examination and Results": ["Her last menstrual period was 2 weeks ago.", "There is no tenderness in the right lower quadrant.", "Urine pregnancy test is negative.", "An ultrasound is ordered to confirm the diagnosis of ruptured ovarian cyst."]}
{"Patient Personal Background": ["She has a history of major depressive disorder but has been off medications for the past 3 years.", "Her father had Parkinson's disease and died 6 months ago.", "She drinks a glass of wine daily."], "Patient Symptoms": ["She has noticed trembling of her hands for the past 5 months.", "These movements are only present when she reaches to pick up an object or answer the phone.", "She appears anxious."], "Examination and Results": ["Her temperature is 37\u00b0C (98.6\u00b0F), pulse is 80/min, and blood pressure is 118/74 mm Hg.", "A low-frequency tremor is present that worsens as she reaches out for an object.", "She consistently overshoots her target.", "There is no tremor present when her arms are held outstretched.", "There is increased tone in the lower extremities and Babinski's sign is positive bilaterally."]}
{"Patient Personal Background": ["Four months ago, he had an episode of narrow-angle glaucoma.", "He takes no medications."], "Patient Symptoms": ["He reports having clear liquid discharge from his nose and sneezing.", "He says that his symptoms began suddenly the previous night, 30 minutes after he had dinner at a seafood restaurant.", "He has had similar symptoms occasionally in the past as well."], "Examination and Results": ["His vital signs are within normal limits.", "Nasal exam shows clear, serous secretions, with edematous and erythematous mucosa and turbinates.", "Paranasal sinuses are not tender to palpation."]}
{"Patient Personal Background": ["He lives in a conservative community and does not know any openly gay men."], "Others": ["Two days ago, he joined a local group considered by many organizations to be a hate group.", "Together with the other members, he attacked a gay couple on their way home from dinner."]}
{"Patient Personal Background": ["The patient was previously healthy except for mild untreated hypertension."], "Patient Symptoms": ["The patient states that she has noticed a pink tinge to her urine as well.", "Of note, she has not had any fevers, but endorses several months of fatigue and constipation."], "Examination and Results": ["On exam, her temperature is 98.6\u00b0F (37.0\u00b0C), blood pressure is 130/84 mmHg, pulse is 76/min, and respirations are 12/min.", "On further workup, the patient is found to have calcium oxalate nephrolithiasis with hypercalciuria.", "Blood studies demonstrate increased parathyroid hormone (PTH) and hypercalcemia."]}
{"Patient Symptoms": ["She has felt tired and unwilling to engage in any activities lately.", "She states that her limbs feel heavy all the time and that completing any activity takes tremendous effort.", "She no longer finds any happiness in activities that she previously enjoyed.", "She also states that she really struggles to sleep and at times can't sleep for several days."], "Treatment": ["The patient is started on appropriate first-line therapy and sent home."], "Others": ["She returns 1 week later stating that her symptoms have not improved.", "She is requesting help as her performance at work and school is suffering."]}
{"Patient Personal Background": ["Since almost a year and a half ago, she intentionally restricted her diet at the expense of carbohydrates, exercised intensively, and lost 18.0 kg (39.7 lb).", "She is not sexually active."], "Patient Symptoms": ["Her last period was 6 months ago."], "Examination and Results": ["On physical examination, the vital signs include blood pressure 100/60 mm Hg, heart rate 55/min, respiratory rate 12/min, and temperature 35.9\u00b0C (96.6\u00b0F).", "Her weight is 55.0 kg (121.3 lb), and her height is 166 cm (5 ft 5 in).", "Physical examination reveals the good development of muscles and decreased adiposity.", "A bone scan shows decreased calcium mineral deposits."], "Others": ["She had her menarche at the age of 12 and menstruated normally until last year."]}
{"Patient Symptoms": ["Her sore throat is worse on the right side.", "She has difficulty swallowing and opening her mouth due to pain.", "She has also noticed a change in the quality of her voice over the last day."], "Examination and Results": ["Her temperature is 38.2\u00b0C (100.8\u00b0F), pulse is 86/min, respirations are 18/min, and blood pressure is 110/75 mm Hg .", "Examination shows cervical lymphadenopathy.", "Oropharyngeal examination shows erythematous tonsils and swelling of the right tonsillar pillar.", "The uvula is deviated to the left."]}
{"Patient Personal Background": ["She has had a lot of stress at work and has been on sick leave for 2 weeks, but states that she would like to return to work.", "She was diagnosed with peptic ulcer disease 6 months ago.", "Her only medication is omeprazole."], "Patient Symptoms": ["She has had several episodes of lower abdominal pain.", "She says, \"\"I know I have cancer.\"\"", "On mental status examination she is tired and has a depressed mood.", "There are numerous crusts along the course of her left arm veins.", "There is generalized weakness of the proximal muscles."], "Examination and Results": ["The patient appears pale.", "Her temperature is 36.5\u00b0 C (97.7\u00b0 F), pulse is 120/min, and blood pressure is 90/65 mm Hg.", "Physical examination shows pale conjunctivae and dry mucous membranes.", "A grade 2/6 systolic ejection murmur is heard along the right-upper sternal border.", "Abdominal examination shows no abnormalities.", "Laboratory studies show:\nHemoglobin 7.5 g/dL\nMean corpuscular volume 89 \u03bcm3\nReticulocyte count 13.3%\nSerum\nSodium 139 mEq/L\nPotassium 3.9 mEq/L\nCalcium 8.5 mg/dL\nTest of the stool for occult blood is negative.", "Abdominal ultrasonography show no abnormalities."], "Treatment": ["She requests a diagnostic laparoscopy."]}
{"Patient Personal Background": ["She has no history of serious illness and takes no medications."], "Patient Symptoms": ["Examination shows jaundice of the skin and conjunctivae.", "Abdominal examination shows moderate tenderness over the liver."], "Examination and Results": ["Her temperature is 38.3\u00b0C (100.9\u00b0F), pulse is 80/min, and blood pressure is 138/76 mm Hg.", "The liver is palpated 2 to 3 cm below the right costal margin.", "Laboratory studies show:\nHemoglobin count 12.0 g/dL\nLeukocyte count 10,400 mm3\nSegmented neutrophils 55%\nBands 1%\nEosinophils 13%\nLymphocytes 28%\nMonocytes 3%\nPlatelet count 160,000 mm3\nSerum\nAlkaline phosphatase 102 U/L\nAspartate aminotransferase 760 U/L\nBilirubin\nTotal 3.8 mg/dL\nDirect 3.1 mg/dL\nAnti-HAV IgG positive\nAnti-HAV IgM negative\nAnti-HBs positive\nHBsAg negative\nAnti-HCV antibodies negative\nAbdominal ultrasonography shows an enlarged liver.", "A biopsy of the liver shows massive centrilobular necrosis."], "Treatment": ["During the surgery, she received a transfusion of 1 unit of packed red blood cells."], "Others": ["Three days after the surgery, she was stable enough to be transported back to the United States."]}
{"Patient Personal Background": ["She has type 2 diabetes mellitus and hypertension.", "She does not smoke or drink alcohol.", "Home medications include metformin, amlodipine, and enalapril."], "Patient Symptoms": ["She has also had several episodes of nosebleeds that resolved with compression after a few minutes."], "Examination and Results": ["Her vital signs are within normal limits.", "Physical examination shows pale conjunctivae.", "There are ecchymoses and petechiae over the upper extremities, chest, and back.", "There is no lymphadenopathy."], "Treatment": ["She recently completed treatment for a urinary tract infection."], "Others": ["She has had no changes in her weight.", "Her last menstrual cycle was 5 years ago.", "The remainder of the physical examination is unremarkable."]}
{"Patient Personal Background": ["He did not take any medications, did not smoke, and had no family history of gastric cancer."], "Patient Symptoms": ["At the last visit a few months ago, he explained that he had been experiencing discomfort in his upper abdomen for awhile.", "Today, despite the PPI, the patient says he is still experiencing discomfort."], "Treatment": ["At that time, the doctor empirically started him on a proton pump inhibitor (PPI)."], "Others": ["He had never vomited up any blood and had not had any substantial weight loss.", "Hearing this, the doctor decides to order a urease breath test."]}
{"Patient Personal Background": ["She reports that she and her husband had been trying to have a child for the past three months.", "She has no history of sexually transmitted disease, intravenous drug use, or blood transfusions, and she has never traveled outside of the United States.", "She was up-to-date on all immunizations before her pregnancy."], "Examination and Results": ["Ultrasound is consistent with an 8-week gestational sac."], "Others": ["The patient requests as few tests as possible, although she does not want to compromise the health of her fetus."]}
{"Patient Symptoms": ["The patient\u2019s wife is with him and states that her husband is always complaining and critical of others.", "He was recently fired from his job to which he claims that his boss was jealous of his hard work.", "He also does not trust his neighbors and thinks they are out to get all the nice things he has.", "His wife also says that he has begun to doubt her fidelity and believes that even the marriage counselor is on her side."]}
{"Patient Personal Background": ["The patient has a past medical history of polysubstance abuse, depression, multiple suicide attempts, neuropathic pain, and schizophrenia."], "Patient Symptoms": ["He was found unconscious and covered in bruises outside of a local bar."]}
{"Patient Symptoms": ["The dad reports he then heard a click and the patient immediately began to cry.", "She refuses to use the affected limb.", "She does allow passive flexion and extension with full range of motion but supination is limited and causes pain."], "Examination and Results": ["On examination, the patient is holding her right forearm in a pronated position and her elbow slightly flexed.", "Pain is localized to the lateral aspect of the elbow."], "Others": ["The mother reports that they were walking in the park and the patient\u2019s dad was swinging the patient in the air by her arms."]}
{"Patient Symptoms": ["He denies any headaches or change in vision."], "Examination and Results": ["A muscle biopsy reveals CD8+ lymphocyte infiltration in the endomysium."]}
{"Patient Personal Background": ["He was born at 38 weeks gestation via a spontaneous vaginal delivery without any complications."], "Patient Symptoms": ["The mother reports that her child has difficulty rolling from his back to his front and sitting unsupported.", "The patient is able to smile and furrow his brow normally, but she has noticed that he has a weak cry and suck.", "The mother said that the patient appeared \"normal\" until the past few weeks."], "Examination and Results": ["On physical exam, his extraocular muscle movements are intact, and a symmetric smile is seen.", "He has symmetric flaccid weakness of both his upper and lower extremities.", "He also has a bell-shaped chest.", "Deep tendon reflexes are diminished."]}
{"Patient Personal Background": ["During this period, he has had 12 bowel movements.", "He feeds 10 to 12 times a day.", "He was born at 38 weeks' gestation and weighed 1800 g (3 lb 15 oz); he currently weighs 1700 g (3 lb 12 oz).", "She has a history of intravenous heroin use."], "Patient Symptoms": ["Examination shows mild diaphoresis and a firm 2-cm midline neck swelling."], "Examination and Results": ["His temperature is 36.9\u00b0C (98.4\u00b0F), pulse is 180/min, and respirations are 50/min.", "The lungs are clear to auscultation."], "Treatment": ["His mother has Graves' disease and received propylthiouracil during the last trimester of pregnancy."]}
{"Patient Symptoms": ["He has also had pain in the right ankle for 3 days and pain and swelling in the left knee for 1 day.", "Two weeks ago, he had several days of fever and bloody diarrhea, for which he was treated with antibiotics."], "Examination and Results": ["Examination shows a small left knee effusion and bilateral conjunctival injection."], "Treatment": ["Two weeks ago, he had several days of fever and bloody diarrhea, for which he was treated with antibiotics."]}
{"Examination and Results": ["Examination shows a 2.5-cm (1-in) firm, irregular swelling on the left side of the neck that moves with swallowing.", "There is painless cervical lymphadenopathy.", "Ultrasound of the neck shows a solitary left lobe thyroid mass with increased vascularity and hyperechogenic punctate regions."], "Treatment": ["A fine needle aspiration biopsy is scheduled for the following week."], "Others": ["She appears healthy."]}
{"Patient Personal Background": ["He has been discontinuing heroin over the last month as part of his treatment plan.", "He is HIV positive, hepatitis B (HBV) positive, and was recently treated for an infection with Streptococcus pneumoniae."], "Patient Symptoms": ["He reports pain over his abdomen, knees, and shoulder."], "Treatment": ["He has been discontinuing heroin over the last month as part of his treatment plan.", "He is HIV positive, hepatitis B (HBV) positive, and was recently treated for an infection with Streptococcus pneumoniae."], "Diagnosis": ["He is HIV positive, hepatitis B (HBV) positive, and was recently treated for an infection with Streptococcus pneumoniae."]}
{"Examination and Results": ["On physical examination, his temperature is 36.9\u00baC (98.4\u00baF), pulse rate is 110/min, blood pressure is 102/74 mm Hg, and respiratory rate is 16/min.", "A resident working under the physician plots a Darrow-Yannet diagram for the patient."], "Others": ["The diagram is shown in the picture where the green dotted line represents the new fluid status."]}
{"Patient Personal Background": ["Her only past medical history is migraines for which she takes appropriate medication.", "She has no known family history."], "Patient Symptoms": ["She describes the pain as squeezing and tightness in her chest.", "This pain has been happening every few days for 3 months.", "She says there is no association of the pain with food or exercise."], "Examination and Results": ["She is able to climb up to her fourth floor apartment daily without issue.", "Here temperature is 98.6\u00b0F (37\u00b0C), blood pressure is 120/68 mmHg, pulse is 60/min, respirations are 16/min, and oxygen saturation is 98% on room air.", "The patient is not in pain on presentation and EKG in the office is normal.", "24-hour ECG monitoring shows transient ST elevations during the episodes of pain that resolve completely."]}
{"Patient Personal Background": ["She cannot confirm her vaccination history."], "Patient Symptoms": ["She complains of a rash involving her chest, face, and arms, a watery nasal discharge, and mild bilateral knee pain.", "She has had these symptoms for about 5 days.", "The symptoms do not seem to bother her too much, but she is concerned for the baby."], "Examination and Results": ["Her vital signs are as follows: blood pressure, 110/70 mmHg; heart rate, 89/min; respiratory rate, 12/min; and temperature, 37.6\u2103 (99.7\u2109).", "Examination shows a moderately dense maculopapular lacy rash spread over the patient\u2019s trunk, extremities, and face.", "No lymph node, liver, or spleen enlargement is noted.", "The knee joints appear normal."], "Diagnosis": ["She had contact with her younger sister, who also had a rash and was diagnosed with rubella infection about 10 days ago at a family gathering."]}
{"Patient Personal Background": ["She is sexually active with multiple partners and admits to using barrier protection inconsistently."], "Patient Symptoms": ["The patient denies any fever, chills, abdominal pain, menorrhagia, or flank pain."], "Examination and Results": ["She is afebrile and the vital signs are within normal limits.", "Speculum examination reveals vaginal erythema with a profuse, greenish-yellow, purulent, malodorous discharge.", "The vaginal pH is 5.5.", "Vaginal swab and urine samples are obtained for microscopy and culture, and results are pending."], "Others": ["Her last menstrual period was 2 weeks ago."]}
{"Patient Symptoms": ["Post-operatively, she reports a hoarse voice and difficulty speaking."], "Diagnosis": ["You suspect that this is likely a complication of her recent surgery."]}
{"Patient Symptoms": ["His mother reports that he had trouble breathing soon after he started playing soccer with some friends and was unable to use his inhaler as it was empty."], "Examination and Results": ["The child\u2019s temperature is 99.0\u00b0F (37.2\u00b0C), blood pressure is 130/90 mmHg, pulse is 130/min, respirations are 28/min, and oxygen saturation is 91% on room air.", "Physical examination demonstrates wheezing bilaterally in all lung fields."], "Treatment": ["The child is started on supplemental oxygen and a nebulized bronchodilator."], "Others": ["His family history is notable for emphysema in his paternal uncle and cirrhosis in his maternal grandfather."]}
{"Patient Personal Background": ["He has no history of serious illness and takes no medications."], "Patient Symptoms": ["He complains of increasing fatigue and dyspnea."], "Examination and Results": ["His temperature is 36.7\u00b0C (98.1\u00b0F), pulse is 90/min, respiratory rate is 18/min, and blood pressure is 125/70 mm Hg.", "His conjunctivae are pale.", "The examination of the heart and lungs shows no abnormalities.", "The splenic margin is palpable 8 cm (3.1 in) below the costal margin.", "No abnormal lymph nodes are found.", "Laboratory studies show:\nHemoglobin 8 g/dL\nMean corpuscular volume 90 \u03bcm3\nLeukocyte count 3,000/mm3\nPlatelet count 85,000/mm3\nPeripheral blood smear shows small lymphocytes with cell membrane projections.", "Bone marrow aspiration is unsuccessful.", "Cell immunophenotyping is positive for CD25."]}
{"Patient Symptoms": ["His symptoms started a few days ago and have been gradually worsening.", "Initially, the patient had a fever and a cough which has progressed to abdominal pain, diarrhea, and confusion.", "Laboratory studies are ordered as seen below."], "Examination and Results": ["His temperature is 102\u00b0F (38.9\u00b0C), blood pressure is 127/68 mmHg, pulse is 120/min, respirations are 17/min, and oxygen saturation is 94% on room air.", "Physical exam is notable for localized crackles and decreased breath sounds in the left lower lung field.", "The patient is confused and is answering questions inappropriately."]}
{"Patient Personal Background": ["He wears contact lenses.", "He has bronchial asthma treated with inhaled salbutamol.", "He works as a kindergarten teacher."], "Patient Symptoms": ["He is struggling to open this eye because of the pain."], "Examination and Results": ["His left eye is asymptomatic.", "The vital signs include: temperature 37.0\u00b0C (98.6\u00b0F), pulse 85/min, and blood pressure 135/75 mm Hg.", "The examination shows a visual acuity in the left eye of 20/25 and the ability to count fingers at 3 feet in the right eye."], "Others": ["A photograph of the right eye is shown."]}
{"Patient Personal Background": ["He describes himself as being \u201cgenerally healthy\u201d before the cough began.", "Past medical history includes hypertension.", "The patient takes clopamide and a multivitamin daily.", "His parents are both well and living in a senior living facility.", "He does not smoke and only drinks alcohol occasionally."], "Patient Symptoms": ["During a review of symptoms, the patient described a hiking trip in and around the desert near Phoenix, Arizona, 4 months ago."], "Examination and Results": ["At the office, his temperature is 38.6\u00b0C (101.4\u00b0F), heart rate is 102/min, respirations are 20/min, and blood pressure is 120/82 mm Hg.", "A focused chest exam reveals mild fremetus and dullness with percussion on the right side.", "A chest X-ray shows a right-sided consolidation of the lower right lung, and a chest CT shows an irregular opacity measuring 3.8 cm x 3.0 cm in the sub-plural region of the right middle lobe, a small right-sided pleural effusion, and mild right-sided hilar adenopathy.", "A lung biopsy is performed to rule out cancer and reveals necrotic granulomatous inflammation with multinucleated giant cells and spherules with endospores in the surrounding tissues."]}
{"Patient Symptoms": ["He was in school when his teacher noted a drooping of his left face."], "Examination and Results": ["His temperature is 99.9\u00b0F (37.7\u00b0C), blood pressure is 122/89 mmHg, pulse is 110/min, respirations are 19/min, and oxygen saturation is 98% on room air.", "Physical exam is notable for facial asymmetry and 4/5 strength in the patient's upper and lower extremity.", "A CT scan of the head does not demonstrate an intracranial bleed."]}
{"Patient Personal Background": ["She is exclusively breastfed every 3\u20134 hours for 15\u201320 minutes.", "She was delivered vaginally at 38 weeks' gestation at home and has not yet been evaluated by a physician.", "The mother had no prenatal care.", "The infant is at the 5th percentile for height and weight.", "The infant has not received any immunizations."], "Patient Symptoms": ["Over the past month, she has had several episodes of watery stools.", "The mother reports that her child is not gaining weight."], "Examination and Results": ["Her temperature is 38.5\u00b0C (101.3\u00b0F), pulse is 155/min, respirations are 45/min, and blood pressure is 88/50 mm Hg.", "Oral examination shows white plaques covering the tongue and the palate.", "Rales are heard bilaterally on cardiopulmonary examination.", "Cervical and inguinal lymphadenopathy is present."]}
{"Patient Personal Background": ["She returned from a business trip to Sudan 3 weeks ago.", "She denies eating any seafood while traveling.", "Medications include iron supplements and a multivitamin.", "Her immunizations are up-to-date and she has never received blood products."], "Patient Symptoms": ["This morning she became drowsy."], "Examination and Results": ["Her temperature is 38.9\u00b0C (102\u00b0F), pulse is 92/min, and blood pressure is 122/76 mm Hg.", "She is oriented to person and place.", "Examination shows jaundice and mild asterixis.", "Pelvic examination shows a uterus consistent in size with a 22-week gestation.", "Laboratory studies show:\nHemoglobin 11.2 g/dL\nProthrombin time 18 sec (INR=2.0)\nSerum\nTotal bilirubin 4.4 mg/dL\nAlkaline phosphatase 398 U/L\nAST 4,702 U/L\nALT 3,551 U/L\nLactate dehydrogenase 3,412 U/L\nAnti-nuclear antibody negative\nAnti-smooth muscle antibody negative\nAnti-CMV antibody negative\nAnti-EBV nuclear antigen antibody negative\nAn ELISA for HIV is negative."]}
{"Patient Personal Background": ["His father underwent surgery for colon cancer 3 years ago.", "He has smoked one pack of cigarettes daily for the last 15 years.", "He drinks two to three beers daily."], "Patient Symptoms": ["The vomitus consists of undigested food and he has also had dark brown emesis twice today.", "He has been having early satiety during this period.", "He has had progressive severe episodic epigastric pain and dyspepsia for the past week.", "The pain is partially relieved with food or over-the-counter antacids, but worsens at night and several hours after eating.", "He has also had a weight gain of 2 kg (4.4 lbs) during this period."], "Examination and Results": ["His temperature is 37.1\u00b0C (98.8\u00b0F), pulse is 106/min and blood pressure is 108/68 mm Hg.", "Examination shows dry mucous membranes.", "The abdomen is mildly tender to palpation in the left upper quadrant; there is a tympanitic mass in the epigastrium.", "A succussion splash is heard with a stethoscope when the patient is rocked back and forth at the hips.", "Bowel sounds are reduced.", "Rectal examination is unremarkable.", "Test of the stool for occult blood is positive."]}
{"Patient Personal Background": ["He has hypercholesterolemia and hypertension.", "He has smoked a pack of cigarettes daily for 34 years.", "His current medications include atorvastatin, enalapril, and hydrochlorothiazide."], "Patient Symptoms": ["For the past 5 days, he has had intermittent stabbing pain in the middle of his chest that worsens with lying down or taking deep breaths.", "He has also had a runny nose and a dry cough for the past 2 weeks.", "He appears pale and sweaty."], "Examination and Results": ["His temperature is 38.3\u00b0C (100.9\u00b0F), pulse is 105/min, and respirations are 25/min.", "Blood pressure is 107/72 mm Hg during expiration and 86/65 mm Hg during inspiration.", "Examination shows jugular venous distention and pitting edema below the knees."]}
{"Patient Personal Background": ["The patient has a past medical history of type II diabetes and is currently taking lisinopril, metformin, insulin, and fish oil."], "Patient Symptoms": ["The patient states that his symptoms came on while he was sleeping."], "Examination and Results": ["On physical exam, you note bipedal edema and jugular venous distention (JVD).", "An EKG and chest radiographs are obtained (Figures A and B).", "Lab values are as follows."], "Treatment": ["The patient is started on BIPAP and medical therapy and his symptoms improve rapidly."]}
{"Patient Personal Background": ["She says that she has always felt a little short of breath compared to her friends; however, she did not think that it was abnormal until she started trying a new exercise regimen."], "Patient Symptoms": ["She says that she has always felt a little short of breath compared to her friends; however, she did not think that it was abnormal until she started trying a new exercise regimen."], "Examination and Results": ["On physical exam, she is found to have mild conjunctival pallor and a peripheral blood smear is obtained showing echinocytes but no intracellular accumulations."], "Others": ["Upon further questioning, she recalls that several relatives have had similar issues with fatigue and pallor in the past."]}
{"Patient Personal Background": ["During high school, the patient went through similar episodes of low mood and poor sleep.", "At that time, she would repeatedly engage in binge eating and purging behavior, for which she was referred to therapy."], "Patient Symptoms": ["During this time, she has also had low energy and lost interest in playing the guitar."], "Treatment": ["The physician offers to prescribe a medication for her current symptoms."], "Others": ["There is no evidence of suicidal ideation."]}
{"Patient Personal Background": ["He was born at 37 weeks' gestation, and the neonatal period was uncomplicated."], "Patient Symptoms": ["His mother reports that he has had multiple episodes of loose stools over the past 3 months.", "He has been treated for otitis media 4 times and bronchiolitis 3 times since birth."], "Examination and Results": ["He is at the 10th percentile for height and 3rd percentile for weight.", "His temperature is 38.3\u00b0C (100.9\u00b0F), pulse is 126/min, and respirations are 35/min.", "Examination shows an erythematous scaly rash over his trunk and extremities.", "The white patches on the tongue and buccal mucosa bleed when scraped.", "Inspiratory crackles are heard in the right lung base.", "An X-ray of the chest shows an infiltrate in the right lower lobe and an absent thymic shadow."]}
{"Patient Personal Background": ["She has a history of hypertension and major depressive disorder.", "She drinks 3 beers daily.", "Current medications include hydrochlorothiazide, aspirin, prophylactic unfractionated heparin, and fluoxetine."], "Patient Symptoms": ["Examination shows multiple hematomas on the upper extremities around the peripheral intravenous access sites.", "The right calf is tender, erythematous and swollen."], "Examination and Results": ["Her temperature is 37.3\u00b0C (99.1\u00b0F), pulse is 90/min, and blood pressure is 118/92 mm Hg.", "There is a healing sternal incision.", "The lungs are clear to auscultation.", "Cardiac examination shows an aortic click."]}
{"Examination and Results": ["Physical examination shows hepatomegaly.", "Laboratory studies show an \u03b1-fetoprotein concentration of 380 ng/ml (N < 10 ng/mL).", "A CT scan of the abdomen with contrast shows a solitary mass in the left lobe of the liver that enhances in the arterial phase."]}
{"Patient Personal Background": ["She is sexually active with multiple partners and has no history of intravenous drug use.", "Urine beta-HCG is negative."], "Patient Symptoms": ["She also notes easy bruising and bleeding from her gums when brushing her teeth."], "Examination and Results": ["Physical exam is remarkable for petechiae and scattered ecchymoses on the patient's bilateral upper and lower extremities.", "Laboratory results are as follows: Hgb 13.0 g/dL, WBCs 6,000/mL, platelets 95,000/mL, PT 13.2s, aPTT 30s.", "Peripheral blood smear shows normocytic, normochromic red blood cells and few platelets with no morphologic abnormalities."]}
{"Patient Personal Background": ["He was diagnosed with a gene defect on chromosome 7, which has caused dysfunction in a transmembrane protein.", "This defect has resulted in several hospitalizations for various respiratory infections."], "Patient Symptoms": ["His temperature has ranged from 38.6\u00b0C\u201339.5\u00b0C (101.5\u00b0F\u2013103.1\u00b0F) over the past week.", "At the present time, he is struggling with a cough with thick purulent sputum."], "Treatment": ["A sputum sample is sent for culture and the patient is started on vancomycin.The pediatrician tells the patient\u2019s family that there is a collection of mucus in the respiratory tree which increases the patient's chances of future infections.", "He will have to undergo chest physiotherapy and they should report any signs of infection immediately to a medical professional."], "Diagnosis": ["He was diagnosed with a gene defect on chromosome 7, which has caused dysfunction in a transmembrane protein."], "Others": ["A sputum sample is sent for culture and the patient is started on vancomycin.The pediatrician tells the patient\u2019s family that there is a collection of mucus in the respiratory tree which increases the patient's chances of future infections.", "He will have to undergo chest physiotherapy and they should report any signs of infection immediately to a medical professional."]}
{"Patient Personal Background": ["The patient has been breastfed since birth, and usually feeds for 30 minutes every 2-3 hours.", "Her older son had a similar problem with vomiting that resolved around 12 months of age."], "Patient Symptoms": ["The patient\u2019s mother is concerned that her milk production is not keeping up with the patient\u2019s nutritional requirements.", "She reports that about two weeks ago the patient began regurgitating breastmilk through his nose and mouth after some feeds.", "She reports that he seems mildly upset during the episodes of regurgitation but usually settles down quickly and is hungry again soon afterwards.", "The patient\u2019s mother has already tried limiting the volume of each feed, which seems to have reduced the frequency of the regurgitation."], "Examination and Results": ["His height and weight are now respectively in the 37th and 36th percentiles.", "On physical exam, the patient is cooing in his mother\u2019s lap and smiles reciprocally with her.", "He lifts his head and shoulders off the examination table when placed in the supine position.", "His abdomen is soft, non-tender and non-distended.", "Bowel sounds are normoactive."], "Others": ["She denies any diarrhea, hematochezia, or family history of food allergies.", "Four weeks ago, the patient\u2019s height and weight were in the 40th and 34th percentiles, respectively."]}
{"Patient Symptoms": ["In addition to the pain from the wound, he complains of weakness in his left leg."], "Examination and Results": ["Upon physical examination you find that he has no other visible injuries; however, he has 2/5 strength in the left lower extremity.", "Complete neurologic exam also finds a deficit in vibration sense and light touch on the left lower extremity as well as a loss of pain and temperature sensation in the right lower extremity."]}
{"Patient Personal Background": ["He says he has been unsuccessful at losing weight and would like help.", "Past medical history is significant for obstructive sleep apnea (OSA) and hypertension.", "Current medications are isosorbide dinitrate/hydralazine and aspirin 81 mg orally daily.", "The patient denies any history of smoking or recreational drug use and drinks 1 or 2 beers on weekends.", "Family history is significant for prostate cancer in his father and hypertension and diabetes mellitus type 2 in his mother."], "Examination and Results": ["His vital signs include: temperature 36.8\u00b0C (98.2\u00b0F), pulse 97/min, respiratory rate 16/min, blood pressure 120/75 mm Hg.", "BMI is 30 kg/m2.", "Physical examination is unremarkable.", "Fasting blood glucose is 90 mg/dL."], "Treatment": ["He is also on CPAP to manage his OSA."], "Others": ["His last colonoscopy was 8 years previously, which was normal."]}
{"Patient Symptoms": ["While observing sinus tachycardia on the patient's telemetry, you note that the radial pulse cannot be palpated during inspiration."], "Examination and Results": ["An EKG shows sinus tachycardia and chest radiograph reveals an enlarged cardiac silhouette."]}
{"Patient Personal Background": ["He has smoked a pack of cigarettes daily for the past 40 years.", "He drinks a beer daily and occasionally more on weekends.", "He does not use illicit drugs.", "He is 183 cm (6 ft 0 in) tall and weighs 66 kg (145 lbs); BMI is 19.7 kg/m2."], "Patient Symptoms": ["He does not experience shortness of breath at rest.", "He also occasionally has a dry cough.", "He has not had fever, chills, or night sweats."], "Examination and Results": ["His temperature is 37\u00b0C (98.6\u00b0F), pulse is 94/min, respirations are 21/min, and blood pressure is 136/88 mm Hg.", "Lung auscultation reveals a prolonged expiratory phase and end-expiratory wheezing.", "Spirometry shows an FEV1:FVC ratio of 62%, an FEV1 of 60% of predicted, and a total lung capacity of 125% of predicted.", "The diffusion capacity of the lung (DLCO) is decreased."]}
{"Patient Symptoms": ["As soon as the infant is clear of the vagina, a congenital malformation of the abdomen is observed.", "Visual inspection shows loops of intestine protruding out of his abdomen on the right side."], "Examination and Results": ["His APGAR scores are 7 at 1 minute and 9 at 5 minutes.", "His heart rate is 125/min, and his respirations are 45/min.", "All reflexes appear normal.", "There are no other visible defects."], "Treatment": ["The infant is removed from the delivery room for further evaluation."]}
{"Patient Personal Background": ["Past medical history is significant for rheumatoid arthritis diagnosed 23 years ago for which she takes naproxen as needed."], "Examination and Results": ["Her vital signs include: temperature 36.9\u00b0C (98.4\u00b0F), blood pressure 135/88 mm Hg, pulse 92/min.", "Physical examination is significant for conjunctival pallor and bilateral ulnar deviation of the metacarpophalangeal joints."]}
{"Patient Personal Background": ["His past medical history is significant for allergic rhinitis."], "Patient Symptoms": ["His mother brings him into your office because she feels she has had to increase the patient\u2019s use of his inhaler to four times per week for the past month.", "She also reports that he has woken up three times during the night from his symptoms this month.", "The boy reports that he is upset because he can\u2019t always keep up with his friends in the playground."], "Examination and Results": ["The patient\u2019s temperature is 98\u00b0F (36.6\u00b0C), blood pressure is 110/70 mmHg, pulse is 88/min, and respirations are 18/min with an oxygen saturation of 98% O2 on room air.", "Auscultation of his lungs reveals bilateral late expiratory wheezes."]}
{"Patient Symptoms": ["She has not had any changes in diet or lifestyle but reports weight loss despite an increase in appetite.", "In addition, she has been experiencing chest palpitations, increased frequency of diarrhea, and heat intolerance."], "Examination and Results": ["Physical exam of her thyroid is unremarkable but her TSH was found to be 0.21 mIU/L.", "A complex structure in her right ovary was detected on ultrasound."]}
{"Patient Personal Background": ["Past medical history is noncontributory and he takes no medication."], "Patient Symptoms": ["On examination, he is very pale and his spleen is enlarged."], "Examination and Results": ["His temperature is 36.5\u00b0C (97.7\u00b0F), the blood pressure is 100/60 mm Hg and the pulse is 100/min.", "His hemoglobin is 5 g/dL and platelet count is slightly reduced.", "His peripheral blood smear is shown in the picture."], "Others": ["His father and aunt both suffer from mild anemia.", "Over the next 2 weeks, the patient recovers, and his hemoglobin is 11 g/dL."]}
{"Examination and Results": ["He is alert and oriented."]}
{"Patient Personal Background": ["He is a bodybuilding competitor and has a competition coming up in 1 week."], "Patient Symptoms": ["He also complains of a gradual decrease in vision over the past 3 months.", "The man reports that his symptoms appeared suddenly, 30 minutes after he took 2 foreign-manufactured fat-burning pills instead of the 1 he usually takes."], "Examination and Results": ["His blood pressure is 140/90 mm Hg, heart rate is 137/min, respiratory rate is 26/min, and temperature is 39.9\u00b0C (103.8\u00b0F).", "Physical examination reveals a reddish maculopapular rash over the patient\u2019s trunk, diminished lung and heart sounds, tenderness to palpation in his abdomen, and rotational bilateral nystagmus with an alternating gaze-dependent fast component.", "Ophthalmologic examination shows bilateral cataracts."]}
{"Patient Personal Background": ["She works as a professional ballet dancer and says, \u201cI'm always trying to be in shape for my upcoming performances.\u201d She is 163 cm (5 ft 4 in) tall and weighs 45 kg (99 lb); BMI is 17 kg/m2."], "Patient Symptoms": ["Physical examination shows tenderness and limited range of motion in her right knee.", "Oral examination shows bleeding and swelling of the gums."], "Examination and Results": ["There are diffuse petechiae around hair follicles on her abdomen and both thighs.", "Laboratory studies show a prothrombin time of 12 seconds, an activated partial thromboplastin time of 35 seconds, and a bleeding time of 11 minutes.", "Arthrocentesis of the right knee shows bloody synovial fluid."]}
{"Patient Personal Background": ["She has had regular menses since menarche at the age of 12.", "She has no history of serious illness but is allergic to certain jewelry and metal alloys.", "She takes no medications.", "She does not wish to become pregnant until she finishes college in six months."], "Examination and Results": ["Her last menstrual period was 3 weeks ago.", "A urine pregnancy test is negative."]}
{"Patient Personal Background": ["The patient has no other significant past medical history and takes no other medications.", "She reports no known allergies."], "Patient Symptoms": ["She says she has been compliant with her medication but has experienced no improvement.", "The patient presents 2 weeks later with an acute onset rash on her torso consisting of targetoid lesions with a vesicular center.", "She says the rash developed 2 days ago which has progressively worsened.", "She also says that 1 week ago she developed fever, lethargy, myalgia, and chills that resolved in 3 days."], "Examination and Results": ["The patient is afebrile, and her vital signs are within normal limits.", "A physical examination is unremarkable."], "Treatment": ["The patient is switched to a different medication."]}
{"Patient Personal Background": ["He is otherwise healthy and has met all developmental milestones.", "He is at the 75th percentile for height and the 65th percentile for weight."], "Patient Symptoms": ["The episodes occur every 1\u20132 months and last for a few hours.", "The pain is located in the epigastrium, radiates to his back, and is occasionally associated with mild nausea."], "Examination and Results": ["Physical examination shows no abdominal distention, guarding, or rebound tenderness."], "Others": ["His mother is concerned that his condition might be hereditary because his older sister was diagnosed with congenital heart disease."]}
{"Examination and Results": ["A chest radiograph is obtained which reveals a boot-shaped heart and absence of a thymus.", "An echocardiogram is done which shows pulmonary stenosis with a hypertrophic right ventricular wall, ventricular septal defect, and overriding of the aorta."]}
{"Patient Personal Background": ["He currently takes hydrochlorothiazide."], "Patient Symptoms": ["He reports that he feels well and has no complaints."], "Examination and Results": ["His temperature is 98.6\u00b0F (37\u00b0C), blood pressure is 135/80 mmHg, pulse is 86/min, and respirations are 17/min.", "His BMI is 31 kg/m2.", "Results of a lipid panel are: Total cholesterol is 280 mg/dl, triglycerides are 110 mg/dl, HDL cholesterol is 40 mg/dl, and LDL cholesterol is 195 mg/dl."], "Treatment": ["Her physician considers starting her on atorvastatin."]}
{"Patient Personal Background": ["The patient\u2019s wife says that he had been on a camping trip a few months earlier to study bats but otherwise has not traveled recently.", "Past medical history is significant for hypertension, managed medically with hydralazine and enalapril."], "Patient Symptoms": ["The patient\u2019s condition rapidly deteriorates, and he passes away."], "Examination and Results": ["An autopsy is performed and a histologic stained section of the brain is shown in the image."]}
{"Treatment": ["Her physician prescribes high-dose niacin and recommends taking the medication along with aspirin."]}
{"Patient Personal Background": ["The patient reports that he was involved in a severe car accident 30 years ago.", "He does not smoke or drink alcohol.", "He has never used illicit intravenous drugs.", "He takes no medications and has no known allergies.", "His father had a history of alcoholism and died of liver cancer.", "The patient appears thin."], "Patient Symptoms": ["He has had occasional headaches over the past year, but otherwise feels well."], "Examination and Results": ["His temperature is 37.8\u00b0C (100\u00b0F), pulse is 100/min, and blood pressure is 110/70 mm Hg.", "Physical examination shows no abnormalities.", "Laboratory studies show:\nHemoglobin 14 g/dL\nLeukocyte count 10,000/mm3\nPlatelet count 146,000/mm3\nSerum\nGlucose 150 mg/dL\nAlbumin 3.2 g/dL\nTotal bilirubin 1.5 mg/dL\nAlkaline phosphatase 75 U/L\nAST 95 U/L\nALT 73 U/L\nHIV negative\nHepatitis B surface antigen negative\nHepatitis C antibody positive\nHCV RNA positive\nHCV genotype 1\nA liver biopsy is performed and shows mononuclear infiltrates that are limited to portal tracts and periportal hepatocyte necrosis."]}
{"Patient Personal Background": ["Her only medication is levothyroxine."], "Patient Symptoms": ["Physical examination shows conjunctival pallor and an ataxic gait.", "Proprioception and sense of vibration are decreased in her toes bilaterally."], "Examination and Results": ["Laboratory studies show macrocytic anemia and normal thyroid hormone levels.", "Histological evaluation of tissue samples obtained by esophagogastroduodenoscopy reveals atrophic changes of the gastric body and fundus with normal antral mucosa."]}
{"Patient Personal Background": ["Her past medical history is significant for bipolar disorder that is treated with lithium for 3 years."], "Patient Symptoms": ["This negatively affects her sleep, as she has to frequently wake up at night to urinate.", "She also complains of increased thirst."], "Examination and Results": ["Serum osmolality is 425 mOsm/kg, and urine osmolality is 176 mOsm/kg."]}
{"Patient Personal Background": ["Her medical history is remarkable for iron deficiency, for which she is on ferrous sulfate.", "The patient has also experienced intermittent episodes of mild diarrhea, previously diagnosed as lactose intolerance."], "Patient Symptoms": ["These lesions occur intermittently but have worsened over time.", "The patient has also experienced intermittent episodes of mild diarrhea, previously diagnosed as lactose intolerance."], "Examination and Results": ["Her height is at the 30th percentile and weight is at the 25th percentile for age and sex.", "An immunoglobulin A (IgA) tissue transglutaminase titer is 5 times the upper limit of normal."]}
{"Patient Personal Background": ["He has hypertension, chronic kidney disease, and type 2 diabetes mellitus.", "Three months ago, he underwent amputation of his left third toe because of a non-healing ulcer.", "He has smoked a pack of cigarettes daily for 48 years.", "Current medications include hydrochlorothiazide, metoprolol, and insulin.", "His temperature is 39.4\u00b0C (102.9\u00b0F), pulse is 102/min, blood pressure is 150/94 mm Hg, and respirations are 18/min."], "Patient Symptoms": ["He has had nausea but no vomiting during this time."], "Examination and Results": ["Examination shows a 1-cm (0.4-in) round ulcer on the sole of his right foot.", "There is costovertebral angle tenderness on the left side.", "The abdomen is soft.", "Laboratory studies show:\nHemoglobin 11.5 g/dL\nLeukocyte count 19,000/mm3\nSerum\nNa+ 140 mEq/L\nCl\u2212 102 mEq/L\nK+ 5.0 mEq/L\nHCO3\u2212 25 mEq/L\nUrea nitrogen 65 mg/dL\nCreatinine 2.4 mg/dL\nGlucose 240 mg/dL\nUrine\nBlood 1+\nProtein 1+\nWBC 100/hpf\nNitrite 2+\nWBC casts numerous\nUrine and blood samples for culture and sensitivity tests are obtained."]}
{"Patient Symptoms": ["In the early morning of postoperative day 4, the nurse states that the patient is difficult to arouse."], "Examination and Results": ["Over the next 3 days, the patient's drainage output is noted to exceed 1 liter per day.", "His temperature is 99.5\u00b0F (37.5\u00b0C), blood pressure is 107/88 mmHg, pulse is 120/min, respirations are 17/min, and oxygen saturation is 98% on room air.", "His skin and mucous membranes are dry on physical exam.", "Laboratory values are ordered as seen below."]}
{"Patient Personal Background": ["Her symptoms began on the return flight from a 2-week yoga retreat in India, where she stayed at a resort.", "She has a 1-year history of gastroesophageal reflux disease and is allergic to shellfish.", "Her only medication is ranitidine."], "Patient Symptoms": ["She was mildly nauseous as she boarded the flight, and diarrhea followed immediately after eating the in-flight meal.", "Since then, she has had up to five watery stools daily.", "She appears lethargic."], "Examination and Results": ["Her temperature is 37\u00b0C (98.6\u00b0F), pulse is 70/min, and blood pressure is 115/72 mm Hg.", "Abdominal examination shows diffuse tenderness with no guarding or rebound.", "Bowel sounds are hyperactive."]}
{"Others": ["A robust clinical trial is performed in a group of 100 subjects comparing the new screening test against the gold standard."]}
{"Patient Personal Background": ["When discussing her infection, the patient says that she uses safe sex practices.", "Her history is significant for meningitis and for infection with Streptococcus pneumoniae."], "Patient Symptoms": ["She previously presented with itching, as well as frequent and painful urination."], "Examination and Results": ["A vaginal swab was taken and sent to the laboratory to confirm the diagnosis.", "Diplococci were seen on Gram stain and were grown on Thayer-Martin agar."], "Diagnosis": ["The physician discusses that the reason behind these infections comes from a defect in the innate immune system."]}
{"Patient Personal Background": ["She has no significant medical history."], "Patient Symptoms": ["On postoperative day 1, she develops perioral numbness and a tingling sensation, along with paresthesia of the hands and feet.", "The physical examination reveals that she is anxious and confused."], "Examination and Results": ["Her pulse is 90/min, the blood pressure is 110/80 mm Hg, the respirations are 22/min, and the temperature is 36.7\u00b0C (98.0\u00b0F).", "Latent tetany (carpal spasm) is evident in the right arm.", "This is observed when the sphygmomanometer cuff pressure is raised above the systolic blood pressure and held for 3 minutes."]}
{"Patient Personal Background": ["He spends most of his time in the basement playing video games and eating bowls of cereal.", "The patient does not smoke or drink alcohol."], "Patient Symptoms": ["The parents report that their son quit doing sports at school because of low energy.", "The patient's academic performance has declined recently."], "Examination and Results": ["His vital signs are within normal limits.", "Examination shows conjunctival pallor, inflammation and fissuring of the corners of the mouth, and concavity of the finger nails."], "Others": ["He has no history of serious illness.", "His mother has Hashimoto's thyroiditis and his father has major depressive disorder."]}
{"Patient Personal Background": ["He has type 2 diabetes mellitus, mitral regurgitation, and atrial fibrillation.", "His only other medications are metformin and lisinopril."], "Examination and Results": ["His temperature is 37.8\u00b0C (100.0\u00b0F), pulse is 108/min and irregularly irregular, and blood pressure is 155/89 mm Hg.", "Examination of the skin shows large purpura, hemorrhagic bullae, and areas of skin necrosis over his anterior legs, gluteal region, and penis."], "Treatment": ["Three days ago, he was started on treatment with warfarin."]}
{"Patient Symptoms": ["His teachers have reported hyperactivity during class, difficulties with social interaction, and poor scores on reading and writing assessments."], "Examination and Results": ["Molecular analysis shows an increased number of CGG trinucleotide repeats."]}
{"Patient Personal Background": ["She is a known hypertensive but is poorly compliant with medications."], "Patient Symptoms": ["The patient claims to have orthopnea, paroxysmal nocturnal dyspnea, and easy fatigability."], "Examination and Results": ["On physical examination, the blood pressure is 80/50 mm Hg.", "There is prominent neck vein distention.", "An S3 gallop, bibasilar crackles, and grade 3 bipedal edema were also detected.", "A 2d echo was performed, which showed a decreased ejection fraction (32%)."]}
{"Patient Personal Background": ["2 weeks ago she had a prophylactic ovariectomy because of a family history of ovarian cancer.", "She is known to have type 2 diabetes mellitus and stage 1 hypertension, but she does not take her antihypertensives because she is not concerned about her blood pressure.", "Also, she has a history of opioid abuse.", "She takes metformin 1000 mg and aspirin 81 mg. She has been smoking 1 pack of cigarettes per day for 22 years."], "Patient Symptoms": ["On examination, the patient is dyspneic and acrocyanotic.", "Lung auscultation reveals bilateral rales over the lower lobes."], "Examination and Results": ["Her vital signs are as follows: blood pressure 155/80 mm Hg, heart rate 101/min, respiratory rate 31/min, and temperature 37.9\u2103 (100.2\u2109).", "Blood saturation on room air is 89%.", "A cardiac examination is significant for S2 accentuation best heard in the second intercostal space at the left sternal border and S3 presence.", "There is no leg edema."], "Others": ["8 hours ago."]}
{"Patient Personal Background": ["She has a past medical history of generalized seizures with her most recent one having occurred 5 days ago.", "The patient admits to occasional cocaine use and binge drinking."], "Patient Symptoms": ["The patient has had severe abdominal pain throughout her entire life with occasional episodes of bloody diarrhea.", "She has recently lost 7 pounds and has felt generally ill for the past 2 days."], "Examination and Results": ["Her temperature is 98.7\u00b0F (37.1\u00b0C), blood pressure is 107/58 mmHg, pulse is 127/min, respirations are 16/min, and oxygen saturation is 99% on room air.", "Physical exam is notable for diffuse abdominal tenderness and guaiac positive stools."], "Others": ["One month ago, the patient was treated for impetigo."]}
{"Patient Personal Background": ["He recalls that he has been told by his primary care physician that he suffers from gastroesophageal reflux disease (GERD)."], "Treatment": ["The gastroenterologist decides to perform an upper endoscopy with biopsy."], "Diagnosis": ["He recalls that he has been told by his primary care physician that he suffers from gastroesophageal reflux disease (GERD)."]}
{"Examination and Results": ["Upon discussions with the patient, it is clear that she is not able to understand that sexual intercourse can lead to pregnancy."], "Treatment": ["The mother states that she wants her daughter to have a bilateral tubal ligation after she recently discovered her looking at pornographic materials."], "Others": ["She states that her daughter is not capable of understanding the repercussions of sexual intercourse, and that she does not want her to be burdened with a child that she would not be able to raise."]}
{"Patient Personal Background": ["He works as a zoologist and was in rural Madagascar studying a rare species of lemur.", "His past medical history is notable for hypertension and gout.", "He takes lisinopril and allopurinol."], "Patient Symptoms": ["He returned from a research trip to Madagascar 2 weeks ago and has since developed a worsening fever with a maximum temperature of 102.2\u00b0F (39\u00b0C).", "He also reports some swelling around his neck and groin."], "Examination and Results": ["His temperature is 101.9\u00b0F (38.3\u00b0C), blood pressure is 145/85 mmHg, pulse is 110/min, and respirations are 22/min.", "On exam, he has painful erythematous cervical, axillary, and inguinal lymphadenopathy.", "Black hemorrhagic eschars are noted on his fingertips bilaterally."]}
{"Examination and Results": ["After reviewing the laboratory tests, the physician decides to write the patient a prescription for miglitol and states that it must be taken with the first bite of the meal."], "Treatment": ["After reviewing the laboratory tests, the physician decides to write the patient a prescription for miglitol and states that it must be taken with the first bite of the meal."]}
{"Patient Personal Background": ["He works as a dental assistant and is concerned about not being able to work.", "He is sexually active with one female partner, and they do not use condoms.", "His father has a history of thromboangiitis obliterans.", "He has smoked one pack of cigarettes daily for 5 years.", "He drinks two to four beers on social occasions."], "Patient Symptoms": ["The patient wonders if the symptoms might be related to a hunting trip he returned from 1 week ago because he remembers seeing a lot of poison oak."], "Examination and Results": ["Vital signs are within normal limits.", "Physical examination shows swelling and erythema of the pulp space of the left index finger; there are multiple 3-mm vesicles.", "Laboratory studies show a leukocyte count of 12,000 cells/mm3."]}
{"Patient Personal Background": ["His past medical history is significant for hypertension and GERD.", "He takes lisinopril for hypertension and has failed multiple different therapies for his GERD."], "Patient Symptoms": ["On physical exam, he is somewhat tender to palpation over his upper abdomen."], "Examination and Results": ["Barium swallow demonstrates a subdiaphragmatic gastroesophageal junction, with herniation of the gastric fundus into the left hemithorax."]}
{"Patient Personal Background": ["Several days prior, he had been swimming in the Gulf coast when he stepped on a sharp rock and cut his right foot."], "Patient Symptoms": ["Three days ago, the patient presented to the emergency room after noticing painful redness spreading along his skin up from his right foot and was subsequently admitted for antibiotic treatment."], "Examination and Results": ["Currently, his temperature is 101.8\u00b0F (38.8\u00b0C), blood pressure is 84/46 mmHg with a mean arterial pressure of 59 mmHg, pulse is 104/min, and respirations are 14/min.", "His telemetry shows sinus tachycardia.", "His blood cultures are pending, but Gram stain demonstrated gram-negative bacilli."]}
{"Patient Personal Background": ["The patient has no relevant past medical history, however, the patient admits to being sexually abused by her boyfriend for the past year.", "Her current medications include ibuprofen for menstrual cramps."], "Patient Symptoms": ["She states that this has been one of many symptoms she has experienced lately.", "At times she has had trouble speaking and has noticed changes in her vision however these episodes occurred over a month ago and have resolved since then.", "Two days ago she experienced extreme pain in her face that was exacerbated with brushing her teeth and plucking out facial hairs."], "Examination and Results": ["On physical exam it is noted that leftward gaze results in only the ipsilateral eye gazing leftward.", "Her vital signs are within normal limits and you note a pale and frightened young lady awaiting further care."], "Treatment": ["The patient's initial workup is started in the emergency department."]}
{"Patient Personal Background": ["Her brother says she has a problem with alcohol use and that he found an empty bottle of vodka on the counter at her home."], "Patient Symptoms": ["She is unable to personally give a history.", "She appears disheveled.", "On mental status examination, she is confused and oriented only to person.", "She recalls 0 out of 3 words after 5 minutes.", "She cannot perform serial sevens and is unable to repeat seven digits forward and five in reverse sequence.", "She has difficulty walking without assistance."], "Examination and Results": ["Her temperature is 37\u00b0C (98.6\u00b0F), pulse is 85/min, and blood pressure is 140/95 mm Hg.", "Neurologic examination shows horizontal nystagmus on lateral gaze."]}
{"Patient Personal Background": ["She did not disclose her past medical history, but her sexual debut occurred with her boyfriend 3 weeks ago."], "Patient Symptoms": ["She is now complaining of a yellow-green, diffuse, malodorous vaginal discharge that she noticed 1 week ago for the first time.", "She also reported mild pelvic and abdominal pain."], "Examination and Results": ["cervical motion tenderness was noted during the pelvic examination.", "The gynecologist also noticed a pink and inflamed nulliparous cervix with a preponderance of small red punctate spots.", "There was a frothy white discharge with a malodorous odor in the vaginal vault.", "A wet mount was prepared for a light microscopic examination, which revealed numerous squamous cells and motile organisms."], "Diagnosis": ["The gynecologist concluded that this was a sexually-transmitted infection."]}
{"Patient Symptoms": ["Initially, he used to forget his children's names or forget to lock the house door.", "During the past year, he has gotten lost twice while returning from the grocery store and was unable to tell passersby his address.", "One time, he went to the park with his granddaughter and returned home alone without realizing he had forgotten her.", "His daughter says that over the past year, he has withdrawn himself from social gatherings and avoids making conversation.", "He does not sleep well at night.", "Short- and long-term memory deficits are present.", "He appears indifferent about his memory lapses and says this is normal for someone his age."], "Examination and Results": ["On mental status examination, he is oriented only to person."], "Treatment": ["His daughter has hired a helper to cook and clean his home."], "Others": ["He describes his mood as fair."]}
{"Patient Personal Background": ["The patient denies having any history of asthma or respiratory symptoms, and does not smoke."], "Patient Symptoms": ["On exam, he is pale and diaphoretic.", "His pupils are contracted."], "Examination and Results": ["His temperature is 99.8\u00b0F (37.7\u00b0C), pulse is 65/min, blood pressure is 126/86 mmHg, and respirations are 20/min.", "His oxygen saturation is 97%.", "Diffuse wheezes are noted in all lung fields."]}
{"Examination and Results": ["Physical examination is notable for frontal bossing and shortened upper and lower extremities.", "His axial skeleton appears normal.", "He is at the 7th percentile for height and 95th percentile for head circumference.", "Genetic analysis reveals an activating mutation in a growth factor receptor."], "Others": ["He demonstrates normal intelligence and is able to speak in three-word sentences.", "He first sat up without support at twelve months and started walking at 24 months."]}
{"Examination and Results": ["Examination of the left breast shows a firm, nontender mass close to the nipple.", "Mammography shows an irregular calcified mass."], "Diagnosis": ["A core needle biopsy shows invasive ductal carcinoma."]}
{"Patient Personal Background": ["Medical history is notable for hypertension and hyperlipidemia, both managed medically.", "He was last seen for follow-up of these conditions 1 month ago."], "Patient Symptoms": ["The patient reports that his bowel habits have changed from every day to every 3 or 4 days.", "He also now has to strain to pass stool.", "On further questioning, his wife has also noticed that he has seemed fatigued, with little interest in going on their usual afternoon walks."], "Examination and Results": ["Physical examination is unremarkable."]}
{"Patient Personal Background": ["The patient has a medical history of chronic dermatitis and chronic sinusitis for which he has prescriptions of topical hydrocortisone and fexofenadine.", "He smokes one-half pack of cigarettes every day."], "Patient Symptoms": ["On physical examination, the patient appears tired but oriented."], "Examination and Results": ["His vital signs include: blood pressure 128/76 mm Hg, heart rate 78/min, and respirations 12/min.", "Examination of the skin reveals a 2 x 2 cm round and erythematous, annular plaque on the abdomen 3 cm to the left of the umbilicus.", "There are no vesicles, pustules, or papules.", "Auscultation of the heart reveals a 1/6 systolic murmur.", "Breath sounds are mildly coarse at the bases.", "A KOH preparation from the skin scraping confirms the presence of hyphae."]}
{"Patient Personal Background": ["He has no history of a similar episode.", "He takes no medications.", "There is no history of abnormal bleeding in the family.", "His vital signs are within normal limits."], "Patient Symptoms": ["The bleeding started spontaneously.", "On examination, he is pressing a gauze against his left nostril while hyperextending his head.", "The gauze is stained with blood and upon withdrawal of the gauze blood slowly drips out of his left nostrils."], "Examination and Results": ["His vital signs are within normal limits.", "There is no bleeding from the right nostril.", "The remainder of the physical examination shows no abnormalities."]}
{"Patient Symptoms": ["Upon further questioning, she reports decreased appetite, fatigue, constipation, and jaw pain."], "Examination and Results": ["Her pulse is 60 bpm and her blood pressure is 130/110 mm Hg.", "Biopsy of her thyroid reveals granulomatous inflammation and multinucleate giant cells surrounding fragmented colloid."]}
{"Patient Personal Background": ["You find out that he has recently been fired from his job as a salesperson for months of tardiness and poor performance.", "The police tell you that his girlfriend, who was there at the time of the fall, mentioned that the patient has been struggling with alcohol for at least a year."], "Patient Symptoms": ["The patient smells of alcohol and is slurring his words."], "Examination and Results": ["Upon physical examination, the patient becomes agitated and starts yelling."], "Others": ["He accuses his ex-boss of being a cocaine addict and says he couldn\u2019t keep up sales percentages compared to someone using cocaine."]}
{"Patient Personal Background": ["Last week she returned from a trip to Africa where she spent several weeks, mostly in rural areas."], "Patient Symptoms": ["Her symptoms began 1 week ago with a severe fever (40\u2103 (104\u2109)) for 3 days.", "When the fever subsided, she developed a maculopapular rash over the trunk and extremities with painful wrists and fingers.", "She also reports abdominal pain, nausea, vomiting, and headaches."], "Examination and Results": ["Her temperature is 37.5\u2103 (99.5\u2109); pulse is 75/min; respiratory rate is 13/min, and blood pressure is 115/70 mm Hg.", "A maculopapular rash is observed over the trunk and limbs.", "Both ankles are swollen and painful to active and passive motion.", "The abdomen is soft without organomegaly.", "Laboratory studies show the following:\nLaboratory test\nHemoglobin 11.4 g/d\nMean corpuscular volume 90 \u00b5m3\nLeukocyte count 4,500/mm3\nSegmented neutrophils 70%\nLymphocytes 15%\nPlatelet count 250,000/mm3\nRing-form trophozoites are absent on the peripheral blood smear."]}
{"Patient Personal Background": ["His past medical history is remarkable for cirrhosis secondary to alcohol abuse and untreated hepatitis C. His current blood pressure is 90/50 mm Hg, heart rate is 128/min, and oxygen saturation in room air is 88%."], "Patient Symptoms": ["Upon examination patient states he feels nauseated as he begins to retch violently and vomit bright red blood."], "Examination and Results": ["His past medical history is remarkable for cirrhosis secondary to alcohol abuse and untreated hepatitis C. His current blood pressure is 90/50 mm Hg, heart rate is 128/min, and oxygen saturation in room air is 88%.", "You begin to review his labs and notice and he has elevated beta-hydroxybutyrate, ammonia, and lactate."], "Treatment": ["IV fluids are initiated and packed RBCs are ordered."], "Others": ["On further questioning, he states that he is scared to die and wants everything done to save his life."]}
{"Patient Personal Background": ["Prior to admission, her only medications were a multivitamin and an herbal weight-loss preparation."], "Patient Symptoms": ["She does not have pain.", "She has nausea but has not vomited.", "She appears uncomfortable."], "Examination and Results": ["Her temperature is 38\u00b0C (100.4\u00b0F), pulse is 90/min, and blood pressure is 118/78 mm Hg.", "Examination shows mild swelling of the right thigh to the ankle; there is no erythema or pitting edema.", "The abdomen is soft and shows diffuse tenderness to palpation.", "There are five abdominal laparoscopic incisions with no erythema or discharge.", "The lungs are clear to auscultation.", "The remainder of the examination shows no abnormalities."], "Treatment": ["She has been using an incentive spirometer every 6 hours since recovering from her surgery."], "Diagnosis": ["She was diagnosed with pancreatic cancer 1 month ago."], "Others": ["Homan's sign is negative."]}
{"Patient Personal Background": ["His father died of sudden cardiac death at the age of 45 years without a history of hypertension or any chronic cardiac disorder."], "Patient Symptoms": ["His symptoms only lasted for a few seconds and resolved spontaneously.", "This is the third time he experienced such an episode.", "He says that he recently started having nightmares."], "Examination and Results": ["A complete physical examination was normal.", "A 12-lead electrocardiogram showed ST-segment elevations in V1, V2, and V3, and the presence of incomplete right bundle branch block (RBBB)."], "Treatment": ["The drug also blocks potassium channels and prolongs action potential duration, but it does not shorten phase 3 repolarization.", "The drug also has mild anticholinergic and alpha-blocking activity."], "Diagnosis": ["After a complete diagnostic evaluation, Brugada syndrome was diagnosed."], "Others": ["He has prescribed a class I anti-arrhythmic drug, which is a sodium channel blocker that slows phase 0 depolarization in ventricular muscle fibers."]}
{"Patient Personal Background": ["He drinks 10\u201312 beers daily and has not seen a physician in 15 years."], "Patient Symptoms": ["He describes the vomitus as bloody and containing black specks.", "He appears pale."], "Examination and Results": ["His temperature is 36.7\u00b0C (98.1\u00b0F), pulse is 122/min, and blood pressure is 85/59 mm Hg.", "Physical examination shows decreased radial pulses, delayed capillary refill, multiple spider angiomata, and a distended abdomen.", "He is oriented to person but not to place or time."]}
{"Patient Personal Background": ["Past medical history is significant for 2 transient ischemic attacks 6 months prior, characterized by a sudden right-sided weakness and trouble speaking but recovered fully within 30 minutes.", "Current medications are sildenafil 100 mg orally as needed.", "Patient reports a 30-pack-year smoking history and heavy alcohol use on the weekends."], "Patient Symptoms": ["The patient states that his symptoms started about a week ago and have steadily worsened.", "He describes the abdominal pain as mild to moderate, dull, and deeply localized to the umbilical region.", "Review of systems is significant for decreased appetite and feeling easily full."], "Examination and Results": ["Vitals are temperature 37\u00b0C (98.6\u00b0F), blood pressure 155/89 mm Hg, pulse 89/min, respirations 16/min, and oxygen saturation 98% on room air.", "The cardiac exam is normal.", "Lungs are clear to auscultation.", "Carotid bruit present on the right.", "The abdomen is soft and nontender.", "Bowel sounds present.", "A pulsatile abdominal mass is felt in the lower umbilical region.", "Abdominal ultrasound reveals the presence of an abdominal aortic aneurysm (AAA).", "Contrast CT reveals a small, unruptured AAA (diameter 4.1 cm)."], "Treatment": ["High flow supplemental oxygen and fluid resuscitation are initiated.", "Morphine sulfate and metoprolol are administered."], "Diagnosis": ["Patient\u2019s feet have the following appearance seen in the picture."], "Others": ["On physical examination, the patient is alert and cooperative."]}
{"Patient Symptoms": ["2 weeks later, the patient presents to the outpatient clinic with hoarseness."], "Treatment": ["During surgery, a young surgeon ligates the inferior thyroid arteries as close to the poles as possible to prevent intraoperative hemorrhage."]}
{"Patient Symptoms": ["He feels increasingly anxious during physical education (PE) class as he has noticed that the size of his penis is significantly smaller when compared to his peers."], "Examination and Results": ["Based on the physical examination, he is Tanner stage 1.", "The weight and height are 60 kg (132 lb) and 175 cm (5 ft 9 in), respectively.", "The cardiopulmonary examination is normal; however, the patient has difficulty identifying coffee grounds by smell."]}
{"Patient Personal Background": ["While on his daily walks he notices a strong cramping pain in his calves that consistently appears after a mile of walking."], "Patient Symptoms": ["While on his daily walks he notices a strong cramping pain in his calves that consistently appears after a mile of walking."], "Treatment": ["To improve his symptoms, cilostazol is prescribed."], "Diagnosis": ["He sees his physician and a diagnosis of peripheral artery disease with intermittent claudication is made."]}
{"Patient Personal Background": ["He recently went on vacation to South America but has returned to his job delivering packages.", "He has several friends who recently had influenza."], "Patient Symptoms": ["In addition to the fever, he has had malaise, chest pain, and a dry cough."], "Examination and Results": ["Hi temperature is 102.8\u00b0F (39.3 \u00b0C), blood pressure is 137/80 mmHg, pulse is 104/min, respirations are 19/min, and oxygen saturation is 98%.", "Chest exam reveals a deep noise found bilaterally in the lung bases.", "Chest radiograph reveals a wider area of opacity near the heart and bilateral lung infiltrates."]}
{"Patient Personal Background": ["He smokes 2 packs per day and drinks 2\u20133 beers every day.", "He denies any previous medical problems except for seasonal allergies for which he takes diphenhydramine on occasions."], "Examination and Results": ["At the hospital, the vital signs include: temperature 40.0\u00b0C (104.0\u00b0F), blood pressure 140/80 mm Hg, heart rate 98/min, and respiratory rate 28/min.", "On physical exam, he is thin and poorly kept.", "His clothes appear dirty.", "Small scars are visible in the decubitus region of both arms.", "The lung sounds are equal with bilateral crackles, and heart auscultation reveals a systolic murmur that radiates to the left axilla.", "Petechiae are seen on the hard palate and palms of his hands."], "Others": ["A chest X-ray and blood cultures are ordered."]}
{"Patient Personal Background": ["He started experiencing episodic headaches and palpitations 3 months ago; however, he thought that these symptoms were simply related to the stress of moving and starting a new job."], "Patient Symptoms": ["He started experiencing episodic headaches and palpitations 3 months ago; however, he thought that these symptoms were simply related to the stress of moving and starting a new job.", "He has continued to experience these intermittent headaches and has also noticed that he sweats profusely during these episodes."], "Examination and Results": ["On presentation his temperature is 99.1\u00b0F (37.3\u00b0C), blood pressure is 163/112 mmHg, pulse is 112/min, and respirations are 15/min.", "Physical exam reveals pallor and perspiration but is otherwise unremarkable."]}
{"Patient Symptoms": ["About 90 minutes ago she was on the couch watching television with her husband when she suddenly noticed that she couldn't see the screen normally.", "She also felt a little dizzy.", "She has never had anything like this happen before."], "Examination and Results": ["Her general physical exam is unremarkable.", "Her neurologic exam is notable for loss of vision in the right visual field of both eyes with macular sparing, though extraocular movements are intact.", "A computed tomography (CT) scan of the head shows no acute intracranial process."]}
{"Patient Symptoms": ["She reports that the child cries several times per day, but sleeps 7-8 hours at night, uninterrupted.", "She has been breastfeeding the infant but feels the latch has been poor and is unsure how much milk he has been consuming but feels it is not enough."], "Examination and Results": ["When asked the mother stated that the baby is currently making stools 2 times per day."], "Treatment": ["A lactation consult was called for the patient and it was noted that despite proper instruction the observed latch was still poor."]}
{"Patient Personal Background": ["History is significant for liver cirrhosis and alcoholism."], "Patient Symptoms": ["His family has noticed progressive confusion.", "On examination, he is jaundiced, lethargic, is oriented to person and place but not date, and has moderate ascites."], "Examination and Results": ["His heart rate is 112/min, temperature is 37.1\u00b0C (98.7\u00b0F), and blood pressure is 110/70 mm Hg.", "Neurological examination reveals asterixis, and his stool is guaiac-positive."]}
{"Patient Personal Background": ["He is in good shape and exercises 3 times per week.", "He takes no medications and denies smoking cigarettes, drinking alcohol, and illicit drug use."], "Examination and Results": ["Prior to starting his run, his heart rate was 70/min, and the blood pressure was 114/74 mm Hg.", "Immediately after stopping his run, the heart rate is 130/min, and the blood pressure is 145/75 mm Hg."]}
{"Patient Personal Background": ["No significant past medical history and no current medications.", "The patient is not sexually active and denies any alcohol, smoking or drug use."], "Patient Symptoms": ["The patient says that he has been limping with mild pain for the past three weeks, but the pain acutely worsened today.", "He describes the pain as severe, non-radiating, sharp and aching in character, and localized to the right hip and knee joints."], "Examination and Results": ["The vital signs include: temperature 37.0\u00b0C (98.6\u00b0F), blood pressure 110/70 mm Hg, pulse 72/min, respiratory rate 15/min, and oxygen saturation 99% on room air.", "Body mass index (BMI) is 32 kg/m2.", "On physical examination, the patient is alert and cooperative.", "The right leg is externally rotated, and there is a limited range of motion in the right hip.", "Strength is 4 out of 5 at the right hip joint and 5 out of 5 elsewhere.", "There is no tenderness to palpation.", "No joint erythema, edema or effusion present.", "Sensation is intact.", "Deep tendon reflexes are 2+ bilaterally.", "Laboratory tests are unremarkable.", "Plain radiographs of the right hip joint are significant for displacement of the right femoral head inferoposterior off the femoral neck."], "Others": ["The patient denies recent illness, travel, trauma, or similar symptoms in the past."]}
{"Patient Personal Background": ["He used to ride his bicycle for exercise 4 times a week but stopped after he had an accident and injured his left testicle 3 months ago.", "For the last 10 years, he drinks one to two beers daily and sometimes more on weekends.", "He occasionally takes pantoprazole for heartburn.", "He is 171 cm (5 ft 7 in) tall and weighs 87 kg (192 lb); BMI is 30 kg/m2."], "Examination and Results": ["Vital signs are within normal limits.", "Examination shows bilaterally symmetrical, mildly tender gynecomastia.", "A nontender 1.5-cm mass is palpated in the left testis; transillumination test is negative.", "The remainder of the examination shows no abnormalities."], "Others": ["He has gained 5 kg (11 lb) during this period."]}
{"Patient Personal Background": ["He has hyperlipidemia and was diagnosed with major depressive disorder 3 years ago.", "He had not been sexually active for the previous 3 years, since the death of his wife.", "He does not smoke.", "He drinks 4\u20136 beers on weekends.", "Current medications include simvastatin and citalopram."], "Patient Symptoms": ["He first noticed the problem 8 months ago, when he became sexually active with a new girlfriend.", "He states that his relationship with his girlfriend is good, but his inability to engage in sexual intercourse has been frustrating."], "Examination and Results": ["His temperature is 37.5\u00b0C (99.5\u00b0F), pulse is 80/min, and blood pressure is 135/82 mm Hg.", "BMI is 30 kg/m2.", "Pedal pulses are difficult to palpate."], "Treatment": ["Current medications include simvastatin and citalopram."], "Diagnosis": ["He has hyperlipidemia and was diagnosed with major depressive disorder 3 years ago."]}
{"Patient Personal Background": ["The patient has a history of mild intermittent asthma and has been using his albuterol inhaler without relief.", "The patient\u2019s past medical history is otherwise unremarkable, and he has no known drug allergies."], "Patient Symptoms": ["He has also been complaining of headache and sore throat, and his mother has noticed worsening rhinorrhea."], "Examination and Results": ["In the office, his temperature is 101.8\u00b0F (38.8\u00b0C), blood pressure is 88/65 mmHg, pulse is 132/min, and respirations are 16/min.", "The patient has purulent mucus draining from the nares, and his face is tender to palpation over the maxillary sinuses.", "His pharynx is erythematous with symmetric swelling of the tonsils.", "On lung exam, he has moderate bilateral expiratory wheezing."]}
{"Patient Personal Background": ["His regular medications include inhaled salmeterol and inhaled fluticasone propionate.", "He was a chronic smoker but quit smoking 2 years ago."], "Patient Symptoms": ["There is no history of fever."], "Examination and Results": ["His temperature is 37.1\u00b0C (98.8\u00b0F), the pulse rate is 88/min, the blood pressure is 128/86 mm Hg, and the respirations are 30/min.", "On physical examination, the use of the accessory muscles of respiration is evident and the arterial saturation of oxygen is 87%.", "Auscultation of the chest reveals the presence of bilateral rhonchi with diminished breath sounds in both lungs."]}
{"Patient Personal Background": ["The patient has a past medical history of constipation, anxiety, and substance abuse.", "She is not currently taking any medications."], "Patient Symptoms": ["The patient has been trying to get pregnant and was successful recently, but now she is experiencing abdominal pain, contractions, and a bloody vaginal discharge."], "Examination and Results": ["According to her last appointment with her primary care provider, she is 10 weeks pregnant.", "Her temperature is 99.5\u00b0F (37.5\u00b0C), blood pressure is 107/58 mmHg, pulse is 90/min, respirations are 17/min, and oxygen saturation is 98% on room air.", "Physical exam is notable for a bloody vaginal discharge and an open cervix."], "Diagnosis": ["Upon hearing the news that she is having a spontaneous abortion, the patient becomes angry and aggressive and states that her physician and the medical staff are incompetent, evil, and she is going to sue all of them."], "Others": ["The patient is initially extremely grateful for the care she is receiving and thanks the doctor and the nursing staff for saving her baby.", "The patient is left to grieve but upon entering the room again you notice that the patient has new lacerations over her wrists and that some of the medical equipment in the room is broken."]}
{"Patient Personal Background": ["She reports taking high doses of acetaminophen and aspirin over several weeks due to persistent upper back pain."], "Examination and Results": ["She denies any previous episodes of hematuria.", "The patient\u2019s blood pressure and temperature are normal, but she is found to have proteinuria.", "Physical examination is negative for palpable flank masses."]}
{"Patient Personal Background": ["The patient also has been taking metformin for the past 2 years and is severely obese, with a BMI of 41 kg/m2."], "Patient Symptoms": ["The pain developed over time and now limits his mobility.", "He states that the pain is worse at the end of the day, though he does have some early-morning stiffness lasting about 20 minutes.", "He used to have some success with over-the-counter NSAIDs; however, they no longer help.", "Additionally, he states that he has felt increasingly tired during the day, often dozes off during work, and no longer feels refreshed when he wakes up in the morning."], "Examination and Results": ["Upon examination, there is no tenderness on palpation or erythema; however, some crepitus is felt."], "Others": ["He has no other complaints but has a family history of rheumatoid arthritis (RA) on his mother\u2019s side."]}
{"Patient Personal Background": ["He has no history of serious medical illness and takes no medications."], "Patient Symptoms": ["Physical examination shows drooping of the eyelids bilaterally.", "He is unable to hold his arms up for longer than 3 minutes."], "Examination and Results": ["A CT scan of the chest shows an anterior mediastinal mass with smooth contours."], "Others": ["A photomicrograph of a specimen from the mass is shown."]}
{"Patient Symptoms": ["On physical examination, the patient appears drowsy and lethargic and is minimally responsive to stimuli."], "Examination and Results": ["His respiratory rate is 8/min and shallow, blood pressure is 130/90 mm Hg, and pulse is 60/min.", "On physical examination, miosis is present, and the pupils appear pinpoint."], "Treatment": ["The patient is given a drug to improve his symptoms."], "Others": ["The patients\u2019 parents say that a bottle of oxycodone was found at his bedside and was missing 15 pills."]}
{"Patient Personal Background": ["She is a research assistant at the university geology laboratory.", "She is originally from Nigeria and visits her family there twice a year; her last trip was 3 months ago."], "Patient Symptoms": ["She has been unable to perform her daily activities.", "She has had malaise and bilateral ankle pain during this period.", "She noticed her symptoms after returning from a vacation to Arizona.", "The remainder of the examination shows no abnormalities."], "Examination and Results": ["Her temperature is 37.8\u00b0C (100\u00b0F), pulse is 100/min, respirations are 24/min, and blood pressure is 112/72 mm Hg.", "Pulse oximetry on room air shows an oxygen saturation of 94%.", "There is no palpable cervical or axillary lymphadenopathy.", "The lungs are clear to auscultation.", "Her left eye is notable for ciliary injection and photophobia.", "A complete blood count is within the reference range.", "An x-ray of the chest is shown."]}
{"Patient Symptoms": ["His more recent complaints include dysphagia for liquids as well.", "The patient states that he has no difficulty initiating swallowing but occasionally food is stuck in his throat.", "He does not complain of pain while swallowing but has noticed minor unintentional weight loss."], "Examination and Results": ["During the examination, the patient appears ill, malnourished, and slightly pale.", "He is not jaundiced nor cyanotic.", "Physical examination is unremarkable.", "A swallowing study reveals a small outpouching in the posterior neck (see image)."], "Others": ["The patient has no history of speech-related pain or nasal regurgitation.", "His family history is unremarkable."]}
{"Patient Symptoms": ["She has had constipation for the past 6 weeks and overall fatigue.", "She also had heavy menstrual bleeding; and often feels extremely cold at home.", "There is also pain associated with swallowing."], "Examination and Results": ["On examination, the thyroid is stony hard, tender and asymmetrically enlarged.", "Laboratory studies show a serum T4 level of 4.4 \u03bcg/dL and a TSH level of 6.3 mU/L.", "A radionuclide thyroid scanning indicates that the nodule has low radioactive iodine uptake."], "Others": ["On the other hand, she has well-controlled asthma and spring allergies."]}
{"Examination and Results": ["When she applies compound X to the cells, she finds that the urinary concentration of sodium and the pH decreases while the urinary potassium increases."]}
{"Patient Symptoms": ["The patient has not been able to eat or drink due to the pain and has been irritable.", "The patient also reports muscle aches."], "Examination and Results": ["His vital signs are as follows: T 39.1, HR 110, BP 90/62, RR 18, SpO2 99%.", "Physical examination is significant for vesicular lesions noted on the tongue, gingiva, and lips, with some vesicles having ruptured and ulcerated, as well as palpable cervical and submandibular lymphadenopathy."]}
{"Others": ["The patient's written advance directive states that he does not wish to be resuscitated in the event of a cardiac arrest.", "The patient's wife arrives and demands that \"everything\" be done to keep him alive because she \"can't go on living without him.\"", "The patient's adult son is on his way to the hospital."]}
{"Patient Personal Background": ["He has coronary artery disease, hypertension, and type 2 diabetes mellitus.", "His current medications are aspirin, simvastatin, metformin, and enalapril.", "He has smoked one pack of cigarettes daily for 33 years.", "On arrival, his pulse is 136/min and irregular, respirations are 20/min, and blood pressure is 85/55 mm Hg."], "Patient Symptoms": ["He describes it as 7 out of 10 in intensity."], "Examination and Results": ["The lungs are clear to auscultation.", "Cardiac examination shows no abnormalities.", "An ECG is shown."]}
{"Examination and Results": ["Based on clinical suspicion, a CBC, a Coombs test, and a bilirubin panel are obtained to determine the etiology of the gallstone.", "These tests reveal a mild normocytic anemia with associated reticulocytosis as well as an increased RDW.", "In addition there is an indirect hyperbilirubinemia and the Coombs test results are negative.", "To confirm the diagnosis, an osmotic fragility test is performed which shows increased fragility in hypotonic solution."]}
{"Patient Personal Background": ["He reports that his symptoms started after he lifted heavy weights at the gym."], "Patient Symptoms": ["He reports that his symptoms started after he lifted heavy weights at the gym."], "Examination and Results": ["Physical examination shows loss of sensation on the lateral side of the right forearm.", "Sensation over the thumb is intact.", "Range of motion of the neck is normal.", "His symptoms do not worsen with axial compression or distraction of the neck."]}
{"Examination and Results": ["Serologic tests reveal positive Anti-HBsAg and Anti-HAV IgM antibodies."]}
{"Patient Personal Background": ["He has had hypertension for the past 10 years for which he takes bisoprolol.", "He does not smoke or drink alcohol."], "Patient Symptoms": ["His condition started suddenly 30 minutes ago.", "On physical examination, the patient appears in severe pain and his left leg is pale and cool."], "Examination and Results": ["His temperature is 37.1\u00b0C (98.7\u00b0F), the blood pressure is 130/80 mm Hg, and the pulse is 100/min and irregular.", "The popliteal pulse is weaker on the left side compared to the right side."]}
{"Patient Symptoms": ["He is concerned that she has not undergone puberty yet, while all of her classmates at school have.", "The patient herself feels well overall, with no specific complaints."], "Examination and Results": ["Examination shows vital signs of T 98.9, HR 71, and BP 137/92.", "The physician notes undeveloped breasts and normal external and internal female genitalia in Tanner I stage of development.", "Her body mass index is within normal limits, she is in the 40th percentile for height, and she is agreeable and pleasant during the interview."]}
{}
{"Others": ["This mutation results in the sickling of their red blood cells when exposed to inciting factors such as hypoxic conditions."]}
{"Patient Personal Background": ["He has a history of cirrhosis of the liver secondary to alcoholism."], "Patient Symptoms": ["He started becoming more confused a few days ago and it has been getting gradually worse."], "Examination and Results": ["His temperature is 98.8\u00b0F (37.1\u00b0C), blood pressure is 134/90 mmHg, pulse is 83/min, respirations are 15/min, and oxygen saturation is 98% on room air.", "Physical exam reveals a distended abdomen that is non-tender.", "Neurological exam is notable for a confused patient and asterixis."]}
{"Patient Personal Background": ["She was born at term via vaginal delivery and her delivery was uncomplicated."], "Patient Symptoms": ["Her parents report that she has not eaten anything during this period and that they were unable to calm her down."], "Examination and Results": ["Her vital signs are within normal limits.", "Examination shows a reddened and swollen 2nd toe of the left foot."], "Others": ["She has not had any trauma.", "A photograph of the left foot is shown."]}
{"Patient Personal Background": ["Her past medical history is significant for asthma and eczema.", "She has no history of any serious illness and takes no medications."], "Patient Symptoms": ["She feels solid food getting stuck in her chest behind the sternum.", "She does not have any issues with liquids.", "She has no coughing or nasal regurgitation.", "She has no hoarseness or weight loss.", "She reports occasional heartburn that has lasted for about a year."], "Examination and Results": ["Her vital signs are within normal limits.", "Physical examination shows no abnormal findings.", "An endoscopic image of the esophagus is shown.", "Mucosal biopsy shows eosinophilic infiltration."]}
{"Patient Symptoms": ["They state that approximately one hour after putting their child to sleep, a \"hacking\" cough was heard from his bedroom.", "After entering his room the parents state their child appeared to be in distress, making a high pitched noise with every breath.", "Beyond a runny nose for the past few days, the child has been healthy."], "Examination and Results": ["Physical exam demonstrates a 2-year-old child in respiratory distress."], "Others": ["He has no toys in his bed or access to any other small objects."]}
{"Patient Symptoms": ["Over the next few months, her symptoms become more severe, as she experiences rapid mental deterioration.", "She also starts to have sudden, jerking movements in response to being startled and gait disturbances.", "Eventually, she lapses into a coma and dies eight months after the onset of symptoms."]}
{"Examination and Results": ["On physical examination, the oral cavity shows mucosal ulceration and atrophy.", "Biopsy of the lower lip shows marked lymphocytic infiltration of the minor salivary glands."]}
{"Patient Personal Background": ["He smoked one pack of cigarettes daily for 20 years but quit 5 years ago."], "Examination and Results": ["Physical examination shows an increased anteroposterior chest diameter and coarse crackles in the lower lung fields bilaterally."], "Treatment": ["Treatment with a drug that directly antagonizes the effects of vagal stimulation on the airways is begun."]}
{"Patient Personal Background": ["He had bilateral orchidopexy for cryptorchidism as an infant."], "Patient Symptoms": ["Two days ago, his mother found that he had left the gas on in the kitchen, and he was unable to smell the odor of the gas.", "The patient is unable to identify several common odors when presented with them."], "Examination and Results": ["As a child, he was consistently in the 40th percentile for height; now he is in the 15th percentile.", "Physical examination shows sparse axillary and pubic hair and Tanner stage 1 genitals."]}
{"Treatment": ["She received appropriate post-exposure prophylaxis in the emergency department and has already received 2 doses of the rabies vaccine.", "The same physician has been managing the post-exposure care regimen.", "After the physician administers the third dose of the rabies vaccine, the patient asks him if he would like to join her for a movie and dinner."], "Others": ["The physician is interested in going on a date with her."]}
{"Patient Symptoms": ["His fever is low-grade and sputum is often blood-tinged.", "He has lost 6.8 kg (15.0 lb) during this period and complains of profound night sweats."], "Examination and Results": ["A plain radiograph of the patient\u2019s chest shows consolidation in the apical part of the right lung.", "Baseline investigations show the following:\nComplete blood count\nHemoglobin 11 g/dL\nWhite blood cells  \nTotal count 16,000/mm3\nDifferential count  \nNeutrophils 35%\nLymphocytes 54%\nEosinophils 11%\nErythrocyte sedimentation rate 84 mm\nThe physician suspects that the patient is suffering from a chronic lung infection."]}
{"Patient Personal Background": ["He informs the physician that he is asthmatic, but does not use inhalers regularly because he does not like using medications.", "He is a non-smoker and occasionally drinks alcohol."], "Patient Symptoms": ["The physician asks the nurse to administer nebulized albuterol; however, the boy declines nebulized albuterol because of a history of palpitations that he experienced previously."], "Examination and Results": ["On physical examination, the temperature is 37.0\u00b0C (98.6\u00b0F), the pulse is 120/min, the blood pressure is 114/76 mm Hg, and the respiratory rate is 32/min.", "Auscultation of the chest reveals bilateral wheezing."], "Treatment": ["The physician then prescribes nebulized ipratropium bromide, which results in significant clinical improvement."]}
{"Patient Personal Background": ["The mother had no prenatal care."], "Patient Symptoms": ["Examination of the smaller newborn shows a flattened nose and left-sided clubfoot."], "Examination and Results": ["Examination of the smaller newborn shows a flattened nose and left-sided clubfoot.", "The hematocrit is 42% for the smaller newborn and 71% for the larger newborn."]}
{"Patient Personal Background": ["The patient has a past medical history of asthma, obesity, and a uterine leimyoma which was definitively treated last year.", "Her last menstrual period was at the age of 47."], "Examination and Results": ["The patient's vital signs and exam are unremarkable."], "Treatment": ["The patient is started on chemotherapy and ultimately has the mass resected.", "She is taking tamoxifen and has regular outpatient follow up appointments to monitor for any recurrence of cancer."], "Diagnosis": ["The mass is biopsied and cytology results are diagnostic for invasive ductal adenocarcinoma that is estrogen receptor positive."]}
{"Patient Symptoms": ["She has also had progressive recurring headaches and visual impairment over the last month.", "Three days ago, she had a seizure but has not seen a physician.", "She is oriented only to person."], "Examination and Results": ["Her temperature is 36.7\u00b0C (98.1\u00b0F), pulse is 90/min, and blood pressure is 110/80 mm Hg.", "Capillary refill time is more than 3 seconds."]}
{"Patient Personal Background": ["She takes no medications."], "Patient Symptoms": ["She has pain around her right eye during eye movement."], "Examination and Results": ["At the clinic, her blood pressure is 110/70 mm Hg, the pulse is 72/min, respirations are 15/min, and the temperature is 36.5\u2103 (97.7\u2109).", "On physical examination, illumination of the left eye results in bilateral pupillary constriction while illumination of the right eye results in a mild bilateral pupillary dilation.", "Fundoscopic examination shows optic disk swelling in the right eye.", "The color vision test shows decreased perception in the right eye.", "The remainder of the physical examination shows no abnormalities."]}
{"Patient Personal Background": ["She has not felt like eating or drinking since her symptoms started, and she has not taken any medications."], "Patient Symptoms": ["The vomitus is watery and contains undigested food particles.", "She also complains of feeling tired and having the \u201csniffles\u201d.", "Her concern now is that she immediately gets dizzy when she stands up."], "Examination and Results": ["Vitals signs include: pulse 120/min, respiratory rate 9/min, and blood pressure 100/70 mm Hg.", "Her eyes are sunken, and her tongue appears dry."]}
{"Patient Personal Background": ["He and his wife have been trying to get pregnant for the past two years.", "They have used fertility monitors and other aids without success.", "The patient has a history of cleft lip and recurrent upper respiratory infections as a child.", "He was briefly hospitalized for severe pneumonia when he was 9-years-old."], "Examination and Results": ["A hysterosalpingogram in his wife was normal.", "His temperature is 98.6\u00b0F (37\u00b0C), blood pressure is 120/85 mmHg, pulse is 90/min, and respirations are 18/min.", "On examination, he is a healthy-appearing male in no acute distress with fully developed reproductive organs.", "Notably, cardiac auscultation is silent in the left 5th intercostal space at the midclavicular line."]}
{"Patient Personal Background": ["She has smoked 1 pack of cigarettes daily for the past 30 years."], "Patient Symptoms": ["She has had multiple episodes of upper abdominal pain over the past year."], "Examination and Results": ["Physical examination shows a distended abdomen with diffuse tenderness and high-pitched bowel sounds.", "An x-ray of the abdomen shows a dilated bowel, multiple air-fluid levels, and branching radiolucencies in the right infra-diaphragmatic region."]}
{"Patient Symptoms": ["Three days after the surgery, he develops fever and redness around the surgical site.", "Four days later, the patient continues to have high-grade fever, pain, and purulent discharge."], "Examination and Results": ["His temperature is 39.5\u00b0C (103.1\u00b0F).", "Physical examination shows purulent discharge from the wound with erythema of the surrounding skin.", "Wound culture of the purulent discharge shows gram-positive cocci in clusters."], "Treatment": ["Treatment with oral dicloxacillin is initiated."]}
{"Patient Symptoms": ["She denies any other symptoms and states that she has not gained any weight."], "Examination and Results": ["On exam, you notice a 2 cm nodule on her anterior neck.", "Her TSH level is normal and radionucleotide scan reveals a cold nodule.", "Fine needle aspiration biopsy (FNAB) reveals follicular architecture suspicious for malignancy."]}
{"Examination and Results": ["All pressures are found to be within normal limits, and the cardiology fellow records a pulmonary wedge pressure of 10 mmHg."]}
{"Patient Personal Background": ["He has a history of recurrent ear infections treated with antibiotics since birth."], "Patient Symptoms": ["Over the past 8 months, his mother reports difficulty understanding the boy's speech.", "On occasion during this period, she has noticed that he does not respond when called by name and cannot follow 1-step instructions.", "His speech is quiet and difficult to understand."], "Examination and Results": ["He is at the 60th percentile for length and 50th percentile for weight.", "Vital signs are within normal limits.", "Otoscopic examination shows retracted tympanic membranes bilaterally that are immobile on pneumatic otoscopy.", "Nasopharyngoscopy shows mild adenoid hypertrophy.", "Pure tone audiometry shows a conductive hearing loss of 26 dB on the right side and 28 dB on the left side."]}
{"Patient Personal Background": ["His past medical history is insignificant for any seizure disorders, and he does not take any medications."], "Patient Symptoms": ["He developed nausea, vomiting, and abdominal cramps.", "The patient noted facial muscle twitching and developed a tonic-clonic seizure that lasted 3 minutes, 4 hours following the onset of his condition.", "He is pale and sweaty."], "Examination and Results": ["His blood pressure is 95/60 mm Hg, heart rate is 104/min, respiratory rate is 10/min, and the temperature is 37.0\u00b0C (98.6\u00b0F).", "On physical examination, the patient\u2019s consciousness is decreased with a Glasgow Coma Scale score of 13.", "His lung sounds are normal, cardiac sounds are decreased, and no murmurs are present.", "Abdominal palpation reveals epigastric tenderness.", "Neurological examination shows rapid downbeating nystagmus, facial muscle twitching, and symmetrically decreased sensation to all the sensory modalities on both the upper and lower extremities.", "Further discussion reveals that the patient was using sodium fluoroacetate as a pesticide, which is known to form fluorocitrate in the cells of aerobic organisms."], "Others": ["His wife reports that 30 min following the onset of her husband\u2019s condition, which started approximately 6 hours ago, he treated his garden bed with pesticides against mice."]}
{"Patient Personal Background": ["Social history is significant for alcohol abuse."], "Patient Symptoms": ["90 minutes ago, the patient was found by a neighbor unarousable on the couch with multiple empty bottles of medication on the floor next to her."], "Examination and Results": ["Physical examination reveals an awake female with a fluctuating level of consciousness, not oriented to time or place.", "No focal neurologic deficits."]}
{"Patient Personal Background": ["He has metastatic colon cancer and has received three cycles of chemotherapy with 5-fluorouracil, leucovorin, and oxaliplatin; his last chemotherapy session was 2.5 months ago.", "His medications include a fluticasone-salmeterol inhaler and a tiotropium bromide inhaler.", "He has smoked one pack of cigarettes daily for 48 years."], "Patient Symptoms": ["The cough is productive of small amounts of green phlegm."], "Examination and Results": ["His temperature is 39.1\u00b0C (103.1\u00b0F), pulse is 112/min, respirations are 32/min, and blood pressure is 88/69 mm Hg.", "Pulse oximetry on room air shows an oxygen saturation of 88%.", "Pulmonary examination shows diffuse crackles and rhonchi.", "An x-ray of the chest shows a left upper-lobe infiltrate of the lung.", "Endotracheal aspirate Gram stain shows gram-negative rods."], "Treatment": ["He has chronic obstructive pulmonary disease and has been treated with antibiotics and prednisolone for acute exacerbations three times in the past year.", "Two sets of blood cultures are obtained.", "Two large bore cannulas are inserted and intravenous fluids are administered."]}
{"Patient Symptoms": ["Over the last 7 months, he has claimed to hear voices telling him that he must prepare for the end of the world.", "He used to be a straight A student but started failing exams recently due to his erratic behavior.", "Furthermore, there are periods of time where he does not sleep for several days and redecorates the entire apartment.", "During those times he spends huge amounts of money on online shopping.", "These periods usually last for about 2 weeks and happen every other month."], "Examination and Results": ["On physical exam, he appears unkept and irritated.", "He seems to respond to invisible stimuli, and he jumps from topic to topic without clear focus."]}
{"Patient Personal Background": ["He had a left basal ganglia hemorrhage 12 years ago and a right middle cerebral artery infarction 4 years ago.", "Current medications are amlodipine, aspirin, clopidogrel, metformin, sitagliptin, and valsartan.", "He lives with his son and can feed himself and change his clothes."], "Patient Symptoms": ["The patient\u2019s son says he has difficulty remembering recent events and names.", "He says the patient\u2019s symptoms have progressively worsened over the last several years but became acutely worse just recently.", "Also, yesterday, the patient complained that he could not see out of his right eye, but today he can.", "When asked about these concerns, the patient seems to have no insight into the problem and reports feeling well."], "Examination and Results": ["His vitals include: blood pressure 137/82 mm Hg, pulse 78/min, respiratory rate 16/min, temperature 37.0\u00b0C (98.6\u00b0F).", "On physical examination, the patient is alert and oriented.", "He is unable to perform simple arithmetic calculations and the mini-mental status exam is inconclusive.", "Muscle strength is 4/5 on the right side.", "The tone is also slightly reduced on the right side with exaggerated reflexes.", "His gait is hemiparetic."], "Others": ["His medical history is significant for diabetes mellitus type 2 and hypertension.", "There is no history of urinary or fecal incontinence."]}
{"Patient Personal Background": ["She is currently unemployed and lives in a low-income neighborhood with her 3 children.", "Current medications include dolutegravir, tenofovir, and emtricitabine."], "Examination and Results": ["For the past 3 years, her HIV RNA viral load was undetectable, but last week, her viral load was 8,391 copies/mL (N < 50)."], "Treatment": ["Current medications include dolutegravir, tenofovir, and emtricitabine."], "Others": ["On questioning, she says that she misses her medications every other day."]}
{"Patient Personal Background": ["He has a history of peripheral arterial disease, type 2 diabetes mellitus, hypertension, hypercholesterolemia, and gout.", "The patient has smoked 1 pack of cigarettes daily for the past 50 years.", "He drinks 3 cans of beer daily.", "His current medications include aspirin, metformin, enalapril, simvastatin, and febuxostat.", "His temperature is 37.3\u00b0C (99.1\u00b0F), pulse is 86/min, and blood pressure is 122/76 mm Hg."], "Patient Symptoms": ["He feels well but reports occasional episodes of weakness and numbness in his left hand."], "Examination and Results": ["The lungs are clear to auscultation.", "Cardiac examination shows no murmurs, rubs, or gallops.", "Auscultation of the right side of the neck shows a bruit.", "There is a right-sided reducible inguinal hernia.", "Neurological examination shows no abnormalities.", "A complete blood count and serum concentrations of electrolytes, creatinine, and glucose are within the reference ranges.", "An electrocardiogram shows signs of mild left ventricular hypertrophy.", "An x-ray of the chest shows no abnormalities."]}
{"Patient Personal Background": ["She has a history of regular menstruation every 4 weeks that lasts about 4 days with mild to moderate bleeding, but she missed her last period 2 weeks ago.", "She has a 6-year history of hyperthyroidism that is well-controlled with daily methimazole."], "Patient Symptoms": ["She is currently asymptomatic and has no complaints or concerns."], "Examination and Results": ["A home pregnancy test was positive.", "A blood specimen is taken and confirms the diagnosis.", "Additionally, her thyroid-stimulating hormone (TSH) is 2.0 \u03bcU/mL."], "Diagnosis": ["A blood specimen is taken and confirms the diagnosis."]}
{"Patient Personal Background": ["The patient has a past medical history of osteoporosis, dyslipidemia, and diabetes.", "He drinks 3 alcoholic drinks every day and has a 44 pack-year smoking history."], "Patient Symptoms": ["The patient states that he has gradually worsening back pain that seems to have worsened after moving furniture the other day.", "He also states that while he walks, he feels numbness and weakness in his legs.", "The only time the patient states his back pain is improved is when he is riding his bike or pushing a cart at the grocery store."], "Examination and Results": ["His temperature is 99.5\u00b0F (37.5\u00b0C), blood pressure is 157/108 mmHg, pulse is 90/min, respirations are 17/min, and oxygen saturation is 98% on room air.", "Physical exam is notable for a non-tender spine with normal mobility in all 4 directions."], "Others": ["Radiography of the spine and basic labs are ordered."]}
{"Patient Symptoms": ["She has experienced 7 similar episodes, each lasting 2\u20135 days in the previous 2 years.", "She has also had intermittent abdominal cramps and recurrent episodes of foul-smelling greasy diarrhea in the past year."], "Examination and Results": ["She is at the 55th percentile for height and 35th percentile for weight.", "Her temperature is 38.9\u00b0C (102\u00b0F), pulse is 100/min, respirations are 24/min, and blood pressure is 110/60 mm Hg.", "Physical examination shows an erythematous oropharynx without exudate and tenderness over the frontoethmoidal sinuses.", "The abdomen is distended, nontender, and tympanitic to percussion.", "Bowel sounds are increased.", "Stool microscopy shows pear-shaped multi-flagellated organisms."]}
{"Patient Personal Background": ["Past medical history is significant for a recent sore throat which caused him to miss several days at school.", "The patient\u2019s vaccination status is unknown."], "Examination and Results": ["On physical examination, the patient is pale and ill-looking.", "There are pink rings present on the torso and inner surfaces of the limbs.", "Cardiac exam is significant for a holosystolic murmur heard best over the apex of the heart."]}
{"Patient Personal Background": ["He has a past medical history of type II diabetes, hypertension, hyperlipidemia, asthma, and depression.", "His home medications are sitagliptin/metformin, lisinopril, atorvastatin, albuterol inhaler, and citalopram."], "Patient Symptoms": ["He has no complaints except for a dry cough."], "Examination and Results": ["His vitals signs are stable, with blood pressure 126/79 mmHg.", "Hemoglobin A1C is 6.3%, and creatinine is 1.3 g/dL.", "The remainder of his physical exam is unremarkable."]}
{"Patient Personal Background": ["He was born at 40 weeks' gestation at 2514 g (5.54 lb) to a 28-year-old woman, gravida 3, para 2, by an uncomplicated cesarean section.", "The mother did not receive prenatal care."], "Patient Symptoms": ["Examination shows hyperreflexia, tremors, and an excessive startle response."], "Examination and Results": ["Apgar scores were 8 and 9 at 1 and 5 minutes, respectively.", "The infant's temperature is 38.0\u00b0C (100.4\u00b0F), pulse is 170/min, and blood pressure is 71/39 mm Hg."]}
{"Patient Personal Background": ["A month ago, she returned from a camping trip to Sri Lanka."], "Patient Symptoms": ["During this time, she has also noticed that her gums bleed while brushing her teeth.", "There are a few scattered petechiae over the trunk and back."], "Examination and Results": ["Her temperature is 39.3\u00b0C (102.8\u00b0F), pulse is 104/min, respirations are 24/min, and blood pressure is 135/88 mm Hg.", "Examination shows pallor and mild scleral icterus.", "There is no lymphadenopathy.", "Test of the stool for occult blood is positive.", "Laboratory studies show:\nHemoglobin 8.2 g/dL\nLeukocyte count 10,000/mm3\nPlatelet count 18,000/mm3\nINR 1.0\nCoomb's test negative\nFibrin split products negative\nSerum\nUrea 20 mg/dL\nCreatinine 1.1 mg/dL\nBilirubin\nTotal 3.0 mg/dL\nDirect 0.8 mg/dL\nAlanine aminotransferase 20 U/L\nAspartate aminotransferase 16 U/L\nLactate dehydrogenase 900 U/L\nUrine\nProtein 1+\nWBCs occasional\nRBCs 50\u201360/hpf\nBacteria nil\nA photograph of the peripheral blood smear is shown.", "Blood and urine cultures are negative."], "Others": ["Physical and neurologic examinations show no other abnormalities."]}
{"Patient Symptoms": ["On arrival, he is oriented to person but not to place or time."], "Examination and Results": ["His temperature is 37.3\u00b0C (99.1\u00b0F), pulse is 116/min, respirations are 18/min, and blood pressure is 79/42 mm Hg.", "Pulse oximetry on room air shows an oxygen saturation of 97%.", "Examination shows multiple abrasions over the arms and thorax.", "There is a 1-cm (0.4-in) entry wound with minimal bleeding on the right side of the chest in the 6th intercostal space at the midclavicular line.", "Cardiopulmonary examination shows no abnormalities.", "Abdominal examination shows diffuse mild tenderness to palpation with no guarding or rebound.", "A focused assessment with sonography shows no obvious free fluid in the pericardium; assessment of the abdomen is equivocal.", "An x-ray of the chest shows mild opacification of the right lower lobe.", "Two large-bore cannulas are inserted and intravenous fluid resuscitation is begun."], "Treatment": ["The patient is intubated and mechanical ventilation is begun."], "Others": ["He sustained a gunshot wound in an altercation outside of a bar."]}
{"Patient Symptoms": ["This mutation results in a rare disease characterized by muscle cramping and stiffening that is usually most severe after exercise or strenuous activity and is typically relieved after affected individuals rest for a few minutes."], "Diagnosis": ["This mutation results in a rare disease characterized by muscle cramping and stiffening that is usually most severe after exercise or strenuous activity and is typically relieved after affected individuals rest for a few minutes."]}
{"Patient Personal Background": ["He has had type 2 diabetes for 27 years and essential hypertension for 19 years.", "He has smoked 20\u201330 cigarettes per day for the past 35 years."], "Patient Symptoms": ["His symptoms started 20 minutes ago while shaving.", "He also feels nauseated, lightheaded and short of breath."], "Examination and Results": ["His temperature is 36.9\u00b0C (98.4\u00b0F), the blood pressure is 115/72 mm Hg and the pulse is 107/min.", "Physical examination is unremarkable.", "Troponins are elevated."], "Treatment": ["The patient is admitted to a unit with continuous cardiac monitoring.", "Aspirin, clopidogrel, sublingual nitroglycerin, and morphine are given immediately and the patient now rates the pain as 4\u20135 out of 10."], "Others": ["Family history is irrelevant.", "ECG is shown in the image."]}
{"Patient Personal Background": ["He underwent appendectomy at the age of 39.", "He drinks two beers daily.", "He takes a topical corticosteroid, ramipril, metformin, and ibuprofen daily.", "He is 176 cm (5 ft 9 in) tall and weighs 108 kg (240 lb); BMI is 35.4 kg/m2."], "Patient Symptoms": ["His last bowel movement was yesterday and he has not passed flatus since then."], "Examination and Results": ["His temperature is 36.8\u00b0C (98.4\u00b0F), respirations are 15/min, pulse is 90/min, and blood pressure is 112/67 mm Hg.", "Examination shows thick, scaly, plaques over both elbows and knees.", "Abdominal examination shows three well-healed laparoscopic scars.", "The abdomen is distended and there are frequent, high-pitched bowel sounds on auscultation.", "Digital rectal examination shows an empty rectum.", "Laboratory studies show:\nHematocrit 44%\nLeukocyte count 9,000/mm3\nPlatelet count 225,000/mm3\nSerum\nNa+ 139 mEq/L\nK+ 4.1 mEq/L\nCl\u2212 101 mEq/L\nHCO3\u2212 26 mEq/L\nGlucose 95 mg/dL\nCreatinine 1.1 mg/dL\nAlkaline phosphatase 78 U/L\nAspartate aminotransferase (AST, GOT) 19 U/L\nAlanine aminotransferase (ALT, GPT) 14 U/L\n\u03b3-Glutamyltransferase (GGT) 52 U/L (N=5\u201350 U/L)\nHemoglobin A1C 6.4%\nAbdominal ultrasound shows nonpropulsive peristalsis of the small bowel."]}
{"Patient Symptoms": ["She additionally reports bloody diarrhea and tenesmus."], "Diagnosis": ["You suspect ulcerative colitis."]}
{"Patient Symptoms": ["During the past 3 months, the patient has had several upper respiratory tract infections and poor weight gain."], "Examination and Results": ["Physical examination shows crackles over both lung fields and enlargement of the tonsils and cervical lymph nodes.", "His serum IgA, IgE, and IgG titers are decreased.", "An x-ray of the chest shows bilateral interstitial infiltrates.", "Methenamine silver staining of bronchial lavage fluid shows disc-shaped cysts."]}
{"Patient Personal Background": ["His past medical history is significant for hypertension that is controlled with lisinopril."], "Patient Symptoms": ["He reports that he gets tired easily compared to his baseline and feels dizzy when he exerts himself (e.g., when he walks long distances)."], "Examination and Results": ["A physical examination demonstrates moderate hepatomegaly and lymphadenopathy.", "His laboratory studies are shown below.", "Leukocyte count and differential:\nLeukocyte count: 11,500/mm^3\nSegmented neutrophils: 40%\nBands: 3%\nEosinophils: 1%\nBasophils: 0%\nLymphocytes: 50%\nMonocytes: 8%\n\nHemoglobin: 11.2 g/dL\nPlatelet count: 120,000/mm^3\nMean corpuscular hemoglobin concentration: 31%\nMean corpuscular volume: 80 \u00b5m^3\nReticulocyte count: 3%\nLactate dehydrogenase: 45 U/L\n\nA subsequent flow cytometry test demonstrates CD20+ cells."]}
{"Patient Personal Background": ["His past medical history is significant for Alzheimer disease though he is still relatively functional at baseline.", "He has also been taking warfarin over the last 3 months after he suffered a deep venous thrombosis."], "Patient Symptoms": ["On presentation, he is found to be somnolent and physical exam reveals ataxia and nystagmus."], "Examination and Results": ["On presentation, he is found to be somnolent and physical exam reveals ataxia and nystagmus."], "Treatment": ["After determining the cause of this patient's symptoms, his physicians begin monitoring his international normalized ratio, because they are concerned that it will start trending down."], "Others": ["After he was transported to the ED, his family found that the pills his grandson takes for seizures were missing."]}
{"Patient Personal Background": ["She returned from a vacation to northern Brazil 4 days ago.", "She took the appropriate medications and immunizations prior to her visit.", "There is no family history of serious illness."], "Patient Symptoms": ["She appears ill."], "Examination and Results": ["Her temperature is 39.4\u00b0C (103\u00b0F), pulse is 110/min and blood pressure is 94/54 mm Hg.", "Examination shows jaundice of the conjunctivae and skin.", "The abdomen is soft and nontender; the spleen is palpated 2 to 3 cm below the left costal margin."]}
{"Patient Personal Background": ["She has no history of serious illnesses and is on no medications.", "There has been no recent contact with any animals or pets."], "Patient Symptoms": ["She has a fever and malaise.", "Last week she noted several painless red papules on her left thigh when she was on a summer trip to Madagascar."], "Examination and Results": ["The temperature is 38.6\u2103 (101.5\u2109), the pulse is 78/min, the respiration rate is 12/min, and the blood pressure is 110/65 mm Hg.", "Swelling of the left inguinal area was noted; however, there were no skin changes.", "Several large, tense, and tender lymph nodes with a boggy consistency were palpated in the inguinal region.", "The right inguinal area is normal on physical exam.", "There was no lymphadenopathy in other areas.", "No abnormalities existed in the lungs, heart, and abdomen.", "Microscopic examination of pus from the inguinal lymph nodes revealed gram-negative Coccobacilli.", "Serum anti-F1 titers show a 4-fold rise."]}
{"Patient Personal Background": ["She has coronary artery disease, hypertension, and type 2 diabetes mellitus; she has had trouble adhering to her medication regimen."], "Examination and Results": ["Her blood pressure is 160/85 mm Hg.", "Examination shows 20/50 vision in the left eye and no perception of light in the right eye.", "Direct pupillary reflex is present in the left eye, but absent in the right eye.", "Accommodation is intact bilaterally.", "Intraocular pressure is 16 mm Hg in the left eye and 18 mm Hg in the right eye.", "Fundoscopic examination of the right eye shows a pale, white retina with a bright red area within the macula.", "The optic disc appears normal."]}
{"Patient Personal Background": ["She returned from a business trip from Europe 3 days ago.", "She has smoked a pack of cigarettes daily for 10 years.", "Her only medication is an oral contraceptive."], "Patient Symptoms": ["The left lower leg is swollen, erythematous, and tender to palpation."], "Examination and Results": ["Her temperature is 38.0\u00b0C (100.4\u00b0F), pulse is 115/min and regular, and blood pressure is 155/85 mm Hg.", "Examination shows decreased muscle strength on the entire right side.", "Deep tendon reflexes are 4+ on the right.", "Babinski sign is present on the right."]}
{"Patient Personal Background": ["They tell you that she has diabetes but do not know anything more about her condition."], "Patient Symptoms": ["On physical examination, the patient is breathing heavily and gives irrelevant responses to questions.", "The skin and mucous membranes appear dry."], "Examination and Results": ["The woman\u2019s vital signs include: pulse 110/min, respiratory rate 24/min, temperature 36.7\u00b0C (98.0\u00b0F), and blood pressure 90/60 mm Hg.", "Examination of the abdomen reveals mild diffuse tenderness to palpation.", "Deep tendon reflexes in the extremities are 1+ bilaterally.", "Laboratory studies show:\nFinger stick glucose 630 mg/dL\nArterial blood gas analysis:\npH 7.1\nPO2 90 mm Hg\nPCO2 33 mm Hg\nHCO3 8 mEq/L\nSerum:\nSodium 135 mEq/L\nPotassium 3.1 mEq/L\nChloride 136 mEq/L\nBlood urea nitrogen 20 mg/dL\nSerum creatinine 1.2 mg/dL\nUrine examination shows:\nGlucose Positive\nKetones Positive\nLeukocytes Negative\nNitrite Negative\nRBCs Negative\nCasts Negative\nThe patient is immediately started on a bolus of intravenous (IV) 0.9% sodium chloride (NaCl)."], "Treatment": []}
{"Patient Personal Background": ["He has a history of hypothyroidism, schizoaffective disorder, type 2 diabetes mellitus, dyslipidemia, and hypertension for which he takes medication.", "Ten days ago, he was started on a new drug."], "Patient Symptoms": ["According to the father, the patient was unable to get out of bed that morning and has become increasingly confused over the past several hours.", "He appears lethargic."], "Examination and Results": ["His rectal temperature is 32\u00b0C (89.6\u00b0F), pulse is 54/min, respirations are 8/min, and blood pressure is 122/80 mm Hg.", "Examination shows weakness in the lower extremities with absent deep tendon reflexes.", "Deep tendon reflexes are 1+ in the upper extremities.", "The pupils are dilated and poorly reactive to light."], "Others": ["The father also noticed it was \u201cpretty cold\u201d in his son's apartment because all of the windows were left open overnight.", "Throughout the examination, the patient attempts to remove his clothing."]}
{"Examination and Results": ["Investigations show her hemoglobin level to be 8.6 gm/dL and serum creatinine of 4.6 mg/dL.", "The serum is negative for antinuclear antibodies (ANA) and positive for C3 nephritic factor.", "Urinalysis shows a 3+ proteinuria.", "The renal biopsy demonstrates hypercellular glomerulus with electron dense deposits along the glomerular basement membrane."]}
{"Patient Personal Background": ["He does not take any medications despite being diagnosed with hypertension 10 years ago."], "Patient Symptoms": ["For the past several months, he has had shortness of breath on exertion and while lying down on the bed, frequent headaches, and swelling of his feet."], "Examination and Results": ["His pulse is 90/min, respirations are 20/min, blood pressure is 150/110 mm Hg, and temperature is 37.0\u00b0C (98.6\u00b0F).", "Physical examination shows an overweight male in acute distress with audible wheezes.", "Crackles are heard bilaterally and are loudest at the lung bases."]}
{"Patient Personal Background": ["Methods:\nIn this double-blind, randomized controlled trial, patients (N=1200) with a history of coronary artery disease, myocardial infarction in the past 2 years, and a diagnosis of comorbid adult-onset asthma were recruited from cardiology clinics at a large academic medical center in Philadelphia, PA.", "Patients who were immunocompromised or had a history of recurrent infections were excluded.", "Patients were subsequently randomly assigned a 12-month course of pulmharkimab 75 mg/day, pulmharkimab 150 mg/day, or a placebo, with each group containing 400 participants."], "Examination and Results": ["Plaque volume was determined by ultrasound.", "Results:\nAt baseline, participants in the two groups did not differ by age, gender, race, plaque volume, serum LDL-C levels, FEV1/FVC ratio, and ACQ scores (p > 0.05 for all).", "All outcome variables were approximately normally distributed."], "Treatment": ["Patients were subsequently randomly assigned a 12-month course of pulmharkimab 75 mg/day, pulmharkimab 150 mg/day, or a placebo, with each group containing 400 participants."], "Others": ["She notices that the standard error surrounding measurements in the pulmharkimab 150 mg/day group is generally greater than the standard errors for the placebo and pulmharkimab 75 mg/day groups.", "Which of the following statements is the best explanation for the increased standard error in the pulmharkimab 150 mg/day group?\"", "\"Impact of pulmharkimab on asthma control and cardiovascular disease progression in patients with coronary artery disease and comorbid asthma\nIntroduction:\nActive asthma has been found to be associated with a more than two-fold increase in the risk of myocardial infarction, even after adjusting for cardiovascular risk factors.", "It has been suggested that the inflammatory mediators and accelerated atherosclerosis characterizing systemic inflammation may increase the risk of both asthma and cardiovascular disease.", "This study evaluated the efficacy of the novel IL-1 inhibitor pulmharkimab in improving asthma and cardiovascular disease progression.", "All participants were included in analysis and analyzed in the groups to which they were randomized regardless of medication adherence.", "Variables measured included plaque volume, serum LDL-C levels, FEV1/FVC ratio, and Asthma Control Questionnaire (ACQ) scores, which quantified the severity of asthma symptoms.", "Analyses were performed from baseline to month 12.", "A total of 215 participants (18%) were lost to follow-up.", "At 12-month follow-up, the groups contained the following numbers of participants:\nPulmharkimab 75 mg/d: 388 participants\nPulmharkimab 150 mg/d: 202 participants\nPlacebo: 395 participants\nTable 1: Association between pulmharkimab and both pulmonary and cardiovascular outcomes.", "Models were adjusted for sociodemographic variables and medical comorbidities.", "Pulmharkimab 75 mg/d, (Mean +/- 2 SE) Pulmharkimab 150 mg/d, (Mean +/- 2 SE) Placebo, (Mean +/- 2 SE) P-value\nPlaque volume (mm3), change from baseline 6.6 \u00b1 2.8 1.2 \u00b1 4.7 15.8 \u00b1 2.9 < 0.01\nLDL-C levels, change from baseline -9.4 \u00b1 3.6 -11.2 \u00b1 14.3 -8.4 \u00b1 3.9 0.28\nFEV1/FVC ratio, change from baseline 0.29 \u00b1 2.21 0.34 \u00b1 5.54 -0.22 \u00b1 3.21 0.27\nACQ scores, change from baseline 0.31 \u00b1 1.22 0.46 \u00b1 3.25 0.12 \u00b1 1.33 0.43\nConclusion:\nPulmharkimab may be effective in reducing plaque volume but does not lead to improved asthma control in patients with a history of myocardial infarction and comorbid asthma."]}
{"Patient Symptoms": ["He appears pale.", "Physical examination shows bright red rectal bleeding."], "Examination and Results": ["His temperature is 37.6\u00b0C (99.6\u00b0F), pulse is 115/min, respirations are 24/min, and blood pressure is 86/60 mm Hg.", "Colonoscopy shows profuse diverticular bleeding; endoscopic hemostasis is performed."], "Treatment": ["After initiating fluid resuscitation, the patient becomes hemodynamically stable."]}
{"Patient Symptoms": ["The patient was found unconscious by the paramedics and regained consciousness briefly during the ambulance ride.", "His is unresponsive to verbal commands and physical touch.", "The right pupil is fixed and dilated."], "Examination and Results": ["Upon arrival at the hospital, the patient\u2019s vitals show: pulse 110/min, respiratory rate 12/min, blood pressure 100/70 mm Hg, and oxygen saturation of 96%.", "Physical examination reveals an unresponsive man with multiple bruises across the chest and along the upper arms with a laceration on the forehead.", "His GCS is 6/15.", "An urgent noncontrast CT of the head is performed and shown in the image."], "Treatment": ["The patient is prepared for emergency neurosurgery."]}
{"Patient Personal Background": ["She is sexually active and inconsistently uses condoms.", "The patient has no past medical history.", "She is allergic to sulfa drugs.", "Physical examination of the genitalia is normal."], "Patient Symptoms": ["She denies having a fever but has experienced intermittent chills."], "Examination and Results": ["Urinalysis shows positive leukocyte esterase and nitrites.", "The urine culture demonstrates gram-negative rods that form pink colonies on MacConkey agar.", "She is treated with an antibiotic and her symptoms quickly improve."], "Treatment": []}
{"Patient Personal Background": ["He has smoked a pack of cigarettes daily for 45 years.", "His medications include warfarin, enalapril, and amiodarone."], "Patient Symptoms": ["His pulse is 85/min and irregularly irregular."], "Examination and Results": ["Physical examination shows enlarged fingertips and markedly curved nails.", "A CT scan of the chest shows clustered air spaces and reticular opacities in the basal parts of the lung."]}
{"Patient Personal Background": ["The patient\u2019s mother mentions that he has been diagnosed with major depressive disorder 3 years ago for which he was taking a medication that resulted in only a slight improvement in his symptoms."], "Patient Symptoms": ["She says he still found it difficult to concentrate on his studies and did not participate in any social events in college.", "He didn\u2019t have many friends and was often found sitting alone in his room.", "He has also threatened to take his life on several occasions, but she did not think he was serious.", "While recording his vital signs, the patient goes into a coma."], "Examination and Results": ["His ECG shows a QT interval of 450 milliseconds."]}
{"Others": ["Sixty similar but healthy individuals are recruited into the control group.", "Educational status is considered to be an important variable, as it would affect the awareness of the disease and its risk factors among the participants.", "Based on the level of education, 2 groups are formed: low educational status and high educational status.", "A chi-square test is performed to test the significance of the relationship, and an odds ratio of 2.1 was computed for the association between low education and the risk of MI, with a confidence interval of 0.9\u20139.7."]}
{"Patient Personal Background": ["She is asymptomatic and has no history of serious illness.", "Her only medication is a prenatal vitamin."], "Examination and Results": ["Her temperature is 37.2\u00b0C (99\u00b0F) and blood pressure is 108/60 mm Hg.", "Pelvic examination shows a uterus consistent in size with a 16-week gestation.", "A quadruple screening test shows maternal serum AFP of 3 times the median and normal levels of serum \u03b2-hCG, estriol, and inhibin A."]}
{"Patient Personal Background": ["He works as a long-haul truck driver, and he informs you that he recently returned to the east coast from a trip to Utah.", "His medical history is significant for gout, hypertension, hypercholesterolemia, diabetes mellitus type 2, and acute lymphoblastic leukemia from when he was a child.", "He currently smokes 2 packs of cigarettes/day, drinks a 6-pack of beer/day, and he denies any illicit drug use."], "Patient Symptoms": ["He says this started abruptly about 6 hours ago.", "He says that he has not noticed that anything that makes his pain better or worse.", "He also denies any other symptoms."], "Examination and Results": ["The vital signs include: temperature 36.7\u00b0C (98.0\u00b0F), blood pressure 126/74 mm Hg, heart rate 98/min, and respiratory rate 23/min.", "His physical examination shows minimal bibasilar rales, but otherwise clear lungs on auscultation, normal heart sounds, and a benign abdominal physical examination."]}
{"Patient Symptoms": ["Specifically, she says that she was gardening 8 hours prior to presentation when she sustained a laceration over her distal interphalangeal (DIP) joints.", "Since then, they have become red and swollen.", "She has also had pain in her proximal interphalangeal (PIP) joints and metacarpophalangeal (MCP) joints for several years and reports that this pain is worse in the morning but improves over the day."], "Examination and Results": ["The cells that are present in this patient's DIP joints and PIP joints are analyzed and compared."]}
{"Patient Personal Background": ["The patient is otherwise healthy and is not currently taking any medications."], "Patient Symptoms": ["She states it is 10/10 in intensity and states that it is associated with chewing.", "She describes it as a dull pain over the sides of her head."], "Examination and Results": ["Her temperature is 97.0\u00b0F (36.4\u00b0C), blood pressure is 111/74 mmHg, pulse is 83/min, respirations are 13/min, and oxygen saturation is 98% on room air.", "Physical exam is notable for pain and tenderness over the mandibular and temporal region that is worsened when the patient opens and closes their mouth."]}
{"Patient Personal Background": ["He has asthma well controlled with an albuterol inhaler.", "His father died of lung cancer at 62 years of age.", "He has smoked one pack of cigarettes daily for 14 years.", "He does not drink alcohol."], "Patient Symptoms": ["He appears uncomfortable."], "Examination and Results": ["His temperature is 37.4\u00b0C (99.3\u00b0F), pulse is 98/min, respirations are 19/min, and blood pressure is 122/76 mm Hg.", "Examination shows reduced breath sounds over the left lung base.", "Cardiac examination shows no abnormalities.", "There is a clean, dry surgical incision over the midline of the abdomen.", "Bowel sounds are hypoactive.", "The calves are soft and nontender.", "His hemoglobin concentration is 12.9 g/dL, leukocyte count is 10,600/mm3, and platelet count is 230,000/mm3.", "An x-ray of the chest in supine position is shown."]}
{"Patient Personal Background": ["He has type 2 diabetes mellitus, hypertension, and hypercholesterolemia.", "His current medications include metformin, enalapril, and atorvastatin.", "He has smoked one pack of cigarettes daily for 35 years.", "He drinks one glass of wine daily.", "He is alert and oriented to time, place and person."], "Patient Symptoms": ["He had difficulty putting on his shirt and shoes before coming to the hospital."], "Examination and Results": ["His temperature is 37\u00b0C (98.6\u00b0F), pulse is 99/min and blood pressure is 170/100 mm Hg.", "Examination shows equal and reactive pupils.", "There is drooping of the left side of the face.", "Muscle strength is decreased in the left upper and lower extremities.", "Plantar reflex shows an extensor response on the left side.", "Speech is dysarthric.", "There is a bruit on the right side of the neck.", "Fundoscopy shows no abnormalities.", "A complete blood count, coagulation profile, and serum concentrations of glucose and electrolytes are within the reference range."]}
{"Patient Symptoms": ["After 3 weeks, the patient presents with complaints of fever and significantly increased cough for 3 days."], "Examination and Results": ["His Mantoux test is 2 mm \u00d7 3 mm, and his chest radiograph is normal.", "His CD4+ T cell count is 90/\u03bcL and HIV RNA is 30,000 copies/mL.", "He is started on a 4-drug regimen consisting of isoniazid, rifampin, pyrazinamide, and ethambutol in appropriate doses.", "There is no respiratory distress but generalized lymphadenopathy is present.", "His chest radiograph shows pulmonary infiltrates and mediastinal lymphadenopathy, sputum smear is negative, Mantoux test is 12 mm \u00d7 14 mm, CD4+ T cell count is 370/\u03bcL, and HIV RNA is 2,900 copies/mL."], "Treatment": ["He becomes sputum smear-negative after 4 weeks and reports significant improvement in symptoms.", "After another 4 weeks, the physician removes pyrazinamide from the antitubercular regimen and adds antiretroviral therapy (dolutegravir/tenofovir/emtricitabine)."], "Diagnosis": ["His sputum smear and culture confirm the diagnosis of pulmonary tuberculosis due to Mycobacterium tuberculosis."]}
{"Patient Symptoms": ["On physical examination, there is erythema, tenderness and enlargement of the thyroid gland that is worse on the left.", "Pain is worsened during neck hyperextension and relieved during neck flexion."], "Examination and Results": ["His vital signs include: body temperature 39.0\u00b0C (102.2\u00b0F), heart rate 120/min, and respiratory rate 18/min and regular.", "Thyroid function tests are within normal limits.", "An ultrasound of the thyroid gland reveals a unifocal perithyroidal hypoechoic space."]}
{"Patient Symptoms": ["He states that he does not experience dysuria."], "Examination and Results": ["On physical exam there is no costovertebral angle tenderness."]}
{"Patient Symptoms": ["The patient\u2019s mother says he started complaining of pain in his abdomen after he got back from school yesterday and vomited 3 times during the night.", "This morning, he seemed confused so she rushed him to the ER.", "She has also noticed that he has been urinating frequently and drinking a lot of water recently, and he has lost 6 kg (13.2 lb) over the past 20 days."], "Examination and Results": ["His vital signs include: blood pressure 100/50 mm Hg, heart rate 110/min, respiratory rate 27/min, and temperature 35.6\u00b0C (96.0\u00b0F).", "His BMI is 18 kg/m2.", "On physical examination, he is disoriented to time and place and is taking deep and labored breaths.", "There is diffuse tenderness to palpation in the abdomen with guarding.", "Laboratory tests are significant for a pH of 7.19 and a blood glucose level of 754 mg/dL."], "Diagnosis": ["The doctor explains to his mother that her son has developed a life-threatening complication of a disease characterized by decreased levels of a hormone."]}
{"Patient Symptoms": ["She reports nausea and vomiting and is unable to tolerate oral intake.", "She appears uncomfortable."], "Examination and Results": ["Her temperature is 38.1\u00b0C (100.6\u00b0F), the pulse is 92/min, the respirations are 18/min, and the blood pressure is 132/85 mm Hg.", "Physical examination shows yellowish discoloration of her sclera.", "Her abdomen is tender in the right upper quadrant.", "There is no abdominal distention or organomegaly.", "The laboratory tests show the following results:\nHemoglobin 13 g/dL\nLeukocyte count 16,000/mm3\nUrea nitrogen 25 mg/dL\nCreatinine 2 mg/dL\nAlkaline phosphatase 432 U/L\nAlanine aminotransferase 196 U/L\nAspartate transaminase 207 U/L\nBilirubin  \nTotal 3.8 mg/dL\nDirect 2.7 mg/dL\nLipase 82 U/L\nUltrasound of the right upper quadrant shows dilated intrahepatic and extrahepatic bile ducts and multiple hyperechoic spheres within the gallbladder.", "The pancreas is not well visualized.", "Her temperature is 39.1\u00b0C (102.4\u00b0F), the pulse is 105/min, the respirations are 22/min, and the blood pressure is 112/82 mm Hg."], "Treatment": ["Intravenous fluid resuscitation and antibiotic therapy with ceftriaxone and metronidazole are initiated."], "Others": ["After 12 hours, the patient appears acutely ill and is not oriented to time."]}
{"Treatment": ["The physician suspects that the patient may have elevated aldosterone levels and wants to initiate a trial of an aldosterone receptor antagonist."], "Others": ["The patient is very concerned about side effects, particularly impotence and gynecomastia, as he had a friend who took a similar medication and had these side-effects."]}
{"Patient Personal Background": ["She says she was previously well and denies any history of similar symptoms.", "No significant past medical history or current medications."], "Patient Symptoms": ["She reports that, at onset, she felt as if she was going to die and says her heart beating has been beating really fast.", "There was also profuse sweating, and she says she feels short of breath.", "She could not recall how long the event lasted but can remember that the symptoms did go away on their own by the time she arrived at the emergency department."], "Examination and Results": ["Her vitals rapidly returned to normal while giving her medical history and she begins to look and act more calm.", "Physical examination is unremarkable.", "Her electrocardiogram and initial cardiac enzymes are normal."]}
{"Patient Personal Background": ["He has no medical conditions and does not take any medications.", "He does not drink alcohol or use recreational drugs."], "Patient Symptoms": ["He was recently kicked off of the school's football team after missing too many practices.", "He has also been avoiding his family and friends because he is not in the mood to see them, but he admits that he is lonely.", "He has not left his room for 2 days, which prompted his father to bring him to the physician.", "He says he wants to use his father's licensed firearm to \u201cend his misery\u201d over the weekend when his parents are at church."], "Examination and Results": ["While the father is in the waiting room, a mental status examination is conducted, which shows a constricted affect.", "Cognition is intact."], "Others": ["He says that he would be better off dead and refuses to be treated."]}
{"Patient Personal Background": ["The parents report that 2 weeks ago, his daycare group visited an animal shelter, after which he developed a rash on the left hand."], "Examination and Results": ["His temperature is 38.5\u00b0C (101.3\u00b0F).", "Physical examination shows three linear crusts on an erythematous background on the dorsum of the left hand.", "There is tender left-sided axillary and cervical lymphadenopathy.", "Histopathologic examination of an axillary lymph node shows necrotizing granulomas."]}
{"Patient Personal Background": ["There is no other history of serious illness.", "He does not take any other medications."], "Patient Symptoms": ["He had a sudden pruritic papular rash on his right thigh when he was in the southwestern USA hiking in northern Arizona and New Mexico.", "The next day he developed severely painful inguinal swelling on the same side; however, he did not see a physician and controlled the pain with painkillers.", "He appears confused."], "Examination and Results": ["The temperature is 39.5\u2103 (103.1\u2109), the pulse is 105/min, the respiration rate is 32/min, and the blood pressure is 95/45 mm Hg.", "Rales are heard in the lower lobe of the left lung on auscultation.", "The right inguinal lymph nodes are enlarged with a spongy consistency and an underlying hard core.", "The surrounding area is edematous without overlying erythema or cellulitis.", "A computerized tomography (CT) scan is shown in the picture."]}
{"Patient Personal Background": ["The patient has no known medical problems and takes no medications.", "He smokes one pack of cigarettes per day and uses intravenous street drugs."], "Patient Symptoms": ["The lesions are non-pruritic and have been present for the last 3 weeks.", "He reports feeling fatigued and malaise for the past few months."], "Examination and Results": ["His heart rate is 82/min, the respiratory rate is 14/min, the temperature is 36.7\u00b0C (98.1\u00b0F), and the blood pressure is 126/80 mm Hg.", "Auscultation of the heart is without murmurs.", "Lungs are clear to auscultation bilaterally.", "Three 2-3 mm, dome-shaped, hardened papules are noted on the left thigh.", "Central umbilication can be observed in each papule.", "There is a non-tender cervical lymphadenopathy present."]}
{"Others": ["However, rather than engaging in homosexual behavior, he holds rallies against gay rights and regularly criticizes gay people."]}
{"Patient Personal Background": ["The patient has a past medical history of diabetes, hypertension, and atrial fibrillation and is currently taking warfarin, insulin, lisinopril, and metoprolol.", "The patient\u2019s brother recently died from a heart attack and he has switched to an all vegetarian diet in order to improve his health."], "Examination and Results": ["His temperature is 98.6\u00b0F (37.0\u00b0C), blood pressure is 167/108 mmHg, pulse is 90/min, respirations are 17/min, and oxygen saturation is 98% on room air.", "The patient\u2019s physical exam is unremarkable.", "His laboratory values are ordered as seen below."]}
{"Patient Personal Background": ["She was in her normal excellent state of health prior to this event.", "Two weeks ago, she had an upper respiratory infection (URI) but has since recovered."], "Patient Symptoms": ["On physical exam, the patient appears to have altered mental status and her skin is dry, hot, and erythematous.", "She is complaining of severe bilateral flank pain and generalized myalgia."], "Examination and Results": ["At the hospital, her temperature is 40.3\u00b0C (104.5\u00b0F), blood pressure is 85/55 mm Hg, pulse is 105/min, and respiratory rate is 24/min.", "Catheterization produces 200 mL of tea-colored urine.", "Urine dipstick is positive for blood, but urinalysis is negative for RBCs or WBCs."], "Others": ["Her father has chronic kidney disease (CKD), bilateral hearing loss, and vision problems."]}
{"Examination and Results": ["His heart rate is 76/min, respiratory rate is 14/min, temperature is 36.0\u00b0C (96.8\u00b0F), and blood pressure is 110/86 mm Hg.", "Physical examination show signs suggestive of liver cirrhosis."]}
{"Patient Personal Background": ["Her family history is negative for malignancies and inherited disorders.", "She is the result of a pregnancy complicated by numerous miscarriages in the 1960s, for which her mother received diethylstilbestrol."], "Examination and Results": ["During a pelvic examination, you notice a polypoid mass on the anterior wall of the vagina.", "The bimanual examination is negative for adnexal masses.", "You suspect the presence of carcinoma and, therefore, send tissue samples to pathology, which confirmed the presence of malignant cells."], "Diagnosis": ["You suspect the presence of carcinoma and, therefore, send tissue samples to pathology, which confirmed the presence of malignant cells."]}
{"Patient Personal Background": ["He was diagnosed with generalized anxiety disorder 6 months ago, which is being treated with citalopram."], "Patient Symptoms": ["He comments that his symptoms have improved since initiating the prescribed therapy; however, in the past 2 months, he has been unable to have sexual intercourse due to weak tumescence and low libido."], "Examination and Results": ["His blood pressure is 122/74 mm Hg, heart rate is 75/min, and respiratory rate is 16/min.", "Physical examination reveals regular heart and lung sounds."], "Diagnosis": ["He was diagnosed with generalized anxiety disorder 6 months ago, which is being treated with citalopram."]}
{"Patient Personal Background": ["Two months ago, he had herpes zoster that was treated with acyclovir."], "Patient Symptoms": ["During this period, the patient has had recurrent episodes of high-grade fever, night sweats, and feelings of fatigue.", "He appears pale."], "Examination and Results": ["Temperature is 38.5\u00b0C (101.3\u00b0F), pulse is 90/min, and blood pressure 130/80 mm Hg.", "Physical examination shows generalized painless lymphadenopathy.", "The liver and the spleen are palpated 2\u20133 cm below the right and the left costal margin, respectively.", "Laboratory studies show:\nHematocrit 42%\nLeukocyte count 15,000/mm3\nSegmented neutrophils 46%\nEosinophils 1%\nLymphocytes 50%\nMonocytes 3%\nPlatelet count 120,000/mm3\nBlood smear shows mature lymphocytes that rupture easily and appear as artifacts on a blood smear.", "Flow cytometry shows lymphocytes expressing CD5, CD19, CD20, and CD23."]}
{"Patient Personal Background": ["His past medical history is notable for hypertension, diabetes mellitus, and hyperlipidemia.", "He takes enalapril, metformin, and atorvastatin.", "He has a 20-pack-year smoking history and is an avid hiker."], "Patient Symptoms": ["He developed severe, crushing, substernal chest pain 10 hours ago while he was hiking in the Adirondack mountains.", "He is diaphoretic and intermittently conscious."], "Examination and Results": ["His temperature is 100\u00b0F (37.8\u00b0C), blood pressure is 102/60 mmHg, pulse is 130/min, and respirations are 28/min.", "Bilateral rales are heard on pulmonary auscultation.", "An electrocardiogram demonstrates ST elevations in leads I and aVL.", "An autopsy is performed demonstrating ischemia in the left atrium and posterior left ventricle."], "Treatment": ["He was with 2 friends at the time who gave him aspirin before carrying him 5 miles to a town to get phone service, where they then called emergency medical services."], "Others": ["Despite appropriate management, the patient expires."]}
{"Patient Personal Background": ["Twenty years ago, he had a painless ulcer on his penis that resolved without treatment.", "He has no history of serious illness."], "Patient Symptoms": ["His gait is unsteady and broad-based."], "Examination and Results": ["Examination shows small pupils that constrict with accommodation but do not react to light.", "Sensation to pinprick and light touch is decreased over the distal lower extremities.", "Patellar reflexes are absent bilaterally."]}
{"Patient Personal Background": ["She denies any similar symptoms in the past.", "No significant past medical history."], "Examination and Results": ["Upon physical examination, scleral icterus is present, and significant hepatosplenomegaly is noted.", "Mild peripheral edema is also present.", "Laboratory findings are significant for elevated serum levels of bilirubin, aminotransferases, alkaline phosphatase (ALP), \u03b3-glutamyl transpeptidase (GGTP), immunoglobulins, as well as cholesterol (especially HDL fraction).", "Antiviral antibodies are not present.", "The erythrocyte sedimentation rate is also elevated.", "Anti-mitochondrial antibodies are found.", "A liver biopsy is performed, and the histopathologic examination shows bile duct injury, cholestasis, and granuloma formation."]}
{"Patient Personal Background": ["His past medical history is not known."], "Patient Symptoms": ["He was at a college party exhibiting belligerent behavior when he suddenly passed out and fell to the ground.", "The patient is covered with emesis and responds incoherently to questions.", "As the patient begins to wake up he continues vomiting.", "Thirty minutes later the patient presents with muscle rigidity and is no longer responding coherently to questions."], "Examination and Results": ["His temperature is 100\u00b0F (37.8\u00b0C), blood pressure is 107/48 mmHg, pulse is 125/min, respirations are 19/min, and oxygen saturation is 99% on room air.", "His temperature is 103\u00b0F (39.4\u00b0C), blood pressure is 127/68 mmHg, pulse is 125/min, respirations are 18/min, and oxygen saturation is 98% on room air."], "Treatment": ["The patient is started on IV fluids, analgesics, and anti-emetics and begins to feel better.", "The patient's basic laboratory studies are drawn and he is started on IV fluids, given lorazepam, and placed under a cooling blanket."], "Others": ["Despite these initial measures, his symptoms persist."]}
{"Patient Personal Background": ["He is an active member of his school's gymnastics team."], "Patient Symptoms": ["The pain is exacerbated by jogging and climbing up stairs.", "Knee extension against resistance causes pain in the anterior proximal tibia."], "Examination and Results": ["His vital signs are within normal limits.", "Examination of the right knee shows a tender swelling at the proximal tibia; range of motion is full.", "The remainder of the examinations shows no abnormalities.", "X-ray of the right knee shows anterior tibial soft tissue swelling with fragmentation of the tibial tuberosity."], "Others": ["He has no history of trauma to the knee.", "He is otherwise healthy."]}
{"Patient Personal Background": ["She underwent an abdominal hysterectomy 16 years ago for multiple fibroids of the uterus.", "She has smoked one pack of cigarettes daily for 17 years."], "Patient Symptoms": ["She has right-sided chest pain that increases on inspiration and has had a productive cough for the last 12 hours.", "She appears uncomfortable."], "Examination and Results": ["Her temperature is 39\u00b0C (102.2\u00b0F), pulse is 98/min, respirations are 18/min, and blood pressure is 128/82 mm Hg.", "Inspiratory crackles are heard at the right lung base.", "The abdomen is soft and nontender.", "There is a healing surgical incision below the right ribcage."], "Treatment": ["She had an episode of hypotension after the operation that resolved with intravenous fluid therapy."], "Others": ["The remainder of the examination shows no abnormalities."]}
{"Patient Personal Background": ["The patient says he moved to Nevada 6 months ago because of a new job where he works outdoors; however, he worked indoors in an office before."], "Patient Symptoms": ["The patient\u2019s rash is shown in the exhibit."], "Examination and Results": ["His vital signs include: blood pressure 100/60 mm Hg, pulse 64/min, respiratory rate 18/min."]}
{"Patient Personal Background": ["She does not smoke."], "Patient Symptoms": ["Her maternal uncle had similar symptoms."], "Examination and Results": ["Cardiac examination shows wide splitting of S2.", "The second component of S2 is loud and best heard at the 2nd left intercostal space.", "The lungs are clear to auscultation."]}
{"Diagnosis": ["You suspect that this patient has experienced a loss of polyanions in his glomerular basement membranes."]}
{"Patient Symptoms": ["She first noticed her symptoms after she got off a rollercoaster ride 2 months ago."], "Examination and Results": ["Physical examination shows weakness when extending the right wrist against resistance.", "An MRI of the head and neck is shown."]}
{"Patient Personal Background": ["Her past medical history is significant for chlamydia.", "She is currently sexually active and does not use contraception.", "Her menstrual periods occur regularly every 30 days."], "Patient Symptoms": ["She states that she was in a kickboxing class when she suddenly developed left-sided abdominal pain."], "Examination and Results": ["The patient\u2019s temperature is 99\u00b0F (37.2\u00b0C), blood pressure is 110/68 mmHg, pulse is 88/min, and respirations are 14/min with an oxygen saturation of 98% on room air.", "On physical exam, there is left-sided, lower abdominal tenderness and guarding.", "Pelvic examination is notable for clear mucous in the vaginal introitus and tenderness of the left adnexa.", "A pelvic ultrasound with Doppler reveals a large amount of fluid in the rectouterine pouch."], "Others": ["Her last menstrual period ended 2 days ago."]}
{"Patient Personal Background": ["He reports a history of myocardial infarction 4 years ago, but he has no supporting documentation.", "At the moment, his only medication is aspirin.", "He also stated that he used to have \u2018high blood sugars\u2019 when checked in the hospital 4 years ago, but he did not follow up regarding this issue.", "He has a 24-pack-year history of smoking and consumes alcohol occasionally."], "Patient Symptoms": ["He works as a farmer and noticed that it became much harder for him to work in the last few days because of fatigue and syncope."], "Examination and Results": ["The vital signs include: blood pressure 150/90 mm Hg, heart rate 83/min, respiratory rate 16/min, and temperature 36.5\u2103 (97.7\u2109).", "On physical examination, the patient is pale and acrocyanotic.", "There is a visible jugular vein distention and bilateral lower leg pitting edema.", "The pulmonary auscultation is significant for occasional bilateral wheezes.", "Cardiac auscultation is significant for a decreased S1, S3 gallop, and grade 3/6 systolic murmur best heard at the left sternal border in the 4th left intercostal space.", "Abdominal percussion and palpation are suggestive of ascites.", "The hepatic margin is 3 cm below the right costal margin.", "Hepatojugular reflux is positive."]}
{"Patient Personal Background": ["She does not drink, smoke, or use illicit drugs.", "She takes no medications."], "Patient Symptoms": ["She says that the accumulation of things in her kitchen and dining room makes regular use of these spaces incredibly difficult.", "Her behavior started when she was in high school.", "She feels anxious when she tries to discard her possessions and her husband tries to clean and organize the home.", "This behavior frustrates her because most of the items she saves have little emotional or monetary value.", "She now feels that her behavior is \u201ctaking over\u201d her life."], "Examination and Results": ["Her temperature is 36\u00b0C (96.8\u00b0F), pulse is 90/min, respirations are 12/min, and blood pressure is 116/80 mm Hg.", "On mental status examination, she is calm, alert, and oriented to person, place, and time."], "Treatment": ["She reports that there has been no improvement despite attending cognitive behavioral therapy sessions for the past 6 months."]}
{"Patient Personal Background": ["She has a history of hypertension and recurrent renal stones for which she takes lisinopril and hydrochlorothiazide.", "She was admitted to the hospital earlier in the year after falling in her front yard and sustaining a distal radius fracture and vertebral compression fracture."], "Patient Symptoms": ["She reports a 3-month history of gradually worsening pain in her shoulders and hips that is worse in her right hip."], "Examination and Results": ["Her temperature is 98.5\u00b0F (36.9\u00b0C), blood pressure is 145/85 mmHg, pulse is 100/min, and respirations are 20/min.", "On exam, she is well-appearing with mild tenderness to palpation in her shoulders and hips.", "She has mild pain with hip flexion and shoulder abduction.", "She has full range of motion in her bilateral upper and lower extremities."]}
{"Patient Personal Background": ["She denies recent use of any medication."], "Patient Symptoms": ["Though this has been stressful for the whole family, the daughter has been hearing voices and having intrusive thoughts ever since.", "These voices have conversations about her and how she should have been the one to die and they encourage her to kill herself.", "She has not been able to concentrate at work or at school.", "She has no other history of medical or psychiatric illness."], "Examination and Results": ["Today, her heart rate is 90/min, respiratory rate is 17/min, blood pressure is 110/65 mm Hg, and temperature is 36.9\u00b0C (98.4\u00b0F).", "On physical exam, she appears gaunt and anxious.", "Her heart has a regular rate and rhythm and her lungs are clear to auscultation bilaterally.", "CMP, CBC, and TSH are normal.", "A urine toxicology test is negative."], "Others": ["The patient\u2019s father died from lung cancer 1 week ago."]}
{"Patient Personal Background": ["She has smoked 10 cigarettes per day for the past 15 years."], "Patient Symptoms": ["She adds that she has lost weight over the last 7 weeks, despite a good appetite, and is anxious most of the time with difficulty sleeping at night."], "Examination and Results": ["Her blood pressure is 100/55 mmHg, temperature is 36.5\u00b0C (97.7\u00b0F), and pulse is irregular with a rate of 140\u2013150/min.", "On physical examination she is thin, frail, and appears anxious.", "Her palms are sweaty and there are fine tremors on extension of both hands.", "She has a palpable smooth thyroid mass.", "Examination of the eyes reveals bilateral exophthalmos."], "Others": ["An electrocardiogram is obtained and shown in the picture."]}
{"Others": ["The patient reports consuming undercooked ground beef four days prior to the onset of the symptoms."]}
{"Patient Personal Background": ["She does not have any sick contacts, and her medical history is significant only for diabetes well-controlled on metformin.", "She says that she recently returned from traveling abroad and had been administered an antibiotic during her travels for an unknown infection."], "Patient Symptoms": ["She also complains of some weakness and back/leg pain."], "Examination and Results": ["On presentation, her temperature is 98.6\u00b0F (37\u00b0C), blood pressure is 119/78 mmHg, pulse is 62/min, and respirations are 25/min.", "An EKG is obtained showing flattening of the T wave."], "Treatment": ["After further testing, the physician prescribes a thiazide for this patient."]}
{"Patient Symptoms": ["Physical exam is notable for subcutaneous emphysema in the clavicular area."], "Examination and Results": ["The patient has a Glasgow Coma Scale of 5 and is subsequently intubated.", "Chest radiography demonstrates proper tube location and resolution of the pneumothorax.", "The patient is transferred to the trauma intensive care unit.", "On the unit, a repeat chest radiograph is notable for a recurrent pneumothorax with the chest tube in place."], "Treatment": ["Needle decompression and chest tube placement are performed, and the patient is stabilized after receiving 2 units of blood and 2 liters of fluid."], "Others": ["He was the front seat unrestrained driver in a head-on collision."]}
{"Patient Personal Background": ["He does not smoke or use illicit drugs."], "Patient Symptoms": ["He has also had a nonproductive cough, fever, and malaise for the past 5 days."], "Examination and Results": ["His temperature is 38\u00b0C (100.4\u00b0F), pulse is 125/min, respirations are 32/min, and blood pressure is 85/45 mm Hg.", "Physical examination shows distended neck veins.", "Auscultation of the chest discloses bilateral basilar rales and muffled heart sounds.", "An ECG shows sinus tachycardia, diffuse ST segment elevation, low voltage QRS complexes, and fluctuating R wave amplitude."]}
{"Patient Symptoms": ["He has also had difficulties achieving an erection over the past few weeks."], "Examination and Results": ["Physical examination shows a temporal visual field deficit bilaterally.", "An MRI of the brain shows an intrasellar mass."]}
{"Patient Personal Background": ["She is currently at 18 weeks gestation and admits to having poor control of her type 1 diabetes before becoming pregnant."], "Examination and Results": ["The physical examination shows a pregnant woman with a fundal height of 20 cm (7.9 in).", "An abdominal ultrasound is ordered."], "Others": ["Her family history is non-contributory."]}
{"Patient Personal Background": ["She does not have urinary or fecal incontinence or any other genitourinary symptoms.", "She has no known gynecologic diseases.", "There were no complications with her pregnancies, all of which were full-term vaginal deliveries.", "She is sexually active with her husband and no longer uses oral contraceptives.", "She has an 11 pack-year history of smoking."], "Examination and Results": ["Her vital signs are within normal limits.", "The physical examination is unremarkable.", "The gynecologic examination reveals descent of the cervix halfway towards the introitus.", "On Valsalva and standing, the cervix descents to the plane of the hymen.", "The uterus is not enlarged and the ovaries are non-palpable."], "Others": ["Her weight is 79 kg (174 lb) and her height is 155 cm (5 ft)."]}
{"Patient Personal Background": ["She has a history of recurrent ovarian cysts.", "Menses occur regularly at 28-day intervals."], "Patient Symptoms": ["She was in her aerobics class when the pain started but denies any trauma to the region."], "Examination and Results": ["Her temperature is 37.1\u00b0C (99.3\u00b0F).", "Abdominal examination shows tenderness in the right lower quadrant with guarding.", "Pelvic ultrasound shows a large simple cyst on the right ovary.", "Right ovarian artery flow is detectable on Doppler, but there is no flow detected in the right ovarian vein."]}
{"Patient Symptoms": ["She feels well."], "Examination and Results": ["Physical examination shows nontender cervical and axillary lymphadenopathy.", "The spleen is palpated 5 cm below the costal margin.", "Her leukocyte count is 12,000/mm3 and platelet count is 217,000/mm3."]}
{"Patient Personal Background": ["She says she visited a physician last year who said she had a pelvic infection, but she was never treated because of insurance issues."], "Patient Symptoms": ["She also complains of scant vaginal bleeding.", "She also says her period has been delayed this month."], "Examination and Results": ["She is afebrile.", "The pulse is 124/min and the blood pressure is 100/70 mm Hg.", "On examination, her abdomen is distended and tender.", "A pregnancy test was positive."]}
{"Patient Personal Background": ["He has a history of intravenous heroin use."], "Patient Symptoms": ["Physical examination shows scleral icterus."], "Examination and Results": ["A serum study is positive for hepatitis C RNA."], "Treatment": ["Therapy with interferon-\u03b1 is initiated in combination with a second drug."]}
{"Patient Personal Background": ["He has not been to the doctor since he was 22 years of age.", "He is otherwise healthy and takes no medications."], "Patient Symptoms": ["He reports that over the past three months, he has felt tired and weak despite no changes in diet or exercise."], "Examination and Results": ["Physical examination is notable for conjunctival pallor.", "A complete blood count reveals a hemoglobin of 9.1 g/dL and hematocrit of 31%.", "A stool sample is hemoccult positive and a colonoscopy reveals a fungating hemorrhagic mass in the ascending colon."], "Others": ["Family history is notable for colorectal cancer in his father and paternal uncle, ovarian cancer in his paternal grandmother, and pancreatic cancer in his paternal uncle."]}
{"Patient Personal Background": ["She is a smoker and drinks alcohol occasionally.", "Past medical history is insignificant except for chronic knee pain, for which she takes over the counter painkillers."], "Patient Symptoms": ["She states that she has experienced similar pain in the past.", "These episodes occur mostly after meals and often subside several hours after she finishes eating.", "Due to this reason she mostly avoids eating.", "She says she has lost a few pounds in the last couple of months."], "Examination and Results": ["Her temperature is 37\u00b0C (98.6\u00b0F), respiratory rate is 16/min, pulse is 77/min, and blood pressure is 120/89 mm Hg.", "A physical abdominal exam is unremarkable, including examination of the abdomen."]}
{"Patient Symptoms": ["One day prior she twisted her right knee and felt a \u201cpop\u201d while chasing after a ball.", "She has since felt severe throbbing knee pain and noticed a rapid increase in swelling around her knee.", "She is able to bear weight but feels \u201cunstable\u201d on her right leg."], "Examination and Results": ["On exam, anterior drawer and Lachman\u2019s tests are positive."], "Diagnosis": ["The physician informs her that she has likely injured an important structure in her knee."]}
{"Patient Personal Background": ["He was delivered at 41 weeks' gestation via Caesarian section and the amniotic fluid was meconium-stained."], "Patient Symptoms": ["His respiratory rate is 75/min.", "Physical examination shows increased work of breathing.", "Three hours later, the newborn is tachypneic and there is blue-grey discoloration of the lips, fingers, and toes."], "Examination and Results": ["X-rays of the abdomen and chest show no abnormalities.", "Echocardiography shows elevated pulmonary artery pressure."], "Treatment": ["He is started on an inhaled medication that increases smooth muscle cGMP, and there is immediate improvement in his tachypnea and oxygenation status."]}
{"Treatment": ["The investigator determines that inactivating this virus can prevent its spread."], "Others": ["One of the agents studied is a picornavirus that preferentially infects hepatocytes."]}
{"Patient Personal Background": ["She has been trying to conceive with her husband since she stopped taking oral contraceptives 6 months ago; she was happy to tell him last week that she is pregnant."], "Patient Symptoms": ["For the past 2 months, she has had increasing breast tenderness, nausea, 3-kg (6.6-lb) weight gain, and urinary frequency."], "Examination and Results": ["Her temperature is 37.2\u00b0C (99\u00b0F), pulse is 100/min, and blood pressure is 110/60 mm Hg.", "Physical examination shows mild, nontender abdominal enlargement.", "The cervical os is closed.", "Urine \u03b2-hCG is negative.", "Transvaginal ultrasonography shows no abnormalities."], "Others": ["She is not sure about the date of her last menstrual period."]}
{"Patient Personal Background": ["He lives in a group home and takes no medications."], "Patient Symptoms": ["During the appointment, he frequently repeats the same information and needs to be reminded why he is at the doctor's office.", "He has a constricted affect."], "Examination and Results": ["His vital signs are within normal limits.", "Neurological examination shows no focal deficits.", "On mental status examination, he has no long-term memory deficits and is able to count in serial sevens without error.", "An MRI of the brain shows atrophy of the anterior thalami and small mamillary bodies."], "Others": ["He says that he is a famous poet and recently had a poem published in a national magazine."]}
{"Others": ["As a member of a research team working on the Hib vaccine, he asks his senior colleague why capsular polysaccharides are conjugated to protein carriers like tetanus toxoid during vaccine development."]}
{"Examination and Results": ["The concentration of glutamate in the CA1 region of the hippocampus is measured using magnetic resonance spectroscopy after Schaffer collateral fibers are electrically stimulated."]}
{"Patient Personal Background": ["When asked about the possibility of pregnancy, she mentioned that she uses combination oral contraceptive pills (OCPs) for contraception."], "Patient Symptoms": ["She currently denies any headaches, vision changes, nausea or vomiting, or neck stiffness."], "Examination and Results": ["Her physical exam is within normal limits.", "Her vital signs are stable."], "Treatment": ["She is prescribed rifampin for prophylaxis with specific instructions on when to follow up if symptoms develop.", "The physician suggested that her husband should use condoms for contraception as she requires antibiotic therapy."], "Others": ["She was told by her friend that she need to see a physician because she needs to be treated as well, even if she is not having symptoms yet."]}
{"Patient Symptoms": ["She initially thought it was an insect bite, but it has slowly increased in size over the past weeks."], "Examination and Results": ["Her temperature is 36.7\u00b0C (98\u00b0F), pulse is 75/min, and blood pressure is 128/76 mm Hg.", "Physical examination shows a 0.8-cm hyperpigmented papule.", "When the skin lesion is squeezed, the surface retracts inwards."], "Others": ["A photograph of the lesion is shown."]}
{"Patient Symptoms": ["Examination shows right-sided anterior cervical lymphadenopathy, bilateral conjunctival injection, erythema of the tongue and lips, and a maculopapular rash involving the hands, feet, perineum, and trunk."], "Examination and Results": ["His temperature is 38.9\u00b0C (102\u00b0F)."]}
{"Patient Personal Background": ["He denies any substance use and states that he was just trying to have a good time.", "The patient has a past medical history of psoriasis which is treated with topical steroids."], "Patient Symptoms": ["The patient is very anxious and initially is hesitant to answer questions.", "The patient's responses are slightly delayed and he seems to have difficulty processing his thoughts.", "The patient tells you he feels very anxious and asks for some medication to calm him down.", "The patient has a past medical history of psoriasis which is treated with topical steroids."], "Examination and Results": ["His temperature is 99.5\u00b0F (37.5\u00b0C), blood pressure is 120/75 mmHg, pulse is 110/min, respirations are 15/min, and oxygen saturation is 99% on room air.", "On physical exam, you note an anxious young man.", "HEENT exam reveals a dry mouth and conjunctival injection.", "Neurological exam reveals cranial nerves II-XII as grossly intact with normal strength and sensation in his upper and lower extremities.", "Cardiac exam reveals tachycardia, and pulmonary exam is within normal limits."], "Others": ["He was found at a local celebration acting very strangely and was reported by other patrons of the event."]}
{"Patient Personal Background": ["He has smoked 1 pack of cigarettes daily for the past 45 years."], "Examination and Results": ["The patient undergoes emergency laparotomy and is found to have dusky discoloration of the hepatic colonic flexure and an adjacent segment of the transverse colon."], "Treatment": ["The patient undergoes emergency laparotomy and is found to have dusky discoloration of the hepatic colonic flexure and an adjacent segment of the transverse colon."]}
{"Diagnosis": ["Higher mortality was also found in patients with a diagnosis of alcohol and drug dependence (SMR = 3.87)."], "Others": ["Mortality was studied in relation to age, sex, diagnosis, care pattern, and registration interval.", "Standardized mortality ratios (SMRs) were calculated, with the overall SMR being 1.63 (lower when compared with studies that looked at hospitalized individuals).", "Men and those in younger age groups showed higher mortality rates (SMRs of 2.24 and 8.82, respectively), and mortality was also higher in the first year following registration (SMR = 2.32).", "The authors concluded that the overall mortality of psychiatric patients managed in a community-based setting was higher than expected; however, it was still lower than the mortality described in other psychiatric settings."]}
{"Patient Personal Background": ["The child\u2019s parents died in a car accident 1 month ago.", "His grandparents also brought the medications he stopped taking after his parents\u2019 death, including multivitamins, allopurinol, and diazepam.", "They say that their grandson has been using these medications for many years; however, they are unable to provide any medical history and claim that their grandson has been behaving strangely, exhibiting facial grimacing, irregular involuntary contractions, and writhing movements for the past few days.", "They also note that he has had no teeth since the time they first met him at the age of 2.", "An intramuscular medication is administered to calm the boy down prior to drawing blood from him for laboratory tests."], "Patient Symptoms": ["He is in a wheelchair with soft restraints because he has been violent and had been trying to hurt himself that day.", "They say that their grandson has been using these medications for many years; however, they are unable to provide any medical history and claim that their grandson has been behaving strangely, exhibiting facial grimacing, irregular involuntary contractions, and writhing movements for the past few days."], "Treatment": ["He is in a wheelchair with soft restraints because he has been violent and had been trying to hurt himself that day."]}
{"Patient Personal Background": ["She had to undergo segmental small bowel resection several times because of intestinal obstruction and fistula formation."], "Patient Symptoms": ["She has also noticed that food has recently tasted bland to her."], "Examination and Results": ["Examination shows several bullous, erythematous perioral plaques.", "There are two well-circumscribed circular patches of hair loss on the scalp."]}
{"Patient Personal Background": ["Her last pregnancy was unremarkable and she gave birth to a healthy rhesus (RhD) positive girl.", "Her past medical history is notable for a blood transfusion after a car accident with a complex femur fracture about 3 years ago."], "Examination and Results": ["Her temperature is 37.2\u00b0C (99\u00b0F), pulse is 92/min, and blood pressure is 138/82 mm Hg.", "Examination shows that the uterus is at the umbilicus.", "Ultrasound examination reveals normal fetal heart rate, movement, and anatomy."]}
{"Patient Personal Background": ["He reports that he emigrated from Mexico 20 years ago and visits his hometown twice a year."], "Patient Symptoms": ["Occasionally, he experiences palpitations, especially during strenuous activities.", "In addition to this, he has been experiencing difficulty in digestion and often experiences regurgitation and dysphagia."], "Examination and Results": ["The vital signs include: blood pressure 120/75 mm Hg, respiratory rate 19/min, and pulse 100/min.", "The physical examination shows jugular vein distention along with pitting edema in the ankles.", "Bilateral basilar crackles and an S3 gallop are heard on auscultation of the chest.", "A chest X-ray is taken.", "An electrocardiogram (ECG) shows no significant findings."]}
{"Patient Personal Background": ["The patient is an immigrant from Spain and works as an office assistant.", "She is not aware of any chronic medical conditions and takes a multivitamin daily."], "Patient Symptoms": ["She says that the pain has been slowly worsening over the past 3 days.", "Otherwise, she complains of fatigue, a subjective fever, and a sunburn on her face which she attributes to gardening."], "Examination and Results": ["Her temperature is 98.7\u00b0F (37.1\u00b0C), blood pressure is 125/64 mmHg, pulse is 80/min, respirations are 13/min, and oxygen saturation is 98% on room air.", "Physical exam reveals bilateral redness over the maxillary prominences."]}
{"Patient Personal Background": ["Past medical history is unremarkable."], "Patient Symptoms": ["Over the weekend, he scraped his left thigh when he fell on a muddy field while playing flag football with some friends.", "Since that time, he has had progressively worsening redness and pain in his left thigh."], "Examination and Results": ["His temperature is 39.4\u00b0C (103.0\u00b0F), heart rate is 120/min, and blood pressure is 95/60 mm Hg.", "Physical exam is significant for a poorly-demarcated area of redness on his left thigh, extending to about a 10 cm radius from a small scrape.", "This area is extremely tender to palpation, and palpation elicits an unusual 'crunchy' sensation.", "CT scan shows free air in the soft tissue of the left leg."]}
{"Patient Personal Background": ["He has had similar episodes in the past, but the symptoms never lasted this long.", "He had a myocardial infarction 4 years ago and currently takes captopril, metoprolol, and atorvastatin."], "Patient Symptoms": ["He denies chest pain, shortness of breath, headaches, and fevers."], "Examination and Results": ["His pulse is irregular and cardiac auscultation reveals an irregular heart rhythm.", "Laboratory reports show:\nSerum glucose 88 mg/dL\nSodium 142 mEq/L\nPotassium 3.9 mEq/L\nChloride 101 mEq/L\nSerum creatinine 0.8 mg/dL\nBlood urea nitrogen 10 mg/dL\nCholesterol, total 170 mg/dL\nHDL-cholesterol 40 mg/dL\nLDL-cholesterol 80 mg/dL\nTriglycerides 170 mg/dL\nHematocrit 38%\nHemoglobin 13 g/dL\nLeucocyte count 7,500/mm3\nPlatelet count 185,000 /mm3\nActivated partial thromboplastin time (aPTT) 30 seconds\nProthrombin time (PT) 12 seconds\nCardiac enzymes Negative\nAn ECG shows the absence of P-waves with an irregular RR complex."], "Treatment": ["A few hours later, his symptoms subside and he is discharged with an additional anticoagulation drug."]}
{"Patient Symptoms": ["These episodes last for approximately 25 minutes and are accompanied by his neck rotating to the right.", "During the last episode, he was able to relieve the stiffness by lightly touching his jaw.", "He appears anxious."], "Examination and Results": ["Examination shows a flexed neck rotated to the right.", "The neck is rigid with limited range of motion.", "His temperature is 37.3\u00b0C (99.1\u00b0F), pulse is 108/min, and blood pressure is 128/86 mm Hg."], "Treatment": ["He has received six doses of haloperidol for auditory hallucinations since his admission."]}
{"Patient Symptoms": ["Three days later, while awaiting treatment, he presents to his physician complaining of generalized swelling and is found to have 4+ protein in his urine."], "Examination and Results": ["After a physical exam and a series of laboratory tests, the patient undergoes a lymph node biopsy (Image A).", "Three days later, while awaiting treatment, he presents to his physician complaining of generalized swelling and is found to have 4+ protein in his urine."]}
{"Others": ["The microbiologist exposes the agar plate to ciprofloxacin, which destroys all of the bacteria except for one surviving colony."]}
{"Patient Personal Background": ["Past medical history is unremarkable.", "No current medications.", "The patient was an alcoholic for several years but abruptly quit drinking 5 days ago."], "Patient Symptoms": ["The patient\u2019s son adds that his father has been having some behavioral problems, as well, and that he was complaining about bugs crawling over his skin this morning even though there were no insects."], "Examination and Results": ["The patient\u2019s temperature is 40.0\u00b0C (104.0\u00b0F), pulse is 130/min, blood pressure is 146/88 mm Hg, and respiratory rate is 24/min.", "On physical examination, he is confused, restless, agitated, and lacks orientation to time, place or person."]}
{"Patient Symptoms": ["She also complains of progressively worsening night-time vision.", "She has had no fever, chills, or vomiting."], "Examination and Results": ["Physical examination shows dry, scaly skin on her extremities and face."]}
{"Patient Personal Background": ["The patient is a known hypertensive for 20 years maintained on amlodipine and telmisartan."], "Treatment": ["The physician notes that he is also being given a diuretic that blocks the Na+ channels in the cortical collecting tubule."]}
{"Patient Personal Background": ["His spleen is surgically absent."], "Patient Symptoms": ["He is extremely lethargic and is unable to provide an adequate history to his physician.", "His wife noted that roughly 3 days ago, her husband mentioned that something bit him, but she cannot remember what exactly."], "Examination and Results": ["The vital signs include blood pressure 85/67 mm Hg, pulse rate 107/min, and respiratory rate 35/min.", "Upon examination, the man is currently afebrile but is lethargic and pale.", "There are some swollen bite marks on his right hand with red streaks extending to his elbow."]}
{"Patient Personal Background": ["She is sexually active with one male partner and does not use condoms."], "Patient Symptoms": ["She also reports a tingling sensation in her legs that is exacerbated by taking a hot shower."], "Examination and Results": ["Her temperature is 37.8\u00b0C (100.1\u00b0F).", "Physical examination shows decreased muscle strength and clonus in both lower extremities.", "Patellar reflex is 4+ bilaterally and plantar reflex shows an extensor response on both sides.", "Abdominal reflex is absent.", "An MRI of the brain is shown."]}
{"Diagnosis": ["They use hospital records to identify 50 people who have been diagnosed with interstitial lung disease.", "They also identify a group of 50 people without interstitial lung disease who are matched in age and geographic location to those with the disease."], "Others": ["The participants' exposure to the chemical is assessed by surveys and home visits."]}
{"Patient Personal Background": ["He has a history of major depressive disorder.", "His only medication is nortriptyline."], "Patient Symptoms": ["His wife found him on the bathroom floor with an empty bottle of medication next to him."], "Examination and Results": ["His pulse is 127/min and blood pressure is 90/61 mm Hg.", "Examination shows dilated pupils and dry skin.", "The abdomen is distended and there is dullness on percussion in the suprapubic region.", "An ECG shows tachycardia and a QRS complex width of 130 ms."]}
{"Patient Personal Background": ["This patient is otherwise healthy, and her history does not indicate any health conditions or known allergies."], "Patient Symptoms": ["After this, the patient became irritable and had difficulty breathing, suggesting an allergic reaction, which was immediately treated with epinephrine."], "Treatment": ["However, due to an unexpected bleeding event, the physician had to order a blood transfusion to replace the blood lost in the surgery.", "After this, the patient became irritable and had difficulty breathing, suggesting an allergic reaction, which was immediately treated with epinephrine."], "Diagnosis": ["The physician suspects an immunodeficiency disorder that was not previously diagnosed."]}
{"Patient Personal Background": ["The mother reports that there is no history of serious illness in the family."], "Patient Symptoms": ["On arrival, he is unable to provide history.", "The patient appears drowsy and dehydrated."], "Examination and Results": ["His temperature is 38.5\u00b0C (101.3\u00b0F), pulse is 110/min, and blood pressure is 170/100 mm Hg.", "Examination shows several track marks on his forearms and large contusions over his forehead, legs, and back.", "There is blood coming from the mouth.", "The patient is catheterized and tea-colored urine is drained.", "Urinalysis shows:\nUrine\npH 5.8\nSpecific gravity 1.045\nBlood 3+\nGlucose 3+\nProteins 1+\nKetones 1+\nRBC none\nWBC 0-1/hpf\nUrine toxicology is positive for opiates and cocaine."], "Treatment": ["Intravenous fluids and sodium nitroprusside drip are started."]}
{"Patient Personal Background": ["Her previous births have been via uncomplicated caesarean sections, but she wishes to attempt vaginal delivery this time.", "Her prenatal care is notable for gestational diabetes controlled with diet and exercise."], "Examination and Results": ["The delivery is prolonged, but the patient's pain is controlled with epidural analgesia.", "She delivers a male infant with Apgar scores of 8 and 9 at 1 and 5 minutes, respectively.", "The patient loses 500 mL of blood over the next minute, during which her blood pressure decreases from 120/80 mmHg to 90/65 mmHg."], "Treatment": ["The delivery is prolonged, but the patient's pain is controlled with epidural analgesia.", "The obstetrician manually removes the placenta, but a red mass protrudes through the vagina attached to the placenta."], "Others": ["Fundal massage is performed, but the placenta does not pass."]}
{"Patient Personal Background": ["He recently moved to the area and has not been to a primary care physician for over 5 years.", "He has no history of serious illness, but has intermittent bilateral knee pain for which he takes 650 mg acetaminophen every other day.", "He is married with three children and is sexually active with his wife.", "During the past 10 years, he has unsuccessfully tried to lose weight.", "He has smoked one half pack of cigarettes daily for 15 years.", "About 2\u20133 times per week he has 1\u20132 glasses of wine with dinner."], "Patient Symptoms": ["He has no history of serious illness, but has intermittent bilateral knee pain for which he takes 650 mg acetaminophen every other day."], "Examination and Results": ["He is 160 cm (5 ft 3 in) tall and weighs 93 kg (205 lb); BMI is 36.3 kg/m2.", "Vital signs are within normal limits.", "On abdominal examination, the liver is palpated 2 to 3 cm below the right costal margin.", "Laboratory studies show:\nHemoglobin 12.6 g/dL\nPlatelet count 360,000/mm3\nHemoglobin A1c 6.3%\nSerum\nFerritin 194 ng/mL\nTotal bilirubin 0.7 mg/dL\nAlkaline phosphatase 52 U/L\nAspartate aminotransferase 92 U/L\nAlanine aminotransferase 144 U/L\nHepatitis B surface antigen Negative\nHepatitis B core IgM antibody Negative\nHepatitis B surface antibody Positive\nHepatitis C antibody Negative\nAntinuclear antibody titers 1:20 (N = < 1:60)\nSmooth muscle antibody titers Negative\nAnti-LKM1 antibody titers Negative\nTransabdominal ultrasonography shows a mildly enlarged, diffusely hyperechoic liver."]}
{"Patient Symptoms": ["He was unable to stand up after this collision and reported severe knee pain."], "Examination and Results": ["On presentation, he was found to have a mild knee effusion.", "Physical exam showed that his knee could be pushed posteriorly at 90 degrees of flexion but it could not be pulled anteriorly in the same position."], "Others": ["During the game, he was about to kick the ball when another player collided with his leg from the front."]}
{"Patient Personal Background": ["He notes that he stopped taking his furosemide two weeks prior, because he ran out of pills."], "Examination and Results": ["On exam, his oxygen saturation is 78%, his lungs have crackles throughout, and jugular venous pulsation is located at the earlobe.", "EKG and troponin levels are normal."]}
{"Patient Personal Background": ["He traveled to the Netherlands for 4 days a month ago."], "Patient Symptoms": ["He adds that he is fatigued all the time and has generalized weakness.", "He has drenching night sweats and has had 2 episodes of non-bilious vomiting over the past few days.", "His symptoms started a few days after he returned home."], "Examination and Results": ["Laboratory testing revealed the following:\nHemoglobin 11.2 g/dL\nHematocrit 29%\nLeukocyte count 2,950/mm3\nNeutrophils  59%\nBands  3%\nEosinophils 1%\nBasophils  0%\nLymphocytes 31%\nMonocytes  4%\nPlatelet count  60,000/mm3\nUnconjugated bilirubin 12 mg/dL\nAlanine aminotransferase 200 IU/L\nAspartate aminotransferase 355 IU/L\nThe peripheral blood smear showed basophilic ring- and pear-shaped structures inside many red cells and extracellular basophilic rings on Wright-Giemsa staining.", "Further evaluation revealed parasitemia and a few schistocytes, poikilocytes, and merozoites in tetrad formation."]}
{"Patient Personal Background": ["Past medical history is negative and family history is irrelevant."], "Patient Symptoms": ["About 10 days ago, she had an episode of unexplained loss of consciousness."], "Examination and Results": ["Clinical examination shows a diastolic murmur, which is prominent when she lies on her left side.", "Jugular venous distention is present, and chest examination reveals fine crackles that do not clear with coughing.", "Chest X-ray shows pulmonary congestion, and 2-dimensional echocardiogram shows a mass in the left atrium attached to the atrial septum."]}
{"Patient Personal Background": ["His past medical history is significant for human immunodeficiency virus (HIV) infection, which was diagnosed last year.", "He also experienced a head trauma 5 years ago, which has been complicated by residual seizures.", "His only medication is daily phenytoin, which was restarted after he had a seizure 3 months ago."], "Patient Symptoms": ["He reports no recent fevers, night sweats, or weight loss."], "Examination and Results": ["His temperature is 36.8\u2103 (98.2\u2109).", "On physical examination, multiple non-tender lymph nodes, averaging 2 cm in diameter, are found to be palpable in the anterior and posterior triangles of the neck bilaterally.", "No other lymphadenopathy is noted.", "The remainder of the physical exam is unremarkable.", "Laboratory studies show the following:\nHemoglobin 14 g/dL\nLeukocyte count 8000/mm3 with a normal differential\nPlatelet count 250,000/mm3\nErythrocyte sedimentation rate 40 mm/h\nAn excisional biopsy of one of the cervical lymph nodes is performed."], "Others": ["The histopathologic analysis is shown in the image."]}
{"Patient Personal Background": ["Her current medications include lisinopril, metformin, insulin, aspirin, atorvastatin, sodium docusate, and loratadine."], "Patient Symptoms": ["She has been waking up every morning with her underwear soaked in urine.", "She notices that at work if she does not take regular bathroom breaks her underwear will have some urine in it.", "She urinates 5 to 11 times per day but she claims it is a small volume."], "Examination and Results": ["Her temperature is 98.2\u00b0F (36.8\u00b0C), blood pressure is 167/108 mmHg, pulse is 90/min, respirations are 15/min, and oxygen saturation is 99% on room air.", "Physical exam is notable for decreased pinprick sensation in the lower extremities and a systolic murmur along the right upper sternal border."]}
{"Patient Personal Background": ["He mentions that he has had a \u2018heart attack\u2019 5 years ago.", "He also says that he continues to consume alcohol on a regular basis even though his doctor has advised against it."], "Patient Symptoms": ["He says that he finds himself out of breath after taking a few steps, and has to sit down and rest, in order to continue.", "He also says that, at night, he has the greatest difficulty in breathing and usually uses at least 3 pillows to sleep comfortably.", "He mentions a cough that appears only at night, but which is persistent enough to wake him up from sleep."], "Examination and Results": ["He has brought his lab reports which he had recently got done on the suggestions of his family doctor.", "An electrocardiogram (ECG) and a chest X-ray are found."]}
{"Examination and Results": ["He is lying supine and is not cyanotic.", "He has a pulse of 195/min, and respirations of 59/min.", "He is found to have a nonradiating continuous machine-like murmur at the left upper sternal border.", "S1 and S2 are normal.", "The peripheral pulses are bounding."]}
{"Patient Symptoms": ["The girl tells you that she gets nervous around other children, as she cannot tell what they are feeling, when they are joking, or what she has in common with them.", "Her teachers describe her as \u201ceasily distracted\u201d and \u201ceasily upset by change.\u201d When asked about her hobbies and interests, she states that \u201cmarine biology\u201d is her only interest and gives you a 15-minute unsolicited explanation of how to identify different penguin species."], "Examination and Results": ["Mental status exam is notable for intense eye contact, flat affect, and concrete thought process."]}
{"Patient Personal Background": ["Current medications include intravenous ceftriaxone and oral azithromycin."], "Examination and Results": ["Stool cultures grow gram-positive, anaerobic rods."], "Treatment": ["Current medications include intravenous ceftriaxone and oral azithromycin."], "Others": ["She is moved to an isolated hospital room."]}
{"Patient Personal Background": ["She was born at 39 weeks via spontaneous vaginal delivery and is meeting all developmental milestones.", "Her mother has one brother that occasionally requires blood transfusions."], "Patient Symptoms": ["They are concerned that she becomes lethargic and irritated between meals.", "On physical exam, the infant is irritated.", "She is slightly jaundiced."], "Examination and Results": ["They found that feeding her often with small servings helps.", "Today, her blood pressure is 55/33 mm Hg, his heart rate is 120/min, respiratory rate is 40/min, and temperature of 37.0\u00b0C (98.6\u00b0F).", "Her heart has a regular rate and rhythm and her lungs are clear to auscultation bilaterally.", "Her blood work shows normocytic anemia with elevated reticulocyte count and decreased haptoglobin.", "Sickle cell anemia and other hemoglobinopathies are also ruled out.", "A Coombs test is negative.", "Red blood cell osmotic fragility gap is normal."], "Diagnosis": ["The physician determined that these findings are related to an enzyme deficiency."]}
{"Patient Personal Background": ["The family lives together in a house built in 1950."], "Patient Symptoms": ["The patient\u2019s parents say he was doing well until a few weeks ago at which time he started to complain of daily abdominal cramps and occasional muscle pains.", "His mother also noticed that he has been less active than usual."], "Examination and Results": ["The patient\u2019s temperature is 36.8\u00b0C (98.2\u00b0F), blood pressure is 100/70 mm Hg, pulse is 100/min and respirations are 20/min.", "Abdominal exam shows mild diffuse tenderness to palpation and normal bowel sounds.", "The patient\u2019s height, weight, and head circumference are normal.", "Laboratory results are as follows:\nHemoglobin 7 g/dL\nMean corpuscular volume (MCV) 72\nLead level (capillary blood) 15 mcg/dL\nLead level (venous blood) 60 mcg/dL\nFindings on a peripheral blood smear are shown in the image."], "Others": ["The parents deny any complaints of headaches or convulsions."]}
{"Patient Personal Background": ["She works as a school teacher but reports that she has had to miss several days of work due to her symptoms.", "She does not smoke or drink alcohol."], "Patient Symptoms": ["She has had intermittent myalgias, arthralgias, fatigue, and skin rashes over the past 10 years that have acutely worsened over the past year."], "Examination and Results": ["Her temperature is 99.2\u00b0F (37.3\u00b0C), blood pressure is 130/75 mmHg, pulse is 80/min, and respirations are 18/min.", "On exam, she is well-appearing and in no acute distress.", "She has erythematous, raised plaques with keratotic scaling and follicular plugging on her hands."], "Treatment": ["She has been on hydroxychloroquine for several years but does not feel that it is adequately controlling her symptoms.", "The physician decides to trial the patient on low-dose prednisone to better control her symptoms."], "Others": ["At 2 months of follow-up, she reports that her flares have subsided and she has been able to return to work full-time."]}
{"Patient Personal Background": ["She also says that they both occasionally take sleeping pills to help them fall asleep."], "Patient Symptoms": ["The patient is unable to provide a history due to her breathing difficulties.", "The patient\u2019s roommate says that she came home and found her in this state."], "Examination and Results": ["Physical examination reveals an obese female, dyspneic with diminished chest wall movements.", "The patient\u2019s A-a gradient is calculated to be 10 mm Hg."]}
{"Patient Symptoms": ["The son says she has been very difficult at home and is \"losing it\".", "He seems very frustrated about her diminishing ability to take care of herself the way she used to and no longer thinks he can trust her watching his children.", "Today, she appears withdrawn and hesitates to make eye-contact with you.", "She lets her son do most of the talking."], "Examination and Results": ["At her last visit you noted mild cognitive impairment."]}
{"Examination and Results": ["Results of the study are shown."], "Others": ["A healthy subject is asked to eat a meal at hour 0, and the pH of stomach contents and rate of stomach acid secretions are measured over the next 4 hours."]}
{"Patient Symptoms": ["She does not have difficulties swallowing, dyspnea, or changes in voice."], "Examination and Results": ["Examination shows a 3-cm, hard swelling on the left side of her neck that moves with swallowing.", "There is no cervical or axillary lymphadenopathy.", "The remainder of the examination shows no abnormalities.", "Thyroid functions tests are within the reference range.", "Ultrasound of the neck shows an irregular, hypoechogenic mass in the left lobe of the thyroid.", "A fine-needle aspiration biopsy is inconclusive."], "Treatment": ["The surgeon and patient agree that the most appropriate next step is a diagnostic lobectomy and isthmectomy.", "Surgery shows a 3.5-cm gray tan thyroid tumor with invasion of surrounding blood vessels, including the veins."]}
{"Patient Personal Background": ["She has no complaints and her past medical history is notable for diabetes and hypertension."], "Examination and Results": ["During this visit, the patient undergoes screening procedures per guidelines including a mammogram.", "On the screening mammogram a spiculated, irregular mass is found on the left breast."], "Diagnosis": ["Further diagnostic mammography and biopsy reveal ductal adenocarcinoma of the breast in the upper outer quadrant of the left breast."]}
{"Patient Symptoms": ["He states that ever since her uncomplicated delivery she has failed to gain weight, has had chronic diarrhea, and has had multiple bacterial and viral infections."], "Examination and Results": ["During the course of the workup, an absent thymic shadow is noted and a lymph node biopsy demonstrates the absence of germinal centers."]}
{"Patient Symptoms": ["His hair is tangled and has a dry, brittle texture."], "Examination and Results": ["His weight, height, and head size were found to be in the lower percentile ranges on standard growth curves.", "Genetic testing reveals that the patient has a connective tissue disorder caused by impaired copper absorption and transport."], "Diagnosis": ["Genetic testing reveals that the patient has a connective tissue disorder caused by impaired copper absorption and transport."]}
{"Patient Personal Background": ["There is no personal or family history of serious illness."], "Examination and Results": ["She is 165 cm (5 ft 5 in) tall and weighs 57 kg (125 lb); BMI is 21 kg/m2.", "Vital signs are within normal limits.", "Examination of the breasts shows a secondary mound formed by the nipple and areola.", "Pubic hair is sparse and lightly pigmented.", "Abdominal examination shows bilateral firm, nontender inguinal masses.", "Pelvic examination shows a blind-ended vaginal pouch.", "Ultrasonography does not show a uterus or ovaries."]}
{"Patient Personal Background": ["He was diagnosed with high cholesterol during that episode and was prescribed medication.", "He also has a 3-year history of gastritis."], "Patient Symptoms": ["He mentions that the pain started several hours ago and radiates to his left neck and shoulder.", "He also mentions that he has some difficulty in breathing.", "He seems a little anxious."], "Examination and Results": ["The blood pressure is 130/80 mm Hg, respirations are 18/min, and the pulse is 110/min.", "The physical examination reveals no significant abnormalities.", "An ECG shows slight changes in the leads."], "Treatment": ["His physician talks to him about the benefits of taking low-dose aspirin daily."]}
{"Patient Personal Background": ["She was diagnosed with rheumatoid arthritis 3 years ago and has since been on medication to assist with her pain and to slow down disease progression."], "Patient Symptoms": ["She has no specific complaints at this visit however, she has noticed that she is more tired than usual these days.", "At first, she ignored it and attributed it to stress but she feels weaker each week.", "She is sometimes out of breath while walking for long distances or when she is involved in strenuous physical activity."], "Examination and Results": ["Her temperature is 37.0\u00b0C (98.6\u00b0F), the respiratory rate is 15/min, the pulse is 107/min, and the blood pressure is 102/98 mm Hg.", "On examination, you notice thinning hair and mildly cool extremities with flattened nail beds.", "A complete blood count and iron studies are ordered."]}
{"Patient Personal Background": ["She has congestive heart failure, atrial fibrillation, age-related macular degeneration, type 2 diabetes mellitus, and chronic renal failure.", "Current medications include warfarin, metoprolol, insulin, digoxin, ramipril, and spironolactone."], "Patient Symptoms": ["She has 2\u20133 loose stools every day.", "She has also had 3 episodes of vomiting.", "She complains of a headache and blurry vision."], "Examination and Results": ["Her temperature is 36.7\u00b0C (98\u00b0F), pulse is 61/min, and blood pressure is 108/74 mm Hg.", "The abdomen is soft, and there is diffuse, mild tenderness to palpation."], "Others": ["Three weeks ago, she returned from a cruise trip to the Bahamas."]}
{"Patient Personal Background": ["She had similar episodes in the past, which were often precipitated by food but resolved spontaneously."], "Patient Symptoms": ["During the ultrasound exam, the patient complains of tenderness when the probe presses down on her right upper quadrant."], "Examination and Results": ["Her temperature is 38.3\u00b0C (101.0\u00b0F), heart rate is 96/min, blood pressure is 118/76 mm Hg, and respiratory rate is 16/min.", "Physical examination reveals tenderness over the right upper quadrant that is severe enough to make her stop breathing when deeply palpated in the area.", "Lab results show:\nLeukocyte count 18,000/mm3 with 79% neutrophils\nAspartate aminotransferase 67 IU/L\nAlanine aminotransferase 71 IU/L\nSerum amylase 46 U/L\nSerum Lipase 55 U/L\nSerum calcium 8.9 mg/dL\nUltrasonography of the abdomen is shown below.", "During the ultrasound exam, the patient complains of tenderness when the probe presses down on her right upper quadrant."]}
{"Patient Personal Background": ["They recently immigrated from another country, and do not have any previous medical records."], "Patient Symptoms": ["The adolescent girl looks relatively short, but otherwise looks healthy.", "She has no complaints except for mild intermittent lower abdominal pain for the past year."], "Examination and Results": ["On physical examination, vitals are within normal limits.", "There is the presence of axillary hair, breast development, and pubic hair at Tanner stage 5."], "Treatment": ["You explain to the mother and the patient that you need to perform a complete vaginal examination, however, both of them declined the procedure and would prefer that lab test be performed."]}
{"Treatment": ["After induction of general anesthesia, preparation of a sterile surgical field, and port placement, the surgeon needs to enter the space posterior to the stomach to access the pancreatic tumor."]}
{"Patient Personal Background": ["His wife says that he has peptic ulcer disease and is being treated with antacids without a good response."], "Patient Symptoms": ["He is unable to give more information about the nature of his pain.", "She adds that he vomited repeatedly  in the last couple of hours, his vomitus being brown/red in color."], "Examination and Results": ["His temperature is 98.6\u00b0F (37\u00b0C), respiratory rate is 16/min, pulse is 97/min, and blood pressure is 100/68 mm Hg.", "A physical exam reveals a tense abdomen with a board like rigidity and positive rebound tenderness."], "Others": ["An erect abdominal x-ray is ordered."]}
{"Patient Personal Background": ["His past medical history is significant for an ischemic stroke of the right anterior cerebral artery 1 month ago, status post intravenous (IV) tissue plasminogen activator (tPA) with still some residual neurologic impairment, and long-standing gastroesophageal reflux secondary to a hiatal hernia, managed medically.", "The patient reports a 15-pack-year smoking history, but no alcohol or recreational drug use."], "Patient Symptoms": ["He says that he has episodes where he feels his heart is \u2018racing and pounding\u2019, lasting 1\u20132 hours on average.", "Initially, he says the episodes would happen 1\u20132 times per week but now happen almost every day.", "This last episode has been constant for the past 2 days.", "He denies any seizure, loss of consciousness, dizziness, chest pain, or similar symptoms in the past."], "Examination and Results": ["The vital signs include: temperature 37.0\u00b0C (98.6\u00b0F), blood pressure 100/70 mm Hg, pulse 105/min, and respiratory rate 16/min.", "On physical examination, muscle strength in the lower extremities is 4/5 on the left and 5/5 on the right, along with sensory loss on the left, all of which is improved from his previous exam 3 weeks ago.", "There is a loss of the left half of the visual field bilaterally which is stable from the previous exam.", "Cardiac examination is significant for a new-onset irregular rate and rhythm.", "No rubs, thrills or murmurs.", "A noncontrast computed tomography (CT) scan shows evidence of an area of infarction in the vicinity of the right anterior cerebral artery showing normal interval change with no evidence of new hemorrhage or expansion of the area of infarction.", "An electrocardiogram (ECG) is performed, which is shown in the exhibit (see image below)."]}
{"Treatment": ["They used data in the registry and surveys about peoples\u2019 surgical history to compare the proportion of each population that had undergone a bilateral salpingo-oophorectomy."], "Others": ["To test this hypothesis, they reviewed a database of women who were known to be BRCA-mutation positive and divided the group into those with breast cancer and those without breast cancer.", "Based on this data, they reported that women undergoing the procedure had a lower chance of developing breast cancer later in life with an odds ratio of 0.46."]}
{"Patient Symptoms": ["The patient has had pain when urinating and difficulty starting a stream of urine for over 4 months now.", "He is bothered because he has to urinate about 9 times every day, including several times when he wakes up at night."], "Examination and Results": ["A digital rectal examination revealed multiple hard nodules in the prostate gland.", "A CT scan shows a nodule in the right lung that measures 3 cm.", "An ultrasound scan of his urinary bladder and prostate shows residual urine of > 200 mL and heterogeneous findings of the prostate gland."], "Treatment": ["Follow-up 9 months later shows his prostate cancer is well controlled with goserelin."], "Diagnosis": ["Biopsy reveals grade 2 prostate adenocarcinoma."]}
{"Patient Personal Background": ["The patient admitted to having trouble sleeping from a young age but became more aware of how much this is affecting his health after attending a sleep conference earlier this year.", "He has no past medical or psychiatric condition and is not known to use any recreational drugs."], "Patient Symptoms": ["The patient admitted to having trouble sleeping from a young age but became more aware of how much this is affecting his health after attending a sleep conference earlier this year.", "He is worried that his health has suffered because of this, and he is also concerned that he will not be able to pay his bills if he were to get sick.", "The patient arrived for his appointment an hour early because he was afraid he might miss it."], "Examination and Results": ["The patient is afebrile and his vital signs are within normal limits.", "Physical examination reveals an irritable middle age man who is tense and somewhat inattentive during the interview."]}
{"Examination and Results": ["She is at the 30th percentile for height and 15th percentile for weight.", "Echocardiography shows a defect in the membranous portion of the interventricular septum and a moderately decreased left ventricular ejection fraction."]}
{"Patient Personal Background": ["He has bronchial asthma and hypertension.", "He has smoked one pack of cigarettes daily for 41 years.", "Current medications include an albuterol inhaler and enalapril.", "His temperature is 37.6\u00b0C (99.7\u00b0F), pulse is 88/min, respirations are 20/min, and blood pressure is 136/89 mm Hg."], "Patient Symptoms": ["Three weeks ago, he had a fever and a cough for 6 days after he returned from a trip to Southeast Asia.", "He has had a 4-kg (9-lb) weight loss over the past 3 months."], "Examination and Results": ["There is dullness to percussion, decreased breath sounds, and decreased tactile fremitus over the left lung base.", "Cardiac examination shows no abnormalities."]}
{"Patient Personal Background": ["He reports that he has a 15-year history of hypertension treated with hydrochlorothiazide."], "Examination and Results": ["He is alert and oriented to time, place, and person.", "Neurological examination shows decreased sensation to light pinprick and temperature on the right side of the face and body.", "Motor strength is 5/5 and deep tendon reflexes are 2+ bilaterally."]}
{"Patient Symptoms": ["The patient\u2019s mother denies any other symptoms and says he is otherwise healthy."], "Examination and Results": ["Physical examination shows multiple petechiae and bruising on the torso and extremities bilaterally.", "The remainder of the physical exam is unremarkable.", "A complete blood count is normal."]}
{"Patient Symptoms": ["There is decreased sensation to pinprick on the thumb, index finger, middle finger, and radial half of the ring finger of the left hand.", "The tingling pain is aggravated by tapping over the swelling."], "Examination and Results": ["Physical examination shows a transilluminating, rubbery, fixed, non-tender mass over the lateral volar aspect of the left wrist.", "The tingling pain is aggravated by tapping over the swelling."]}
{"Patient Symptoms": ["The swelling started several weeks ago but is not always present."], "Examination and Results": ["Physical examination shows an 8-cm, soft, cystic nontender right-sided scrotal mass that transilluminates.", "The mass does not increase in size on coughing and it is possible to palpate normal tissue above the mass.", "There are no bowel sounds in the mass, and it does not reduce when the patient is in a supine position.", "Examination of the testis shows no abnormalities."]}
{"Patient Symptoms": ["While evaluating him per your institution's trauma guidelines, you discover pain upon palpation of his right lower extremity which is much larger than his left counterpart.", "The patient admits to decreased sensation over his right lower extremity and cannot move his leg."], "Examination and Results": ["There are no palpable dorsalis pedis or posterior tibial pulses on this extremity, and it is colder and paler in comparison to his left side.", "Measured compartment pressure of his distal right leg is 35 mm Hg."]}
{"Patient Personal Background": ["He has not received any childhood vaccinations because his parents believe that they are dangerous."], "Examination and Results": ["His temperature is 38.0\u00b0C (100.4\u00b0F)."], "Others": ["A photograph of the rash is shown."]}
{"Patient Personal Background": ["He is visibly intoxicated, and hospital records indicate a long history of alcohol substance abuse treated with antabuse (disulfiram)."], "Examination and Results": ["Vital signs include T 98.4, HR 89, BP 154/92, and RR 20.", "EGD is notable for mild esophagitis, and a longitudinal esophageal tear at the gastroesophageal junction, with no active bleeding."]}
{"Treatment": ["He is asked by the surgeon to disinfect the patient\u2019s skin with a chlorhexidine-isopropyl alcohol solution before the procedure."], "Others": ["Recent studies have shown that this solution substantially reduces the risk of surgical site infections compared with a povidone-iodine preparation without alcohol in clean-contaminated surgery."]}
{"Patient Personal Background": ["Relevant social history includes participation in school wrestling."], "Patient Symptoms": ["Other than the pruritic rash, a review of systems is negative."], "Examination and Results": ["On physical examination, there is an erythematous, well-demarcated patch on his left thigh, over his pubic region, and throughout the perineum.", "The scrotum is spared."], "Others": ["He has no significant family history."]}
{"Patient Personal Background": ["She was born at 38 weeks gestation to a 25-year-old woman via an uncomplicated spontaneous vaginal delivery.", "The mother reports that prenatal screening revealed no developmental abnormalities and that the baby has been gaining weight, feeding, stooling, and urinating appropriately.", "The mother has a history of polycystic ovarian syndrome and is curious about the development of her daughter's ovaries."], "Examination and Results": ["Physical exam of the infant is unremarkable."]}
{"Patient Personal Background": ["His father had gallstones, for which he underwent a cholecystectomy at the age of 26 years."], "Patient Symptoms": ["Examination shows pallor of the mucosal membranes, mild scleral icterus, a swollen, red tongue, and several mouth ulcers.", "There is darkening of the skin over the dorsal surfaces of the fingers, toes, and creases of the palms and soles."], "Examination and Results": ["One year ago, a peripheral blood smear performed during workup of fatigue revealed erythrocytes without central pallor.", "His spleen is enlarged and palpable 3 cm below the left costal margin.", "Laboratory studies show a hemoglobin concentration of 9.1 gm/dL, mean corpuscular volume of 104 \u03bcm3, and a reticulocyte count of 9%."]}
{"Others": ["This further increased glucose-dependent insulin production."]}
{"Patient Personal Background": ["His asthmatic symptoms are usually well controlled with regular high-dose inhaled triamcinolone, but over the last week or so he has developed a nocturnal cough and mild wheezing despite good compliance with controller medications."], "Patient Symptoms": ["His asthmatic symptoms are usually well controlled with regular high-dose inhaled triamcinolone, but over the last week or so he has developed a nocturnal cough and mild wheezing despite good compliance with controller medications."], "Examination and Results": ["A review of several spirometry reports suggest of bronchial asthma with a partial irreversible airway obstruction."], "Diagnosis": ["A review of several spirometry reports suggest of bronchial asthma with a partial irreversible airway obstruction."]}
{"Patient Symptoms": ["His temperature is 38\u00b0C (100.4\u00b0F) and respirations are 32/min.", "Crackles are heard over the right upper and the entire left lung fields."], "Examination and Results": ["His temperature is 38\u00b0C (100.4\u00b0F) and respirations are 32/min.", "Crackles are heard over the right upper and the entire left lung fields.", "Sputum culture confirms infection with Streptococcus pneumoniae."], "Diagnosis": ["Sputum culture confirms infection with Streptococcus pneumoniae."], "Others": ["Despite appropriate therapy, the patient dies.", "A photomicrograph of a section of the lung obtained during the autopsy is shown."]}
{"Patient Personal Background": ["The patient was born prematurely at 36 weeks estimated gestational age via vacuum-assisted vaginal delivery."], "Patient Symptoms": ["Tearfully, the patient\u2019s mother describes witnessing her child fall from the changing table."], "Examination and Results": ["The patient is afebrile.", "Her vital signs include: blood pressure of 94/60 mm Hg, pulse 200/min, and respiratory rate 70/min.", "Physical examination reveals a subconjunctival hemorrhage in the left eye and multiple bruises on the chest and back."]}
{"Examination and Results": ["The measured outcomes include progression to pyelonephritis, positive urine culture on day 7 after initiation of treatment, and likelihood of re-presenting to the emergency room for another UTI within 90 days."], "Treatment": ["Of 200 consecutive women who present to the emergency room for such a UTI, 50 are randomized to each of the following: nitrofurantoin 100 mg every 12 hours for 5 days, nitrofurantoin 100 mg every 12 hours for 7 days, cefpodoxime 100 mg every 12 hours for 5 days, and cefpodoxime 100 mg every 12 hours for 7 days."]}
{"Patient Symptoms": ["Specifically, he reports that he has been experiencing pain and swelling of the anterior portion of his neck near the midline.", "Otherwise, he says that he has been getting tired easily and feels cold often."], "Examination and Results": ["Physical exam reveals a painful diffusely enlarged thyroid gland with many small nodules.", "A biopsy is obtained showing diffuse cellular hyperplasia with areas of focal colloid hyperplasia."], "Treatment": ["Given these findings, the patient is started on appropriate therapy, and the neck mass becomes smaller over time."]}
{"Patient Personal Background": ["He admits to using illicit intravenous drugs in the past.", "He does not have any immunization records because he moved from Africa to the US at the age of 18."], "Patient Symptoms": ["He is also worried about his skin looking yellow."], "Examination and Results": ["He does not have any other complaints and denies fever and headache.", "His vital signs are as follows: heart rate 72/min, respiratory rate 14/min, temperature 37.9\u00b0C (100.2\u00b0F), and blood pressure 100/74 mm Hg.", "Physical examination is not significant except for mild diffuse abdominal tenderness.", "His blood is drawn for routine tests and shows an alanine aminotransferase level (ALT) of 2,000 IU/L."]}
{"Patient Personal Background": ["Past medical history is positive for systemic lupus erythematosus.", "She also has a history of one spontaneous abortion at 12 weeks gestation."], "Patient Symptoms": ["She recently had an unfortunate sporting incident resulting in large bruises along both legs and lower thighs."], "Examination and Results": ["An X-ray after the event was negative for fracture.", "Today, her heart rate is 90/min, respiratory rate is 17/min, blood pressure is 119/80 mm Hg, and temperature is 37.0\u00b0C (98.6\u00b0F).", "On physical examination, her left leg appears pink and slightly swollen.", "Homan\u2019s sign is positive.", "A Doppler ultrasound reveals a thrombus in the left popliteal vein."]}
{"Patient Symptoms": ["She states that she feels as though her \u201clungs are falling apart,\u201d noting that her lung function has been steadily deteriorating.", "She further states that she has visited a number of other physicians who prescribed several different types of inhalers, but she feels that they have not helped her control her asthma exacerbations.", "She has experienced 4 episodes of pneumonia in the last 3 years and often suffers from \u201crandom\u201d bouts of excessive coughing and wheezing.", "When asked if her coughing episodes produce sputum, she states, \u201cYes, the stuff is greenish with specks of red in it.\u201d She also states that her coughing and wheezing episodes are associated with fever, malaise, and occasional expectoration of brown mucous plugs."], "Examination and Results": ["The vital signs include: blood pressure 122/70 mm Hg, pulse 66/min, respiratory rate 26/min, and temperature 37.0\u00b0C (98.6\u00b0F).", "On physical exam, the patient appears frail-looking and in moderate respiratory distress.", "Auscultation reveals inspiratory crackles in the right lung base and coarse breath sounds in the bilateral upper lung lobes.", "Chest radiograph, as shown below, reveals atelectasis in the right lung base.", "There are also branched radiodensities that the radiologist notes as being \u201cglove-finger shadows\u201d (noted by the arrow in the image).", "Serum immunoglobulin E (IgE) levels are elevated."]}
{"Patient Personal Background": ["The past medical history is unobtainable due to a language barrier (the patient recently immigrated from abroad), but his wife says her husband had a motor vehicle accident when he was a teenager that required surgery."], "Patient Symptoms": ["There is no history of headaches, vomiting, or loss of consciousness.", "He is transferred to the ICU after a few hours in the ED because of dyspnea, cyanosis, and near-collapse."], "Examination and Results": ["There are no signs of a meningeal infection.", "The Blood pressure was 70/30 mm Hg at the time of transfer.", "A chest X-ray at the time of admission showed interstitial infiltrates without homogeneous opacities.", "The initial laboratory results reveal metabolic acidosis, leukopenia with a count of 2,000/mm\u00b3, thrombocytopenia (15,000/mm\u00b3), and a coagulation profile suggestive of disseminated coagulation.", "A gram stain from an autopsy specimen of the lungs revealed gram-positive, lancet-shaped diplococci occurring singly or in chains."], "Treatment": ["Despite ventilatory support, administration of intravenous fluids, antibiotics, and vasopressor agents, the patient died the next day."], "Others": ["A peripheral smear was performed and is shown below."]}
{"Patient Personal Background": ["She had a similar episode of facial swelling after a bicycle accident 1 year ago, which resolved within 48 hours without treatment."], "Patient Symptoms": ["The patient also manifests symptoms of redness and swelling of the face and lips without pruritus.", "Her symptoms began following a tooth extraction earlier in the morning."], "Examination and Results": ["Vital signs are within normal limits.", "Examination shows a nontender facial edema, erythema of the oral mucosa, and an enlarged tongue.", "The abdomen is soft, and there is tenderness to palpation over the lower quadrants.", "An abdominal ultrasound shows segmental thickening of the intestinal wall."]}
{"Examination and Results": ["To evaluate his pulmonary function, lung and thoracic compliance are measured at different system pressures.", "A graph of the relationship between his lung volume and transpulmonary pressure is shown."]}
{"Patient Personal Background": ["He is exclusively breastfed."], "Examination and Results": ["His serum glucose concentration is 88 mg/dL and his serum ammonia concentration is 850 \u03bcmol/L (N<90).", "Urinalysis shows an increased orotic acid to creatinine ratio.", "Urinary ketones are absent."]}
{"Patient Symptoms": ["Menses occur at irregular 30- to 45-day intervals; her last menstrual period was 5 weeks ago."], "Examination and Results": ["Her temperature is 38\u00b0C (100.4\u00b0F), heart rate is 102/min, and blood pressure is 128/84 mm Hg.", "Physical examination shows hyperreflexia.", "Urine pregnancy test is negative.", "Ultrasonography shows a 6-cm hypoechoic adnexal mass."]}
{"Patient Personal Background": ["The patient has smoked a pack of cigarettes daily for the last 40 years and binge drinks alcohol after work and on the weekends.", "He underwent an appendectomy when he was 14 years old.", "He is a long-distance truck driver.", "Neither of his parents had any significant medical history.", "His temperature is 37.7\u00b0C (100\u00b0F), blood pressure is 135/75 mm Hg, pulse is 102/min, respiratory rate is 20/min, and BMI is 25 kg/m2."], "Patient Symptoms": ["The pain is so severe that it woke him up."], "Examination and Results": ["On examination, his right first metatarsophalangeal joint is very tender, swollen, warm, and red in color.", "Range of motion cannot be assessed due to extreme tenderness.", "Laboratory test\nComplete blood count:\nHemoglobin 11.5 g/dL\nLeukocytes 16,000/mm3\nPlatelets 150,000/mm3\nESR 50 mm/hr\nSynovial fluid is aspirated from the joint.", "The findings are:\nAppearance Cloudy, dense yellow\nWBC 30,000 cells/\u00b5L\nCulture Negative\nNeedle-shaped birefringent crystals are observed in the joint aspirate."]}
{"Patient Symptoms": ["He was recently admitted to the hospital with fever, shortness of breath, and cough, and was found to have Pneumocystic jirovecii pneumonia and a new diagnosis of HIV."], "Examination and Results": ["His CD4 count is 175, viral load is pending.", "As part of routine laboratory studies given his new diagnosis, an RPR was found to be positive with a titer of 1:64, and this is confirmed with a positive FTA-ABS.", "His neurological examination is normal, and he has no symptoms."], "Diagnosis": ["He was recently admitted to the hospital with fever, shortness of breath, and cough, and was found to have Pneumocystic jirovecii pneumonia and a new diagnosis of HIV.", "As part of routine laboratory studies given his new diagnosis, an RPR was found to be positive with a titer of 1:64, and this is confirmed with a positive FTA-ABS."], "Others": ["He is unsure when or how he acquired HIV or syphilis."]}
{"Patient Personal Background": ["He has not noticed any major changes in his health over the last year but says that unfortunately, he stopped exercising because he has been stressed by work.", "His past medical history is significant for obesity, hypertension, diabetes, hypercholesterolemia, and hyperlipidemia.", "He is taking a number of drugs but does not remember what they are."], "Examination and Results": ["A panel of metabolic and lipid tests are ordered and show worsening of his metabolic parameters."], "Treatment": ["Based on these findings, his physician prescribes a drug that leads to a large decrease in triglycerides with a much smaller increase in high-density lipoproteins and decrease in low-density lipoproteins."]}
{"Patient Personal Background": ["She wishes to become pregnant within the next several months.", "A thorough history reveals that the patient suffers from phenylketonuria (PKU).", "She recalls being instructed by prior physicians to follow a diet that avoids certain foods; however, she admits to not being complaint with these recommendations."], "Examination and Results": ["Laboratory testing reveals a plasma phenylalanine level of 20.2 mg/dL (normal range <2 mg/dL)."]}
{"Patient Symptoms": ["He is having difficulty seeing properly and is extremely worried about losing his vision.", "Further history reveals that he has had progressive lower back pain for over 2 months now.", "The pain is usually at its worst in the morning, but it remains throughout the day.", "It gets better with movement, however, so he tends to do some light exercises every day.", "He also has heel pain and feels significant pressure while walking."], "Examination and Results": ["Laboratory analysis reveals increased ESR and CRP serum levels."]}
{"Patient Personal Background": ["The remainder of her history is unremarkable and she takes no regular medications.", "She works as an accountant.", "There is no history of smoking or drug use, however, she does consume 5 alcoholic drinks per week."], "Patient Symptoms": ["While usually occurring late at night, she has also had similar pains during the day at random times, most recently while sitting at her desk in her office and at other times while doing the dishes at home.", "The pain lasts 10\u201315 minutes and resolves spontaneously.", "She is unable to identify any common preceding event to pain onset."], "Examination and Results": ["Examination reveals: pulse 70/min, respirations 16/min, and blood pressure 120/70 mm Hg.", "A physical examination is unremarkable."]}
{"Examination and Results": ["His vital signs are as follows: T 39.1 C, HR 82, BP 122/76, RR 14, and SpO2 99%.", "Physical examination is significant for splenomegaly, tonsillar exudate, and posterior auricular lymphadenopathy.", "Laboratory work-up shows an elevated lymphocyte count, atypical lymphocytes on a peripheral blood smear, and a positive heterophile antibody screen."]}
{"Patient Personal Background": ["He drinks 9 glasses of water per day and takes his medication regularly.", "He has hypertension, for which he has been taking hydrochlorothiazide for the past 6 months.", "He is 168 cm (5 ft 6 in) tall and weighs 90 kg (198 lb); BMI is 32 kg/m2."], "Patient Symptoms": ["Over the past 2 days, he has also been feeling weak and tired.", "When standing up after sitting for a while, he feels dizzy.", "He says he has to go to the bathroom more often than usual, and that he is urinating \u201ca normal amount\u201d each time."], "Examination and Results": ["His temperature is 36.5\u00b0C (97.7\u00b0F), blood pressure is 106/54 mm Hg, and pulse is 92/min.", "Physical examination shows whitening of the tongue.", "Skin that is pinched on the back of the hand retracts after 5 seconds.", "On mental status examination, his speech is slowed; he is oriented to person, place, and time."], "Others": ["He has not had diarrhea."]}
{"Patient Symptoms": ["Her only complaint is difficulty losing weight."], "Examination and Results": ["Her BMI is 34 kg/m^2.", "In addition to a standard physical exam, the physician orders a glucose tolerance test.", "The woman's fasting blood glucose level is 120 mg/dL and two-hour post 75g glucose load blood glucose level is 190 mg/dL."], "Treatment": [], "Diagnosis": ["The physician informs the patient that she is \"pre-diabetic\" or at risk of developing diabetes and recommends lifestyle modification with follow-up in 6 months."]}
{"Patient Symptoms": ["On further questioning, he admits having hematuria."], "Examination and Results": ["A chest X-ray reveals bilateral focal pulmonary consolidation.", "Urinalysis shows RBC casts and 400 mL of urine is excreted in 24 hours."]}
{"Patient Personal Background": ["He is a veteran who returned from a deployment to Afghanistan 2 years ago."], "Patient Symptoms": ["He is worried he may lose his job due to poor performance.", "He feels constantly tired but attributes his fatigue to waking up early most mornings and being unable to fall back asleep.", "His wife has noticed that he has been speaking more slowly than usual and his appetite has decreased.", "He used to enjoy dance classes with her but has not been as interested in this recently."]}
{"Patient Personal Background": ["She first started seeing double after a long day at her work as a radiation technologist.", "She has a history of type I diabetes mellitus and her most recent hemoglobin A1c was 7.4%.", "Her family history is notable for Sjogren\u2019s syndrome in her mother and hypertension, hyperlipidemia, and carotid dissection in her father."], "Patient Symptoms": ["She first started seeing double after a long day at her work as a radiation technologist.", "Since then, her vision has appeared to worsen in the evenings.", "She has also felt worsening fatigue despite no change in her work hours or sleep habits."], "Examination and Results": ["Her temperature is 98.9\u00b0F (37.2\u00b0C), blood pressure is 105/70 mmHg, pulse is 75/min, and respirations are 16/min.", "On examination, her pupils are equally round and reactive to light.", "Extraocular movements are intact.", "Mild ptosis is noted bilaterally but worse on the left.", "A visual acuity test reveals no abnormalities."]}
{"Patient Personal Background": ["Six months prior, she had a cerebral stroke with left hemiparesis, from which she has almost completely recovered with physiotherapy.", "She has a history of hypertension and atrial fibrillation (AF).", "She takes metoprolol, amlodipine, warfarin, and atorvastatin."], "Patient Symptoms": ["She is asymptomatic.", "She has a minor limp and weakness in her left arm and leg."], "Examination and Results": ["Blood pressure is 125/70 mm Hg, pulse is 75/min with an irregular rhythm.", "Respirations are 13/min.", "Heart exam shows no abnormalities other than irregular beats."], "Treatment": ["She has no significant ischemic, valvular, or structural heart disease.", "She takes metoprolol, amlodipine, warfarin, and atorvastatin."]}
{"Patient Symptoms": ["He is found to be delayed in reaching normal childhood cognitive and social milestones, which is consistent with observations at previous check-ups.", "Physically, he is also found to be significantly overweight with hypogonadism.", "Notably, the boy was limp when he was born and did not have a normal motor response to stimuli."], "Examination and Results": ["Physically, he is also found to be significantly overweight with hypogonadism.", "Elevated levels of a gastrointestinal hormone are associated with the cause of this patient's weight gain."]}
{"Examination and Results": ["A study from Brazil demonstrated 76.7% accuracy, 67.9% sensitivity, 84.4% specificity, 79.1% positive predictive value, and 75% negative predictive value when using 5-mm skin elevation as a threshold, or cut-off, point for the screening test (following intradermal injection)."], "Others": ["One of the key strategies for the detection of TB is the use of tuberculin skin testing as a globally pertinent screening method, due to its low cost and technical simplicity."]}
{"Patient Personal Background": ["He admits to smoking cigarettes since his early teenage years."], "Patient Symptoms": ["Moderate icterus is evident during physical examination, the abdomen is distended and dull to percussion, and there is periumbilical tenderness."], "Examination and Results": ["While in the county hospital, he did not develop fever, and his vital signs were stable for the 48 hours he spent at there.", "Initial laboratory tests are given below:\nTotal bilirubin 7 mg/dL\nDirect bilirubin 6.4 mg/dL\nAST 100\nALT 40\nAlkaline phosphatase 480 IU/L\nGlucose 160 mg/dL\nThe patient\u2019s medical history is relevant for hypertension and diabetes mellitus."]}
{"Patient Symptoms": ["She reports that the child cries several times per day and sleeps 7-8 hours at night, uninterrupted."], "Treatment": ["She has been breastfeeding exclusively and feels that he has been feeding well."]}
{"Patient Personal Background": ["She had an uncomplicated vaginal delivery 10 years ago and a cesarean section 4 years ago.", "She has had no other surgeries.", "She drinks at least 6 glasses of water a day but may drink more on days she goes for a long run.", "She also has a large coffee in the morning and another coffee mid-day if she \u201cneeds to focus.\u201d The patient denies tobacco, alcohol, and other recreational drug use.", "Pelvic examination and speculum examination are unremarkable."], "Patient Symptoms": ["At first, she would notice leakage only during athletic exercise, but now the incontinence occurs even when she laughs or coughs.", "The patient states that she goes to the bathroom more frequently to try to prevent \u201cwetting myself.\u201d She wakes up once a night to urinate.", "The patient has bipolar syndrome and takes lithium."], "Examination and Results": ["When that patient is asked to Valsalva, leakage of urine is observed.", "A urinalysis, including specific gravity, is within normal limits.", "A beta-human chorionic gonadotropin is negative."]}
{"Patient Personal Background": ["The patient has a past medical history of substance abuse, depression, and anxiety."], "Patient Symptoms": ["She was at a party when she suddenly fell to the floor.", "Her friends state that she was not responsive and was acting oddly.", "After the episode, the patient seemed confused and had no memory of the event.", "Physical exam reveals a girl who seems confused and responds to questions slowly."], "Examination and Results": ["Her temperature is 98.6\u00b0F (37.0\u00b0C), blood pressure is 117/69 mmHg, pulse is 80/min, respirations are 12/min, and oxygen saturation is 99% on room air.", "Her gait is stable, and she demonstrates 5/5 strength in her upper and lower extremities."]}
{"Patient Personal Background": ["The past medical history is unremarkable.", "She does not take any medications."], "Patient Symptoms": ["Her symptoms began following a company picnic a few days ago.", "Initially, she was unable to tolerate any solids or liquids by mouth, but now has been able to drink sips of water.", "She had a mild headache, which was relieved with acetaminophen."], "Examination and Results": ["The blood pressure is 120/60 mm Hg and the heart rate is 60/min.", "On examination, the mucous membranes are dry and the eyes are slightly sunken."]}
{"Patient Personal Background": ["The patient is breast fed and takes no medications."], "Patient Symptoms": ["His mother notes that the symptoms started shortly after birth and have been progressively worsening."], "Examination and Results": ["His labs are within normal limits with the exception of his liver function tests as follows:\n\nALT: 8 U/ L\nAST: 10 U/L\nAlkaline phosphatase: 50 U/L\nAlbumin: 3.7 g/dL\nTotal protein: 6.7 g/dL\nBilirubin, total: 29.4 mg/dL\nBilirubin, unconjugated: 29.2 mg/dL\nBilirubin, conjugated: 0.2 mg/dL\n\nThe boy is taken immediately for treatment."], "Treatment": []}
{}
{"Patient Personal Background": ["He has Crohn disease and underwent a small bowel resection 5 years ago.", "He currently takes mesalamine and a multivitamin."], "Patient Symptoms": ["He reports alternating episodes of decreased urine output followed by a temporary increase in urine output for the past 2 days."], "Examination and Results": ["His vital signs are within normal limits.", "Examination shows right costovertebral angle tenderness.", "Urinalysis shows 70 RBC/hpf and envelope-shaped crystals.", "A CT scan of the abdomen shows a 6-mm stone in the proximal right ureter and two 4-mm stones in the left kidney."], "Others": ["In the past year, he has had two urinary tract infections.", "His father had recurrent kidney stones."]}
{"Patient Symptoms": ["His mother says that he has had dry, scaly skin since he was 6 months old.", "She says it is worse in winter and better in summer.", "There is no associated itching, redness, or discharge."], "Examination and Results": ["Examination reveals generalized fine scales with coarse skin all over the body, except in the skin creases of the neck and in the cubital and popliteal fossae (see image).", "There are multiple papular elevations at the base of hair follicles and darkening of the palmar and plantar creases."]}
{"Patient Personal Background": ["Her current pregnancy was achieved by means of in vitro fertilization due to azoospermia in her partner.", "Prenatal course has been uncomplicated with regular prenatal visits.", "Her first child was delivered by lower segment transverse cesarean section because of a nonreassuring fetal heart rate; her other child was delivered vaginally.", "She has had abnormal Pap smears due to HPV in the past."], "Patient Symptoms": ["Speculum examination shows a tender, bruised cervix, with a closed cervical os."], "Examination and Results": ["Her pulse is 82/min, respirations are 18/min, and blood pressure is 134/76 mm Hg.", "The abdomen is nontender, the uterus is consistent with 24 weeks' gestation, and the fetus is in a cephalic presentation.", "Fetal heart rate is 166/min and CTG shows a reassuring fetal heart rate tracing.", "Ultrasound shows a uniformly echogenic placenta located at the fundal end of the posterior uterine wall."], "Others": ["After a period of having avoided sexual intercourse during her early pregnancy, she resumed sexual activity with her partner at week 22 of gestation.", "There are traces of blood on the vulva and the introitus."]}
{"Patient Personal Background": ["He has diabetes and takes insulin but stopped taking it when he began to feel poorly two days ago."], "Patient Symptoms": ["His parents say that the boy was doing well until two days ago when he told them that he was feeling unwell.", "He appears severely dehydrated, showing signs of fatigue, and poor skin turgor.", "His breath has a fruity smell to it."], "Examination and Results": ["His temperature is 37\u00b0C (98.6\u00b0F), respirations are shallow and rapid with a rate of 33/min, pulse is 107/min, and blood pressure is 101/68 mm Hg.", "His blood glucose level is 691 mg/dL.", "Blood is drawn for labs and the results are given below:\nSerum:  \n  pH: 7.21\n  pCO2: 32 mm HG\n  HCO 3-: 15.2 mEq/L\nSodium: 122 mEq/L\nPotassium: 5.8 mEq/L\nUrinalysis is positive for ketone bodies."]}
{"Patient Personal Background": ["The patient\u2019s past medical history is significant for a heart murmur that is being followed by his outpatient cardiologist.", "He takes no medications.", "The patient works as a carpenter and reports being monogamous with his wife.", "He denies any history of intravenous drug use or recent travel."], "Patient Symptoms": ["He reports that one hour ago he was climbing the stairs in his home when he suddenly developed excruciating chest pain.", "He describes the pain as ripping and radiating to the back."], "Examination and Results": ["In the emergency department, the patient\u2019s temperature is 99.4\u00b0F (37.4\u00b0C), blood pressure is 94/56 mmHg, pulse is 121/min, and respirations are 14/min.", "On physical exam, the patient appears to be in moderate distress and is clutching his chest.", "He is tall and has joint hypermobility.", "His breath sounds are equal and full bilaterally and has weak distal pulses."]}
{"Patient Symptoms": ["Three times now in the last month the child has begun screaming and crying in the middle of the night.", "When the parents rush to the child's room, they find her crying inconsolably.", "They try to ask her what is wrong, but she does not respond and persists crying for approximately 20 minutes, after which she goes back to sleeping comfortably.", "Upon awaking the following morning, she has no recollection of the night's events."]}
{"Treatment": ["This morning, she started a course of ceftriaxone for treatment of pyelonephritis."], "Others": ["A photograph of the rash is shown."]}
{"Patient Personal Background": ["She underwent a laparoscopic cholecystectomy 4 years ago.", "She lives with her daughter and reports frequent fights with her at home.", "Her current medications include sertraline, insulin, enalapril, sodium bicarbonate, and sevelamer."], "Patient Symptoms": ["The pain is 8 out of 10 in intensity and radiates down the legs.", "She appears uncomfortable."], "Examination and Results": ["Her temperature is 37.3\u00b0C (99.1\u00b0F), pulse is 102/min, respirations are 15/min, and blood pressure is 132/94 mm Hg.", "There is severe tenderness on palpation over the L2 vertebra; range of motion is limited.", "Neurologic examination shows no focal findings.", "Laboratory studies show:\nHemoglobin 10.1 g/dL\nLeukocyte count 8,700/mm3\nPlatelet count 130,000/mm3\nSerum\nNa+ 136 mEq/L\nCl- 101 mEq/L\nK+ 5.1 mEq/L\nCalcium 8.2 mg/dL\nUrea nitrogen 33 mg/dL\nGlucose 190 mg/dL\nCreatinine 3.8 mg/dL\nAn x-ray of the spine shows a wedge compression fracture of the L2 vertebra."], "Treatment": ["Her current medications include sertraline, insulin, enalapril, sodium bicarbonate, and sevelamer."]}
{"Patient Personal Background": ["Three months ago, he was diagnosed with hypertension and started on a new medication."], "Examination and Results": ["His blood pressure is 145/95 mm Hg.", "Physical examination shows 2+ edema in both lower extremities.", "Laboratory studies are within the reference ranges."]}
{"Others": ["A subset of normal human cells with an elevated intracellular concentration of bisphosphoglycerate mutase is harvested and isolated."]}
{"Patient Symptoms": ["On arrival, she is stable and says that she hit a car at an intersection that \"came out of nowhere\".", "She states that she had similar close encounters with other cars these past few weeks but was able to avoid collisions with those.", "She has also had intermittent headaches over the last month and has noticed that her shirts have been getting wet unexpectedly."], "Examination and Results": ["Blood tests reveal an abnormal elevation of a circulating substance."]}
{"Patient Symptoms": ["Over-the-counter pain medications have failed to reduce her symptoms."], "Examination and Results": ["An MRI of the brain shows isolated dilation of the left lateral ventricle."]}
{"Patient Personal Background": ["The girl was born at 39 weeks gestation via spontaneous vaginal delivery at home with minimal prenatal or postnatal care.", "This is her first visit to a physician of any type."], "Patient Symptoms": ["They are concerned about lethargy and easy bruising.", "Her mother reports that she has been eating less for the past few days.", "Today she was difficult to arouse.", "She normally nurses four-five times a day, but ate less yesterday and this morning."], "Examination and Results": ["The daughter\u2019s pulse is 97/min, respirations are 35/min, temperature is 35.8\u00b0C (96.4\u00b0F), and blood pressure is 71/46 mm Hg.", "Physical examination shows diffuse petechiae and bruising."], "Others": ["The family is carefully questioned and child abuse is ruled out."]}
{"Patient Personal Background": ["He has not received any routine childhood vaccinations."], "Patient Symptoms": ["He has also had a fever and sore throat for 4 days."], "Examination and Results": ["Examination shows a flushed face except around his mouth.", "A diffuse, papular, erythematous rash that blanches with pressure is seen over the trunk.", "Pharyngeal erythema and a red beefy tongue are noted.", "His leukocyte count is 11,200/mm3 (75% segmented neutrophils, 22% lymphocytes)."]}
{"Patient Personal Background": ["He has a past medical history of asthma, and his current medications include albuterol and fluticasone."], "Patient Symptoms": ["The patient states that his symptoms started last night and have persisted to this morning."], "Examination and Results": ["His temperature is 102\u00b0F (38.9\u00b0C), blood pressure is 110/60 mmHg, pulse is 95/min, respirations are 17/min, and oxygen saturation is 98% on room air.", "On physical exam, the patient seems uncomfortable.", "He requests that the lights in the room stay turned off during the physical exam.", "The patient's cardiac exam demonstrates a normal rate and rhythm, and his pulmonary exam is clear to auscultation bilaterally.", "Musculoskeletal exam reveals diminished mobility of the neck in all four directions, with flexion of the neck causing the patient discomfort."], "Others": ["Lumbar puncture is performed and results are seen below."]}
{"Patient Personal Background": ["He has had asthma for more than 20 years.", "His only medication is a high-dose combination salmeterol/fluticasone inhaler."], "Patient Symptoms": ["He says that swallowing is not painful."], "Examination and Results": ["His temperature is 37.1\u00b0C (98.8\u00b0F), pulse is 74/min, respirations are 14/min, and blood pressure is 125/65 mm Hg.", "Indirect mirror examination of the posterior oropharynx, larynx, and hypopharynx shows no abnormalities."], "Others": ["A photograph of his oral mucosa is shown."]}
{"Patient Personal Background": ["She has multiple sclerosis and a chronic indwelling bladder catheter for neurogenic bladder dysfunction."], "Patient Symptoms": ["Physical examination shows marked tenderness in the right costovertebral area."], "Examination and Results": ["Her temperature is 39.3\u00b0C (102.8\u00b0C).", "Urine cultures grow a non-lactose fermenting, oxidase-positive, gram-negative rod."], "Treatment": ["One week ago, she was discharged from the hospital after treatment for a multiple sclerosis flare."]}
{"Patient Symptoms": ["He reports that the fever lasts for 7 to 10 days, then subsides completely for about a week before returning again.", "His temperature is 39\u00b0C (102.2\u00b0F)."], "Examination and Results": ["Physical examination shows nontender cervical and supraclavicular lymphadenopathy.", "An x-ray of the chest shows bilateral mediastinal masses."], "Treatment": ["Resection of a cervical lymph node is performed."], "Others": ["A photomicrograph of the resected specimen is shown."]}
{"Patient Personal Background": ["There is no personal history of serious illness."], "Patient Symptoms": ["During this period, she has had increased urinary frequency and fatigue.", "She also reports two episodes of non-bloody vomiting.", "Her last menstrual period was 6 weeks ago."], "Examination and Results": ["Physical examination shows bilateral breast tenderness.", "The remainder of the examination shows no abnormalities.", "A urine pregnancy test is positive."]}
{"Patient Personal Background": ["He has Down syndrome.", "His vaccinations are up-to-date."], "Patient Symptoms": ["Vomiting occurs almost immediately after most feeds.", "Each time, he becomes irritable while feeding and refuses to finish the bottle.", "He appears agitated and cries during the examination."], "Examination and Results": ["He was born at 37 weeks' gestation and weighed 3300 g (7 lb 4 oz); he currently weighs 4000 g (8 lb 13 oz).", "His temperature is 37.2\u00b0C (99\u00b0F), pulse is 156/min, respirations are 32/min, and blood pressure is 100/49 mm Hg.", "Examination shows upward slanting of the eyelids, a broad and flat nasal bridge, and a single transverse palmar crease on both hands.", "The abdomen is soft and nontender.", "A 2.5-cm (1-inch) epigastric mass is palpated.", "Cardiac examination shows no abnormalities.", "Arterial blood gas analysis is within normal limits."]}
{"Patient Personal Background": ["She is known to have an allergy to cephalosporins.", "She was born at 39 weeks gestation via spontaneous vaginal delivery.", "She has met all of her developmental milestones and most of her vaccines.", "Her vital signs are as follows: blood pressure 105/60 mm Hg, heart rate 98/min, respiratory rate 18/min, and temperature 37.0\u00b0C (98.6\u00b0F)."], "Patient Symptoms": ["Her mother describes photophobia, bilateral lacrimation, eye itching, and eyelid swelling for the last week."], "Examination and Results": ["Her vital signs are as follows: blood pressure 105/60 mm Hg, heart rate 98/min, respiratory rate 18/min, and temperature 37.0\u00b0C (98.6\u00b0F).", "The physical examination is mostly normal except for her eye exam as presented in the image below."]}
{"Patient Symptoms": ["He is fully conscious."], "Examination and Results": ["His blood pressure is 110/65 mm Hg, temperature is 39.5\u00b0C (103.1\u00b0F), pulse is 98/min, and respiratory rate is 14/min.", "Physical examination including examination of the central venous catheter site shows no source of infection."], "Treatment": ["Broad-spectrum antibiotics are initiated."], "Diagnosis": ["He was initially diagnosed with t(9;22)-positive acute T cell lymphoblastic leukemia following workup for fatigue and pancytopenia."]}
{"Patient Personal Background": ["He has smoked one pack of cigarettes daily for 20 years and drinks four beers daily.", "The patient is a known user of intravenous heroin.", "There are several track marks on both forearms."], "Patient Symptoms": ["He also reports headaches and numbness in both hands.", "Over the past 4 months, he has had intermittent lower back pain after waking up.", "The back pain improves with movement.", "He also has recurrent episodes of gout in the metatarsophalangeal joint of his right big toe.", "Examination of the neck shows warmth, erythema, and limited range of motion.", "Gentle palpation over the midcervical spinal processes causes severe pain."], "Examination and Results": ["He appears acutely ill. His temperature is 39\u00b0C (102.2\u00b0F), pulse is 110/min, and blood pressure is 140/85 mm Hg.", "Laboratory studies show:\nHemoglobin 11 g/dL\nLeukocyte count 14,200/mm3\nSegmented neutrophils 77%\nEosinophils 1%\nLymphocytes 20%\nMonocytes 2%\nPlatelet count 278,000/mm3\nErythrocyte sedimentation rate 54 mm/h\nBlood cultures are pending.", "An x-ray of the cervical spine shows no abnormalities.", "An MRI of the spine shows signs of inflammation.", "A bone biopsy confirms the diagnosis."], "Diagnosis": []}
{"Patient Personal Background": ["She was born at 39 weeks gestation via spontaneous vaginal delivery and is breastfed exclusively."], "Patient Symptoms": ["Over the past week, she has been projectile vomiting after most feedings.", "Initially, the vomiting would occur just once or twice a day, but now it occurs after every feed.", "However, her appetite hasn\u2019t decreased, and she seeks milk right after each episode of vomiting."], "Examination and Results": ["On physical exam, the vital signs include: temperature 37.5\u00b0C (99.5\u00b0F), blood pressure 85/55 mm Hg, respiratory rate 28/min, and heart rate 150/min.", "On examination, she appears to be mildly dehydrated, listless, and irritable.", "Her abdomen is soft and nontender with a palpable olive-shaped mass in the epigastric region."]}
{"Patient Personal Background": ["The girl has been HIV-positive since birth and is being treated with HAART.", "Her baseline viral load is <50/mL."], "Patient Symptoms": ["She has also developed shallow erythematous ulcers inside of her mouth.", "Her appetite has decreased."], "Examination and Results": ["There is no history of chills, rigors, or headaches.", "On general examination, the girl appears ill. Diffuse inspiratory crackles are heard on chest auscultation with normal heart sounds.", "No lymphadenopathy or hepatosplenomegaly is noted on physical examination.", "A blood sample is drawn, which shows a CD4 count of 100/mm3 and a viral load of 25,050/mL."]}
{"Patient Personal Background": ["The patient lives in a nursing home and has Alzheimer dementia at baseline."], "Patient Symptoms": ["His nurse noticed that he was more confused than usual and was somnolent for the past 12 hours.", "The patient\u2019s nurse also noticed that he was soiling his diapers more frequently with copious amounts of urine.", "The patient has lost 15 pounds since his last physician appointment 3 weeks ago."], "Examination and Results": ["Laboratory values are ordered as seen below.", "Serum:\nNa+: 139 mEq/L\nCl-: 100 mEq/L\nK+: 4.3 mEq/L\nHCO3-: 25 mEq/L\nBUN: 20 mg/dL\nGlucose: 99 mg/dL\nCreatinine: 1.1 mg/dL\nCa2+: 12.2 mg/dL\nPTH: 8 pg/mL\n\nThe patient is referred to another physician for a more thorough workup including laboratory work and CT imaging."]}
{"Patient Personal Background": ["For the 3 months that she had her urinary symptoms, she avoided places like long lines and long train rides."], "Patient Symptoms": ["Even after being successfully treated for her urinary condition, she continues to show restricted social interaction."], "Treatment": ["The patient is being treated for urge incontinence but is being referred for psychiatric evaluation to help with some of her old avoidance behavior."], "Others": ["The patient is being treated for urge incontinence but is being referred for psychiatric evaluation to help with some of her old avoidance behavior."]}
{"Patient Personal Background": ["He does not smoke cigarettes or consume alcohol, and past medical history is insignificant."], "Patient Symptoms": ["Heart rhythm is irregularly irregular."], "Examination and Results": ["Blood pressure is 115/75 mmHG and heart rate is 125/min."], "Treatment": ["After initial treatment with IV digoxin the patient's heart rate drops to 85/min and remains irregular."]}
{"Examination and Results": ["The incidence of hepatitis A infection was found to be 25%, and the total number of deaths recorded among the incident cases was 5 individuals."], "Others": ["A case series investigation with prospective and retrospective follow-up found that 500 individuals dined at the restaurant during the week of study."]}
{"Patient Symptoms": ["The EMT personnel found the patient alert with anterograde amnesia for the several minutes preceding the accident.", "On physical examination, the patient is drowsy but follows commands.", "While the patient is being transferred to observation, his level of consciousness acutely declines."], "Examination and Results": ["Vital signs are within normal limits.", "Pupils are equal, round, and reactive to light.", "The remainder of the initial examination is unremarkable.", "Repeat vital signs are significant for a blood pressure of 190/110 mm Hg.", "Ophthalmic examination now shows a fixed and dilated left pupil with no pupillary light reflex.", "A noncontrast CT of the head is performed and is shown in the image."], "Others": ["He was driving a motorcycle and collided with a bus."]}
{"Patient Personal Background": ["He has type 1 diabetes mellitus, for which he takes insulin."], "Patient Symptoms": ["He complains of frequent episodes of waking up in the middle of his sleep.", "When he wakes up, he feels excessive sweating, hand tremors, and weakness."], "Examination and Results": ["His morning blood glucose is high on repeated measurement."]}
{"Others": ["To ensure that all instruments are free of the pathogenic organism, he uses a disinfectant that oxidizes and denatures proteins."]}
{"Patient Personal Background": ["She is at the 24th week of gestation.", "She has had type 1 diabetes mellitus for 5 years and is on insulin."], "Examination and Results": ["Her temperature is 37.1\u00b0C (98.7\u00b0F), blood pressure is 120/60 mm Hg, and pulse is 90/minute.", "Her random blood glucose is 220 mg/dL and HbA1C is 8.5%."], "Treatment": ["She also has mitral stenosis, for which she has been advised to undergo a balloon valvotomy."], "Others": ["She wants to discuss possible complications concerning her pregnancy."]}
{"Patient Symptoms": ["The pain is present throughout the day, and even at night when he lies down.", "He also complains of difficulty walking upstairs and says he recently started to wear adult diapers because he seems to have difficulty controlling his bowel movements."], "Examination and Results": ["His vital signs are within normal limits.", "The neurological examination revealed bilateral lower limb weakness, diminished temperature sensation, and decreased vibratory sense.", "The rectal examination revealed a hard nodular mass and a weak rectal sphincter tone."]}
{"Patient Personal Background": ["He reports that he goes to bed around 9 p.m. and wakes up for class at 8 a.m.."], "Patient Symptoms": ["He first noticed the daytime sleepiness about a year ago but reports that it significantly worsened once he started college.", "He naps between classes for a total of 4 hours during the day.", "Despite this, he wakes up feeling exhausted.", "He easily falls asleep during class and while studying.", "This has started to affect both his academics and his social life.", "On weekends, he can sleep up to 20 hours a day.", "He reports 2 recent episodes of sudden generalized body weakness along with ptosis and difficulty speaking that occurred after he became angry.", "Each episode lasted about 10 seconds, but he says he felt back to normal within 15 minutes without any persistent deficits."], "Examination and Results": ["His Epworth Sleepiness Scale score is 17."]}
{"Patient Personal Background": ["She has had diabetes mellitus for 22 years.", "Her medications include folic acid, vitamin B12, amlodipine, and erythropoietin."], "Patient Symptoms": ["She worries she might eventually lose her balance and fall."], "Examination and Results": ["At the clinic, her blood pressure is 135/80 mm Hg when lying down before dialysis and 110/55 mm Hg when seated after hemodialysis.", "Cardiopulmonary examination shows no abnormal findings.", "Laboratory studies after hemodialysis show a Hb of 10.5 mg/dL, a blood sugar of 189 mg/dL, and a hemoglobin A1C of 7.1%."]}
{"Patient Personal Background": ["Her past medical history is notable for major depressive disorder, obesity, fibromyalgia, and severe tension headaches.", "She previously took paroxetine for a 2-month trial but switched to citalopram 6 months ago as she did not feel like paroxetine was adequately helping her symptoms.", "Her mood has been stable on her current dose of citalopram.", "She takes ibuprofen for her headaches but previously borrowed a friend\u2019s headache medication when her headaches became very severe.", "Of note, she has been trying to lose weight and recently started taking an amino acid supplement at the suggestion of her nephew who is a nutritionist.", "She is also trying out a new low-carbohydrate diet.", "She works as a nurse at a local primary care clinic.", "Her temperature is 101.5\u00b0F (38.6\u00b0C), blood pressure is 144/80 mmHg, pulse is 108/min, and respirations are 22/min."], "Patient Symptoms": ["She developed worsening malaise and diaphoresis over the past 48 hours.", "She is diaphoretic and shivering."], "Examination and Results": ["Her maximum temperature was 102\u00b0F (38.9\u00b0C) taken the night before presentation.", "Her temperature is 101.5\u00b0F (38.6\u00b0C), blood pressure is 144/80 mmHg, pulse is 108/min, and respirations are 22/min.", "Patellar and brachioradialis reflexes are 3+ bilaterally.", "Tone is increased in her bilateral upper and lower extremities.", "Rapid dorsiflexion of her right ankle elicits 3 beats of clonus.", "Pupils are equally round and reactive to light.", "A basic metabolic panel is within normal limits."]}
{"Patient Personal Background": ["He has had these symptoms before but did not seek treatment.", "His past medical history is not known as he is not typically followed by a doctor and is homeless."], "Examination and Results": ["His temperature is 99.0\u00b0F (37.2\u00b0C), blood pressure is 154/94 mmHg, pulse is 89/min, respirations are 22/min, and oxygen saturation is 90% on room air.", "Physical examination is notable for crackles noted in the bases of the lungs bilaterally.", "Labs values are ordered as seen below."]}
{"Examination and Results": ["Her blood pressure is 160/100 mm Hg and pulse is 67/min.", "Blood tests reveal high blood glucose and low potassium level.", "Abdominal CT scan shows a well-circumscribed homogeneous mass in the left adrenal gland."]}
{"Patient Personal Background": ["He has a past medical history of insomnia and is currently taking alprazolam."], "Patient Symptoms": ["He states that this is the worst headache he has ever had and that his symptoms have not been improving.", "The patient complains of pain in his jaw that is worse when he chews."], "Examination and Results": ["His temperature is 98.2\u00b0F (36.8\u00b0C), blood pressure is 157/98 mmHg, pulse is 90/min, respirations are 15/min, and oxygen saturation is 98% on room air.", "Physical exam is notable for tenderness over the patient's scalp, jaw, and temporal area."]}
{"Patient Symptoms": ["In addition to intermittent nausea, he has mild weakness, tingling, and numbness in his left hand.", "With his affected hand, he is able to grip, but occasionally drops small objects."], "Treatment": ["He was recently treated with cyclophosphamide, vincristine, doxorubicin, dexamethasone, and dasatinib."], "Diagnosis": ["His oncologist tells him that one of his chemotherapy agents likely caused his neuropathy given its strong association with neurotoxicity."]}
{"Patient Personal Background": ["The mother is a healthy 32-year-old woman who did not have regular prenatal exams."], "Examination and Results": ["On physical examination, you notice low-set ears and retrognathia with abnormal extremity development."]}
{"Patient Symptoms": ["She reports extreme fatigue since beginning her chemotherapy regimen."], "Examination and Results": ["Her pulse is 98/min, respirations are 16/min, and blood pressure is 132/84 mm Hg.", "Her hemoglobin is 10.4 g/dL, leukocyte count is 800/mm3 with 5% monocytes, and platelet count is 50,000/mm3.", "One week later, serum studies show a hemoglobin of 10.6 g/dL, a leukocyte count of 2,000/mm3 with 2% monocytes, and a platelet count of 56,000/mm3."], "Treatment": ["The patient is started on a new medication."]}
{"Patient Personal Background": ["His mother had no prenatal care."], "Patient Symptoms": ["Cardiopulmonary examination shows normal heart sounds, intercostal retractions, and nasal flaring."], "Examination and Results": ["An x-ray of the chest shows low lung volumes, air bronchograms, and diffuse ground-glass opacities."], "Treatment": ["He is started on nasal continuous positive airway pressure."]}
{"Patient Personal Background": ["She has hypertension and hyperlipidemia.", "Seven years ago, she underwent resection of the terminal ileum because of severe Crohn's disease.", "She is 155 cm (5 ft 2 in) tall and weighs 79 kg (175 lb); BMI is 32 kg/m2."], "Patient Symptoms": ["During these episodes, she has had nausea and vomiting.", "She has no diarrhea, dysuria, or hematuria and is asymptomatic between episodes."], "Examination and Results": ["Her temperature is 36.9\u00b0C (98.5\u00b0F), pulse is 80/min, and blood pressure is 130/95 mm Hg.", "There is mild scleral icterus.", "Cardiopulmonary examination shows no abnormalities.", "The abdomen is soft, and there is tenderness to palpation of the right upper quadrant without guarding or rebound.", "Bowel sounds are normal.", "The stool is brown, and test for occult blood is negative.", "Laboratory studies show:\nHemoglobin 12.5 g/dL\nLeukocyte count 9,500 mm3\nPlatelet count 170,000 mm3\nSerum\nTotal bilirubin 4.1 mg/dL\nAlkaline phosphatase 348 U/L\nAST 187 U/L\nALT 260 U/L\nAbdominal ultrasonography shows a normal liver, a common bile duct caliber of 10 mm (normal < 6 mm) and a gallbladder with multiple gallstones and no wall thickening or pericholecystic fluid."]}
{"Patient Personal Background": ["She works as a graduate student at the local university, and she informs you that she recently returned to the west coast from a trip to New York for an Economics conference.", "Her medical history is positive only for frequent bouts of sinusitis.", "She currently denies any smoking, drinks a glass of red wine/day, and she denies any past illicit drug use."], "Examination and Results": ["The vital signs include: temperature 36.7\u00b0C (98.0\u00b0F), blood pressure 126/74 mm Hg, heart rate 87/min, and respiratory rate 23/min.", "Her physical examination shows decreased air movement throughout the right lung but otherwise clear lungs on auscultation, grade 2/6 holosystolic murmur, and a gravid uterus without acute findings.", "On physical examination, she is afebrile, tachycardic to 121/min, normotensive, and demonstrates an O2 saturation of 92%."]}
{"Patient Symptoms": ["He denies fever or recent upper respiratory tract infections.", "After the first cycle of chemotherapy, the patient notices that his urine becomes red.", "The urine tests are positive for blood on further analysis."], "Examination and Results": ["His temperature is 37.1\u00b0C (98.7\u00b0F), the blood pressure is 115/72 mm Hg, and the pulse are 82/min.", "On examination, a 4-cm (1.5 in), firm, non-tender mass is detected on the mid-left neck.", "Excisional biopsy of the mass reveals Hodgkin\u2019s cells."], "Treatment": ["The patient is referred to the oncology department and chemotherapy is started."], "Diagnosis": ["Excisional biopsy of the mass reveals Hodgkin\u2019s cells."]}
{"Patient Symptoms": ["She has had nausea, occasional episodes of vomiting, myalgia, and a generalized rash for the past week.", "She also reports feeling lethargic."], "Examination and Results": ["She has no shortness of breath.", "Her temperature is 39.1\u00b0C (102.3\u00b0F), pulse is 118/min, and blood pressure is 94/60 mm Hg.", "Cardiac examination shows no abnormalities.", "There is a widespread erythematous rash on the trunk and extremities with skin peeling on the palms and soles.", "Laboratory studies show:\nHemoglobin 13.6 g/dL\nLeukocyte count 19,300/mm3\nPlatelet count 98,000/mm3\nSerum\nUrea nitrogen 47 mg/dL\nGlucose 88 mg/dL\nCreatinine 1.8 mg/dL\nTotal bilirubin 2.1 mg/dL\nAST 190 U/L\nALT 175 U/L\nUrinalysis shows no abnormalities."], "Others": ["There is no family history of serious illness.", "She appears ill."]}
{"Patient Personal Background": ["His long-standing male partner passed away 2 years ago in a fatal car accident."], "Patient Symptoms": ["He reports that over the last 6 months he slept a lot more than usual and lost 14.9 kg (33 lbs) without trying to lose weight.", "He also complains of chest pain and shortness of breath that is worse when he is working and in the yard."], "Examination and Results": ["His blood pressure is 145/75 mm Hg, the pulse is 90/min, the respiratory rate is 23/min, and the temperature is 38\u00b0C (100.5\u00b0F).", "On physical examination, he has pale mucous membranes, conjunctival hemorrhages, and petechiae on his lower extremities.", "There is a new-onset high-pitched blowing diastolic murmur best heard over the right upper sternal border.", "His head bobs with each heartbeat.", "There are small, painless, red macules on both palms.", "His spleen is palpable 3 cm below the left costal margin.", "His laboratory results are shown below."], "Diagnosis": ["Hemoglobin 8.4 g/dL\nMean corpuscular volume 72 \u00b5m3\nPlatelet count 400,000/mm3\nLeukocytes 6,000/mm3\nSerum ferritin 8 ng/mL\nSerum iron 27 \u00b5g/dL\nTotal iron-binding capacity 450 \u00b5g/dL\nColonoscopy with biopsy is later performed showing a neoplastic growth in the descending colon."], "Others": ["There is no significant family history."]}
{"Patient Personal Background": ["She is in good spirits and has been fully compliant with her medications and clinic visits.", "Other medications include prophylactic co-trimoxazole."], "Patient Symptoms": ["Thirty minutes after the first dose, the patient develops difficulty breathing, severe muscle pain, and vomiting."], "Examination and Results": ["Recent blood studies show the following:\nHemoglobin (Hb%)  11 g/dL\nMean corpuscular volume (MCV)  80 fl\nReticulocyte count 0.5%\nErythrocyte count 2 x 106/mm3\nLeucocyte count 700/mm3\nNeutrophils 40%\nPlatelet count 20,000/mm3\nAssays also show a decreased viral DNA and mRNA burden, as well as a significantly diminished viral load.", "Her pulse rate is 120/min and the blood pressure is 80/50 mm Hg."], "Treatment": ["To avoid modifying the effective anti-retroviral therapy, she is started on a \u2018blood improving\u2019 medication."]}
{"Patient Personal Background": ["She has hypertension treated with hydrochlorothiazide.", "She was diagnosed with breast cancer 12 years ago and was treated with left-sided mastectomy."], "Patient Symptoms": ["She has been mumbling to herself and wandering around the neighborhood.", "These symptoms are worse in the evenings and she has hardly slept at night.", "She has not been eating or drinking much for the past 6 days.", "The patient is oriented to person but not to place or time."], "Examination and Results": ["Her temperature is 37.1\u00b0C (98.8\u00b0F), pulse is 78/min, respirations are 18/min, and blood pressure is 122/80 mm Hg.", "Physical examination shows a supple neck.", "Neurologic examination shows psychomotor agitation.", "Attention and concentration are impaired; she makes multiple errors while performing the serial sevens test.", "Her speech is disorganized.", "Her fingerstick blood glucose concentration is 122 mg/dL."]}
{"Patient Personal Background": ["She has no history of travel outside the United States.", "She has type 1 diabetes mellitus.", "Current medications include insulin and an oral contraceptive."], "Patient Symptoms": ["She has been having dull right-side abdominal pain during this period.", "She has nausea.", "She appears ill."], "Examination and Results": ["Her temperature is 40\u00b0C (104\u00b0F), pulse is 118/min, and blood pressure is 106/70 mm Hg.", "On examination, the liver is palpated 2\u20133 cm below the right costal margin and is tender.", "There are decreased breath sounds over the right lung base.", "Laboratory studies show:\nHemoglobin 14.1 g/dL\nLeukocyte count 17,100/mm3\nSegmented neutrophils 74%\nEosinophils 1%\nLymphocytes 20%\nMonocytes 5%\nSerum\nGlucose 79 mg/dL\nCreatinine 1.1 mg/dL\nTotal bilirubin 0.9 mg/dL\nAlkaline phosphatase 180 U/L\nAST 69 U/L\nALT 100 U/L\nA right upper quadrant ultrasound is shown."], "Others": ["The remainder of the examination shows no abnormalities."]}
{"Patient Personal Background": ["He was diagnosed with type 2 diabetes 3 months ago and has been started on metformin and lifestyle modifications."], "Patient Symptoms": ["The patient does not have any current complaints except for occasional numbness in both hands and feet."], "Examination and Results": ["His HbA1C is 8.5% and serum glucose is 240 mg/dL."], "Treatment": ["He was diagnosed with type 2 diabetes 3 months ago and has been started on metformin and lifestyle modifications."], "Diagnosis": ["He was diagnosed with type 2 diabetes 3 months ago and has been started on metformin and lifestyle modifications."]}
{"Patient Symptoms": ["He presents with severe retrograde memory loss, confusion, and confabulation."], "Examination and Results": ["Neurologic examination showed horizontal nystagmus.", "CT studies of the brain were normal."], "Others": ["He also has bilateral pretibial pitting edema and perioral erythema.", "The duty physician suspects the patient may be vitamin deficient."]}
{"Patient Symptoms": ["She is in active labor and has lost a lot of blood in the past 2 hours, but appears alert and cooperative."], "Examination and Results": ["At the hospital, her blood pressure is 88/65 mm Hg, the pulse is 110/min, and the respirations are 23/min."], "Others": ["Neither the hospital nor the emergency department is equipped for high-risk pregnancies.", "The patient and her husband request a transfer to a more capable center.", "They are informed of the hospital\u2019s obligations under the Emergency Medical Treatment and Labor Act and the risks of transfer.", "They insist to be transferred."]}
{"Examination and Results": ["Laboratory work reveals eosinophilia and positive skin tests for allergens."]}
{"Patient Personal Background": ["She has no past medical history and takes no medications.", "She plays volleyball and gets good grades in school."], "Examination and Results": ["Her BMI is 22 kg/m2.", "Physical examination reveals normal female external genitalia and pubic hair along the mons pubis and superomedial thighs.", "Her breasts appear normal.", "Transabdominal ultrasound reveals an absent uterus.", "Serum testosterone levels is within the normal range for females."]}
{"Patient Personal Background": ["She has gastroesophageal reflux disease and Hashimoto's thyroiditis.", "Menarche was at the age of 10 years and her last menstrual period was 2 years ago.", "Current medications include omeprazole and levothyroxine."], "Patient Symptoms": ["On questioning, she has had fatigue and an increase in abdominal girth despite a 5-kg (11.0-lb) weight loss over the past 6 months."], "Examination and Results": ["Her last Pap smear 3 years ago showed atypical squamous cells of undetermined significance.", "HPV testing was negative at that time.", "Abdominal examination shows shifting dullness.", "There is tenderness to palpation of the right lower quadrant but no guarding or rebound.", "Bimanual palpation shows a small uterus and a right adnexal mass."]}
{"Patient Personal Background": ["Approx.", "1 month ago, he had a radical prostatectomy, pelvic radiation, and several rounds of chemotherapy for aggressive prostate cancer in Nicaragua and was discharged from the hospital with a suprapelvic catheter and a plan for more chemotherapy.", "He was coming to the United States to spend time with some extended family.", "She is not aware of his past medical status or medications."], "Patient Symptoms": ["According to the grand-daughter his mental status was altered upon arrival and his health began to decline."], "Examination and Results": ["At the hospital, his blood pressure is 98/60 mm Hg, the pulse id 110/min, the respiratory rate is 21/min, and the temperature is 35.6\u00b0C (96.1\u00b0F).", "On physical exam, the patient appears cachectic, drowsy, and only responds to questions by nodding his head.", "His heart rate is tachycardic with a regular rhythm and his lungs are clear to auscultation bilaterally.", "The patient admitted to the hospital and stabilized and started on broad-spectrum antibiotics.", "The catheter tube produces no urine over 24 hours and only thick green-white puss can be expressed."], "Treatment": ["The cystotomy incision for his suprapelvic catheter is red and swollen."], "Diagnosis": ["The treatment team concludes this patient has urinary tract obstruction."]}
{"Patient Personal Background": ["His past medical history is otherwise notable for hypertension and hyperlipidemia.", "His only home medication is pravastatin.", "The patient smokes half a pack per day of cigarettes and drinks 2-3 beers throughout the day.", "His family history is significant for Parkinson disease in his father."], "Patient Symptoms": ["He reports that for the last several years he has noticed this \"shaking\" when he brushes his teeth and prepares a cup of coffee in the morning.", "The shaking then gradually improves over the course of the day."], "Examination and Results": ["On physical exam, his blood pressure is 159/84, pulse is 74/min, and respirations are 12/min.", "He has a high frequency bilateral hand tremor elicited on finger-to-nose testing."]}
{"Patient Symptoms": ["They range in age from 7 to 11, and most of them had no abnormal activities prior to developing the paralysis."], "Others": ["These patients concern her because she has not seen this type of paralytic illness in over 20 years of practice.", "Based on this experience, she decides to write up the initial presentation and clinical course of these patients and publish them in a journal."]}
{"Patient Symptoms": ["He is unconscious upon arrival and is found to have severe internal bleeding due to trauma."], "Examination and Results": ["Over the subsequent week, serial labs are drawn showing target cells, thrombocytosis, and leukocytosis."], "Treatment": ["He is taken for emergency surgery and severely damaged tissues are removed.", "After surgery, the boy is taken into the PICU for recovery.", "He is started on a prophylactic regimen that is continued upon discharge."]}
{"Patient Personal Background": ["The patient has a previous documented allergy to albendazole."], "Patient Symptoms": ["Of note, the patient denies any recent travel, sexual contacts, fever, dysuria, or diarrhea."], "Examination and Results": ["His temperature is 98.1\u00b0F (36.7\u00b0C), blood pressure is 110/70 mmHg, pulse is 65/min, and respirations are 12/min.", "On exam, the patient demonstrates severe excoriations in his perianal region with slight erythema over the areas that are torn.", "He does not have any other dermatologic findings.", "The scotch tape test is positive."]}
{"Patient Personal Background": ["You have seen the patient in the past for amenorrhea and infertility issues, but she denies taking any medication at this time."], "Examination and Results": ["At the office, the blood pressure is 168/114 mm Hg.", "On examination, the patient is short and normal weight but has a webbed neck."]}
{"Patient Personal Background": ["He is a well-known case of sickle cell disease treated with hydroxyurea and tramadol as needed for pain.", "He does not smoke or drink alcohol."], "Diagnosis": ["He is a well-known case of sickle cell disease treated with hydroxyurea and tramadol as needed for pain."], "Others": ["The patient asks if his disease can adversely affect his kidneys because his friend was recently diagnosed with end-stage renal failure."]}
{"Examination and Results": ["You note a penetrating wound at the level of L3."]}
{"Treatment": ["Group 1, the study treatment group, is given drug A, while group 2, the control group, is given the current standard antifungal therapy."], "Others": ["A total of 500 participants are recruited for the study and are randomized into 2 groups in equal numbers.", "After the completion of therapy, 190 participants from the study treatment group and 165 participants from the control group are cured."]}
{"Patient Personal Background": ["Past medical history includes generalized anxiety disorder, for which she currently takes no medication.", "The patient had been previously medicated with paroxetine for 5 years."], "Patient Symptoms": ["This pain has been accompanied by sleeping issues.", "Her friend recommended that she try yoga to relieve the pain, but she says this has not helped her at all.", "Se says the symptoms have begun to impact her daily functions and keep her from doing things she used to enjoy."], "Examination and Results": ["On physical examination, several areas of point tenderness are found on the occipital region, elbows, and medial surface of both knees.", "Laboratory work up is unremarkable."]}
{"Patient Personal Background": ["He currently works and trains 60 hours per week as a resident and has a 10-hour shift external to his residency program on Saturdays.", "He is free of any educational and work obligations on Sundays."]}
{"Patient Personal Background": ["He has no past medical history and does not take any medications."], "Patient Symptoms": ["On presentation, he is found to have scalp and trunk lacerations that are still actively bleeding.", "On physical exam, he is found to be anxious but does not have any visible injuries other than the lacerations."], "Examination and Results": ["On presentation, his temperature is 98.6\u00b0F (37\u00b0C), blood pressure is 110/74 mmHg, pulse is 82/min, and respirations are 17/min."]}
{"Patient Symptoms": ["His mother notes that he seems to have gained a lot of weight despite the fact that he eats a healthy, well-balanced diet.", "His teachers have also become concerned because he leaves class to use the restroom frequently throughout the day."], "Examination and Results": ["A physical exam is significant for a short, overweight child with nonpitting edema and decreased reflexes.", "His systolic blood pressure drops by 20 mm Hg when he stands.", "Fundoscopic exam is significant for papilledema and visual field exam is significant for bitemporal hemianopsia."], "Others": ["He has no medical problems and family history is insignificant."]}
{"Others": ["In normoxia, von Hippel-Lindau (VHL) protein hydroxylates prolyl residues on oxygen-dependent degradation domains of HIF-1a, targeting it for proteasomal degradation.", "Hydroxylation by VHL is inhibited under hypoxic conditions, allowing HIF-1a to escape degradation, dimerize with HIF-1\u00df, and translocate to the nucleus.", "This results in the upregulation of hypoxic response elements, leading to angiogenesis.", "Renal cell carcinoma (RCC) can mimic the hypoxic state to promote angiogenesis by inhibiting HIF-1a hydroxylation, even in the absence of hypoxia.", "A researcher wants to perform an experiment to detect HIF-1a in RCC under normoxic conditions with blotting techniques."]}
{"Patient Personal Background": ["She denies alcohol intake or drug use.", "She has no history of convulsive disorders and the antepartum course has been unremarkable.", "She was compliant with the recommended prenatal care and her last prenatal visit was 2 weeks ago.", "She has gained 2 kg (4.4 lb) since her last visit."], "Patient Symptoms": ["She is conscious, but lethargic and complains of a headache that started 2 hours prior to the seizure."], "Examination and Results": ["The blood pressure was 160/90 mm Hg, the heart rate was 79/min, the respiratory rate was 14/min, and the temperature was 37.0\u2103 (98.6\u2109).", "The physical examination shows leg and perineal edema.", "The neurologic examination is significant for symmetric upper and lower extremity hyperreflexia and ankle clonus."]}
{"Patient Personal Background": ["The mother and child are refugees from Somalia and arrived in the United States one week ago.", "The child was born at 38 weeks gestation with the help of a local midwife."], "Patient Symptoms": ["The mother reports that the child has been chronically tired and subdued since before their arrival in the United States."], "Examination and Results": ["The child\u2019s temperature is 98.2\u00b0F (36.8\u00b0C), blood pressure is 105/60 mmHg, pulse is 90/min, and respirations are 18/min.", "Physical examination reveals a listless child with a rotund abdomen and positive fluid wave.", "Notable lower extremity edema is present."], "Others": ["They were recently placed in temporary housing."]}
{"Patient Personal Background": ["The patient recently found out she was pregnant after having unprotected intercourse with her husband for the past year.", "She is currently taking prenatal vitamins and folate supplements."], "Patient Symptoms": ["She states that she is feeling well and has experienced some nausea and vomiting."], "Examination and Results": ["Her temperature is 99.5\u00b0F (37.5\u00b0C), blood pressure is 127/68 mmHg, pulse is 90/min, respirations are 19/min, and oxygen saturation is 98% on room air.", "On physical exam, you notice a gravid uterus 10 cm above the pubic symphysis.", "The patient's external genitalia appear within normal limits."], "Treatment": ["She is currently taking prenatal vitamins and folate supplements."]}
{"Patient Symptoms": ["He also has a 2-month history of post-prandial fullness and recurrent nonbilious vomiting.", "He appears pale."], "Examination and Results": ["Abdominal examination shows hepatosplenomegaly and shifting dullness; there is mild tenderness to palpation.", "Examination of the skin shows multiple nonblanching maculae.", "A CT scan of the abdomen shows mesenteric and retroperitoneal lymph node enlargement and nodular thickening of the omentum.", "A photomicrograph of a biopsy specimen from an enlarged mesenteric lymph node is shown.", "Immunohistochemical staining of the Ki-67 nuclear antigen shows that the proliferation index of the specimen is > 99%."]}
{"Patient Personal Background": ["His past medical history is significant for abnormal coagulation lab tests before an appendectomy, but his mother cannot recall the exact details."], "Patient Symptoms": ["On presentation, he is found to be in pain with a hot, swollen, erythematous left knee."]}
{"Patient Personal Background": ["He had been treated for urinary tract infections twice in the past 6 months.", "He is currently taking infliximab."], "Examination and Results": ["Cystoscopy shows pearl-like plaques on the bladder wall.", "Biopsy of these lesions shows a focal layer of stratified squamous epithelium with hyperkeratosis."]}
{"Patient Personal Background": ["She has a history of preterm birth."], "Examination and Results": ["The vital signs are as follows: blood pressure 125/80 mm Hg; heart rate 100/min; respiratory rate 13/min; and temperature 36.6\u2103 (97.9\u2109).", "The pelvic examination reveals cervical softening and shortening.", "Transvaginal ultrasound shows a cervical length of 12 mm, which is consistent with preterm labor."], "Treatment": ["A tocolytic and a single dose of betamethasone are administered."]}
{"Patient Personal Background": ["He has a history of hypertension, type 2 diabetes mellitus, and is currently being treated as an outpatient for pneumonia.", "His current medications include lisinopril, metformin, and azithromycin."], "Patient Symptoms": ["He has no chest pain or dizziness.", "During the examination, he loses consciousness again."], "Examination and Results": ["He has no sign of injury, and he appears well.", "Telemetry shows polymorphic ventricular tachycardia with cyclic alteration of the QRS axis, which spontaneously resolves after 30 seconds."], "Treatment": ["His current medications include lisinopril, metformin, and azithromycin."]}
{"Examination and Results": ["Sensitivity analysis of a sputum culture shows a minimal inhibitory concentration of 1 \u03bcg/mL for the causative pathogen."], "Treatment": ["The plasma clearance of the drug is calculated as 15.0 L/h.", "Oral bioavailability of the drug is 75%.", "The target plasma concentration is 2 mg/L."]}
{"Patient Symptoms": ["The child has been complaining of difficulty in passing urine and has lower abdominal pain.", "He seems more bloated than usual.", "On some occasions, he starts crying while passing urine, primarily because of a burning sensation."], "Examination and Results": ["A urinalysis is performed, and the results are as follows:\nUrine pH 6.2\nUrine specific gravity 1.010\nGlucose Negative\nKetones Negative\nRBCs 1-2/hpf\nWBCs 0-1/hpf\nCasts 2-3/hpf\nThe pediatrician believes the boy has a bladder infection with a double-stranded DNA virus."], "Diagnosis": []}
{"Patient Symptoms": ["She reports making multiple mistakes at her office job, has an inability to concentrate, and feels sleepy throughout the day.", "She is worried that her sleeping troubles will cause her to get fired."]}
{"Patient Personal Background": ["The parents deny any history of head trauma or infection."], "Patient Symptoms": ["Her kindergarten teacher voiced her concern that the child \u2018spaces out\u2019 often and thinks she may have ADHD."], "Examination and Results": ["Her blood pressure is 106/74 mm Hg, the heart rate is 69/min, and the respiratory rate is 14/min.", "Physical exam demonstrates a happy child who has reached developmental milestones.", "Laboratory results are within normal limits.", "EEG demonstrates a 3-Hz spike and wave pattern (see image)."], "Treatment": ["The decision is made to start the child on medical therapy."]}
{"Patient Personal Background": ["He has hypertension and hyperlipidemia.", "He has smoked one pack of cigarettes daily for the past 50 years.", "He does not drink alcohol.", "His medications include enalapril, atorvastatin, and low-dose aspirin.", "His temperature is 37\u00b0C (98.6\u00b0F), pulse is 70/min, respirations are 18/min, and blood pressure is 100/80 mm Hg."], "Patient Symptoms": ["He reports that he cannot climb more than one flight of stairs without experiencing shortness of breath and dizziness."], "Examination and Results": ["Physical examination shows weak peripheral pulses.", "Cardiac examination is shown."]}
{"Patient Personal Background": ["He has a 12-year history of hypertension treated with lisinopril."], "Examination and Results": ["Results of the testing show decreased concentrations of arginine in vascular endothelial cells."]}
{"Treatment": ["To test the new therapy, the physician is asked to oversee the operations of testing this new treatment."], "Others": ["The rate of chlamydial infection is exceptionally high in the area, and the local government is wanting to test a new treatment for these infections.", "When asking what this would entail, the officials tell the physician that they plan to infect the local prison population with chlamydia and then test the new treatment on these individuals."]}
{"Patient Personal Background": ["She has a history of asthma and has frequent exacerbations despite receiving maximal medical therapy."], "Patient Symptoms": ["Physical examination shows scattered expiratory wheezing."], "Examination and Results": ["Laboratory studies show a leukocyte count of 9,800/mm3 (13% eosinophils) and elevated serum concentration of immunoglobulin E. An x-ray of the chest shows thickened bronchial walls and perihilar opacities.", "Sputum culture shows scattered septate hyphae that branch at 45 degrees."]}
{"Examination and Results": ["Physical exam demonstrates a uterine size greater than expected for her gestational age and taut, shiny skin with scattered striae on her abdomen.", "Ultrasound examination of the fetus reveals 2.5 L of amniotic fluid (normal 1.5-2.0 L) with an amniotic fluid index (AFI) of 34 (normal AFI 20-25)."]}
{"Patient Personal Background": ["Her past medical history is notable for hypertension, hyperlipidemia, diabetes mellitus, obesity, and a prior myocardial infarction requiring a coronary artery bypass graft 2 years ago.", "She takes aspirin, metoprolol, lisinopril, spironolactone, atorvastatin, and insulin.", "She is retired and lives a sedentary lifestyle at home."], "Patient Symptoms": ["She reports sudden severe and crushing substernal chest pain that started 1 hour ago.", "Before being able to start the physical examination, the patient loses consciousness.", "Her pulse is palpable but weak.", "Her skin is pale, cold, and clammy."], "Examination and Results": ["Her temperature is 98.8\u00b0F (37.1\u00b0C), blood pressure is 109/68 mmHg, pulse is 118/min, and respirations are 24/min.", "Her blood pressure is now 88/50 mmHg and pulse is 130/min.", "An electrocardiogram demonstrates ST elevations in leads I, aVL, V3, V4, V5, and V6."]}
{"Others": ["Prior to the onset of symptoms, he was seen playing with his mother\u2019s purse containing a bottle of vitamin supplements, which she takes for chronic microcytic anemia."]}
{"Patient Personal Background": ["She has a history of a seizure disorder treated with carbamazepine."], "Examination and Results": ["Physical examination shows no abnormalities.", "A urine pregnancy test is positive."], "Others": ["Her last menstrual period was 7 weeks ago."]}
{"Examination and Results": ["The first child\u2019s mother reports that he seems to be breastfeeding well and voids at least eight times per day.", "His stools are a yellow color, and he does not seem to be straining.", "In the office, he can lift his head and chest when in the prone position, and he can track an object with his eyes to the midline.", "His hands remain fisted 50% of the time.", "In the office, she can roll from supine to prone and can transfer her rattle from hand to hand.", "The third child\u2019s father reports that he is starting to explore the world around him.", "He has begun taking independent steps at home."], "Diagnosis": [], "Others": ["The second child\u2019s parents report that she is doing well at home and seems to enjoy playing with her older brother.", "She cannot yet say any words.", "In the office, he seems to recognize the name of several objects, but he cannot follow the direction to \u201cgrab the ball.\u201d All three children are assessed as developmentally normal."]}
{"Patient Personal Background": ["The patient has a past medical history of hypertension, atrial fibrillation, diabetes, morbid obesity, gout, and vascular claudication."], "Patient Symptoms": ["On the drive over to the hospital, her symptoms have resolved completely."], "Examination and Results": ["Her temperature is 99.0\u00b0F (37.2\u00b0C), blood pressure is 184/111 mmHg, pulse is 88/min, respirations are 15/min, and oxygen saturation is 98% on room air.", "Physical exam reveals cranial nerves II-XII as grossly intact with normal strength and sensation in the patient's upper and lower extremities.", "The patient's memory is intact and her speech seems normal and fluent.", "Her gait is stable with no ataxia.", "An initial head CT demonstrates diffuse atrophy which is consistent with previous head CT scans."]}
{"Patient Personal Background": ["The patient works as a farmer and harvests and cans his own foods."], "Patient Symptoms": ["He states that it started yesterday and has been progressively worsening.", "Initially, he noticed blurry vision and some trouble speaking and swallowing but thought he was just coming down with a cold.", "He then noticed weakness of his facial muscles and shortness of breath.", "He has had diarrhea recently and a cough prior to these symptoms of weakness."], "Examination and Results": ["His temperature is 97.9\u00b0F (36.6\u00b0C), blood pressure is 144/94 mmHg, pulse is 87/min, respirations are 18/min, and oxygen saturation is 94% on room air.", "Physical exam is notable for a man who seems unable to smile with dysarthric speech.", "He takes shallow and weak breaths on pulmonary exam.", "The patient demonstrates 3/5 strength with diminished reflexes in his upper extremities."], "Treatment": ["The patient is subsequently intubated."]}
{"Examination and Results": ["Pelvic speculum examination in the lithotomy position shows a pink structure at the vaginal introitus that protrudes from the anterior vaginal wall when the patient is asked to cough."]}
{"Patient Personal Background": ["She denies any recent travel history, and she works at a nursing home as a caretaker.", "She is not currently on any medications."], "Patient Symptoms": ["She reports that diarrhea has been intermittently present for the past month.", "The stool is often loose and associated with blood and lower abdominal pain."], "Examination and Results": ["Clinical examination shows mild tenderness in the suprapubic region, and there is no organomegaly.", "Findings on colonoscopy include patchy erythema and ulceration in the cecum, ascending, descending, and sigmoid colon.", "Mucosal biopsy shows colonic crypts with lymphocytic and neutrophilic infiltrates."]}
{"Examination and Results": ["His temperature is 95\u00b0F (35\u00b0C), blood pressure is 50/40 mmHg, and pulse is 80/min, and respirations are controlled at 20/min on lung-protective volume control.", "A stat ScvO2 results as 39% with a SaO2 of 100% on 100% oxygen.", "His extremities remain cold despite having the ambient room temperature increased to 80\u00b0F (26.7\u00b0C)."], "Treatment": ["Due to his Glasgow Coma Scale score of 3, an endotracheal airway and large-bore access are secured prior to arrival.", "He is aggressively resuscitated with a massive transfusion protocol as the operating room is prepared for an exploratory laparotomy.", "An arterial line and central access are obtained.", "After a 6:6:1 ratio of red blood cells, plasma, and platelets and the use of continuous phenylephrine infusion, the patient's vital signs remain the same."], "Others": ["Paramedics report extensive blood loss at the scene where he was found.", "The surgical team reports no active blood loss."]}
{"Patient Personal Background": ["It is known that her father had dementia."], "Patient Symptoms": ["She has no complaints, but her son states that the patient has impaired memory and poor orientation in space.", "She is ambulatory and is capable of self-care, but she tends to forget newly introduced information.", "Also, she got lost on the way from the home to the local market several times for the past 6 months, and her family is now afraid to let her go anywhere on her own."], "Examination and Results": ["The vital signs include: blood pressure is 130/80 mm Hg, heart rate is 62/min, respiratory rate is 11/min, and the temperature is 36.5\u00b0C (97.7\u00b0F).", "The respiratory, cardiologic, and abdominal examinations are unremarkable.", "The neurological examination shows equal, round pupils with a normal reaction to light.", "The eye movements are normal with no nystagmus and normal oculocephalic reflex.", "There is no facial droop, the facial sensation is preserved, and there is no tongue deviation noted.", "There is no motor or sensory deficits on the upper and lower extremities.", "The patient scores 18 on the Montreal Cognitive Assessment."], "Others": ["She does not have any concomitant chronic conditions nor did she have major cardiovascular events or head trauma."]}
{"Patient Symptoms": ["He describes the pain as the worst pain he has ever felt.", "He denies any recent trauma or injury to the knee.", "The joint appears red and swollen and is hot to the touch.", "He denies any lower extremity numbness."], "Examination and Results": ["On physical examination, his blood pressure is 124/82 mm Hg, respirations are 17/min, pulse is 104/min, and temperature is 39.1\u00b0C (102.4\u00b0F).", "On palpation of the affected joint, there is evidence of tenderness and capsular swelling; the joint is red and warm.", "Laboratory studies show increased serum CRP and procalcitonin levels."], "Others": ["There is no family history of joint or connective tissue disorders.", "The teenager is otherwise healthy."]}
{"Patient Symptoms": ["The physical examination is remarkable for scleral icterus and moderate splenomegaly."], "Examination and Results": ["The lab test results are as follows:\nLaboratory test\nHemoglobin\n12.1 g/dL\nMean corpuscular volume (MCV)\n85 \u03bcm3\nMean corpuscular hemoglobin concentration (MCHC)\n47%\nReticulocyte count\n3.4 %\nWhite blood cell count\n9700/mm3\nPlatelet count\n229,000/mm3\nA peripheral blood smear reveals spherocytes.", "The Coombs test is negative."]}
{"Patient Personal Background": ["His father had dementia in his mid-40s, but the details of his condition are unclear."], "Patient Symptoms": ["He has become increasingly irritable, loud, aggressive, and impulsive.", "His wife also reports jerky movements of his limbs and trunk for the past few months.", "The patient appears restless."], "Examination and Results": ["Examination shows irregular movements of the extremities and twitching of the face and tongue.", "Mental status examination shows impaired memory."]}
{"Patient Personal Background": ["She drinks a glass of wine every night and does not smoke.", "She has a history of hypertension and osteoarthritis.", "She does not take any medications.", "She has never traveled out of the country.", "She works as an accountant.", "Her temperature is 37.0\u00b0C (98.6\u00b0F), pulse is 94/min, and blood pressure is 130/90 mm Hg."], "Patient Symptoms": ["Over the past 8 months, she has had a nonproductive cough, fatigue, and a 9-kg (20-lb) weight loss."], "Examination and Results": ["Lungs are clear to auscultation.", "An x-ray of the chest shows a 2.5-cm nodule with irregular borders at the apex of the left lung with no mediastinal or hilar enlargement."]}
{"Patient Personal Background": ["He reports feeling fine with no trouble with his medications.", "He exercises regularly and sleeps well without snoring or daytime somnolence.", "Today, his pressure is 150/100 mmHg with a pulse of 65/min while on hydrochlorothiazide and ramipril."], "Examination and Results": ["His blood pressure measurements in the past have ranged from 160 - 170/80 - 100 mmHg.", "Physical exam reveals a II/VI early systolic murmur with split S2 is appreciated at the right upper sternal border.", "There is unremarkable carotid, renal, or abdominal bruits."]}
{"Examination and Results": ["He is growing along with the 75th percentile and meeting all milestones.", "Physical examination shows a poorly rugated scrotum.", "The palpation of the scrotum shows only 1 testicle.", "A 2nd testicle is palpated in the inguinal canal.", "The examination of the penis shows a normal urethral meatus.", "The remainder of the physical examination shows no abnormalities."]}
{"Patient Personal Background": ["She has no history of serious illness.", "She is sexually active with 2 male partners and uses an oral contraceptive; she uses condoms inconsistently."], "Patient Symptoms": ["Physical examination shows right costovertebral angle tenderness."], "Examination and Results": ["Her last menstrual period was 4 days ago.", "Her temperature is 37.8\u00b0C (100\u00b0F), pulse is 88/min, respirations are 18/min, and blood pressure is 115/70 mm Hg.", "The abdomen is soft and nontender.", "Cardiopulmonary examination shows no abnormalities."]}
{"Patient Personal Background": ["She does not have any children.", "Menopause was at age 55.", "She has hypertension for which she takes ramipril."], "Examination and Results": ["Dual-energy x-ray absorptiometry at the femoral neck shows a T-score of -2.7 SD."], "Treatment": ["The physician considers treatment with raloxifene."], "Others": ["Her mother died of breast cancer at the age of 48 years."]}
{}
{"Patient Personal Background": ["She has a history of recurrent fetal loss.", "In total, she has had 4 miscarriages between the gestational ages of 8 and 15 weeks.", "She has a history of systemic lupus erythematosus and has had several DVTs in the past and a clot in her lung once.", "Her vitals today are unremarkable."], "Examination and Results": ["She is asking if there are any treatments she should receive to prevent fetal loss."], "Treatment": [], "Others": ["She has just learned that she is pregnant and estimates she is approximately 6 weeks pregnant given the timing of her last menstrual cycle."]}
{"Patient Personal Background": ["There is no personal or family history of serious illness."], "Examination and Results": ["She is 168 cm (5 ft 5 in) tall and weighs 63 kg (139 lb); BMI is 22.3 kg/m2.", "Examination shows normal breast development.", "Scant axillary hair is present.", "Abdominal examination shows a firm, nontender left inguinal mass.", "Pelvic examination shows a blind vaginal pouch.", "Ultrasonography does not show a uterus or ovaries."]}
{"Patient Symptoms": ["He is especially concerned about a recent episode in which he noticed a blurring of his vision and headache; he also notes that his \u201cmemory is not as good as it used to be,\u201d which his wife confirms."], "Examination and Results": ["Physical exam is notable only for pallor and general weakness.", "Laboratory studies reveal anemia as well as an elevated erythrocyte sedimentation rate.", "Serum protein electrophoresis (SPEP) reveals a sharp, narrow spike of monoclonal IgM; serum IgM concentration is 6.3 g/dL."]}
{"Patient Personal Background": ["She was recently asked to step down from her position as volunteer accountant for a local charity organization because she was no longer able to coordinate her tasks."], "Patient Symptoms": ["She reports that she has become unable to taste or smell her food."], "Examination and Results": ["At autopsy, examination of the brain shows generalized cortical atrophy."], "Others": ["Two years later, the patient dies.", "A photomicrograph of a section of the brain is shown."]}
{"Patient Personal Background": ["The patient has a past medical history of marijuana use, IV drug use, alcohol use, and asthma.", "His current medications include albuterol, fluticasone, and ibuprofen."], "Patient Symptoms": ["The patient went on a long hike this morning, and his girlfriend noticed that his skin had changed color when they were driving home.", "Hemoglobin: 10 g/dL\nHematocrit: 32%\nLeukocyte count: 5,500 cells/mm^3 with normal differential\nPlatelet count: 207,000/mm^3\n\nSerum:\nNa+: 139 mEq/L\nCl-: 99 mEq/L\nK+: 4.3 mEq/L\nHCO3-: 24 mEq/L\nBUN: 17 mg/dL\nGlucose: 89 mg/dL\nCreatinine: 1.0 mg/dL\nCa2+: 10.1 mg/dL\nBilirubin, total: 11.3 mg/dL\nBilirubin, direct: 7.8 mg/dL\n\nPhysical exam is notable for a patient with skin that appears yellow/orange."], "Examination and Results": ["His temperature is 97.5\u00b0F (36.4\u00b0C), blood pressure is 120/75 mmHg, pulse is 60/min, respirations are 10/min, and oxygen saturation is 98% on room air.", "Laboratory studies are ordered and are seen below.", "Hemoglobin: 10 g/dL\nHematocrit: 32%\nLeukocyte count: 5,500 cells/mm^3 with normal differential\nPlatelet count: 207,000/mm^3\n\nSerum:\nNa+: 139 mEq/L\nCl-: 99 mEq/L\nK+: 4.3 mEq/L\nHCO3-: 24 mEq/L\nBUN: 17 mg/dL\nGlucose: 89 mg/dL\nCreatinine: 1.0 mg/dL\nCa2+: 10.1 mg/dL\nBilirubin, total: 11.3 mg/dL\nBilirubin, direct: 7.8 mg/dL\n\nPhysical exam is notable for a patient with skin that appears yellow/orange."]}
{"Patient Personal Background": ["Past medical history is significant for sickle cell anemia."], "Examination and Results": ["Physical examination is significant for severe tenderness to palpation in the left upper quadrant.", "Significant splenomegaly is also noted.", "Laboratory findings drawn sometime after admission demonstrate a normal prothrombin time (PT) and elevated partial thromboplastin time (PTT)."], "Treatment": ["The patient is admitted to the hospital for close observation and placed on deep vein thrombosis (DVT) prophylaxis as part of a routine protocol."]}
{"Patient Personal Background": ["He is interested in including maraviroc in his maintenance regimen after seeing advertisements about the medication."], "Examination and Results": ["On exam, his temperature is 98.8\u00b0F (37.1\u00b0C), blood pressure is 116/74 mmHg, pulse is 64/min, and respirations are 12/min.", "His viral load is undetectable on his current regimen, and his blood count, electrolytes, and liver function tests have all been within normal limits."], "Treatment": ["In order to consider maraviroc for therapy, a tropism assay needs to be performed."]}
{"Patient Personal Background": ["The patient is an avid softball player at her high school and denies alcohol, smoking, or illicit drug use."], "Patient Symptoms": ["She reports that the lump seemed to enlarge and became tender just preceding her last 2 menses.", "It is otherwise painless, and the patient denies any discharge or skin changes."], "Examination and Results": ["On exam, the breasts appear symmetric and normal.", "A 3-cm round, mobile mass is palpated in the upper outer quadrant of the left breast.", "There is slight tenderness to deep palpation of the mass.", "There is no axillary lymphadenopathy on either side."], "Others": ["She has no past medical history but her grandmother, age 72, was just diagnosed with invasive ductal carcinoma of the breast."]}
{"Patient Personal Background": ["The patient has a past medical history of headaches, obesity, polycystic ovarian syndrome, and constipation."], "Patient Symptoms": ["She has had episodic headaches like this in the past and states that her headache today is severe, worse when laying down, and not responding to ibuprofen.", "She also reports a transient episode of vision loss and current blurry vision.", "She states she has a ringing in her ears as well."], "Examination and Results": ["Her temperature is 98.7\u00b0F (37.1\u00b0C), blood pressure is 149/92 mmHg, pulse is 83/min, respirations are 15/min, and oxygen saturation is 99% on room air.", "Physical exam is not remarkable and an initial head CT is within normal limits."]}
{"Patient Personal Background": ["She first started having periods at age 13 and her periods have been unremarkable up until they stopped 4 months ago.", "Her past medical history is significant for radius and ulnar forearm fractures that she sustained in a car crash 3 months ago.", "Otherwise she has been healthy with no previous pregnancies."], "Patient Symptoms": ["Her last period occurred 4 months ago but she has not had sex in the last year and home pregnancy tests have come back negative.", "She didn't see the car coming and has had increasing difficulty noticing objects in her peripheral vision.", "She also notes having recurrent headaches 5 months ago."], "Examination and Results": ["Physical exam reveals galactorrhea and temporal field visual defects."]}
{"Patient Symptoms": ["On physical examination, he appears confused and unable to give a complete history."], "Examination and Results": ["His vital signs include a temperature of 37.1\u00b0C (98.8\u00b0F), pulse of 95/min, and blood pressure of 85/60 mm Hg.", "He is noted to have jaundice, palpable firm liver, mild splenomegaly, and shifting dullness consistent with the presence of ascites."]}
{"Patient Personal Background": ["The patient has a past medical history of diabetes and hypertension.", "He is currently taking insulin, metformin, lisinopril, and atorvastatin."], "Patient Symptoms": ["The patient was brought in from a nursing home with documentation stating that he has seemed confused for the past day according to the staff."], "Examination and Results": ["His temperature is 102\u00b0F (38.9\u00b0C), blood pressure is 107/58 mmHg, pulse is 120/min, respirations are 15/min, and oxygen saturation is 98% on room air.", "Physical exam reveals crackles on pulmonary exam and S4 on cardiac auscultation."]}
{"Patient Personal Background": ["The medical history includes ischemic heart disease diagnosed 2 months ago, and long histories of diabetes and hypertension (30 and 25 years, respectively)."], "Patient Symptoms": ["There has been a gradual increase in the degree of weakness.", "The patient is disoriented."], "Examination and Results": ["On examination, the reflexes are hypertonic and the Babinski reflex is positive.", "The CT scan is shown."]}
{"Patient Personal Background": ["Past medical history is significant for a recent severe sore throat and fever 1 week ago which resolved without treatment."], "Patient Symptoms": ["The patient\u2019s mother says that his symptoms started 3 days ago with a low-grade fever, malaise, and joint pain.", "He began to improve over the next 2 days, but this morning, when he woke up, she noticed multiple painful red bumps on his shins."], "Examination and Results": ["The vital signs include: temperature 38.0\u00b0C (100.4\u00b0F), blood pressure 120/70 mm Hg, pulse 85/min, and respiratory rate 15/min.", "Physical examination reveals multiple, firm and tender erythematous nodules with indistinct borders, averaging 4 cm in diameter.", "Lesions are localized to the anterior surface of the lower legs.", "No evidence of drainage, bleeding, abscess formation or ulceration."]}
{"Patient Personal Background": ["Her pregnancy was uncomplicated with the exception of a positive vaginal swab for group B streptococci 3 weeks ago, for which she received one dose of intravenous penicillin."], "Patient Symptoms": ["Physical examination shows labored breathing and thready pulses."], "Examination and Results": ["Her temperature is 37.6\u00b0C (99.8\u00b0F), pulse is 130/min, respirations are 30/min, and blood pressure is 70/30 mm Hg.", "Pulse oximetry on room air shows an oxygen saturation of 82%.", "Crackles are heard at both lung bases.", "The abdomen is nontender.", "Speculum examination shows pooling of bright red blood in the cervical canal.", "Laboratory studies show a hemoglobin concentration of 7.6 mg/dL and an undetectable fibrinogen concentration."], "Treatment": ["The patient successfully underwent combined spinal-epidural anesthesia 1 hour ago."]}
{"Patient Personal Background": ["His past medical history is notable for hyperlipidemia and hypertension.", "He takes lovastatin and lisinopril.", "He drinks socially and has a 20 pack-year smoking history.", "His temperature is 99\u00b0F (37.2\u00b0C), blood pressure is 130/75 mmHg, pulse is 80/min, and respirations are 16/min."], "Patient Symptoms": ["He reports that he recently went on a vacation to South America with his family but just wanted to stay in his hotel all day due to fatigue."], "Examination and Results": ["On exam, the patient is appropriately interactive and in no acute distress.", "Mild splenomegaly is noted.", "Laboratory analysis reveals the following:\n\nHemoglobin: 11.0 g/dL\nHematocrit: 36%\nLeukocyte count: 3,800/mm^3 with normal differential\nPlatelet count: 140,000/mm^3\n\nA bone marrow aspiration is ordered but after multiple attempts, they are unable to obtain an adequate bone marrow sample."]}
{}
{"Patient Symptoms": ["Physical examination shows pale conjunctivae."], "Examination and Results": ["Laboratory studies show decreased serum hemoglobin levels and increased serum gastrin levels.", "Esophagogastroduodenoscopy shows inflammation of the gastric body and fundus.", "A photomicrograph of a biopsy specimen taken from the gastric antrum is shown."]}
{"Examination and Results": ["You notice an abnormality on his laboratory results caused by his regimen of captopril and triamterene."], "Treatment": ["You notice an abnormality on his laboratory results caused by his regimen of captopril and triamterene."]}
{"Patient Personal Background": ["Current medications include spironolactone and furosemide.", "She used to drink over a pint of vodka daily but quit 2 months ago."], "Patient Symptoms": ["She has been unable to recall her husband's name or their address.", "She has had insomnia and daytime sleepiness during this period.", "Her last bowel movement was 3 days ago."], "Examination and Results": ["She is oriented to place and person.", "Her temperature is 37.3\u00b0C (99.1\u00b0F), pulse is 88/min, and blood pressure is 102/64 mm Hg.", "Examination shows scleral icterus and jaundice.", "There are several telangiectasias over the chest and back.", "Palmar erythema is present.", "The abdomen is mildly distended and nontender.", "Shifting dullness is present.", "There is a flapping tremor of both hands when outstretched and dorsiflexed.", "Neurologic examination shows no other focal findings.", "She completes the number connection test slower than the age-normalized standard."], "Treatment": ["One month ago, she underwent a transjugular intrahepatic portal shunt (TIPS) placement."], "Diagnosis": ["She has alcoholic liver cirrhosis."]}
{"Patient Symptoms": ["She is slightly confused and can\u2019t remember when the pain started.", "Her daughter states that the pain has been present for approximately one month.", "She expresses concern that her mother has been progressively more confused during the past week.", "She reports that her mother also has had worsening nausea for several months."], "Examination and Results": ["The patient\u2019s vital signs are heart rate 92/min, respiratory rate 13/min, temperature 37.1\u00b0C (98.8\u00b0F), and blood pressure 120/86 mm Hg.", "Upon physical examination, the patient reports pain when the fingers of the left hand are palpated, and small palpable tumors are visible on the fingers.", "An X-ray image of the left-hand shows thin bones with brown tumors and osteolysis of the distal phalanges."]}
{"Patient Personal Background": ["Five months ago, she was treated for an episode of thrombophlebitis."], "Patient Symptoms": ["Physical examination shows multiple bruises on her limbs."], "Examination and Results": ["Laboratory studies show a platelet count of 900,000/mm3 and elevated levels of serum lactate dehydrogenase and uric acid."], "Treatment": ["Treatment with a medication is begun that is also used in the treatment of sickle cell disease."]}
{"Examination and Results": ["Forty-eight hours later, there is a 14 mm raised, slightly hardened area at the injection site."]}
{"Patient Personal Background": ["He is asymptomatic, but his father died of large intestinal cancer."], "Examination and Results": ["Abdominal and rectal exams are normal.", "A colonoscopy subsequently reveals a polyp in the descending colon but no other abnormalities.", "Excisional biopsy of the polyp shows 75% tubular architecture."]}
{"Patient Symptoms": ["He says that his symptoms began an hour after he ate the food."], "Examination and Results": ["His temperature is 37\u00b0C (98.6\u00b0F), respiratory rate is 15/min, pulse is 106/min, and blood pressure is 90/78 mm Hg.", "A physical examination is within normal limits except for signs of dehydration."], "Others": ["He was studying for his exams last night when he became hungry and ate some food from the afternoon after heating it for a while."]}
{"Patient Personal Background": ["She describes herself as being \u201cgenerally healthy\u201d before the cold started.", "Medical history includes hypertension and hyperlipidemia.", "The patient takes hydrochlorothiazide, lisinopril, and atorvastatin.", "She does not smoke and only drinks alcohol occasionally.", "During a review of symptoms, she described a month-long trip to St. Louis, Missouri, to visit family."], "Examination and Results": ["At the physician\u2019s office, her temperature is 37.0\u00b0C (98.6\u00b0F), pulse is 82/min, respirations are 20/min, and blood pressure is 130/82 mm Hg.", "A focused chest exam reveals mild crepitus on the right side.", "A chest X-ray shows a cavitary lesion in the right lung which is confirmed on chest computed tomography (CT).", "A lung biopsy is performed to rule out cancer and reveals necrotic granulomatous inflammation with oval yeast in macrophages."], "Others": ["Her parents are both deceased."]}
{"Examination and Results": ["She is at the 10th percentile for height and 25th percentile for weight.", "Examination shows a broad chest with widely spaced nipples, a low posterior hairline, forearms angled 20\u00b0 away from the body when fully extended, and shortened fourth metacarpals bilaterally.", "Sexual development is Tanner stage 1."]}
{"Examination and Results": ["Images and tissue samples are collected from 4 athletes with cartilaginous injury and 4 athletes with bone fractures.", "After 8 weeks, the athletes with bone fractures show almost complete resolution, while the athletes with cartilaginous injuries show only minimal signs of healing."], "Others": ["The investigator hypothesizes that this is due to the absence of progenitor cells for matrix regeneration."]}
{"Patient Personal Background": ["She has no history of serious illness.", "She has had 10 male sexual partners in her lifetime and uses condoms inconsistently."], "Patient Symptoms": ["During the past 2 days, she has had urinary incontinence not related to sneezing or laughing.", "Last summer, she had weakness and numbness of her right lower extremity that was worse when she was outside; she regained her strength 3 weeks later."], "Examination and Results": ["Vital signs are within normal limits.", "Examination shows an impaired tandem gait.", "There is mild spasticity and muscle strength is decreased in both upper extremities.", "Deep tendon reflexes are 4+ bilaterally.", "The abdominal reflex is absent.", "Muscle strength in the right lower extremity is mildly decreased.", "Sensation to vibration and fine touch is decreased over the upper extremities."]}
{"Treatment": ["You prescribe triple therapy of omeprazole, clarithromycin, and amoxicillin."], "Diagnosis": ["Following an extensive workup, you diagnose her with a duodenal ulcer secondary to H. pylori infection."]}
{"Patient Personal Background": ["Two days ago, she was camping outdoors in Texas with her two young children."], "Patient Symptoms": ["She was awoken in the middle of the night by \u201csomething crawling on my hand.\u201d The following morning, she saw a wound on her hand that was initially painless, but over the next several hours she noticed reddening and blistering.", "Yesterday, the lesion turned blue with a blackish discoloration at the center."], "Examination and Results": ["Her temperature is 38\u00b0C (100.4\u00b0F), pulse is 83/min, and blood pressure is 128/84 mm Hg.", "Physical examination shows a bluish plaque with a central area of necrosis surrounded by a rim of erythema at the dorsum of the right hand."]}
{"Patient Symptoms": ["His symptoms improve significantly after the administration of metoclopramide."], "Treatment": ["His symptoms improve significantly after the administration of metoclopramide."]}
{"Patient Symptoms": ["According to bystanders, the cable struck him on his right arm, after which the man slumped to the ground with his arms and legs shaking.", "In the emergency department, the man is alert but in severe pain localizing bilaterally in the flanks as well as in his right arm where contact with the power line occurred."], "Examination and Results": ["A 6 cm burn is present on the right arm.", "His vitals are within normal limits except for mild tachypnea at 21/min."]}
{"Patient Personal Background": ["The patient sees no primary care physician and is currently not taking any medications."], "Patient Symptoms": ["The patient has presented three times this past month with similar complaints.", "The patient states his shortness of breath started when he was walking from his car to a local restaurant."], "Examination and Results": ["His temperature is 99.5\u00b0F (37.5\u00b0C), pulse is 100/min, blood pressure is 130/90 mmHg, respirations are 18/min, and oxygen saturation is 96% on room air.", "On physical exam you note a fatigued appearing gentleman.", "Cardiovascular exam reveals an additional heart sound after S2.", "Pulmonary exam is notable for bilateral crackles.", "Abdominal exam reveals an obese abdomen without pain in any of the quadrants.", "Lower extremity pitting edema is noted bilaterally."]}
{"Patient Symptoms": ["He mentions that he has been experiencing intermittent episodes of pain at the same location over the last 3 months and that these episodes usually occur after a heavy meal and subside within 1 or 2 hours."], "Examination and Results": ["On physical examination, his temperature is 38.5\u00b0C (101.3\u00b0F), pulse is 130/min, respirations are 24/min, and blood pressure is 130/84 mm Hg.", "On examination of the abdomen, tenderness is present over the right upper quadrant; palpation over the area produces an inspiratory pause.", "An urgent bedside ultrasonogram shows a dilated common bile duct stone, but no stone in the common bile duct or in the gallbladder."]}
{"Patient Personal Background": ["The patient recently started college and has presented to the emergency department once before for polysubstance intoxication."], "Patient Symptoms": ["The patient refuses to answer any questions as he suspects that his care team is spying on him.", "When the patient is able to be examined, he is somnolent and non-responsive.", "He does not comply with any commands, and it is not possible to freely manipulate his extremities due to rigidity.", "His mucous membranes are dry."], "Examination and Results": ["His temperature is 104\u00b0F (40\u00b0C), blood pressure is 147/98 mmHg, pulse is 120/min, respirations are 17/min, and oxygen saturation is 98% on room air."], "Treatment": ["The patient attempts to assault a nurse, is restrained, and given diphenhydramine and haloperidol."]}
{"Patient Personal Background": ["She gave birth to a healthy baby boy three days prior to presentation."], "Patient Symptoms": ["Since then, she has been feeling sick, and she is concerned that she has been getting worse over time."], "Examination and Results": ["On presentation, her temperature is 100.7\u00b0F (38.1\u00b0C), blood pressure is 115/78 mmHg, pulse is 105/min, and respirations are 14/min.", "Physical exam reveals abdominal discomfort with uterine tenderness, and laboratory results show elevated white blood cell count with many plasma cells."]}
{"Patient Personal Background": ["The boy was born at 37 weeks\u2019 gestation and spent 1 night in the neonatal intensive care unit for respiratory distress.", "He otherwise has been healthy and started walking independently at 12 months.", "On exam, the child demonstrates muscle rigidity and diffuse muscle wasting."], "Patient Symptoms": ["However, his mother reports that he has stopped walking and appears weaker than he was a few months ago.", "He also has started having brief convulsive episodes over the past week."], "Examination and Results": ["He is unable to stand or sit up straight.", "His patellar, Achilles, and brachioradialis reflexes are absent.", "Fundoscopic examination is unremarkable.", "A urine sample demonstrates metachromic granules."], "Others": ["His parents are both healthy with no medical conditions."]}
{"Patient Personal Background": ["Upon further questioning, the patient is found to have unprotected sex with both men and women with 3-5 partners per month."], "Examination and Results": ["On workup, he is found to have an HIV viral load of 15,000 copies/mL with a CD4+ of 170 cells/mm^3."], "Treatment": ["He is started on medical therapy."]}
{"Patient Symptoms": ["She has had decreased appetite and a 6-kg (13-lb) weight loss in the past 2 months."], "Examination and Results": ["Physical examination shows that on the left medial ankle there is a 2-cm reddish-black nodule with a verrucous surface.", "A full-thickness excisional biopsy of the lesion shows S100-protein-positive epithelioid cells.", "A subsequent CT scan of the chest, abdomen, and pelvis shows metastases to the liver; a diagnosis of metastatic melanoma is made."], "Treatment": ["Chemotherapy with aldesleukin is initiated."], "Diagnosis": ["A subsequent CT scan of the chest, abdomen, and pelvis shows metastases to the liver; a diagnosis of metastatic melanoma is made."]}
{"Examination and Results": ["Iodine uptake testing shows that the nodule has decreased iodine uptake compared with the rest of the thyroid gland."], "Diagnosis": ["A fine-needle aspiration is performed and the physician calls telling the patient that she has a neoplasm of the thyroid."]}
{"Patient Symptoms": ["The patient complains of a headache and chest pain, and he has been vomiting for the last several hours."], "Examination and Results": ["Physical exam demonstrates papilledema and a depressed level of consciousness."], "Treatment": ["To treat this patient's hypertensive emergency, he is started on an IV medication commonly used in this situation.", "The agent exerts its effect by releasing nitric oxide as a metabolite, which subsequently activates guanylate cyclase and increases production of cGMP in vascular smooth muscle."]}
{"Patient Symptoms": ["The next morning, she says she is unable to lactate when she tries to breastfeed her child."], "Examination and Results": ["The Apgar counts are 9 and 10 at 1 and 5 minutes, respectively.", "Thirty minutes after delivery, the mother\u2019s blood pressure drops to 80/60 mm Hg and her pulse is 124/min.", "On physical examination, her distal extremities are clammy and cold, and the uterus is boggy."], "Treatment": ["Aggressive fluid resuscitation is initiated.", "After administering 4 units of IV fluids and 4 units of whole blood, her vitals stabilize."]}
{"Patient Symptoms": ["One week ago, he had an upper respiratory tract infection."], "Examination and Results": ["Examination shows jaundice of the skin and conjunctivae.", "The spleen tip is palpated 2 cm below the left costal margin.", "His hemoglobin concentration is 9.4 g/dl and his mean corpuscular hemoglobin concentration is 39% Hb/cell.", "A Coombs test is negative.", "A peripheral blood smear is shown."]}
{"Patient Personal Background": ["She has been doing well in school and has no complaints.", "The patient has a past medical history of asthma which is controlled with albuterol.", "She is currently sexually active but states that she uses birth control.", "She has many friends and states that her mood is typically positive.", "Her father died of colon cancer at the age of 68, and her mother was diagnosed with breast cancer at the age of 65."], "Examination and Results": ["The patient's last pap smear was 1 year ago.", "Her temperature is 98.7\u00b0F (37.1\u00b0C), blood pressure is 147/108 mmHg, pulse is 80/min, respirations are 15/min, and oxygen saturation is 99% on room air.", "The patient's BMI is 19 kg/m^2.", "Physical exam demonstrates a normal S1 and S2, normal breath sounds, and an abdominal exam that is within normal limits."]}
{"Patient Personal Background": ["Her past medical history shows she was hospitalized 10 years ago for an appendectomy and 4 years ago for a fractured ulna following a motor vehicle accident."], "Patient Symptoms": ["She has also had watery diarrhea for several days with no blood or pus in the stools.", "She is taking an over-the-counter anti-diarrheal medication, which she cannot remember the name of, and drinking oral rehydration solution, which has helped a little."], "Examination and Results": ["Vital signs are pulse is 104/min, blood pressure is 120/80 mm Hg, respiratory rate of 14/min with shallow breathing, and temperature is 36.7\u00b0C (98.0\u00b0F).", "On physical examination, pupils are constricted.", "Extremities are pale and cold.", "The abdomen is soft but mildly, diffusely tender to palpation with a palpable bladder.", "Fingerstick blood glucose is 124 mg/dL.", "A urinary catheter is placed, and intravenous fluids are started.", "Abdominal imaging shows no abnormalities."], "Treatment": ["Laboratory tests are pending."]}
{"Patient Symptoms": ["He complains of extreme abdominal pain worse in the left upper quadrant which has worsened over the past 30 minutes."], "Examination and Results": ["Vital signs on presentation are T 99.0 F, BP 100/60 mmHg, HR 125 bpm, RR 16/min, SpO2 98% on room air.", "Exam demonstrates abdominal wall rigidity, involuntary guarding, and tenderness on light percussion.", "Bedside sonography shows evidence for hemoperitoneum.", "Despite administering more intravenous fluids, repeat vitals are T 98.9 F, BP 82/50 mm hg, HR 180 bpm, RR 20/min, SpO2 97% on room air."]}
{"Patient Personal Background": ["He underwent stenting of the right coronary artery 10 years ago.", "He smoked one pack of cigarettes daily for 40 years but quit 2 weeks ago for surgery.", "He drinks one to two beers daily.", "His current medications include metformin, enalapril, aspirin, atorvastatin, and a multivitamin.", "His temperature is 37\u00b0C (98.6\u00b0F), pulse is 102/min, respirations are 20/min, and blood pressure is 130/80 mm Hg."], "Patient Symptoms": ["Five minutes later, he becomes unresponsive."], "Examination and Results": ["Directly following the procedure, his temperature is 37\u00b0C (98.6\u00b0F), pulse is 80/min, and blood pressure is 110/80 mm Hg.", "Pulse oximetry shows an oxygen saturation of 73%."], "Treatment": ["Surgery is performed under general anesthesia for which the patient is intubated with an endotracheal tube.", "He is extubated as soon as he showed signs of alertness.", "He is put on a non-rebreather mask with an FiO2 of 100%."], "Others": ["He has type 2 diabetes mellitus, coronary artery disease, and hypertension.", "Three minutes later, he is still unresponsive."]}
{"Patient Personal Background": ["He was born vaginally to a 33-year-old woman (gravida 3, para 2) from an uncomplicated pregnancy at 39 weeks.", "His mother explains that he can normally stand without help and can walk briefly on his own.", "The mother denies any child abuse from her family or child care.", "His length and weight are both between the 15th and 25th percentile.", "On physical examination, blue-grayish discoloration of the sclerae are noted."], "Patient Symptoms": ["She is concerned about his leg and his inability to stand.", "However, he hit his right leg against a chair 2 days ago.", "The area became edematous and bruised overtime and the infant became unable to stand or crawl and cries when he puts weight on it.", "The patient begins to cry loudly when the physician palpates his leg."], "Examination and Results": ["His length and weight are both between the 15th and 25th percentile.", "Respiratory, cardiovascular, and abdominal examinations are within normal limits for his age.", "There is joint hypermobility and decreased tone in both upper and lower extremities.", "The patient\u2019s right calf appears slightly deformed, edematous, and warm to the tough.", "The patient\u2019s X-ray shows an incomplete fracture of the right tibial diaphysis."], "Diagnosis": [], "Others": ["He has met all developmental milestones and is up to date on all vaccinations.", "The patient\u2019s vital signs are as follows: blood pressure 80/40 mm Hg, heart rate 137/min, respiratory rate 25/min, and temperature 36.7\u00b0C (97.0\u00b0F)."]}
{"Patient Personal Background": ["He has no history of serious illness or trauma.", "His father has a history of pulmonary embolism.", "He has smoked one pack of cigarettes daily since he started college 3 years ago."], "Patient Symptoms": ["He appears very distressed."], "Examination and Results": ["He is 173 cm (5 ft 8 in) tall and weighs 92 kg (203 lb); BMI is 30.7 kg/m2.", "His temperature is 37\u00b0C (98.6\u00b0F), pulse is 94/min, respirations are 17/min, and blood pressure is 130/78 mm Hg.", "Physical examination shows a tender and mildly swollen left lower leg; dorsiflexion of the left foot causes severe pain in the calf.", "Laboratory studies show a platelet count of 184,000/mm3, a prothrombin time of 11 seconds, an activated partial thromboplastin time of 26 seconds, and positive fibrin split products.", "Ultrasonography of the left leg shows incompressibility of the popliteal vein with a hyperechoic mass and absent blood flow."], "Treatment": ["The patient is administered a 5000 IU intravenous bolus of unfractionated heparin followed by a constant infusion."]}
{"Patient Personal Background": ["He has a history of hyperlipidemia, type 2 diabetes mellitus, hypertension, osteoarthritis, and asthma.", "Current medications include simvastatin, metformin, lisinopril, albuterol, and ibuprofen."], "Patient Symptoms": ["He does not have chest pain, palpitations, or difficulty breathing."], "Examination and Results": ["His pulse is 48/min and blood pressure is 89/50 mm Hg.", "He responds slowly to questions but is oriented to person, place, and time.", "Examination shows dry mucous membranes.", "His lungs are clear to auscultation and bowel sounds are positive with no pulsatile masses or bruits.", "Pedal pulses are nonpalpable, distal extremities are cold, and capillary refill time is 4 seconds.", "An ECG shows left axis deviation, a Q wave in lead III, a constant PR interval of 0.15 seconds with every third P wave that is nonconducted, and a QRS interval of .09 seconds."]}
{"Others": ["A study is done with a null hypothesis that there is no association between alcohol use and gastro-oesophageal reflux disease (GERD).", "The data obtained shows, of the 200 alcoholics who were followed-up, 30 developed GERD; and out of the 400 non-alcoholics, 30 developed GERD."]}
{"Patient Personal Background": ["He has a history of bulimia with laxative abuse several years ago."], "Patient Symptoms": ["He also mentions that he has grossly bloody stool and most of the time an urge to defecate.", "He admits having lost about 5 lb in the past month."], "Examination and Results": ["His temperature is 37\u00b0 C (98.6\u00b0 F), respiratory rate is 15/min, pulse is 77/min, and blood pressure is 105/86 mm Hg.", "On physical examination, a mild conjunctival pallor is evident, and the rectum is erythematous, indurated, and tender.", "Colonoscopy demonstrates continuous mucosal lesions throughout the rectum to the hepatic flexure of the colon."]}
{"Patient Symptoms": ["He has been evaluated by several practitioners, who have all prescribed antimicrobial therapy, including ciprofloxacin, with no improvement and leading to emotional distress and sleep disturbances.", "Additionally to this health issue, you have also been following him for recurrent abdominal pain, periods of constipation and diarrhea, and fatigability, with all test results within the normal range thus far."], "Examination and Results": ["The physical examination is unremarkable, except for a mildly tender prostate, without masses or nodules.", "There are no testicular masses, hernias, or hemorrhoids."], "Treatment": ["He has been evaluated by several practitioners, who have all prescribed antimicrobial therapy, including ciprofloxacin, with no improvement and leading to emotional distress and sleep disturbances."]}
{"Examination and Results": ["The patient undergoes an exploratory laparotomy, during which, it is discovered that his splenic artery was damaged at its origin from the celiac trunk."], "Treatment": ["The surgeon ligates the splenic artery at its origin."]}
{"Patient Personal Background": ["The child was born to a gravida 2, para 0 mother with known hepatitis B.", "The mother made it to all of her prenatal appointments and took the recommended dose of folic acid since conception.", "She gave up smoking when she discovered she was pregnant."], "Examination and Results": ["The infant\u2019s heart rate is 150/min, respiratory rate is 48/min, temperature is 37.5\u00b0C (99.5\u00b0F), and blood pressure is 80/52 mm Hg.", "APGAR testing exhibits a score of 7 and 8 at 1 and 5 minutes, respectively.", "The head is normocephalic.", "No neural tube defects are present on inspection or palpation of the spine.", "There is strong flexion in all 4 extremities.", "Cranial nerves 2\u201312 are intact.", "Sensory and deep tendon reflexes are without any abnormalities."], "Others": ["Which of the following is the best course of action for the newborn child?"]}
{"Patient Personal Background": ["The patient is otherwise healthy and is currently taking metformin and albuterol."], "Patient Symptoms": ["He states that 2 weeks ago, he had a fever, chills, and a cough, which his primary doctor treated with acetaminophen, ibuprofen, and rest.", "Since then, the patient\u2019s symptoms have resolved with the exception of a chronic cough and a small amount of clear sputum that is occasionally laced with blood.", "The patient denies chest pain, shortness of breath, fever, or chills."], "Examination and Results": ["His temperature is 98.3\u00b0F (36.8\u00b0C), blood pressure is 129/75 mmHg, pulse is 84/min, respirations are 15/min, and oxygen saturation is 99% on room air.", "Physical exam is notable for bilateral clear breath sounds, absence of lymphadenopathy on HEENT exam, and a normal oropharynx."]}
{"Patient Symptoms": ["The urge to urinate occurs suddenly, and he often is unable to make it to the bathroom before leaking urine.", "He has no incontinence with coughing or laughing."], "Examination and Results": ["Digital rectal examination shows no abnormalities.", "Ultrasonography shows a normal post-void residual volume."]}
{"Patient Personal Background": ["Her depression has improved, and she has stopped taking her sertraline 2 months ago.", "Other than ibuprofen as needed, she is not currently taking any additional medications."], "Patient Symptoms": ["She last took ibuprofen 2 hours ago but did not feel any improvement in the pain.", "She has been nauseous and unable to get out of bed and is currently laying in the dark with the lights off."]}
{}
{"Patient Personal Background": ["He has a past medical history of asthma, and his only medication is an albuterol inhaler."], "Patient Symptoms": ["He fainted when he realized his finger had been cut off."], "Examination and Results": ["The patient's current blood pressure is 122/78 mmHg."], "Treatment": ["Analgesics are administered."], "Others": ["The teacher immediately transported the patient to the emergency department and he arrived within 20 minutes.", "The teacher states that he left the amputated finger in the classroom, but that the principal would be transporting it to the hospital."]}
{"Patient Personal Background": ["Menses had previously occurred at irregular 15\u201345 day intervals with moderate to heavy flow.", "Menarche was at the age of 14 years.", "She started having sexual intercourse with her boyfriend about 3 months ago.", "Six months ago she had a manic episode, which was treated with risperidone.", "She is very conscious of her weight and appearance."], "Examination and Results": ["She is 171 cm (5 ft 6 in) tall and weighs 79 kg (174 lb); BMI is 27.02 kg/m2.", "Her temperature is 37\u00b0C (98.6\u00b0F), pulse is 60/min, and blood pressure is 116/70 mm Hg.", "The abdomen is soft and nontender.", "Pelvic examination shows a normal vagina and cervix.", "Serum hormone studies show:\nProlactin 16 ng/mL\nThyroid-stimulating hormone 3.8 \u03bcU/mL\nFollicle-stimulating hormone 6 mIU/mL\nLuteinizing hormone 5.1 mIU/mL\nProgesterone 0.8 ng/mL (follicular N <3; luteal N >3\u20135)\nTestosterone 2.2 nmol/L (N <3.5)\nA urine pregnancy test is negative."], "Others": ["Her mother has PCOS and her father has diabetes mellitus."]}
{"Patient Personal Background": ["She is a student who exercises and eats a well-balanced diet every day.", "There is no family history of hypertension or other metabolic syndromes."], "Patient Symptoms": ["She is concerned about her health especially after her colleagues noticed that her face gets red at times while at work.", "She has even started to use blankets to cover her feet, even on the warmest days in the summer, even though her hands feel warm to the touch."], "Examination and Results": ["On examination, her blood pressure is 145/92 mm Hg, respirations are 19/min, pulse is 64/min, and temperature is 36.7\u00b0C (98.0\u00b0F)."], "Others": ["An echocardiogram is ordered for investigation."]}
{"Patient Symptoms": ["There is clubbing present in the fingers bilaterally."], "Examination and Results": ["Cardiopulmonary examination shows fine inspiratory crackles bilaterally.", "Pulmonary function tests (PFTs) show FVC is 78% of expected and FEV1/FVC ratio is 92%.", "A CT scan of the chest is shown."], "Treatment": ["Following an orchiectomy, he was placed on chemotherapy."], "Diagnosis": ["He was recently diagnosed with stage 3 embryonal carcinoma testicular cancer."], "Others": []}
{"Patient Personal Background": ["He has a history of hypertension, chronic constipation, and type 2 diabetes mellitus.", "Prior to admission, his medications were insulin, metoprolol, and losartan."], "Patient Symptoms": ["The abdomen is soft on physical examination, and there is tenderness to palpation of the left lower quadrant."], "Examination and Results": ["On admission, a complete blood count showed a hemoglobin concentration of 15.5 g/dL and a leukocyte count of 14,000/mm3.", "Urinalysis showed 2+ proteinuria, and serum studies showed a blood glucose of 145 mg/dL and a creatinine concentration of 1.2 mg/dL.", "Today, his temperature is 37.7\u00b0C (99.9\u00b0F), pulse is 97/min, respirations are 12/min, and blood pressure is 135/87 mm Hg.", "The remainder of the examination shows no abnormalities."], "Treatment": ["Therapy with intravenous ketoprofen, piperacillin, and tazobactam was begun, and the patient was placed on bowel rest."], "Diagnosis": ["A CT scan of the abdomen confirmed the diagnosis."]}
{"Others": ["While talking about inflammasomes, he describes the process via an example: products of cellular stress are detected by NLRP3, which includes NOD-, LRR-, and pyrin domain-containing 3; the latter interacts with apoptosis-associated speck-like protein containing CARD (ASC) via the pyrin domain, which leads to the formation of a protein speck that consists of multimers of ASC dimers."]}
{"Others": ["The location of the ribosome within the cell can vary and provides a clue to the function of the particular cell."]}
{"Patient Personal Background": ["The patient's current medications that she can recall include sumatriptan and naproxen.", "She has been admitted to the hospital several times recently for panic attacks and suicide attempts."], "Patient Symptoms": ["She states that the pain started 1 hour ago after rugby practice.", "Typically, she takes a special medication for bad headaches, but this time she took 2 doses and noticed no improvement in her symptoms.", "Two hours later, the patient demonstrates slurring of her speech.", "On physical exam there is drooping of the left side of her mouth, and her left upper extremity demonstrates 2/5 strength."], "Examination and Results": ["Her temperature is 99.2\u00b0F (37.3\u00b0C), blood pressure is 129/65 mmHg, pulse is 90/min, respirations are 15/min, and oxygen saturation is 98% on room air.", "On physical exam there is drooping of the left side of her mouth, and her left upper extremity demonstrates 2/5 strength."], "Treatment": ["The patient is given dihydroergotamine, IV fluids, and is started on 100% oxygen."], "Others": ["A head CT is ordered."]}
{"Patient Personal Background": ["Her last pap smear at age 22 showed no intraepithelial lesions nor malignancy of the cervical cells.", "Menses occur at regular 28-day intervals and last 4 days.", "Her last menstrual period was 2 weeks ago.", "She is sexually active with one male partner.", "Her father died of colon cancer at the age of 75 years and her mother was diagnosed with breast cancer at the age of 40 years.", "She mentions that she is planning a backpacking trip through Europe in 2 months.", "Her routine immunizations are all up-to-date."], "Examination and Results": ["Her temperature is 36.9\u00b0C (98.5\u00b0F) and her blood pressure is 94/58 mm Hg.", "Pelvic and speculum examination show no abnormalities."]}
{"Patient Personal Background": ["The patient has a past medical history of asthma and cocaine use.", "His current medications include albuterol and ibuprofen."], "Patient Symptoms": ["The patient suddenly becomes short of breath with notable bilateral wheezing with poor air movement."], "Examination and Results": ["His temperature is 99.5\u00b0F (37.5\u00b0C), blood pressure is 70/35 mmHg, pulse is 150/min, respirations are 19/min, and oxygen saturation is 98% on room air.", "On initial trauma evaluation, his airway is intact and he is breathing spontaneously.", "The patient's dorsalis pedis and radial pulses are palpable bilaterally.", "His Glasgow Coma Scale is 9.", "Head to toe examination reveals instability of the pelvis when downwards force is applied.", "The patient's vitals are measured again and his temperature is 99.5\u00b0F (37.5\u00b0C), blood pressure is 100/55 mmHg, pulse is 150/min, respirations are 17/min, and oxygen saturation is 98% on room air.", "His blood pressure is 60/35 mmHg and pulse is 160/min."], "Treatment": ["The patient is started on IV fluids and norepinephrine, and a pelvic binder is placed.", "A blood transfusion is started, and the patient is given hydromorphone.", "The patient is treated appropriately, intubated, stabilized, and transferred to the surgical intensive care unit."]}
{"Others": ["Per chart review he finds that a prior cesarian birth is associated with a statistically significant increased risk of placenta accreta.", "The relative risk associated with this finding is 1.23.", "The associated p-value is 0.03."]}
{"Patient Personal Background": ["He has no family history available as he was adopted.", "He does not have any significant past medical history."], "Patient Symptoms": ["Although he has had gum bleeding in the past, it has never been this severe."], "Examination and Results": ["His physical exam is within normal limits.", "Screening lab work is ordered with the following values:\nPlatelet count 330,000/mm3\nBleeding time 6 mins\nProthrombin time 12 sec\nActivated partial thromboplastin time 42 sec\nFactor VIII activity decreased\nRistocetin cofactor assay decreased\nHe is subsequently referred to a hematologist for further work-up and treatment."], "Treatment": []}
{"Patient Personal Background": ["She had a Colles' fracture 2 years ago.", "The rest of her past medical history is unremarkable.", "She has a sedentary lifestyle.", "She has been smoking 1 pack of cigarettes daily for 30 years.", "She drinks alcohol moderately.", "Her mother had a fracture of the wrist when she was in her late 60s."], "Examination and Results": ["The physical examination shows no abnormal findings.", "Dual-energy X-ray absorptiometry (DEXA scan) shows a T-score of -3.2 standard deviations (SDs) in the hip."], "Treatment": ["The patient is educated regarding her risk of falls.", "Exercise regimen and smoking cessation assistance are provided."]}
{"Patient Personal Background": ["She has a history of recurrent painful ulcers on her vulva, but she currently does not have them.", "Her current medications include acyclovir, folic acid, and a multivitamin."], "Patient Symptoms": ["The contractions last 40 seconds, occur every 2 minutes, and are increasing in intensity.", "Contractions are felt on the abdomen."], "Examination and Results": ["Her temperature is 36.9\u00b0C (98.4\u00b0F), heart rate is 88/min, and blood pressure is 126/76 mm Hg.", "The cervix is dilated to 5 cm, 70% effaced, and the station of the head is -2.", "A fetal ultrasound shows no abnormalities."], "Others": ["Her first child was delivered by lower segment transverse cesarean section because of a non-reassuring fetal heart rate."]}
{"Patient Personal Background": ["The patient lives in a homeless shelter and has not seen a doctor in the last 20 years.", "He has been drinking 5-8 drinks of alcohol per day for the last 20 years.", "Family history is non-significant, and the patient does not take any medications."], "Patient Symptoms": ["He reports using extra pillows at night to sleep and two nighttime awakenings to catch his breath in the last month."], "Examination and Results": ["His temperature is 37.1\u00b0C (98.9\u00b0F), blood pressure is 135/115 mm Hg, pulse is 85/min, and respiratory rate is 24/min.", "Physical examination reveals 2+ bilateral pitting edema.", "Chest auscultation reveals bibasilar crackles."]}
{"Patient Personal Background": ["The patient has no past medical history and takes no prescription medications.", "He does not drink alcohol or smoke cigarettes."], "Patient Symptoms": ["On examination, the physician notices 2 clean puncture wounds with localized cellulitis."], "Examination and Results": ["The patient\u2019s vitals are currently within normal limits.", "Capillary refill is 2 seconds.", "Sensorimotor evaluation of the hand is without deficits."]}
{"Patient Personal Background": ["Her family has been displaced several times over the last few years.", "Nutrition and housing were frequently inadequate."], "Patient Symptoms": ["At the physician\u2019s clinic, the boy appears irritated and drowsy.", "He is difficult to arouse."], "Examination and Results": ["Physical examination shows pitting edema over the ankles and feet and around his eyes.", "Abdominal examination is positive for ascites and hepatomegaly.", "Oral examination shows several missing teeth."]}
{"Patient Symptoms": ["Since his 18-month visit, the parents have become concerned that his speech does not seem to be developing appropriately.", "The parents report that the patient\u2019s vocabulary is still limited to fewer than 10 words, and he is still only using single words to describe things.", "At times the patient seems hyperactive and can be difficult to redirect."], "Examination and Results": ["On exam, his temperature is 98.4\u00b0F (36.9\u00b0C), blood pressure is 110/70 mmHg, pulse is 80/min, and respirations are 14/min.", "The rest of the exam is unremarkable, except that the patient\u2019s face appears to be abnormally long and narrow."], "Diagnosis": ["The patient is further referred to a geneticist, as he is believed to have a trinucleotide repeat disorder."], "Others": ["The parents say that his motor milestones do not seem to be affected, as the patient is very physically active and can run and kick a ball."]}
{"Patient Personal Background": ["He had always been a quiet boy, who needed some time on his own, but he used to meet with friends at least once a week.", "He used to smoke marijuana occasionally but quit 1 year ago."], "Patient Symptoms": ["The mother reports that over the past 7 months her son has become increasingly withdrawn; he has not answered any phone calls or visited his family and friends.", "The patient says that he cannot leave the house because aliens are watching him and \u201cstealing his thoughts\u201d.", "On mental status examination, it is impossible to follow the patient's sequence of thoughts.", "He is anxious and has a flat affect."], "Examination and Results": ["His vital signs are within normal limits.", "Physical examination shows no abnormalities."], "Others": ["He does not drink alcohol."]}
{"Patient Personal Background": ["Her medical history is significant for systemic lupus erythematosus.", "She takes ibuprofen and hydroxychloroquine."], "Patient Symptoms": ["She states that she first noticed the swelling 6 weeks ago.", "Initially, the swelling was minimal, but now she is finding it difficult to walk and she can\u2019t fit into any of her shoes.", "Two days later the patient returns to clinic complaining of blood in her urine."], "Examination and Results": ["Her temperature is 99\u00b0F (37.2\u00b0C), blood pressure is 153/86 mmHg, and pulse is 88 beats/min.", "Pitting edema to bilateral knees is noted on physical examination.", "Urinalysis reveals proteinuria.", "A urinalysis reveals moderate erythrocytes but is negative for leukocyte esterase, nitrites, or crystals.", "Diffuse oozing of the bladder mucosa with neovascularization is seen on cystoscopy."], "Treatment": ["The patient is started on an immunosuppressant."]}
{"Patient Personal Background": ["Medical history is significant for essential hypertension.", "She has worked from home as a web graphic designer for 20 years.", "Questions about her social life reveal that she is very shy with few friends, and she often makes excuses to avoid parties and social gatherings."], "Patient Symptoms": ["She has no complaints and offers very little information voluntarily.", "She answers each question with soft, short sentences and avoids eye contact.", "She appears timid, anxious and admits that this is one of the very few times she has left the house in the last several years.", "Despite this, she expresses a strong desire to be in a relationship."], "Examination and Results": ["Today, her blood pressure is 125/85 mm Hg, heart rate is 95/min, respiratory rate is 18/min, and temperature is 37.0\u00b0C (98.6\u00b0F).", "On physical examination, her heart has a regular rhythm and her lungs are clear to auscultation bilaterally."], "Treatment": ["She takes hydrochlorothiazide and a daily vitamin."]}
{"Patient Personal Background": ["The boy has no past medical history and takes no medications."], "Patient Symptoms": ["On exam, the boy is lethargic but responsive.", "He appears to be grasping at his ears and swaying from side-to-side when attempting to ambulate.", "He vomited once in the emergency room."], "Examination and Results": ["His temperature is 98.6\u00b0F (37\u00b0C), blood pressure is 110/65 mmHg, pulse is 85/min, and respirations are 28/min."], "Others": ["The boy had seemingly opened several different pill bottles that were in a cabinet in his parent\u2019s bathroom.", "The mother has brought the empty bottles to the emergency room, and they include aspirin, metoprolol, acetaminophen, levothyroxine, and lorazepam."]}
{"Patient Personal Background": ["Past medical history is significant for peptic ulcer disease diagnosed 2 years ago for which he is not compliant with his medications.", "He reports a 10-pack-year smoking history and occasionally alcohol use."], "Examination and Results": ["His vital signs include: temperature 37.1\u00b0C (98.7\u00b0F), blood pressure 142/91 mm Hg, pulse 98/min.", "Physical examination is unremarkable."]}
{"Patient Personal Background": ["She is 13 weeks pregnant based on the date of her last menstrual period."], "Patient Symptoms": ["She is dizzy and weak, and is unable to move around the house and perform her daily tasks.", "Initially, she had only light spotting, but later on in the day the bleeding increased."], "Examination and Results": ["The blood pressure is 90/60 mm Hg, the temperature is 37.8\u00b0C (100\u00b0F), the pulse is 125/min, and the respiratory rate is 14/min.", "On pelvic examination, the vagina contains blood and the cervical os is open.", "She also complains of cervical motion and adnexal tenderness on examination.", "An ultrasound shows an intrauterine gestational sac low in the uterine cavity.", "No fetal movement or cardiac activity are observed.", "Slight downward migration of the gestational sac is observed with no change in the fetal status."], "Treatment": ["A saline infusion is started, and blood and urine specimens are sent for analysis."], "Others": ["Thus far, she has used six sanitary pads.", "She is advised to rest for a couple of hours, after which the scan is repeated."]}
{"Patient Personal Background": ["She went camping with her new boyfriend 3 weeks ago but does not recall any tick bites."], "Patient Symptoms": ["Her temperature is 37.8\u00b0C (100.0\u00b0F).", "Examination of the right knee shows swelling, warmth, and tenderness on passive movement."], "Examination and Results": ["There is a tender pustule on the sole of the left foot.", "Arthrocentesis of the right knee joint yields 8 mL of cloudy fluid with a leukocyte count of 45,000/mm3 (90% segmented neutrophils with intracellular organisms)."]}
{"Patient Personal Background": ["He is currently on cimetidine for his condition and reports that his GERD initially improved."], "Patient Symptoms": ["However, following his recent move to Michigan, he is experiencing more frequent episodes of chest pain (4-5 times a week).", "The pain is described as burning in quality and is concentrated around his epigastric region following food ingestion.", "It does not radiate anywhere and is alleviated when he takes antacids."], "Examination and Results": ["A physical examination demonstrates a healthy male with unremarkable findings."], "Treatment": ["He is subsequently prescribed a new medication for control of his symptoms."]}
{"Patient Personal Background": ["He has no history of major medical illness."], "Patient Symptoms": ["He had a sore throat and cough 2 weeks ago that resolved spontaneously."], "Examination and Results": ["Physical examination shows moderate periorbital edema and 2+ pitting edema of the lower extremities bilaterally.", "A kidney biopsy specimen shows effacement of the podocytes on electron microscopy."]}
{"Examination and Results": ["Results: A total of 2759 patients underwent randomization: 908 to point-of-care ultrasonography, 893 to radiology ultrasonography, and 958 to non-contrast CT abdomen The incidence of high-risk diagnoses with complications in the first 30 days was low (0.4%) and did not vary according to imaging method.", "The mean 6-month cumulative radiation exposure was significantly lower in the ultrasonography groups than in the CT group (p < 0.001).", "Serious adverse events occurred in 12.4% of the patients assigned to point-of-care ultrasonography, 10.8% of those assigned to radiology ultrasonography, and 11.2% of those assigned to CT (p = 0.50).", "By 7 days, the average pain score was 2.0 in each group (p = 0.84).", "Return emergency department visits, hospitalizations, and diagnostic accuracy did not differ significantly among the groups."], "Others": ["Methods: In this multicenter, pragmatic, comparative effectiveness trial, we randomly assigned patients 18 to 76 years of age who presented to the emergency department with suspected nephrolithiasis to undergo initial diagnostic ultrasonography performed by an emergency physician (point-of-care ultrasonography), ultrasonography performed by a radiologist (radiology ultrasonography), or abdominal non-contrast CT.", "Subsequent management, including additional imaging, was at the discretion of the physician.", "We compared the three groups with respect to the 30-day incidence of high-risk diagnoses with complications that could be related to missed or delayed diagnosis and the 6-month cumulative radiation exposure.", "Secondary outcomes were serious adverse events, related serious adverse events (deemed attributable to study participation), pain (assessed on an 11-point visual-analog scale, with higher scores indicating more severe pain), return emergency department visits, hospitalizations, and diagnostic accuracy.", "Related adverse events were infrequent (incidence, 0.4%) and similar across groups.", "Conclusions: Initial ultrasonography was associated with lower cumulative radiation exposure than initial CT, without significant differences in high-risk diagnoses with complications, serious adverse events, pain scores, return emergency department visits, or hospitalizations."]}
{"Patient Personal Background": ["She has no history of serious medical illness."], "Patient Symptoms": ["She also complains of dyspnea on exertion and has had a 4.5-kg (10-lb) weight loss in the past 2 months despite normal appetite."], "Examination and Results": ["Cardiac examination shows an irregularly irregular rhythm and a grade 3/6, low pitched, rumbling, mid-diastolic murmur heard best over the apex.", "Diffuse wheezing and bilateral rales are present in the lung bases.", "A transthoracic echocardiogram shows a left-ventricular ejection fraction of 40% and a mass in the left atrium."]}
{"Patient Personal Background": ["Her left leg was amputated below the knee after a motorcycle accident 25 years ago.", "She is currently waiting for a new prosthesis and walks with crutches.", "Current medications include captopril, glyburide, and ibuprofen.", "She does not smoke or drink alcohol."], "Patient Symptoms": ["The pain is recurrent and occurs when she exerts herself or when she is outside during cold weather.", "She also experiences shortness of breath and palpitations during these episodes.", "The symptoms resolve spontaneously when she stops or sits down for a while.", "Over the past few days, the episodes have increased in frequency."], "Examination and Results": ["Her pulse is 88/min, respirations are 20/min, and blood pressure is 144/90 mm Hg.", "Cardiac examination shows no abnormalities.", "An x-ray of the chest shows no abnormalities.", "An ECG shows a normal sinus rhythm without any signs of ischemia.", "Serum cardiac markers are within the reference range."]}
{"Patient Personal Background": ["She was diagnosed with asymptomatic bacteriuria at her last appointment 2 weeks ago, and was treated with amoxicillin."], "Patient Symptoms": ["She has no concurrent diseases and no complaints."], "Examination and Results": ["Her vital signs are as follows: blood pressure 110/80 mm Hg, heart rate 82/min, respiratory rate 11/min, and temperature 36.6\u2103 (97.7\u2109).", "The physical examination reveals no abnormalities.", "On gynecologic examination, the cervix is soft and non-tender with no discharge from the external os.", "The uterus is enlarged to the umbilicus and the fetal heart rate is normal."], "Diagnosis": ["She was diagnosed with asymptomatic bacteriuria at her last appointment 2 weeks ago, and was treated with amoxicillin."]}
{"Examination and Results": ["On physical examination in the delivery room, the pediatrician notes that the baby has upslanting palpebral fissures, epicanthal folds, a flat facial profile, small ears, a single palmar crease, and hypotonia."]}
{"Patient Symptoms": ["Her headache is diffuse, dull in character, moderate in intensity, and is worse in the morning.", "It is not associated with fever and sensitivity to light or sound.", "She experiences occasional nausea but no vomiting.", "She did not have similar headaches in the past."], "Examination and Results": ["Her blood pressure is 140/90 mm Hg; pulse, 60/min, and body mass index is 33.5 kg/m2.", "The neurological examination reveals normal extraocular movements.", "Mild bilateral papilledema is present.", "A magnetic resonance imaging of the brain reveals a solitary lesion in the left temporal region with predominant hemorrhage."], "Others": ["Refer to the image below of the MRI of the brain."]}
{"Patient Personal Background": ["She has smoked 2 packs of cigarettes daily for 10 years and is actively trying to quit smoking."], "Patient Symptoms": ["During this time, she has had a 5-kg (11-lb) weight gain.", "She reports trouble concentrating at her job as a preschool teacher and has missed work several times in recent weeks due to generalized fatigue."], "Treatment": ["A drug is prescribed that will treat the patient's mood disturbance and support smoking cessation."]}
{"Patient Symptoms": ["A few days ago, she began to notice an eruption of small red bumps that cover her torso, back, and buttocks.", "The patient first thought she had acne, but became worried when the rash continued to itch."], "Examination and Results": ["The patient denies other symptoms.", "Vital signs are within normal limits.", "Physical exam is notable for red papules and pustules scattered across the trunk, abdomen, back, and buttocks, while sparing the limbs.", "Closer examination indicates inflammation of the hair follicles.", "Culture yields motile, gram-negative rods that are non-lactose fermenting and oxidase positive."]}
{"Patient Personal Background": ["Her past medical history is notable for asthma and takes albuterol as needed.", "She does not smoke but drinks alcohol socially.", "Her family history is notable for cystic fibrosis in her paternal uncle and interstitial lung disease in her paternal grandfather."], "Examination and Results": ["Her temperature is 101\u00b0F (38.3\u00b0C), blood pressure is 115/75 mmHg, pulse is 110/min, and respirations are 21/min.", "Rales are noted in the right lower lung, and a chest radiograph demonstrates focal consolidation in the right lower lung lobe."], "Treatment": ["After initiating the appropriate treatment, she agrees to take part in a study assessing the immune response to lung infections."], "Others": ["A protein is identified in her serum that is thought to be elevated in response to her condition.", "An amino acid sequence at the carboxy terminus of the protein is isolated and a fluorescent marker is added to the sequence.", "This labeled sequence is subsequently added to a gel containing a protein isolated from the cell surface of the patient\u2019s own neutrophils and macrophages and subsequently labeled with another fluorescent marker.", "The sequence binds strongly to this protein as evidenced by increased fluorescence in the gel."]}
{"Examination and Results": ["On arrival, the police found his body to be cold and stiff."], "Others": ["His body was discovered 7 hours later by a group of campers who promptly called the police."]}
{"Patient Symptoms": ["The patient mentions her friend who is a medical student told her that her symptoms are suggestive of a parvovirus B19 infection which may adversely affect her baby."], "Examination and Results": ["Physical examination reveals a mild lace-like rash and arthritis."], "Others": ["The patient mentions her friend who is a medical student told her that her symptoms are suggestive of a parvovirus B19 infection which may adversely affect her baby."]}
{"Patient Personal Background": ["He reports drinking 2 glasses of whiskey earlier that day, after a stressful day at work.", "Current medications include hydrochlorothiazide and atorvastatin.", "He has smoked one pack of cigarettes daily for the past 20 years."], "Examination and Results": ["His pulse is 102/min, and blood pressure is 135/88 mm Hg.", "Cardiopulmonary examination shows normal heart sounds.", "An ECG obtained on arrival at the emergency department shows ST-segment elevations in the anterior leads.", "15 minutes later, the patient's chest pain has resolved and a repeat ECG shows no abnormalities."]}
{"Patient Personal Background": ["He has asthma and has been hospitalized multiple times.", "His mother has type 2 diabetes mellitus."], "Patient Symptoms": ["He is somnolent and diaphoretic.", "Overnight, he has another episode of decreased consciousness."], "Examination and Results": ["Serum studies show a glucose concentration of 22 mg/dL and a potassium concentration of 2.4 mEq/L.", "Serum studies taken during the episode show a glucose concentration of 19 mg/dL, an insulin concentration of 108 mIU/L (N=2.6\u201324.9), and a C-peptide concentration of 0.3 ng/mL (N = 0.8\u20133.1)."], "Treatment": ["A dextrose infusion is administered, after which his glucose concentration normalizes and his symptoms improve."], "Others": ["He is admitted to the hospital for further observation."]}
{"Patient Personal Background": ["The medical history is significant for arterial hypertension and poorly controlled type 2 diabetes mellitus for 8 years, and depression for 3 years.", "She is prescribed amlodipine, valsartan, atorvastatin, metformin, and amitriptyline."], "Patient Symptoms": ["She reports that she has not urinated for the past 2 days and that the urine leakage occurs during both day and night and is not associated with physical exertion."], "Examination and Results": ["Her weight is 75 kg (165 lb) and her height is 166 cm (5 ft 40 in).", "Her vital signs are as follows: blood pressure, 120/80 mm Hg; heart rate, 91/min; respiratory rate, 13/min; and temperature, 36.4\u2103 (97.5\u2109).", "The physical examination reveals lower abdominal tenderness with a distended urinary bladder that is palpated in the suprapubic region.", "The neurological examination shows decreased Achilles reflexes bilaterally, and diminished fine touch and vibratory sensation.", "On gynecologic examination, the cervix was normally positioned, mobile, and without any visible lesions.", "Bulging of the posterior vaginal wall was noted.", "The adnexa were not palpable.", "An ultrasound examination showed an overdistended urinary bladder with no structural abnormalities."]}
{"Patient Personal Background": ["The patient states that this weekend he had a barbecue.", "The patient has a past medical history of obesity, diabetes, depression, anxiety, diverticulosis, constipation, and a surgical repair of his anterior cruciate ligament.", "His current medications include metformin, insulin, lisinopril, fluoxetine, and sodium docusate."], "Patient Symptoms": ["When he was lifting a heavy object he suddenly felt pain in his lower back.", "He describes the pain as in his buttocks but states that at times it travels down his leg.", "The patient states that it feels, \"electrical.\""]}
{"Patient Symptoms": ["She adds that she is having difficulty swallowing.", "She denies trouble with her breathing but endorses 5\u201310 lb of unintentional weight loss over the past few months."], "Examination and Results": ["On physical exam, the patient\u2019s fingernails appear flat and mild conjunctival pallor is noted.", "An upper barium esophagram shows an upper esophageal web."]}
{"Patient Personal Background": ["The patient has a past medical history of diabetes diagnosed 20 years ago and osteoarthritis.", "Her medications include metformin, glimepiride, and ibuprofen as needed for pain."], "Patient Symptoms": ["The patient\u2019s only complaint is that she feels her vision has been getting more blurry over the past year."], "Examination and Results": ["Fundoscopic examination of this patient reveals narrowing of retinal arteries and microaneurysms."]}
{"Patient Personal Background": ["The boy attends daycare.", "His older brother has asthma.", "The patient's immunizations are up-to-date."], "Patient Symptoms": ["The episodes of lesions started at the age of 2 months and multiple treatment options have been attempted without success.", "He has also had several episodes of respiratory tract infections, enlarged lymph nodes, and recurrent fevers since birth."], "Examination and Results": ["He is at the 5th percentile for length and 10th percentile for weight.", "He appears ill. His temperature is 38\u00b0C (100.4\u00b0F), pulse is 100/min, and blood pressure is 100/60 mm Hg.", "Examination shows several raised, erythematous lesions of different sizes over the face, neck, groins, and extremities; some secrete pus.", "Cervical and axillary lymph nodes are enlarged bilaterally."], "Others": ["The remainder of the examination shows no abnormalities."]}
{"Patient Personal Background": ["Over the weekend he \"strained his shoulder\" during a pick-up basketball game and reports an acute exacerbation of his pain symptoms."], "Patient Symptoms": ["Over the weekend he \"strained his shoulder\" during a pick-up basketball game and reports an acute exacerbation of his pain symptoms.", "On exam, he complains of pain to palpation just below the acromion."], "Examination and Results": ["On exam, he complains of pain to palpation just below the acromion."], "Diagnosis": ["You suspect he has torn his supraspinatus."]}
{"Patient Personal Background": ["She has hypercholesterolemia and hypertension.", "Her mother died of metastatic breast cancer 15 years ago, at the age of 65 years.", "She does not smoke or drink alcohol.", "Current medications include atorvastatin, labetalol, and aspirin.", "She is 163 cm (5 ft 4 in) tall and weighs 84 kg (185 lb); BMI is 31.8 kg/m2."], "Patient Symptoms": ["The pain is worse after standing a lot at work and when she climbs stairs.", "Over the past 2 months, she has been taking over-the-counter ibuprofen as needed for the joint pain."], "Examination and Results": ["Her temperature is 37\u00b0C (98.6\u00b0F), pulse is 88/min, and blood pressure is 114/68 mm Hg.", "Examination of the left knee shows tenderness on palpation of the anteromedial joint line; there is crepitus and pain with full flexion and extension.", "Serum uric acid concentration is 8.0 mg/dL and erythrocyte sedimentation rate is 15 mm/h."], "Treatment": ["Current medications include atorvastatin, labetalol, and aspirin.", "Over the past 2 months, she has been taking over-the-counter ibuprofen as needed for the joint pain."], "Others": ["There is no history of trauma."]}
{"Patient Personal Background": ["He has a history of a variety of bacterial infections since birth."], "Examination and Results": ["Physical examination reveals light-colored skin with silver-colored hair.", "Study of the boy\u2019s neutrophils reveals that they contain large cytoplasmic vacuoles.", "Genetic studies show a mutation in the LYST gene."], "Diagnosis": ["The pediatrician suspects an immunodeficiency disorder and decides to order several tests."]}
{"Patient Symptoms": ["He denies any pain, fevers, or chills.", "He returns to the emergency department one week later with difficulty breathing."], "Examination and Results": ["His temperature is 101\u00b0F (38.3\u00b0C), blood pressure is 150/80 mmHg, pulse is 80/min, and respirations are 22/min.", "An ulcer with associated erythema and purulence is noted on his foot.", "His temperature is 98\u00b0F (37\u00b0C), blood pressure is 100/70 mmHg, pulse is 130/min, respirations are 27/min, and oxygen saturation is 92% on room air.", "His amputated foot stump is erythematous and edematous but not tender to palpation.", "An electrocardiogram reveals sinus tachycardia."], "Treatment": ["He is given appropriate prophylaxis for tetanus and discharged 5 hospital days later on antibiotics.", "He requests something to help calm his breathing down."], "Diagnosis": ["Based on his radiography, he is diagnosed with osteomyelitis and admitted to the hospital for partial amputation of his right foot."]}
{"Patient Personal Background": ["He has a history of hypertension treated with hydrochlorothiazide and nephrolithiasis."], "Patient Symptoms": ["Four months ago, he had an episode of severe joint pain involving his left knee that lasted several days and resolved with over-the-counter analgesics.", "Examination shows erythema, swelling, warmth, and tenderness of the right metatarsophalangeal joint; range of movement is limited by pain."], "Examination and Results": ["His serum uric acid is 12 mg/dL.", "Arthrocentesis yields cloudy fluid with a leukocyte count of 18,500/mm3 (80% segmented neutrophils).", "Polarized light microscopy of the synovial fluid is shown."]}
{"Patient Personal Background": ["Past medical history is significant for hypertension for which he takes labetalol."], "Patient Symptoms": ["His symptoms began approx.", "20 minutes after being stung by a bee on the left arm.", "While being questioned, the patient becomes obtunded."], "Examination and Results": ["His vital signs include: temperature 37.0\u00b0C (98.6\u00b0F); blood pressure 85/55 mm Hg; pulse 110/min; respiratory rate 31/min; and oxygen saturation 90% on room air.", "On physical examination, an area of severe edema and erythema is noted on the extensor surface of the left forearm, and there is severe angioedema of the face and neck."], "Treatment": ["The patient is intubated, and aggressive fluid resuscitation and intramuscular epinephrine are administered."]}
{"Patient Personal Background": ["He is on an experimental drug (drug X) that is used to reduce the action of testosterone by blocking the androgen receptor."], "Patient Symptoms": ["The patient has no significant complaints, except for excessive sweating at times."], "Examination and Results": ["On physical examination, a small area of tissue around his nipples is enlarged bilaterally."], "Treatment": ["He is on an experimental drug (drug X) that is used to reduce the action of testosterone by blocking the androgen receptor."], "Others": ["Since the initiation of therapy, the growth of the cancerous tissue has slowed.", "This medication is known to be excreted by the kidneys at the current dose that he is taking."]}
{"Patient Personal Background": ["He is a known alcoholic."], "Patient Symptoms": ["Suddenly, he is unable to move his arms and legs in addition to experiencing difficulty chewing, swallowing, moving his face, and speaking."], "Examination and Results": ["He was started on IV fluids and received a head CT, which was negative."], "Treatment": ["He was started on IV fluids and received a head CT, which was negative."], "Others": ["It was decided that he would be watched for one day before being discharged, after a negative work-up."]}
{"Patient Personal Background": ["He works at a community center and volunteers at a local homeless shelter."], "Patient Symptoms": ["Two months later, he has numbness and burning over both feet and an unsteady gait."], "Examination and Results": ["A tuberculin skin test shows an induration of 14 mm.", "An x-ray of the chest is normal.", "Physical examination shows decreased sensation to light touch extending from the soles of the feet to the mid-shin bilaterally."], "Treatment": ["Treatment with an antimycobacterial drug is initiated."]}
{"Patient Symptoms": ["He reports pain with climbing stairs and with extended walks of greater than 100 yards.", "The pain worsens with activity throughout the day and is alleviated by periods of rest.", "He states that he has minimal morning stiffness, lasting approximately 5-10 minutes after waking up most days."], "Examination and Results": ["Physical examination reveals tenderness to palpation of the bony structures on the medial aspect of the bilateral knees as well as crepitus and a decreased range of motion, limited at the extremes of flexion and extension.", "Both knee joints are cool to touch and exhibit bony enlargement upon palpation of the medial joint line."]}
{"Patient Personal Background": ["Her vaccinations are up-to-date."], "Patient Symptoms": ["She had a 4-day history of diarrhea and vomiting that subsided two days ago.", "One month ago, she had a 3-day episode of high fever, followed by a rash with bright red discoloration over her cheeks for two days before subsiding without treatment.", "She appears pale and irritable."], "Examination and Results": ["Her vital signs are within normal limits.", "Examination shows petechiae on her trunk and extremities.", "Abdominal examination shows diffuse abdominal tenderness with hyperactive bowel sounds.", "Laboratory studies show:\nHemoglobin 8 g/dL\nMean corpuscular volume 82 fL\nLeukocyte count 17,000/mm3\nPlatelet count 49,000/mm3\nProthrombin time 12 seconds\nPartial thromboplastin time 34 seconds\nSerum\nUrea nitrogen 42 mg/dL\nCreatinine 1.4 mg/dL\nBilirubin\nTotal 3 mg/dL\nIndirect 2.8 mg/dL\nLactate dehydrogenase 300 U/L\nUrine\nBlood 2+\nProtein 2+\nA peripheral blood smear shows schistocytes."], "Others": ["The remainder of the exam shows no abnormalities."]}
{"Patient Personal Background": ["He has no history of any serious illnesses and takes no medications."], "Examination and Results": ["A diagnostic workup including endoscopy and biopsy shows gastric adenocarcinoma."], "Diagnosis": ["A diagnostic workup including endoscopy and biopsy shows gastric adenocarcinoma."], "Others": ["Before further workup and staging, the biopsy results are discussed with the patient.", "He refuses any type of life-prolonging treatment, including chemotherapy, radiation, or surgery, but he requests appropriate palliative care without any significant burden of healthcare costs."]}
{"Patient Symptoms": ["She has no specific complaints."], "Examination and Results": ["Vital signs include: blood pressure is 130/80 mm Hg, heart rate is 76/min, respiratory rate is 15/min, and temperature is 36.8\u00b0C (98.2\u00b0F).", "Her physical examination is within normal limits.", "The woman\u2019s complete blood count shows an absolute increase in the cells shown in the first image."]}
{"Patient Personal Background": ["The patient has a past medical history of constipation which is treated with fiber supplements."], "Patient Symptoms": ["The patient states she has pain in the right side of her abdomen which started yesterday and has been worsening.", "She has experienced a few episodes of vomiting and diarrhea during this time."], "Examination and Results": ["Her temperature is 99.5\u00b0F (37.5\u00b0C), blood pressure is 110/68 mmHg, pulse is 110/min, respirations are 17/min, and oxygen saturation is 98% on room air.", "On physical exam, you note a young woman who appears to be in pain.", "Cardiopulmonary exam is within normal limits.", "Abdominal exam is notable for right lower quadrant pain that is reproducible when the left lower quadrant is palpated."], "Treatment": ["The patient is given morphine."]}
{"Patient Personal Background": ["She is gravida 2 para 0 with a history of the same complaints in her last pregnancy which ended with a stillbirth at the 31st week.", "Her older sister had preeclampsia in both of her pregnancies."], "Patient Symptoms": ["Currently, the patient is responsive but lethargic."], "Examination and Results": ["The vital signs are as follows: blood pressure 150/90 mm Hg, heart rate 85/min, respiratory rate 15/min, and temperature 36.4\u00b0C (97.5\u00b0F).", "The physical examination shows jaundice, right upper quadrant tenderness, and 2+ pitting edema of the lower extremities."]}
{"Patient Personal Background": ["He has had several similar episodes since birth, all of which resolved spontaneously.", "He has a 5-year history of poorly controlled type II diabetes mellitus and was started on glipizide one week ago.", "He predominantly eats fast food, although he tried a new Lebanese restaurant about one month ago."], "Patient Symptoms": ["Prior to the episode, he felt well without any upper respiratory or gastrointestinal symptoms."]}
{"Examination and Results": ["Examination shows erythema with scaling on both cheeks that spares the nasolabial folds and two 1-cm ulcers in the oral cavity."]}
{"Examination and Results": ["On exam, you note an elevated JVP and 2+ pitting edema of bilateral lower extremities."]}
{"Patient Personal Background": ["He feels well and has no history of serious illness.", "He has smoked one pack of cigarettes daily for the past 25 years and drinks two to three glasses of wine weekly."]}
{"Patient Personal Background": ["There is no personal or family history of serious illness."], "Patient Symptoms": ["Menses occur at irregular 35- to 50-day intervals and last 3\u20137 days.", "Her last menstrual period was 5 weeks ago.", "She has had an unintentional 10-kg (22-lb) weight gain over this period.", "She also reports decreased sexual desire and increased hair growth on her face and arms.", "She appears lethargic."], "Examination and Results": ["Her temperature is 37\u00b0C (98.6\u00b0F), pulse is 80/min, and blood pressure is 150/90 mm Hg.", "Physical examination shows central obesity, increased pigmented hair over the chin and upper lip, and purple stretch marks on the abdomen.", "She has a prominent hump of fat over the base of the dorsum of her neck and decreased proximal muscle tone and strength."]}
{}
{"Patient Personal Background": ["He has a history of diet-controlled type 2 diabetes mellitus.", "He has smoked one-half pack of cigarettes daily for 15 years and reports occasionally using marijuana."], "Examination and Results": ["His temperature is 38.7\u00b0C (101.1\u00b0F), pulse is 85/min, respirations are 25/min, and blood pressure is 110/65 mm Hg."]}
{}
{"Patient Personal Background": ["There is no personal or family history of serious illness.", "He drinks one pint of rum daily.", "He works as a foreman in a factory that produces industrial solvents."], "Patient Symptoms": ["Examination shows a wide-based gait.", "The patient is unable to stand with his feet together without support.", "There is a coarse tremor of the hands when he is asked to grab a pen.", "Rapid alternating movements of the hands is impaired."], "Examination and Results": ["He is alert and oriented to time, place, and person.", "His temperature is 36.7\u00b0C (98.1\u00b0F), pulse is 88/min, and blood pressure is 108/70 mm Hg.", "Muscle strength and tone are normal in all extremities.", "Sensation to pain, vibration, and position is intact bilaterally.", "Mental status examination shows no abnormalities."]}
{"Patient Personal Background": ["She has no history of serious illness.", "Immunizations are up-to-date."], "Patient Symptoms": ["The mother reports that she had her first menstrual period 1 week ago."], "Examination and Results": ["Physical examination shows Tanner stage 3 breast development and pubic hair."]}
{"Patient Personal Background": ["The patient has a past medical history of hypertension and peripheral vascular disease."], "Patient Symptoms": ["He was released from the hospital 1 week ago for an appropriately managed ST-elevation myocardial infarction (STEMI); however, he has not filled any of his prescriptions and did not attend his follow up appointment as scheduled.", "Physical exam is notable for jugular venous distention and bilateral lower extremity pitting edema."], "Examination and Results": ["His temperature is 97.5\u00b0F (36.4\u00b0C), blood pressure is 167/118 mmHg, pulse is 90/min, respirations are 14/min, and oxygen saturation is 99% on room air.", "Physical exam is notable for jugular venous distention and bilateral lower extremity pitting edema.", "Echocardiography demonstrates an ejection fraction of 55%."]}
{"Patient Personal Background": ["He had smoked 2 packs of cigarettes daily for 30 years but quit 1 year ago."], "Patient Symptoms": ["He has had frequent episodes of a productive cough over the past 3 years.", "He appears distressed."], "Examination and Results": ["Pulse oximetry on room air shows an oxygen saturation of 91%.", "Chest auscultation reveals diffuse wheezes and coarse crackles.", "A chest x-ray shows increased lung lucency bilaterally and flattening of the diaphragm."]}
{"Examination and Results": ["She has obtained a tissue sample from a normal thyroid gland for histopathologic examination.", "It shows follicles lined by a single layer of cube-like cells with large central nuclei."]}
{"Patient Personal Background": ["She feels well but asks for advice about smoking cessation.", "She has smoked one pack of cigarettes daily for 7 years.", "She has tried to quit several times without success.", "She has bulimia nervosa.", "She takes no medications."], "Patient Symptoms": ["During the previous attempts, she has been extremely nervous and also gained weight.", "She has also tried nicotine lozenges but stopped taking them because of severe headaches and insomnia."], "Examination and Results": ["She is 168 cm (5 ft 6 in) tall and weighs 68 kg (150 lb); BMI is 24 kg/m2.", "Physical and neurologic examinations show no other abnormalities."]}
{"Patient Personal Background": ["He has no history of any serious illnesses and takes no medications.", "He has no history of recent travel."], "Examination and Results": ["His vital signs are within normal limits.", "Physical examination is unremarkable."], "Treatment": ["At discharge from the hospital, he is given complete instructions for a strict gluten-free diet."]}
{"Patient Personal Background": ["His personal history is significant for a myocardial infarction 6 years ago that required revascularization and hypertension.", "His medication consists of simvastatin and lisinopril."], "Examination and Results": ["In the ED, he has a blood pressure of 100/80 mm Hg, a pulse of 88/min, a respiratory rate of 28/min, and a temperature of 36.5\u00b0C (97.7\u00b0F).", "On physical examination, he has jugular vein distention, displaced point of maximal impulse (PMI), an S4-gallop, a holosystolic murmur, and 2+ pitting edema up to the mid calf.", "After 6-hours of continued therapy, his blood pressure remains low, and his serum creatinine is found to be 1.9 mg/dL."], "Treatment": ["He is started on furosemide, carvedilol, and oxygen therapy."]}
{"Patient Personal Background": ["Her family and past medical history are unremarkable."], "Patient Symptoms": ["She has also noticed a decrease in urination."], "Examination and Results": ["Her temperature is 38.2\u00b0C (100.7\u00b0F), blood pressure is 118/76 mm Hg, heart rate is 74/min, and respiratory rate is 15/min.", "Upon physical examination, her mucous membranes are moist and she has no abdominal tenderness."]}
{"Patient Symptoms": ["She states that while she used to be able to go for short walks, she is no longer able to do so.", "Now, even simple tasks like getting ready in the morning have become burdensome for her.", "When she gets tired, sitting down helps to alleviate her symptoms."], "Examination and Results": ["Her blood pressure is 136/92 mm Hg and heart rate is 76/min.", "On physical examination, she has regular heart sounds but does have 1+ pitting edema to her bilateral lower extremities."]}
{"Patient Personal Background": ["Family history is notable for migrainous headaches in her mother and brother."], "Patient Symptoms": ["The pain typically occurs in waves of several individual episodes lasting about one second.", "It is bilateral, but rarely occurs on both sides simultaneously.", "Touching her face or brushing her teeth can trigger an attack.", "Four months ago, she had an episode of weakness in her right arm that lasted for about a week."], "Examination and Results": ["Vital signs are within normal limits.", "There is decreased sensation in the V2 and V3 distribution of her face bilaterally.", "Muscle strength is 3/5 in the left upper extremity and 5/5 in the right upper extremity.", "There is spasticity of the lower extremities with sustained clonus."]}
{"Patient Personal Background": ["Her previous pregnancy was uncomplicated and she gave birth to a healthy boy."], "Examination and Results": ["Her blood group is A, Rh-negative.", "The father's blood group is B, Rh-positive."]}
{"Patient Personal Background": ["His family history is significant for type 2 diabetes mellitus in his mother and cousin."], "Examination and Results": ["His weight is 112 kg ( 246.9 lb), height 187 cm (6 ft 1 in), blood pressure: 150/90 mm Hg, heart rate: 89/min, respiratory rate: 14/min, and temperature: 36.7\u2103 (98.4\u2109).", "The physical examination is significant for dry skin, a pustular rash over the patient\u2019s shoulders and back, an accentuated second heart sound (S2) best heard in the second intercostal space at the right sternal border, and distal loss of vibration sensitivity in both feet.", "A fundoscopic examination shows small red dots in the superficial retinal layers suggestive of microaneurysms."]}
{"Patient Personal Background": ["The patient has a past medical history of diabetes mellitus type II, obesity, and hypertension.", "His current medications include metformin, insulin, lisinopril, and hydrochlorothiazide.", "The patient admits to leading a sedentary life in which he tends to stay home and watch television.", "He does not engage in any physical or strenuous activity."], "Patient Symptoms": ["He states that he has been having trouble combing his hair and reaching objects that are high on the shelf."], "Examination and Results": ["On physical exam the patient has decreased passive and active range of motion of his shoulder.", "Strength of the patient's upper extremity is 4/5."]}
{"Patient Personal Background": ["His medications include amlodipine, metformin, glimepiride, and a fluticasone/salmeterol inhaler.", "The patient has been living at his upstate cabin for the past 5 weeks but denies other recent travel.", "He denies smoking tobacco or illicit drug use."], "Patient Symptoms": ["The patient reports that about 4 weeks ago he developed a \u201cnagging\u201d headache.", "He thought he had a cold, so he tried over the counter ibuprofen that provided only mild and temporary relief.", "Recently, he also started feeling dizzy and nauseous, which only resolves when he steps outside to shovel the snow."], "Examination and Results": ["The patient\u2019s temperature is 99\u00b0F (37.2\u00b0C), blood pressure is 130/78 mmHg, pulse is 72/min, and respirations are 16/min with an oxygen saturation of 98% on room air.", "The patient is currently asymptomatic while sitting in the office, and physical examination is unremarkable."], "Others": ["The patient\u2019s medical history is significant for hypertension, type II diabetes mellitus, and asthma."]}
{"Patient Personal Background": ["Since then, she has been compliant with her medications and currently has no significant complaints."], "Patient Symptoms": ["At that time, she was acutely severely manic and was brought to the emergency department by her concerned boyfriend.", "A week after discharge, the patient forgot to take her medication for a few days and quickly began to manifest manic symptoms again which required brought her to the emergency department again."], "Treatment": ["She was started on lithium, and after subsequent improvement, she was discharged.", "A week after discharge, the patient forgot to take her medication for a few days and quickly began to manifest manic symptoms again which required brought her to the emergency department again."]}
{"Patient Personal Background": ["The patient has no significant past medical history but was recently treated with ciprofloxacin for an uncomplicated urinary tract infection.", "She also notes irregular periods, with a last menstrual period 6 weeks ago.", "She is a college student who has had 3 sexual partners in the last year with inconsistent use of barrier protection."], "Patient Symptoms": ["She states that her symptoms have progressed and she now feels feverish as well.", "She also notes an episode of nonbloody diarrhea 2 days ago and has been increasingly nauseous.", "While being evaluated in the emergency room, she vomits three times."], "Examination and Results": ["Her temperature is 100.5\u00b0C (38.1\u00b0F), blood pressure is 102/68 mmHg, pulse is 97/min, and respirations are 14/min.", "On exam, the patient is noticeably uncomfortable.", "There is marked tenderness to palpation in the suprapubic region and right lower quadrant, with voluntary guarding but no rebound.", "Pelvic exam shows moderate purulent discharge in the vaginal vault, cervical motion tenderness, and a tender adnexal mass on the right side."]}
{"Examination and Results": ["His pulse is 100/min, and blood pressure is 90/60 mm Hg.", "Further evaluation shows a systemic vascular resistance of 35 mm Hg \u00d7 min/L with an end-systolic volume of 80 mL."]}
{"Patient Personal Background": ["She has a past medical history of uterine fibroids.", "She takes mifepristone daily to reduce the size of the fibroids."], "Patient Symptoms": ["She complains of vomiting and complete hearing loss in her left ear.", "The patient believes she had an ear infection in the same ear but never sought out treatment.", "The patient appears pale and in mild distress."], "Examination and Results": ["Her blood pressure is 114/72 mm Hg, the heart rate is 68/min, the respiratory rate is 12/min, and the temperature is 36.8\u00b0C (98.2\u00b0F).", "Otoscopy reveals a suppurative, erythematous, bulging tympanic membrane.", "The tympanic membrane is observed to be immobile as confirmed by the pneumatoscope.", "Pure-tone audiometry testing reveals hearing loss across all frequencies in the left ear.", "Heart auscultation is without murmurs.", "Lungs are clear to auscultation bilaterally.", "Nystagmus is positive to the right.", "MRI of the brain does not reveal a tumor or abscess."]}
{"Patient Personal Background": ["Her medical history is significant for obesity, hypertension, inflammatory bowel disease, and extensive alcohol use.", "She takes a number of medications but does not remember what they are."], "Patient Symptoms": ["This pain started acutely, and she describes the pain as sharp."], "Examination and Results": ["On physical exam, her right first MTP joint appears warm, swollen, erythematous, and exquisitely painful to the touch.", "One month later on follow-up, she is found to have pancytopenia."], "Treatment": ["After resolution of this acute episode, the patient is started on a drug to prevent recurrence of the symptoms."]}
{"Patient Symptoms": ["5 days ago, he had a burning sensation in his chest and discomfort in his left shoulder.", "The patient now describes discomfort in his chest and left shoulder, somewhat similar in nature to what initially brought him into the hospital."], "Examination and Results": ["A pulse of 86/min, respiratory rate of 16/min, and a blood pressure of 146/90 mm Hg are observed.", "Auscultation of the chest reveals no abnormal findings.", "The patient\u2019s ECG is difficult to interpret."], "Treatment": ["Upon initial presentation to the hospital\u2019s emergency department, he was diagnosed with an ST-elevation myocardial infarction and treated with alteplase."], "Diagnosis": ["Upon initial presentation to the hospital\u2019s emergency department, he was diagnosed with an ST-elevation myocardial infarction and treated with alteplase."], "Others": ["He has been under close observation since then."]}
{"Patient Personal Background": ["Her only medication is an oral contraceptive pill.", "Her immunizations are up-to-date."], "Patient Symptoms": ["She fell on an outstretched hand while playing basketball.", "She ignored it initially as she thought it was just a bruise, but the pain and swelling worsened throughout the day.", "The analgesic spray she used did not provide adequate relief.", "She appears anxious."], "Examination and Results": ["Her temperature is 37.1\u00b0C (99\u00b0F), pulse is 88/min, and blood pressure is 118/72 mm Hg.", "Examination shows a swollen and tender left wrist; range of motion is limited.", "The anatomical snuffbox is tender to palpation.", "The grip strength of the left hand is decreased.", "The thumb can be opposed towards the other fingers.", "Finkelstein's test is negative.", "X-rays of the wrist shows no abnormalities."], "Others": ["There is no family history of serious illness."]}
{"Patient Personal Background": ["He was diagnosed with ulcerative colitis 7 years ago.", "At the time of diagnosis, a pANCA test was also positive."], "Patient Symptoms": ["Physical examination shows scleral icterus and multiple scratch marks on the trunk and extremities."], "Examination and Results": ["Abdominal examination is unremarkable.", "Serum studies show a total bilirubin concentration of 3.2 mg/dL, direct bilirubin concentration of 2.5 mg/dL, and alkaline phosphatase level of 450 U/L.", "Magnetic resonance cholangiopancreatography shows focal areas of intrahepatic bile duct strictures alternating with areas of dilation."]}
{"Patient Personal Background": ["Her past medical history is notable for mild intermittent asthma, gout, and obesity.", "She uses an albuterol inhaler as needed and takes allopurinol.", "She has had 5 sexual partners in the past year and uses the pull-out method for contraception.", "She has a 10-pack-year smoking history and drinks 10-12 alcoholic beverages per week."], "Patient Symptoms": ["She first noticed the lesion 3 days ago.", "The patient describes the lesion as painful and swollen.", "She denies vaginal discharge."], "Examination and Results": ["On exam, she has an ulcerated, tender, and purulent ulcer on the left labia majora.", "The patient has mild unilateral painful inguinal lymphadenopathy."]}
{"Patient Personal Background": ["The patient reports no smoking or alcohol use but mentions that he had tried cocaine and heroin in his 20s and 30s."], "Patient Symptoms": ["He mentions that lately, he has been feeling increasingly restless and is unable to control feelings of nervousness pertaining to all his daily tasks.", "He noticed that these feelings were more prominent in the last 2 months but have been present on and off for the last year.", "On many occasions, his mind will be racing with thoughts that keep him up at night.", "During these moments, he finds his heart racing and feels light-headed and dizzy to the point of blacking out.", "He has also been experiencing back and neck pain with increased muscle tension in these areas."]}
{"Patient Personal Background": ["She has systemic lupus erythematosus and hypertension.", "Prior to hospitalization, her medications included nifedipine and prednisolone."], "Patient Symptoms": ["Examination shows central obesity."], "Examination and Results": ["Her pulse is 112/min and blood pressure is 90/64 mm Hg.", "The abdomen is soft and non-tender, and the laparoscopic incisions have no discharge.", "Her serum cortisol and serum ACTH are decreased."]}
{"Patient Personal Background": ["The patient has attended many prenatal appointments and followed her physician's advice about screening for diseases, laboratory testing, diet, and exercise.", "She has no history of a serious illness.", "Her first child was delivered via normal vaginal delivery."], "Examination and Results": ["Her vital signs are within normal limits.", "Cervical examination shows 100% effacement and 10 cm dilation."], "Others": ["Her pregnancy has been uncomplicated.", "A cardiotocograph is shown."]}
{"Patient Personal Background": ["She has a past medical history of Hashimoto\u2019s thyroiditis."], "Examination and Results": ["Her hematocrit is 29%.", "On peripheral blood smear, you notice neutrophils with 7 lobes and large oval-shaped red blood cells.", "On physical exam, you notice the patient has decreased position sense and a loss in vibratory sensation in her lower extremities."]}
{"Patient Personal Background": ["He has a medical history significant for chronic obstructive pulmonary disease and osteoarthritis.", "He smoked 2 and a half packs per day, and had done so for the past 26 years.", "After ceasing tobacco use for 1 year, he has recently begun smoking again."], "Patient Symptoms": ["This has been progressively worsening.", "On physical examination, the patient appears disoriented and is only somewhat comprehensible."], "Examination and Results": ["The blood pressure is 138/88 mm Hg, the respiratory rate is 12/min, the heart rate is 76/min, and the pulse oximetry is 87% on room air.", "The pupils are equal, round, and reactive to light with extraocular movements intact.", "Cranial nerves VII-XII also intact.", "The auscultation of the heart is absent of murmur, rubs, or gallops.", "The auscultation of the lungs demonstrate audible rales in the bases bilaterally."], "Treatment": ["He takes albuterol, ipratropium and aspirin."]}
{"Patient Symptoms": ["He admits that he has noticed himself flirting with some of the female co-workers at his new workplace.", "When he goes on a dinner date with his wife after work one evening, he accuses her of giving their waiter flirtatious looks and asks her whether she has been cheating on him or trying to spend time with other men."]}
{"Patient Personal Background": ["Her previous menstrual cycles were regular, occurring every 28\u201335 days consistently.", "Her past medical history reveals two uncomplicated and normal vaginal deliveries at term.", "She has a 2-year-old boy and a 6-month-old girl.", "The patient and her partner use the withdrawal method for contraception."], "Patient Symptoms": ["The patient does not have any other complaints currently."], "Examination and Results": ["The urine pregnancy test result is positive."], "Others": ["The patient returns to the clinic after 1 week expressing her desire to discontinue with the pregnancy and inquires about the possibility of an elective abortion."]}
{"Patient Symptoms": []}
{"Patient Personal Background": ["His past medical history is significant for diabetes, hypertension, and early stage prostate cancer that was removed 10 years ago without recurrence.", "He has smoked 1 pack per day for the past 55 years and drinks about 6 drinks per week."], "Patient Symptoms": ["He says that he used to enjoy playing golf with his friends but now he cannot walk for long enough to play.", "The shortness of breath is now starting to complicate his ability to get around in daily life."], "Examination and Results": ["On presentation he is found to be breathing with pursed lips.", "Physical exam reveals decreased breath sounds on auscultation, increased chest diameter, and hyperresonance to percussion."]}
{"Patient Symptoms": ["He reports that over the past month he has become more easily \u201cwinded\" to the point that he now sleeps in his living room because he can\u2019t make it up the stairs.", "A review of systems is notable for headaches and fatigue."], "Examination and Results": ["On physical exam you note decreased breath sounds and a dullness to percussion on the right.", "A chest radiograph is obtained, which shows a right-sided pleural effusion."]}
{"Patient Personal Background": ["This is her fourth loss in the second trimester and she is concerned about her inability to have a successful pregnancy."], "Examination and Results": ["She is otherwise healthy and has no acute complaints.", "Her vitals are unremarkable and exam is notable only for a firm, asymmetric uterus.", "Laboratory studies are ordered as seen below."]}
{"Patient Personal Background": ["She has suffered from seasonal allergies for the past 2 years and takes diphenhydramine as needed when her symptoms worsen.", "She has not yet seen a physician for her allergies.", "Her past medical history is also notable for well-controlled asthma.", "She uses an albuterol inhaler on an as-needed basis.", "She smokes marijuana daily."], "Patient Symptoms": ["She reports that diphenhydramine has been helpful in controlling her symptoms, but she does not like feeling drowsy from the medication.", "Her nasal turbinates are boggy and bluish-gray.", "She has copious thin and watery nasal mucus."], "Examination and Results": ["Her temperature is 99.2\u00b0F (37.3\u00b0C), blood pressure is 120/70 mmHg, pulse is 76/min, and respirations are 16/min.", "She has a prominent nasal crease.", "Her nasal turbinates are boggy and bluish-gray.", "She has copious thin and watery nasal mucus."], "Treatment": ["The physician suggests replacing diphenhydramine with fexofenadine to improve her drowsiness."]}
{"Patient Personal Background": ["He reports that he worked in a naval shipyard for 10 years during his twenties."], "Examination and Results": ["His vital signs were within normal limits.", "A CT scan of his chest shows diffuse thickening of the pleura and a diagnosis of mesothelioma is made."], "Diagnosis": ["A CT scan of his chest shows diffuse thickening of the pleura and a diagnosis of mesothelioma is made."]}
{"Patient Personal Background": ["He states that he has abstained from alcohol and attends a support group regularly.", "He has not taken any new medications or encountered any sick contacts."], "Examination and Results": ["The patient's blood pressure is 110/70 mmHg, pulse is 65/min, and respirations are 15/min.", "His physical exam is grossly unremarkable.", "He has brought an gastroduodenoscopy report for review, which reveals that the patient has small esophageal varices with red spots."]}
{"Patient Symptoms": ["Upon first inspection you note the man is drooling and his eyes are tearing excessively.", "The patient seemed confused so the wife brought him in promptly, and states it has only been ten minutes since the patient was found down in the fields.", "Physical exam is deferred due to a confused and combative patient who is speaking clearly yet his sentences do not make any sense."], "Treatment": ["Vital signs are currently being obtained."], "Others": ["The patient's wife explains that the man was tilling the fields on the family beet farm when she found him collapsed on a pile of freshly picked beets.", "The patients clothes are removed in the ED."]}
{"Patient Personal Background": ["The past medical history includes hypertension.", "His diet is full of vegetables.", "He exercises every day.", "He has no history of smoking.", "He had a brother who died at the age of 84 due to hematologic malignancy."], "Patient Symptoms": ["He has no complaints other than occasional knee pain."], "Examination and Results": ["The temperature is 36.8\u2103 (98.2\u2109), and the blood pressure is 125/85 mm Hg.", "The physical examination shows no abnormalities other than a reduced range of motion and crepitus in both knees.", "The laboratory test results are as follows:\nHemoglobin 15 g/dL\nLeukocyte count 58,000/mm3\nPlatelet count 250,000/mm3\nFlow cytometry on the peripheral blood reveals an absolute lymphocyte count of 50,000/mm3."], "Treatment": ["He has had knee osteoarthritis for several years and takes occasional acetaminophen for pain control."]}
{"Patient Personal Background": ["He has a history of pulmonary tuberculosis."], "Examination and Results": ["He is afebrile.", "Pulmonary examination shows inspiratory crackles at the left infraclavicular area.", "An x-ray of his chest shows a radiopaque mass in the left upper lung lobe that shifts upon repositioning.", "A sputum sample does not grow acid-fast bacteria despite multiple cultures."]}
{"Patient Personal Background": ["He was delivered at home in Romania.", "His mother had no prenatal care.", "She reports that he has required more time to reach developmental milestones compared to his older brother.", "The patient's immunization records are not available.", "He takes no medications."], "Patient Symptoms": ["He has not had fever, cough, or a runny nose.", "He has poor eye contact."], "Examination and Results": ["He appears pale with blue eyes and has a musty odor."], "Others": ["He has been healthy, except for occasional eczema."]}
{"Diagnosis": ["He rejects his null hypothesis and concludes that low birth weight is associated with obesity."], "Others": ["He conducts a study with a 95% confidence interval with a p-value of 0.049 to disprove his null hypothesis."]}
{"Patient Personal Background": ["The patient has a past medical history of anxiety and depression and is currently taking fluoxetine."], "Patient Symptoms": ["The patient states that she has been experiencing watery diarrhea for weeks now.", "During this same period she states she has been constantly thirsty and does not have the same energy levels that she once had."], "Examination and Results": ["Her temperature is 99.5\u00b0F (37.5\u00b0C), blood pressure is 110/58 mmHg, pulse is 100/min, respirations are 17/min, and oxygen saturation is 98% on room air.", "Laboratory values are obtained and shown below."], "Treatment": ["She was recently treated for a middle ear infection and sinusitis with amoxicillin-clavulanic acid one week ago."]}
{"Patient Personal Background": ["The patient was born at term and had his first bowel movement at 50 hours of life.", "He has since had one bowel movement daily.", "He is at the 50th percentile for length, 10th percentile for weight, and 40th percentile for head circumference."], "Patient Symptoms": ["The vomitus is greenish in color and smells strange.", "His parents have tried to feed him every 4 hours, but the patient often spits up or refuses to eat.", "The abdomen is distended."], "Examination and Results": ["He does not appear to be in acute distress.", "His temperature is 36.9\u00b0C (98.4\u00b0F), pulse is 140/min, respirations are 40/min, and blood pressure is 90/60 mm Hg.", "Physical examination shows that the patient has small, low-set ears, a broad and flat nasal bridge, and a large space between the first and second toes bilaterally.", "When the finger is removed following a rectal exam, there is an explosive release of stool from the patient's rectum.", "An x-ray of the abdomen shows a section of dilated colon followed by a segment of colon without stool or air."]}
{"Patient Personal Background": ["His mother has been giving him ibuprofen at night for \u201cgrowing pains,\u201d but his symptoms have not improved."], "Patient Symptoms": ["One week before the pain started, the patient was hit in the thigh by a baseball, which caused his leg to become red and swollen for several days.", "Examination shows marked tenderness along the left mid-femur."], "Examination and Results": ["Vital signs are within normal limits.", "His gait is normal.", "Laboratory studies show a leukocyte count of 21,000/mm3 and an ESR of 68 mm/h.", "An x-ray of the left lower extremity shows multiple lytic lesions in the middle third of the femur, and the surrounding cortex is covered by several layers of new bone.", "A biopsy of the left femur shows small round blue cells."]}
{"Patient Symptoms": ["During your meeting, you note that the patient is exhibiting the defense mechanism of suppression."], "Examination and Results": ["You intend to discuss the results from his recent surveillance colonoscopy, which showed no remaining cancer, no polyps, and a well-healed anastmosis."]}
{"Patient Personal Background": ["The past medical history is significant for hypercholesterolemia, for which he takes lovastatin.", "He smoked as a youth but quit at 40 years of age."], "Patient Symptoms": ["The pain radiates to his left shoulder and is associated with sweating.", "He is sweating profusely."], "Examination and Results": ["On arrival at the emergency department, the vital signs were as follows: pulse 58/min, respiratory rate 22/min, and blood pressure 90/56 mm Hg.", "The jugular venous pulse is visible 2.5 cm above the sternal angle.", "Auscultation reveals soft S1 and S2 heart sounds with an added S4 and bilateral inspiratory crackles at the lung bases.", "The electrocardiogram shows ST-elevations in leads V1 and V2."], "Treatment": ["The patient was given aspirin on the way to the hospital.", "He is started on dopamine, morphine, nitroglycerin, and streptokinase."], "Diagnosis": ["A diagnosis of an anteroseptal infarction is made."]}
{"Patient Personal Background": ["He has a history of chronic progressive dyspnea over the past five years.", "His past medical history is notable for hyperlipidemia and hypertension.", "He drinks alcohol socially and has a 45 pack-year smoking history."], "Patient Symptoms": ["He has a history of chronic progressive dyspnea over the past five years.", "He uses oxygen at home and was seen in the emergency room two months prior for an exacerbation of his dyspnea."], "Examination and Results": ["His temperature is 98.6\u00b0F (37\u00b0C), blood pressure is 140/75 mmHg, pulse is 110/min, and respirations are 22/min.", "On examination, increased work of breathing is noted."], "Treatment": ["The physician decides to start the patient on an additional medication that has both mucoactive and anti-oxidative properties."], "Others": ["He was discharged following stabilization."]}
{"Patient Personal Background": ["Her pregnancy has been uncomplicated.", "Her two other children were born after uncomplicated vaginal deliveries at 41 and 42 weeks' gestation, respectively.", "Her only medication is a prenatal vitamin."], "Examination and Results": ["She is 165 cm (5 ft 5 in) tall and weighs 86 kg (200 lb); BMI is 33 kg/m2.", "Her temperature is 36.8\u00b0C (98.4\u00b0F), pulse is 90/min, respirations are 14/min, and blood pressure is 110/80 mmHg.", "Examination shows a nontender, soft uterus consistent in size with a 42-weeks' gestation."]}
{}
{"Patient Symptoms": ["She was found unconscious on a park bench by a bystander.", "Her breathing is shallow.", "The pupils are constricted, and a response to light cannot be determined."], "Examination and Results": ["Her history is unobtainable.", "Vitals include a pulse of 64/min, a respiratory rate of 7/min, and a blood pressure of 110/70 mm Hg.", "On examination, the patient is unresponsive to voice and touch but shows a flexor response to pain."]}
{"Diagnosis": ["After a thorough workup, you determine that the patient has pancreatic cancer."]}
{"Patient Personal Background": ["Past medical history is significant for well-controlled schizophrenia.", "He takes a low-potency typical antipsychotics and a multivitamin every day.", "He has been compliant with his medication and has regular follow-up visits."], "Patient Symptoms": ["He complains of mild vision impairment over the last 6 months.", "His vision has continued to slowly deteriorate and his condition is now affecting his night driving."]}
{"Patient Personal Background": ["He is a vegetarian.", "The patient denies any smoking history, alcohol consumption, or illicit drug use."], "Patient Symptoms": ["The patient\u2019s family says that he had been high functioning but has had significant behavioral changes over the past year.", "He is irritable, paranoid, and delusional but denies any hallucinations.", "An unstable, wide-based ataxic gait is noted."], "Examination and Results": ["No significant family history.", "His vital signs include: blood pressure 90/50 mm Hg without postural changes, pulse 92/min, respiratory rate 16/min, temperature 37.0\u2103 (98.6\u2109).", "Physical examination reveals a poorly groomed, disheveled, thin man.", "Laboratory results are significant for the following:\nHb 6.1 g/dL\nMCV 109 fL\nPlatelets 90,0000/mm3\nTotal count 3,000/mm3\nReticulocyte count 0.8%\nA peripheral blood smear demonstrates hypersegmented neutrophils.", "Anti-intrinsic factor antibodies are negative."]}
{"Patient Personal Background": ["He has recently migrated from Sweden and has not had any checkups in the last 3 years.", "He has been a smoker for 13 years."], "Patient Symptoms": ["He first started having back pain 3 years ago, but his pain has begun to be excruciating in the mornings.", "He is no longer able to get relief with over the counter medications.", "He also feels stiff every morning and this usually lasts between 30 minutes and an hour.", "Both of his knees are also very painful, particularly upon standing up from a seated position.", "His pain improves when he moves around, so he tries to be somewhat physically active.", "He also reports that he cannot use his hands for long periods of time due to joint pain and stiffness."], "Examination and Results": ["Upon physical examination, his wrist and proximal interphalangeal (PIP) joints are warm and swollen."], "Others": ["His father and sister also have joint issues, and his mother was recently diagnosed with osteoporosis."]}
{"Patient Personal Background": ["Prior to the onset of the symptoms, he attended a bachelor party where he lost several drinking games."], "Examination and Results": ["An ECG is shown."]}
{"Patient Personal Background": ["She takes lisinopril for hypertension."], "Patient Symptoms": ["She has recently avoided drinking alcohol and eating spicy food because it worsens her diarrhea and causes episodes of heart palpitations and reddening of the face and neck."], "Examination and Results": ["Her temperature is 36.5\u00b0C (97.7\u00b0F), pulse is 98/min, and blood pressure is 149/90 mm Hg.", "The abdomen is soft, and there is mild tenderness to palpation with no guarding or rebound.", "Laboratory studies show an increased urine 5-hydroxyindoleacetic acid concentration."]}
{"Patient Personal Background": ["Medical history is significant for hypertension, hyperlipidemia, and chronic obstructive pulmonary disease (COPD).", "He has smoked approximately 1 pack of cigarettes per day for the past 45 years."], "Patient Symptoms": ["His cough has been increasing in frequency and severity over the course of 3 days, and his sputum production has increased in volume.", "The color of his sputum is yellow-green.", "He denies any chest pain or palpitations but has experienced worsening shortness of breath with exertion and at rest, which is above his baseline."], "Examination and Results": ["His temperature is 102\u00b0F (38.9\u00b0C), blood pressure is 156/94 mmHg, pulse is 101/min, and respirations are 26/min with an oxygen saturation of 85% on room air.", "On physical exam, the patient has difficulty speaking, and there is asynchronous motion between the chest and abdomen with respiration.", "Wheezing is appreciated on pulmonary auscultation.", "An ECG demonstrates normal sinus rhythm."], "Treatment": ["He is started on ipratropium, albuterol, and methylprednisolone."], "Others": ["He has not noticed any changes in his weight or edema in his lower extremities.", "He denies any recent history of long travel.", "He has been hospitalized four times for similar symptoms within the last year."]}
{"Patient Personal Background": ["His past medical history is unremarkable."], "Patient Symptoms": ["He reports he has lost 4 kg (8.8 lb) in the last two months with no changes in his diet.", "He has also been suffering from mild to moderate joint pain in the left knee for the last year."], "Examination and Results": ["His vitals include: blood pressure 120/70 mm Hg, temperature 37.0\u2103 (98.6\u2109), pulse 70/min, respiratory rate 14/min.", "Physical examination is significant for nasal ulcers.", "Diffuse crackles are present over all lobes of the lung bilaterally.", "Laboratory findings are significant for the following:\nHemoglobin 12.9 g/dL\nHematocrit 37.7%\nLeukocyte count 5500/mm3\nNeutrophils 65%\nLymphocytes 30%\nMonocytes 5%\nMean corpuscular volume 82.2 \u03bcm3\nPlatelet count 190,000/mm3\nErythrocyte sedimentation rate 35 mm/h\nC-reactive protein 14 mg/dL\nCreatinine 3.09 mg/dL\nThe patient is prescribed a corticosteroid nasal spray and oral antibiotics but returns in 2 weeks without any clinical improvement."], "Treatment": []}
{"Patient Symptoms": ["The patient is found to be tachycardic and has marked edema and waxy discoloration in his legs."], "Examination and Results": ["Serum analysis shows increased levels of T4 and T3, as well as the presence of thyroglobulin-stimulating immunoglobulins."]}
{"Patient Personal Background": ["The patient was born at 35 weeks gestation to a 27-year-old gravida 4.", "The patient is of Ashkenazi Jewish descent, and the patient\u2019s parents denied all prenatal genetic testing.", "The pregnancy was uncomplicated until the patient\u2019s mother had spontaneous rupture of membranes at 35 weeks gestation.", "The patient\u2019s three older siblings are all healthy.", "In the hospital nursery, the patient\u2019s temperature is 98.2\u00b0F (36.8\u00b0C), blood pressure is 48/32 mmHg, pulse is 164/min, and respirations are 48/min."], "Patient Symptoms": ["On physical exam, he appears to be in moderate distress.", "He has no dysmorphic features, and his abdomen is distended and non-tender."], "Examination and Results": ["His mother is breastfeeding and has started to produce milk.", "The patient has been feeding well every two hours and is urinating over eight times per day.", "Bowel sounds are absent."]}
{"Patient Personal Background": ["Her medical history is significant for Alzheimer\u2019s dementia, coronary artery disease, diabetes mellitus, hypothyroidism, congestive heart failure, osteoarthritis and centrilobular emphysema.", "The patient takes memantine, atorvastatin, metformin, levothyroxine, lisinopril, aspirin, albuterol, and ipratropium."], "Patient Symptoms": ["She has no complaints during this visit but her daughter states that she is having difficulty locating objects such as the television remote, car keys, and her purse."], "Examination and Results": ["The patient\u2019s vitals are within normal limits today.", "Physical exam reveals an elderly female in no acute distress, oriented to person, place and year, but not to month or day of the week.", "She has a 3/6 holosystolic murmur at the left sternal border along with an S3 gallop.", "There are mild crackles at the lung bases.", "A previous urine culture reports growth of > 100,000 CFU of Enterobacter."], "Others": ["The remainder of the exam is normal."]}
{"Patient Personal Background": ["She has a history of rheumatoid arthritis and was started on a new medication 4 months ago."], "Patient Symptoms": ["Over the past 2 months, she has had increasing fatigue and difficulties concentrating."], "Examination and Results": ["Examination shows pallor of the mucosal membranes and three tender ulcerative lesions in her mouth.", "Her hemoglobin concentration is 8.7 g/dL and mean corpuscular volume is 109 \u03bcm3.", "A blood smear shows hypersegmented neutrophils."]}
{"Patient Personal Background": ["She admits to having unprotected sex with a male partner a month ago while she was traveling in Southeast Asia."], "Patient Symptoms": ["She says that her symptoms began 4 days ago as a painful mass that slowly enlarged, ruptured, and ulcerated.", "However, she denies fever, chills, dysuria, or hematuria.", "Three weeks prior to her current symptoms she noted a small, painless ulcer on her labium majorum that resolved after a few days."], "Examination and Results": ["Temperature is 99\u00b0F (37.2\u00b0C), blood pressure is 139/84 mmHg, pulse is 76/min, and respirations are 18/min.", "Physical examination is significant for left-sided, tender, ulcerative lymph nodes with a dark discoloration."]}
{"Patient Personal Background": ["The patient was on 2 antihypertensive medications and a statin, but she was not receiving any antiplatelet drugs."], "Patient Symptoms": ["Initial examination shows global aphasia, right homonymous hemianopia, and hemisensory loss."], "Examination and Results": ["She has a blood pressure of 136/94, heart rate of 84/min, and respiratory rate of 15/min.", "An acute ischemic stroke caused by distal left internal carotid artery occlusion with salvageable penumbral tissue is diagnosed based on a non-contrast CT scan, brain MRI, and catheter cerebral angiogram."], "Treatment": ["Intravenous tissue plasminogen activator is given as treatment within 3 hours of presentation."], "Diagnosis": ["An acute ischemic stroke caused by distal left internal carotid artery occlusion with salvageable penumbral tissue is diagnosed based on a non-contrast CT scan, brain MRI, and catheter cerebral angiogram."]}
{"Others": ["If these waste products are not cleared by the liver and kidneys, hyperammonemia can occur, leading to confusion and delirium.", "Fortunately, a healthy liver can clear these waste products via the urea cycle."]}
{"Patient Personal Background": ["The patient denies any smoking history, alcohol, or recreational drug use.", "He was diagnosed with type 2 diabetes mellitus 1 year ago and has had difficulty controlling his blood glucose levels."], "Patient Symptoms": ["He says the pain is most severe in the proximal parts of his fingers and his wrists, but it has now spread to his elbows, and, occasionally, his knees.", "He says the joint involvement is symmetric.", "He also complains of morning joint stiffness that improves with activity and reports feeling fatigued during the day.", "A review of systems is significant for a weight loss of 3.0 kg (6.6 lb) over the last 3 months despite no change in diet or activity level."], "Treatment": ["He started taking ibuprofen 2 months ago for the pain which initially subsided, but, over the last few weeks, it has worsened despite the medication."]}
{"Patient Personal Background": ["Current medications include folic acid and a multivitamin."], "Examination and Results": ["A rectovaginal swab culture grows bacitracin-resistant colonies of gram-positive cocci with surrounding areas of clear hemolysis."]}
{"Patient Personal Background": ["Her parents note that she was diagnosed with a heart murmur, but it was never treated."], "Patient Symptoms": ["They state that their daughter has recently been more irritable than usual, and she occasionally becomes pale and blue.", "She is laying on the examination table with her knees drawn to her chest."], "Examination and Results": ["Physical examination reveals a small child in distress.", "Cardiac auscultation reveals a harsh, systolic ejection murmur that is best heard at the upper left sternal border."]}
{"Patient Symptoms": ["The patient was an unrestrained passenger in a motor vehicle crash and was ejected from the vehicle after collision.", "He is noted to have multiple ecchymoses over his body, as well as petechiae and purpura.", "He has a laceration over his clavicle that continues to bleed despite a pressure bandage.", "Two large bore IV lines are placed, and the patient oozes from around the sites of venepuncture."], "Examination and Results": ["Upon arrival to the trauma bay, the patient has a Glasgow coma scale (GCS) of 6.", "He is rapidly intubated, and vitals are a temperature of 99.5\u00b0F (37.5\u00b0C), pulse of 130 bpm, and blood pressure of 83/64 mmHg.", "Radiographs of his lower extremity show multiple long bone fractures.", "Labs are notable for a WBC of 20,000/mm^3, Hb of 10.1g/dL, platelets of 48,000/mm^3, and prolongation of the PT and aPTT."], "Treatment": ["He is rapidly intubated, and vitals are a temperature of 99.5\u00b0F (37.5\u00b0C), pulse of 130 bpm, and blood pressure of 83/64 mmHg.", "Two large bore IV lines are placed, and the patient oozes from around the sites of venepuncture."]}
{"Patient Personal Background": ["His personal medical history is relevant for frequent visits to the ER for lower gastrointestinal bleeding in the last month with a recent colonoscopy that reported an ulcerative lesion suggestive of colorectal cancer.", "He has not been subjected to dental procedures recently, and he denies the use of psychoactive drugs."], "Patient Symptoms": ["His palms and soles show non-tender erythematous lesions."], "Examination and Results": ["He is found with a blood pressure of 100/80 mm Hg, a heart rate of 84/min, an elevated respiratory rate, and a holosystolic heart murmur III/VI.", "A chest plain film shows clear lungs and mild cardiomegaly, and echocardiography reports the presence of vegetations involving the mitral valve."]}
{"Patient Personal Background": ["His past medical history is only notable for a recent office note from his primary care doctor for treatment of seasonal allergies."], "Patient Symptoms": ["Physical exam is notable for a man who is very irritable and restless.", "The patient is answering questions and states he wants to kill himself."], "Examination and Results": ["His temperature is 101\u00b0F (38.3\u00b0C), blood pressure is 173/97 mmHg, pulse is 105/min, respirations are 16/min, and oxygen saturation is 98% on room air.", "He is not cooperative with exam or history and becomes combative requiring intramuscular medications and security restraining him.", "After this event, the rest of his exam is notable for 7 mm pupils which are equal and reactive to light, spontaneous movement of all limbs, normal sensation, and warm and sweaty skin."], "Treatment": ["He is not cooperative with exam or history and becomes combative requiring intramuscular medications and security restraining him."]}
{"Patient Symptoms": ["Upon further questioning, it is found that although his sleeping hours are adequate, he does not feel refreshed in the morning.", "His wife complains that he snores loudly all night."], "Examination and Results": ["After ruling out common medical disorders and possible drug abuse, he is advised an overnight polysomnogram that records 12 episodes of apnea and 30 episodes of hypopnea during a 7-hour sleep."]}
{"Patient Personal Background": ["The patient is a retired welder and has been living with his son since his wife passed away 5 years ago.", "He denies any smoking history or current alcohol or drug use."], "Patient Symptoms": ["He feels short of breath even without exertion and states he \u2018got winded\u2019 while walking to his bedroom last night.", "He describes his cough as non-productive and says he can identify no recognizable triggers."], "Examination and Results": ["His vital signs include: pulse rate 72/min, respiratory rate 15/min, blood pressure 134/80 mm Hg, and temperature 36.8\u00b0C (98.0\u00b0F).", "On physical examination, digital clubbing is noted.", "Bilateral basilar fine crackles on noted on pulmonary auscultation.", "Expiratory flow rates are measured and found to be high when corrected for lung volume.", "A chest X-ray is performed and shown in the image below."], "Others": ["No significant past medical history."]}
{"Patient Personal Background": ["She underwent a hysterectomy 9 years ago for leiomyomata uteri.", "She has a 5-year history of hypertension treated with lisinopril."], "Patient Symptoms": ["Examination shows a mildly tender abdominal wound without erythema."], "Examination and Results": ["Her temperature is 39.5\u00b0C (102.3\u00b0F), pulse is 90/min, respirations are 18/min, and blood pressure is 125/90 mm Hg.", "The lungs are clear to auscultation.", "Cardiac examination shows no abnormalities.", "She had a Foley catheter and peripheral line access placed at the time of the procedure."], "Treatment": ["The patient received cephalexin for antibiotic prophylaxis and one unit of packed red blood cells during the procedure."]}
{"Patient Personal Background": ["He was born at 38 weeks' gestation to a 30-year-old woman, gravida 2, para 1, after an uncomplicated labor and delivery.", "The mother did not receive prenatal care.", "She takes codeine syrup frequently for dry cough."], "Patient Symptoms": ["Examination shows hyperreflexia, tremors, and an excessive startle response."], "Examination and Results": ["Apgar scores were 8 and 9 at 1 and 5 minutes, respectively.", "The infant's temperature is 37.8\u00b0C (100\u00b0F), pulse is 165/min, and blood pressure is 83/50 mm Hg.", "Complete blood count and serum levels of glucose, bilirubin, and calcium are within normal limits."], "Treatment": ["The baby is swaddled to prevent excoriations, and fluid resuscitation is initiated."]}
{"Patient Personal Background": ["The patient works in the adult entertainment industry."], "Patient Symptoms": ["She says that she first noticed these blisters shortly after returning from a weekend trip to the beach two weeks prior.", "She denies any fevers, joint pains, or other skin rash during this period."], "Examination and Results": ["On examination, there are multiple flaccid blisters of the bilateral dorsal hands with hemorrhagic crusts, mild scarring, and hyperpigmentation.", "In addition, increased hair growth is noted on the bilateral malar cheeks.", "Her temperature is 99.1\u00b0 F (37.3\u00b0 C), pulse is 95/min, blood pressure is 130/87 mmHg, respirations are 13/min, and oxygen saturation is 98% on room air."]}
{"Patient Personal Background": ["Past history involves congestive heart failure (CHF)."], "Patient Symptoms": ["This has onset over the past 3 weeks, progressively worsening."], "Examination and Results": ["Due to concerns of concurrent pneumonia, sputum studies are ordered.", "Microscopic examination of his sputum demonstrates heart failure cells (hemosiderin-containing macrophages)."]}
{"Patient Symptoms": ["On arrival, she is in acute distress but is fully oriented.", "20 hours later, she has several large, tarry black stools and develops hypotension and tachycardia."], "Treatment": ["Aggressive intravenous fluid resuscitation is begun and the patient is transferred to the intensive care unit of a burn center."], "Others": ["Despite appropriate lifesaving measures, she dies."]}
{"Patient Personal Background": ["His wife divorced him about 6 months ago and took the kids and moved out of state."], "Patient Symptoms": ["Since then he has had difficulty waking up in the morning and getting to work on time.", "He takes some comfort in food and has gained about 9.1 kg (20 lb).", "He eats out several times a week and sometimes consumes 2 whole meals in one sitting.", "Other than this new obsession with eating large quantities of food and excess sleeping he no longer enjoys doing things he liked doing in the past.", "Besides eating and sleeping he is always excited to see his children and looks forward to their visits.", "Additionally, he does not feel like he has the same drive or focuses at work."], "Examination and Results": ["His blood pressure is 119/81 mm Hg, pulse rate is 85/min, respiratory rate is 12/min, and the temperature is 36.8\u00b0C (98.2\u00b0F).", "His physical exam is normal."], "Others": ["He says it's the one thing keeping him going.", "He reports that he has no interest in hurting himself or others."]}
{"Patient Personal Background": ["He weighs 50-kg (110-lb)."], "Examination and Results": ["His pulse is 124/min and pulse oximetry on room air shows an oxygen saturation of 90%."], "Treatment": ["A diagnosis of pulmonary embolism is suspected and intravenous heparin is initiated."], "Diagnosis": []}
{"Patient Personal Background": ["He also mentions that his father and brother have lipomas over the extremities."], "Patient Symptoms": ["He noticed the swelling 6 months ago, but he ignored it because it was painless.", "However, he is now concerned as the swelling has been increasing in size over the last 6 months."], "Examination and Results": ["On physical examination, the swelling is well-circumscribed and non-tender, measuring approximately 4 x 5 cm.", "The pathologist reports the tumor to be a liposarcoma rather than a lipoma."], "Treatment": ["After evaluation, the surgeon performs a surgical resection of the tumor and sends the tissue for histopathological examination."], "Diagnosis": ["The pathologist reports the tumor to be a liposarcoma rather than a lipoma."]}
{"Patient Personal Background": ["Her past medical history is significant for asthma.", "Her father is not living and had Parkinson disease, and her mother has poorly controlled rheumatoid arthritis.", "She is currently sexually active in a monogamous relationship and uses contraception consistently.", "She denies cigarette smoking and occasionally drinks wine.", "She experimented once with lysergic acid diethylamide 6 years ago."], "Patient Symptoms": ["She says that she has been generally healthy but has noticed difficulty concentrating, becoming increasingly fatigued, and a 15-pound weight increase over the course of a few months.", "She also reports mild constipation and joint pain.", "Approximately 6-months ago, she experienced palpitations, increased stool frequency, and a hand tremor."], "Examination and Results": ["Her temperature is 99\u00b0F (37.2\u00b0C), blood pressure is 127/98 mmHg, pulse is 55/min, and respirations are 13/min.", "On physical exam, the patient has slow speech and movement.", "She has tenderness to palpation of her wrist and ankle joints.", "She has delayed relaxation of deep tendon reflexes."]}
{"Patient Personal Background": ["The mother has a history of schizophrenia and was treated with lithium until 5 weeks' gestation, when she found out that she was pregnant.", "The mother was treated for alcohol abuse disorder 2 years ago.", "She has been sober for 14 months now."], "Examination and Results": ["Apgar scores are 7 and 8, at 1 and 5 minutes, respectively.", "Examination shows that the child has micrognathia, a broad nasal bridge, a short philtrum, and small, low-set ears.", "Examination of the mouth shows a cleft palate.", "A grade 3/6 systolic ejection murmur can be heard over the left sternal border.", "Echocardiography shows a single overriding great vessel arising from the heart."]}
{"Examination and Results": ["Results from tumor markers and a biopsy are as follows:\nAFP 350 ng/mL (normal value < 10 ng/mL)\nhCG 0.4 IU/L (normal value < 0.5 IU/L)\nBiopsy: Presence of glomeruli-like structures with a central capillary within a mesodermal core, lined by flattened layers of germ cells."]}
{"Patient Personal Background": ["He says he has been hospitalized 3 other times this year for COPD exacerbations.", "The medical history is significant for a left main coronary artery myocardial infarction after a coronary artery bypass graft (CABG) 2 months ago, mild cognitive impairment, and type 2 diabetes mellitus.", "Current medications are metformin, aspirin, clopidogrel, metoprolol, atorvastatin, galantamine, and enalapril.", "He reports a 40-pack-year smoking history but quit 10 years ago.", "His temperature is 39.0\u00b0C (102.5\u00b0F); blood pressure is 100/75 mm Hg; pulse is 122/min; respiratory rate is 20/min, and oxygen saturation is 88% on room air."], "Patient Symptoms": ["He says that symptoms had an acute onset while he was in the ICU for a COPD exacerbation due to a recent upper respiratory infection, which was treated with nebulized albuterol and ipratropium bromide, continuous oxygen, IV methylprednisolone, and levofloxacin.", "A foul-smelling discharge is also noted.", "Pain seems out of proportion to the exam findings."], "Examination and Results": ["The physical examination is significant for the cutaneous finding shown in the picture.", "The involved area is severely tender to palpation and there are warmth and crepitus."], "Treatment": ["He says that symptoms had an acute onset while he was in the ICU for a COPD exacerbation due to a recent upper respiratory infection, which was treated with nebulized albuterol and ipratropium bromide, continuous oxygen, IV methylprednisolone, and levofloxacin."]}
{"Patient Personal Background": ["She says that the symptoms started after she went on a hike in the woods and foraged from plants along the way."], "Patient Symptoms": ["On presentation, she is found to be somnolent though she is able to be woken by vocal stimuli.", "She says that over the last 12 hours, she has been experiencing muscle spasms, blurred vision, dry mouth, and hallucinations.", "Her bladder is also found to be completely full though she says she is unable to urinate."], "Examination and Results": ["Physical exam reveals dry red skin and enlarged pupils.", "Her bladder is also found to be completely full though she says she is unable to urinate."]}
{"Patient Symptoms": ["However, she has noticed a small whistling noise when she respires through her nose, which you appreciate on physical exam."], "Examination and Results": ["However, she has noticed a small whistling noise when she respires through her nose, which you appreciate on physical exam."], "Others": ["The patient has been recovering well."]}
{"Patient Personal Background": ["She does not smoke or drink alcohol and takes no medications."], "Patient Symptoms": ["A friend of hers who also visited the spa has developed a similar rash."], "Examination and Results": ["Her vital signs are within normal limits.", "Examination shows multiple erythematous, excoriated papules and pustules over the trunk and upper thighs."], "Others": ["Three days ago, she visited a spa resort with multiple swimming pools and whirlpools.", "She appears well."]}
{"Examination and Results": ["Examination shows the right upper extremity is externally rotated and slightly abducted.", "There is loss of the the normal rounded appearance of the shoulder.", "The right humeral head is palpated below the coracoid process."]}
{"Patient Symptoms": ["The patient is conscious and tearful.", "She is currently complaining of severe abdominal pain but refuses to give any other history."], "Examination and Results": ["She has a blood pressure of 135/86, respiratory rate of 18/min, and heart rate of 86/min.", "On examination, her abdomen is exquisitely tender with evidence of crepitus in the epigastric region.", "Abdominal CT reveals a gastric perforation."], "Diagnosis": [], "Others": ["Her mother states that she found a large empty pill bottle next to her."]}
{"Patient Personal Background": ["Upon review, this patient reveals that he has not had care from a physician since he graduated from college.", "In the interim he has been largely unemployed and admits that he has recently been homeless.", "When asked directly, the patient admits to alcohol and marijuana use but denies illicit drug use."], "Patient Symptoms": ["He appears anxious and agitated and a careful exam reveals dilated pupils and a perforated nasal septum."], "Examination and Results": ["His blood pressure is 157/90 mmHg and his his pulse is 116/min.", "An EKG reveals ST segment elevation so he is urgently taken for cardiac intervention."], "Treatment": ["An EKG reveals ST segment elevation so he is urgently taken for cardiac intervention."]}
{"Patient Personal Background": ["She exercises regularly and eats a well-balanced diet.", "She admits that she has been under a lot of stress lately."], "Patient Symptoms": ["She wakes up frequently during the night and gets up earlier than desired.", "She experiences discomfort in her legs when lying down at night and feels the urge to move her legs.", "The discomfort resolves when she gets up and walks around or moves her legs.", "She has tried an over-the-counter sleep aid that contains diphenhydramine, which worsened her symptoms.", "Her brother has similar symptoms.", "The patient appears anxious."], "Examination and Results": ["Physical examination shows no abnormalities.", "A complete blood count and iron studies are within the reference range."], "Treatment": ["She has tried an over-the-counter sleep aid that contains diphenhydramine, which worsened her symptoms."]}
{"Patient Personal Background": ["She has hypertension and hyperlipidemia, for which she takes enalapril, furosemide, and simvastatin."], "Patient Symptoms": ["She reports that the pain radiates to her back and is associated with nausea."], "Examination and Results": ["Her temperature is 37.5\u00b0C (99.5\u00b0F), blood pressure is 84/58 mm Hg, and pulse is 115/min.", "The lungs are clear to auscultation.", "Examination shows abdominal distention with epigastric tenderness and guarding.", "Bowel sounds are decreased.", "Extremities are warm.", "Laboratory studies show:\nHematocrit 48%\nLeukocyte count 13,800/mm3\nPlatelet count 175,000/mm3\nSerum  \nCalcium 8.0 mg/dL\nUrea nitrogen 32 mg/dL\nAmylase 250 U/L\nAn ECG shows sinus tachycardia."]}
{"Patient Symptoms": ["Specifically, they have noticed that he has been exhibiting aggressive behavior as well as hyperactivity.", "In addition, he has had intellectual disability and is slow to hit developmental milestones."], "Examination and Results": ["Physical exam reveals coarse facies, short stature, and joint stiffness.", "Eye exam reveals no abnormalities of the cornea or lens."], "Others": ["Based on these findings, the patient is referred to a geneticist for further evaluation."]}
{"Patient Personal Background": ["He is relatively high functioning and currently has no additional significant medical conditions.", "He denies any current tobacco use, alcohol use, or illicit drug use."], "Examination and Results": ["He feels well and a physical examination shows that he is within normal limits.", "His vital signs include: temperature, 36.7\u00b0C (98.0\u00b0F); blood pressure, 126/74 mm Hg; heart rate, 87/min; and respiratory rate, 17/min."]}
{"Patient Personal Background": ["She has no relevant past medical history."], "Examination and Results": ["Her vital signs are within normal limits.", "On physical exam of the thyroid gland, a solitary nodule is palpated.", "It is fixed to the surrounding tissues and nontender.", "TSH is normal, and antithyroid antibodies are negative."]}
{"Patient Symptoms": ["His mother complains that he has been sleeping poorly, and she has noticed that he often scratches his perianal area."], "Examination and Results": ["A scotch tape test is found to be positive and mebendazole is prescribed."], "Treatment": ["A scotch tape test is found to be positive and mebendazole is prescribed."]}
{"Patient Personal Background": ["He has hypertension and takes hydrochlorothiazide."], "Patient Symptoms": ["On questioning, he has had some difficulty speaking for 3 months.", "During a conversation, he often has difficulty repeating what his interlocutor has said.", "When asked to say the word \u201ckindergarten,\u201d he replies with, \u201cSintelmarvin\u2026 no, that's wrong\u2026kinterflargin, no that isn't it either...kantolargen...no?"], "Examination and Results": ["His vital signs are within normal limits.", "The patient speaks fluently in full sentences and demonstrates normal comprehension."]}
{"Examination and Results": ["A representative sample of 100 men shows a normal distribution of hemoglobin concentration with a mean concentration of 17 g/dL and a standard error of 0.1 g/dL."]}
{"Patient Personal Background": ["She does not smoke or drink alcohol.", "She uses eyedrops for persistent dryness of the eyes."], "Patient Symptoms": ["She also reports generalized itchiness that started approximately 2 months ago.", "Two weeks ago, she noticed yellowing of her eyes."], "Examination and Results": ["Her vital signs are within normal limits.", "Physical examination shows jaundice of the conjunctivae and skin.", "The mucous membranes of the mouth are dry.", "The abdomen is soft.", "The liver edge is palpable 3 cm below the right costal margin.", "There are generalized skin excoriations.", "Laboratory studies show:\nHemoglobin 15 g/dL\nLeukocyte count 7,700/mm3\nPlatelet count 332,000/mm3\nSerum\nGlucose 122 mg/dL\nTotal bilirubin 3.1 mg/dL\nDirect 2.5 mg/dL\nAlkaline phosphatase 452 U/L\nAST 155 U/L\nALT 168 U/L\nHepatitis B surface antigen negative\nHepatitis B core IgM antibody negative\nHepatitis B surface antibody positive\nHepatitis C antibody negative\nUltrasonography of the abdomen shows mildly increased echogenicity of the liver."]}
{"Patient Personal Background": ["Currently, she is at her 29th week of gestation and has received the tetanus vaccination as part of the antenatal care program she received since she immigrated at the end of her first trimester from Romania.", "She is otherwise healthy."], "Patient Symptoms": ["She has a runny nose, mild headache, and feels achy.", "She has a mild fever and diffuse rash over her body."], "Treatment": ["She is concerned about the health of her baby and wants to know if there are any medications that will make her feel better in a short time."]}
{"Patient Symptoms": ["Some of the animals exposed to these bacteria develop symptoms of infection."], "Others": ["Animals exposed to the noninfectious isolate do not develop symptoms of infection.", "The investigator cultivates the noninfectious isolate in a culture with lysed bacteria from the infectious isolate."]}
{"Patient Personal Background": ["Her current medications include hydrochlorothiazide, levothyroxine, albuterol, oral contraceptives, and a multivitamin."], "Patient Symptoms": ["She has tried several different statins, all of which have resulted in bothersome side effects."], "Examination and Results": ["Her physical examination is unremarkable.", "Her blood pressure is 116/82 mm Hg and her heart rate is 82/min."], "Treatment": ["You decide to initiate colesevelam (Welchol)."]}
{"Others": ["This novel drug has the property where its clearance is relatively predictable based on patient demographics and can easily be extrapolated from other data.", "Its metabolism and volume of distribution also do not change dramatically from patient to patient.", "The investigator wants to make sure that the plasma concentration of the drug in this patient is 15 mg/L and he knows the following drug characteristics."]}
{"Patient Personal Background": ["His parents are recent immigrants to the United States.", "He was born in a traditional home birth and has never seen a medical provider.", "Mom had no prenatal care, has no medical issues, and is unvaccinated."], "Patient Symptoms": ["The baby had been breastfeeding well until 24 hours ago when mom noticed he started having trouble latching.", "In the last 12 hours, he has completely refused to feed.", "He has had a decreased number of wet diapers and has stooled twice in the last 24 hours."], "Examination and Results": ["His temperature is 98.6\u00b0F (37.0\u00b0C), pulse is 180/min, respirations are 52/min, and blood pressure is 70/50 mmHg.", "On exam, the infant has increased tone, a clenched jaw, no head lag, and clenched hands.", "Initial screening bloodwork is normal."]}
{"Patient Personal Background": ["She denies any history of smoking, alcohol use, or recreational drug use.", "The patient was on a trip to Thailand 2 years ago with her family but denies any recent travel."], "Examination and Results": ["Her blood pressure is 120/88 mm Hg, pulse is 78/min, temperature is 37.2\u00b0C (99.0\u00b0F), and respiratory rate is 16/min.", "Laboratory findings are unremarkable, except for a potassium level of 3.3 mmol/L and serum calcium of 11 mg/dL."], "Diagnosis": ["The attending physician suspects that this might be a case of a genetic mutation in the menin 1 gene on chromosome 11 and orders a genetic analysis."]}
{"Patient Personal Background": ["The patient was helping his son move this past weekend, and he noticed after the move that he had pain and weakness in his right shoulder.", "The patient has a past medical history of diabetes, obesity, and asthma.", "His current medications include albuterol, lisinopril, metformin, and glipizide."], "Patient Symptoms": ["The patient was helping his son move this past weekend, and he noticed after the move that he had pain and weakness in his right shoulder.", "The patient thought that this pain was just him being in poor shape so he started going to the gym and lifting weights which made his symptoms significantly worse."], "Examination and Results": ["On physical exam you note an obese gentleman who seems to be in pain.", "You note prominent weakness of external rotation of his right upper extremity.", "When you ask the patient to slowly lower his right arm to his side when he holds it overhead, you note that he suddenly drops his arm and appears to be in pain.", "The patient's strength is 1/5 for abduction of the right arm."]}
{"Examination and Results": ["Upon examination, the patient exhibits painless subcutaneous nodules on the back of the wrist, the outside elbow, and the front of the knees, as well as inflammation in the joints of the lower extremities."]}
{"Patient Personal Background": ["The patient was diagnosed with schizophrenia 4 years ago and has since tried several antipsychotic medications, none of which have been able to treat his negative symptoms."], "Patient Symptoms": ["He has changed to clozapine 2 weeks ago and says that he does feel better."], "Examination and Results": ["His physical exam is unremarkable, and he is responding appropriately to questioning."], "Treatment": ["He has changed to clozapine 2 weeks ago and says that he does feel better."], "Diagnosis": ["The patient was diagnosed with schizophrenia 4 years ago and has since tried several antipsychotic medications, none of which have been able to treat his negative symptoms."]}
{"Examination and Results": ["Auscultation of the lungs shows coarse crackles at the right upper posterior field.", "An x-ray of the chest shows an opacity in the right upper lobe.", "Sputum analysis shows acid-fast bacilli.", "Examination of the injected area 48 hours later shows no induration or erythema."], "Treatment": ["A small amount of tuberculin fluid is injected into the subcutaneous tissue on the left forearm."]}
{"Patient Personal Background": ["He does not have any significant past medical history.", "His vaccination records are up to date."], "Patient Symptoms": ["The patient\u2019s mother says that he has had a \u201crunning nose\u201d for the past few days However, he did not receive any treatment for it, and his condition rapidly worsened today.", "There is a petechial rash present on his chest, and he has some neck rigidity."], "Examination and Results": ["His temperature is 38.2\u00b0C (100.7\u00b0F), blood pressure is 90/50 mm Hg, heart rate is 120/min, and respiratory rate is 22/min.", "On physical examination, the patient is unresponsive.", "Empiric intravenous antibiotics are started, and a lumbar puncture is performed."], "Treatment": []}
{"Patient Personal Background": ["Following the operation, the man is started on a patient controlled analgesia (PCA) thought to be dosed adequately to control his pain in the face of his opioid tolerance."], "Patient Symptoms": ["He reports intense pain 6 hours after the conclusion of the surgery."], "Treatment": ["Following the operation, the man is started on a patient controlled analgesia (PCA) thought to be dosed adequately to control his pain in the face of his opioid tolerance."]}
{"Patient Symptoms": ["Within the first 24 hours after birth, the newborn develops fever and a yellow discoloration of skin and sclerae.", "Examination shows loss of flexion in the extremities, splenomegaly, and cyanosis."], "Examination and Results": ["Examination shows loss of flexion in the extremities, splenomegaly, and cyanosis.", "Laboratory studies show decreased haptoglobin levels and increased LDH levels.", "A photomicrograph of a peripheral blood smear is shown."]}
{"Patient Personal Background": ["She is currently on methimazole, which she last took approximately 1 week ago."], "Patient Symptoms": ["She is accompanied by her sister who says that her symptoms developed acutely and is unsure about what caused it.", "Approximately 5 days ago she developed an upper respiratory infection managed with bed rest and ibuprofen."], "Examination and Results": ["Her temperature is 105\u00b0F (40.6\u00b0C), blood pressure is 95/68 mmHg, pulse is 145/min, and respirations are 23/min.", "On physical examination, the patient has altered mentation and is agitated and diaphoretic.", "The patient also has a goiter, exophthalmos, warm skin, and a hand tremor."], "Treatment": ["She is started on intravenous fluids."]}
{"Patient Personal Background": ["His parents said that he has had a fever and cough for several days prior to presentation and was given an over the counter medication."], "Patient Symptoms": ["On presentation, he is found to be confused and very lethargic.", "His parents said that he has had a fever and cough for several days prior to presentation and was given an over the counter medication."], "Examination and Results": ["Physical exam of this patient reveals mild hepatomegaly and dry mucous membranes."]}
{"Patient Personal Background": ["She says she is postmenopausal, and her last menstrual period was 5 years ago."], "Examination and Results": ["A detailed workup is performed, and several premalignant lesions are found in her uterus."], "Treatment": ["The patient agrees to a hysterectomy.", "The surgical team decides to use an anesthesia protocol consisting of nitrous oxide, desflurane, and atracurium."]}
{"Patient Personal Background": ["Past medical history is noncontributory."], "Patient Symptoms": ["The symptoms usually resolve in 2 to 3 days.", "She has had these swelling events her whole life; however, they have become more debilitating recently.", "Last week she had an event that restricted her ability to eat and swallow."], "Examination and Results": ["Today, her physical exam is within normal limits.", "C1-inhibitor levels are ordered and found to be extremely low."], "Diagnosis": ["The treating physician has a strong suspicion of an inherited disorder."], "Others": ["Her father is alive and well with no significant medical history.", "Her mother and her maternal aunt have a similar condition.", "She brought a picture of her swollen hand as seen in the picture."]}
{"Patient Personal Background": ["Her earlier pregnancy was uncomplicated.", "She had an ultrasound scan 2 weeks ago that showed a live intrauterine pregnancy consistent with a 22-week gestation with no anomalies.", "She had a normal Pap smear 2 years ago."], "Examination and Results": ["She feels well.", "Vital signs are within normal limits.", "Pelvic examination shows a uterus consistent in size with a 24-week gestation.", "Her blood group and type is B positive."], "Others": ["This is her 4th prenatal visit."]}
{"Patient Personal Background": ["He is currently visiting the United States as a tourist from Turkey, where he works at a factory that processes sheep wool and hide."], "Examination and Results": ["An x-ray of the chest shows widening of the mediastinum.", "A sputum culture grows gram-positive rods in gray colonies that have irregular margins with wavy projections on microscopy."]}
{"Patient Personal Background": ["The pregnancy was complicated by gestational diabetes and fetal weight is estimated to be at the 90th percentile for gestational age."], "Examination and Results": ["Postpartum examination shows a third-degree laceration in the vagina extending into the perineum at the 6 o'clock position."], "Treatment": ["During delivery, there is an arrest in the second stage of labor, and a vacuum-assisted delivery is performed."]}
{"Patient Personal Background": ["His medications include pravastatin, lisinopril, and hydrochlorothiazide."], "Patient Symptoms": ["He reports a slow and steady weight gain of 6 pounds over the past 6 months, despite attempts to control his diet and increase his level of exercise."], "Examination and Results": ["On exam, his vital signs are stable.", "He is obese (BMI 32), and his waist circumference is 43 inches.", "His physician is concerned about an abnormal fasting blood glucose and dyslipidemia."], "Diagnosis": ["On further work-up with oral glucose tolerance test, the patient is diagnosed with diabetes."]}
{"Patient Symptoms": ["It has rapidly increased in size during this period.", "She does not have pain."], "Examination and Results": ["Vital signs are within normal limits.", "Examination shows large dense breasts; a 5-cm, nontender, multinodular mass is palpated in the right outer quadrant of the right breast.", "There are no changes in the skin or nipple.", "There is no palpable cervical or axillary adenopathy.", "Mammography shows a smooth polylobulated mass.", "Biopsy of the mass shows papillary projections of epithelial-lined stroma with hyperplasia and atypia."]}
{}
{"Patient Personal Background": ["He has no history of serious illness and takes no medication."], "Patient Symptoms": ["His mother said that when he tried to get out of bed that he was unable to stand without support.", "He also complained of prickling in his hands and feet.", "Three weeks ago, he had a fever, dry cough, and a sore throat.", "The fever and sore throat subsided a week after they began, but the cough is persisting."], "Examination and Results": ["His vital signs are within normal limits.", "The lungs are clear to auscultation.", "There is severe weakness in both lower extremities and mild sensory loss of the hands and feet.", "Knee and ankle jerk reflexes are absent.", "The remainder of the examination shows no abnormalities.", "Laboratory studies show:\nHemoglobin 12.0 g/dL\nLeukocyte count 6000/mm3\nSegmented neutrophils 64%\nEosinophils 2%\nLymphocytes 26%\nMonocytes 7%\nPlatelet count 160,000/mm3\nErythrocyte sedimentation rate 27 mm/h\nSerum\nNa+ 138 mEq/L\nCl- 101 mEq/L\nK+ 4.9 mEq/L\nHCO3- 26 mEq/L\nCa2+ 9.7 mg/dL\nCreatine kinase 93 U/L\nA lumbar puncture is performed; cerebrospinal fluid analysis shows a leukocyte count of 2/mm3, a glucose concentration of 60 mg/dL, and a protein concentration of 91 mg/dL."]}
{"Patient Personal Background": ["He has recently been fired from his job because he is always late and lost his fiancee as she could not deal with his habits anymore."], "Patient Symptoms": ["He explains that he has this fear that something terrible will happen to his house if he does not check every appliance, outlet, window and door lock, faucet, and light fixture before he leaves.", "He states that he must check everything 7 times in a specific order and if he goes out of order he must start from the beginning and perform it all over."], "Treatment": ["The physician explained that cognitive-behavioral therapy may be of assistance and also prescribed clomipramine."]}
{"Examination and Results": ["During the physical exam, the physician finds that the patient is hypertensive.", "Serum analysis reveals hyperglycemia."], "Diagnosis": ["The physician suspects a pituitary adenoma."]}
{"Patient Personal Background": ["He denies smoking, drinking alcohol, and using illicit drugs."], "Patient Symptoms": ["He complains of anxiety, nausea, abdominal cramping, vomiting, and diarrhea for three days.", "He appears restless."], "Examination and Results": ["His temperature is 37\u00b0C (98.6\u00b0F), pulse is 110/min, and blood pressure is 150/86 mm Hg.", "Physical examination shows dilated pupils, diaphoresis, and piloerection.", "His abdominal exam shows diffuse mild tenderness.", "There is no rebound tenderness or guarding.", "His hemoglobin concentration is 14.5 g/dL, leukocyte count is 8,000/mm, and platelet count is 250,000/mm3; serum studies and urinalysis show no abnormalities."]}
{"Patient Personal Background": ["He has smoked one pack of cigarettes daily for 35 years."], "Patient Symptoms": ["He has noticed that it is easier for him to climb the stairs after he has exercised.", "He has also had a 4.6-kg (10.1-lb) weight loss over the past 6 months."], "Examination and Results": ["Examination shows dry mucous membranes.", "The pupils are equal and react sluggishly to light.", "Muscle strength in the proximal lower extremity is initially 3/5 but increases to 5/5 after repeated muscle tapping.", "His achilles reflex is 1+."]}
{"Examination and Results": ["CT demonstrates a mass in the head of the pancreas, and biopsy is planned for the following day.", "Endoscopic ultrasound-guided biopsy the next morning confirms the diagnosis of pancreatic adenocarcinoma."], "Diagnosis": ["Endoscopic ultrasound-guided biopsy the next morning confirms the diagnosis of pancreatic adenocarcinoma."], "Others": ["The patient's daughter approaches you outside the room to request that the results of the biopsy not be shared with the patient.", "She asks that the results instead be shared with her and her brother, who is the patient's documented health care proxy.", "She explains that she and her brother have discussed the situation and decided that it is best to not inform the patient that she has cancer."]}
{"Patient Personal Background": ["He has been seen in the emergency room 5 times in the past 2 years for acute alcohol intoxication.", "His past medical history is notable for diabetes mellitus and gout.", "He takes metformin, glyburide, and allopurinol."], "Patient Symptoms": ["A positive fluid wave is noted.", "The dorsal surface of the tongue is depapillated, and there are erythematous swollen patches at the oral commissures."], "Examination and Results": ["His temperature is 98.6\u00b0F (37\u00b0C), blood pressure is 130/85 mmHg, pulse is 86/min, and respirations are 16/min.", "He is in no acute distress."]}
{"Examination and Results": ["His blood pressure is 50/20 mm Hg.", "The ECG monitor shows a tachycardic irregular rhythm with erratic undulations, but no discernible P waves or QRS complexes.", "After another attempt at defibrillation, the patient remains pulseless and his blood pressure is 60/35 mm Hg.", "The ECG monitor shows no changes."], "Treatment": ["During immediate advanced cardiac life support, two attempts at defibrillation are made, after which the patient is given 1 mg of IV epinephrine."]}
{"Patient Personal Background": ["He has a past medical history of type-2 diabetes mellitus, hypertension, hypercholesterolemia, and ischemic heart disease.", "In addition, he had an ischemic stroke 9 years ago, from which he recovered completely with physiotherapy and rehabilitation.", "He has a history of a 56-pack-year cigarette smoking habit.", "His medications include aspirin, atorvastatin, glimepiride, metformin, metoprolol, and ramipril."], "Patient Symptoms": ["The diplopia is more prominent on his left-side lateral gaze.", "He denies having fever, headache, ocular pain, lacrimation, changes in color vision, or limb weakness."], "Examination and Results": ["The mental status examination is unremarkable.", "His muscle strength is normal in all 4 limbs.", "His sensations are decreased on his left side, including his face.", "The examination of extraocular movements is shown in the image."]}
{"Patient Personal Background": ["The mother did not receive any prenatal care."], "Examination and Results": ["His respirations are 26/min.", "Physical examination shows sunken fontanelles, tightly clenched fists, and erythema around the umbilical cord stump."]}
{"Patient Personal Background": ["She recently retired after working for 28 years as a typist at a data entry firm."], "Patient Symptoms": ["The stiffness is worse at the end of the day."], "Examination and Results": ["Physical examination shows swelling, joint-line tenderness, and decreased range of motion of the first metacarpophalangeal joint and the distal interphalangeal joints of the right hand.", "Discrete, hard, mildly tender nodules are palpated over the 2nd and 4th distal interphalangeal joints of the right hand.", "An x-ray of her right hand shows narrowing of the interphalangeal joint spaces with subchondral sclerosis and osteophytes."]}
{"Patient Personal Background": ["He attributes these to a poor diet.", "He also complains that the nurse practitioner at the facility started him on 4 new medications, in addition to his existing prescriptions."], "Examination and Results": ["On physical examination, tense axillary bullae are noted that do not rupture with light, gloved touch.", "On direct immunofluorescence, linear C3 and IgG deposits are seen along the basement membrane."], "Treatment": ["He also complains that the nurse practitioner at the facility started him on 4 new medications, in addition to his existing prescriptions."]}
{"Patient Personal Background": ["He recently started basic infantry training and has been running several kilometers daily."], "Patient Symptoms": ["Initially, the pain only occurred while running, but now it is also present at rest.", "The pain is located diffusely over the right forefoot.", "He walks with an antalgic gait."], "Examination and Results": ["Vital signs are within normal range.", "Examination shows mild swelling over the distal right forefoot.", "Pressing the metatarsal of the third right toe results in pain.", "The remainder of the examination shows no abnormalities.", "An x-ray of the right foot shows a slight loss of cortical density and callus formation at the third metatarsal shaft."]}
{"Patient Personal Background": ["She was born at 38 weeks' gestation and required bag-mask resuscitation immediately after delivery.", "Pregnancy was uncomplicated."], "Patient Symptoms": ["Her mother has noticed the bluish lip discoloration worsen when she fed and improve when she cried."], "Examination and Results": ["The patient's pulse is 163/min, respirations are 62/min, and blood pressure is 60/30 mm Hg.", "The crying infant's lungs are clear to auscultation."]}
{"Patient Symptoms": ["The symptoms began 5 minutes after she ate a peanut butter sandwich.", "There is stridor on auscultation of the chest."], "Examination and Results": ["Her respirations are 36/min and blood pressure is 84/50 mm Hg."], "Treatment": ["She is intubated and mechanical ventilation is begun.", "Intravenous fluid resuscitation and the appropriate pharmacotherapy are begun."]}
{"Patient Personal Background": ["He was born to a 33-year-old woman at 31 weeks gestation via cesarean section.", "His birth weight was 1400 grams."], "Patient Symptoms": ["Vital signs are significant for systemic hypotension, bradycardia, and hypoventilation.", "On physical exam, the patient has an altered level of consciousness with decreased spontaneous and elicited movements.", "The patient is hypotonic on motor testing, has bulging anterior fontanelle, and appears cyanotic."], "Examination and Results": ["Vital signs are significant for systemic hypotension, bradycardia, and hypoventilation.", "On physical exam, the patient has an altered level of consciousness with decreased spontaneous and elicited movements.", "The patient is hypotonic on motor testing, has bulging anterior fontanelle, and appears cyanotic."]}
{"Patient Symptoms": ["He says that he has felt increasing shortness of breath while exercising over the past 6 months.", "He is a well-built man in mild distress."], "Examination and Results": ["The vital signs include heart rate 98/min, respiratory rate 18/min, temperature 36.5\u00b0C (97.7\u00b0F), and blood pressure 135/90 mm Hg.", "The cardiac examination is significant for a harsh systolic ejection murmur at the left lower sternal border which is accentuated by forceful expiration against a closed airway.", "Palpation of the carotid artery shows 2 closely spaced pulses which occur during systole."]}
{"Patient Symptoms": ["Her only complaints are fatigability and a depressed mood for the past 2 weeks."], "Examination and Results": ["Her vital signs are as follows: blood pressure, 125/80 mm Hg; heart rate, 87/min; respiratory rate, 14/min; and temperature, 36.7\u2103 (98\u2109).", "The physical examination is unremarkable and the gynecologic examination is consistent with 18 weeks gestation."], "Others": ["She has no co-morbidities."]}
{"Patient Symptoms": ["The patient states that he has been having trouble chewing his food, but is not experiencing any pain."], "Examination and Results": ["On examination, the patient has an obvious distortion of the facial features on the right without erythema or lymphadenopathy.", "A neurological exam reveals no deficits.", "His blood pressure is 115/80 mm Hg, heart rate is 65/min, and the temperature is 37.2\u00b0C (98.9\u00b0F)."], "Others": ["The patient is up to date on all of his immunizations."]}
{"Patient Personal Background": ["She is worried he may be going through some sort of \u201cproblem.\u201d He is currently in 9th grade; his mother says that he is the captain of his high school wrestling team and does reasonably well in school."], "Patient Symptoms": ["His mother reports multiple instances over the past month when she walked into his room while he was masturbating.", "On examination, he seems embarrassed and avoids making eye contact."], "Examination and Results": ["Physical examination shows no abnormalities."]}
{"Patient Personal Background": ["He has had hypertension for the last 20 years and is on antihypertensive medications."], "Patient Symptoms": ["He also mentions that he occasionally has bouts of cough at night after about 2\u20133 hours of sleep which is relieved when he sits upright.", "He denies shortness of breath at rest, palpitations, and loss of consciousness."], "Examination and Results": ["On physical examination, his temperature is 36.9\u00b0C (98.4\u00b0F), pulse is 104/min, blood pressure is 122/82 mm Hg, and respirations are 18/min.", "Chest auscultation reveals crackles over the lung bases bilaterally.", "Examination of his abdomen reveals mildly tender hepatomegaly.", "Laboratory investigation results include a hemoglobin of 14.8 g/dL (9.18 mmol/L) and an elevated serum B-type natriuretic peptide.", "His two-dimensional echocardiogram reveals an enlarged left atrium and an ejection fraction of 55%."]}
{"Patient Personal Background": ["The patient states that he recently retired from working the day shift at a cemetery.", "The patient has a past medical history of irritable bowel syndrome which is managed with fiber supplements."], "Patient Symptoms": ["When the patient retired, his goal was to finally be able to go out with his wife; however, he finds that he is unable to stay awake past 6 pm in the evening.", "His inability to stay awake has been straining his marriage as his wife is disappointed that they cannot do any activities in the evening together.", "The patient has tried drinking caffeine but finds that it does not help."], "Examination and Results": ["The patient\u2019s neurological exam is within normal limits."], "Others": ["The patient\u2019s wife claims that the patient seems to sleep peacefully, and the patient states he feels rested when he awakes."]}
{"Patient Personal Background": ["She feels well.", "Six months ago, she was vaccinated against influenza.", "She has a history of hypertension.", "Her father died of a myocardial infarction at the age of 50 years.", "She emigrated from Japan 30 years ago.", "She has smoked one-half pack of cigarettes daily for the last 18 years.", "She drinks 4\u20135 glasses of wine per day.", "She goes ballroom dancing twice each week.", "Her medications include enalapril and low-dose aspirin."], "Examination and Results": ["Her last mammography 1 year ago showed no abnormalities.", "Two years ago, a pap smear and colonoscopy were normal.", "She is 165 cm (5 ft 5 in) tall and weighs 50 kg (110 lb); BMI is 18 kg/m2.", "Vital signs are within normal limits.", "Cardiopulmonary examination shows a soft S4 gallop.", "The remainder of the examination shows no abnormalities."], "Treatment": ["Her medications include enalapril and low-dose aspirin."]}
{"Examination and Results": ["Lab studies show:\n\nSerum Na+: 140 mmol/L\nSerum K+: 3.5 mmol/L\nSerum albumin: 1.9 g/dL\nTotal serum bilirubin: 1.0 mg/dL\nSerum creatinine: 1.2 mg/dL\n\nUrinalysis shows 4+ proteinuria and fatty casts."]}
{"Patient Symptoms": ["He has had a weight loss of 41 kgs (90 lbs) in the past year."], "Examination and Results": ["Physical examination shows a soft bulge inferior and lateral to the navel on the left.", "A CT scan of the abdomen of a patient with the same condition is shown."]}
{"Patient Personal Background": ["Her mother reports that the patient recently received a pair of fashionable silver earrings from her older sister as a birthday present.", "Her medical history is non-significant."], "Patient Symptoms": ["Physical examination is only significant for erythema and tenderness over the lobules of the ears bilaterally."], "Examination and Results": ["Her vital signs show a blood pressure of 121/73 mm Hg, heart rate of 72/min, and a respiratory rate of 21/min."]}
{"Patient Symptoms": ["He has bowel movements 10\u201312 times daily; the stool contains blood and mucus.", "He constantly has the urge to defecate."], "Examination and Results": ["His vital signs are within normal limits.", "Examination of the abdomen shows diffuse tenderness to palpation.", "Serum concentration of C-reactive protein is 20 mg/L (N<10).", "Colonoscopy shows a bleeding, ulcerated rectal mucosa with several pseudopolyps."]}
{"Patient Symptoms": ["The last menstrual period was 4 months ago.", "She also reports having a mild headache for 1 month.", "There has been a grape-like mass protruding from her vagina for the last 15 days."], "Examination and Results": ["On examination, the fundus of the uterus is at the level of the umbilicus and no fetal heart sounds are heard.", "The vital signs are as follows: blood pressure 160/100 mm Hg, pulse rate 108/min.", "On USG examination, no fetal parts are seen."]}
{"Patient Personal Background": ["She recently moved from New Jersey, and her medical records show a total colectomy."]}
{"Patient Personal Background": ["He was born at home and had unreliable prenatal care because his parents have been experiencing housing instability."], "Patient Symptoms": ["About a day after birth, he started to become lethargic and was feeding poorly.", "His parents thought that he might just be tired so they put him to bed; however, by the next morning he started to vomit and act extremely irritable."], "Examination and Results": ["On presentation, he is found to have nuchal rigidity and bulging fontanelles."], "Treatment": ["Based on this presentation, appropriate cultures are obtained and he is placed on empiric antibiotics."]}
{"Patient Personal Background": ["When asked about his diet, he says, \u201cBeing overweight runs in my family."], "Patient Symptoms": ["He says he feels well."], "Examination and Results": ["He is 180 cm (5 ft 11 in) tall and weighs 103 kg (227 lb); BMI is 32 kg/m2.", "His BMI last year was 27 kg/m2."]}
{"Patient Personal Background": ["He is a foreign exchange student and is concerned he will fail out of his academic program.", "The patient is a first year college student, drinks alcohol regularly, smokes marijuana, and has unprotected sex with multiple partners."], "Patient Symptoms": ["The patient states that for the past several weeks he has felt oddly fatigued and has struggled to complete his work.", "He has experienced some occasional nausea and vomiting which has caused him to lose weight."], "Examination and Results": ["His temperature is 99.5\u00b0F (37.5\u00b0C), blood pressure is 127/68 mmHg, pulse is 90/min, respirations are 17/min, and oxygen saturation is 98% on room air.", "Serum:\nNa+: 139 mEq/L\nCl-: 100 mEq/L\nK+: 4.3 mEq/L\nHCO3-: 25 mEq/L\nBUN: 20 mg/dL\nGlucose: 99 mg/dL\nCreatinine: 1.1 mg/dL\nCa2+: 10.2 mg/dL\nTotal bilirubin: 2.0 mg/dL\nAST: 85 U/L\nALT: 92 U/L\n\nUrine\nColor: Amber/brown\nMarijuana: Positive\nAmphetamines: Positive\nCocaine: Positive\n\nThe patient refuses an examination of his genitals."], "Others": ["Laboratory values are ordered as seen below."]}
{"Patient Personal Background": ["She has a history of sleep apnea."], "Examination and Results": ["Examination of the lower extremities shows bilateral pitting pedal and ankle edema.", "Cardiac examination shows a widely split S2 that varies with respiration.", "An ECG shows right bundle branch block."]}
{"Patient Personal Background": ["Past medical history is significant for gastroesophageal reflux disease, and recent appendicitis, status post laparoscopic appendectomy complicated by delirium tremens."], "Patient Symptoms": ["He denies fever, weight loss, pain, pruritus or urinary symptoms."], "Examination and Results": ["His vitals are a temperature of 37.0\u00b0C (98.6\u00b0F), blood pressure of 130/80 mm Hg, pulse of 78/min, and respiratory rate of 12/min.", "Physical examination reveals a distended abdomen with shifting dullness on percussion.", "In addition, multiple purple spider web-like lesions are present on the chest and arms, which blanch when pressure is applied.", "Fecal occult blood test is negative.", "On anoscopy, a non-tender, dilated vascular protrusion is noted superior to the pectinate line."]}
{"Patient Personal Background": ["She has no past medical history."], "Patient Symptoms": ["For the past 2 years, she has been urinating a considerable volume every time she goes to the bathroom."], "Examination and Results": ["Her heart rate is 86/min, respiratory rate is 15/min, temperature is 37.4\u00b0C (99.3\u00b0F), and blood pressure is 111/79 mm Hg.", "Laboratory studies are significant for the following:\nCalcium 13.8 mg/dL\nPTH 230 pg/mL\nHer complete metabolic panel is otherwise within normal limits.", "Imaging studies show subperiosteal resorption and osteoporosis.", "Scintigraphy reveals the most common pathologic condition associated with the patient\u2019s diagnosis."]}
{"Patient Personal Background": ["Her past medical history is notable for obesity, type I diabetes mellitus, and rheumatoid arthritis.", "She is on insulin and takes methotrexate.", "She smokes marijuana occasionally."], "Patient Symptoms": ["She reports that for the past 3 years, she has experienced several periods of depressed mood.", "The episodes do not coincide with any specific life events and seem to resolve after 4-6 weeks.", "During these episodes, she experiences a depressed mood, sleep disturbances, and a poor appetite, but she at times is able to enjoy spending time with her children and husband but other times she is distressed and cannot enjoy time with them.", "Upon further questioning, she also reports experiencing occasional episodes of elevated mood over the past ten years.", "During these episodes, she is very productive at her work as a lawyer and requires less sleep than usual."], "Examination and Results": ["Her temperature is 99.2\u00b0F (37.3\u00b0C), blood pressure is 124/80 mmHg, pulse is 78/min, and respirations are 17/min.", "On exam, she is quiet with a flattened affect, but is cooperative and answers questions thoroughly."]}
{"Patient Personal Background": ["She has a history of hypertension well controlled with diet and exercise.", "She has no history of smoking or illicit drug use.", "She walks one mile daily."], "Examination and Results": ["Her pulse is 68/min, respirations are 16/min, and blood pressure is 119/76 mm Hg.", "Physical examination shows no abnormalities."]}
{"Examination and Results": ["Paramedics arrive quickly, and he is taken to the hospital where several stable lumbar fractures and a shattered right calcaneus are found."], "Treatment": ["He undergoes surgery and his calcaneus is repaired with 11 screws."]}
{"Patient Personal Background": ["He has allergic asthma treated with inhaled salbutamol.", "He immigrated to the USA from Thailand 9 years ago.", "He lives by himself and works as a waiter in a restaurant.", "He has had 6 lifetime male sexual partners and uses condoms inconsistently.", "He drinks 1\u20132 beers daily."], "Patient Symptoms": ["On mental status examination, the patient is somnolent and has short-term memory deficits."], "Examination and Results": ["His temperature is 38.2\u00b0C (100.8\u00b0F), pulse is 88/min, and blood pressure is 128/76 mm Hg.", "Examination of the mouth shows several white patches on the tongue and oral mucosa that can be easily scraped off with a tongue blade.", "The remainder of the examination shows no abnormalities.", "Laboratory studies show:\nHemoglobin 13.6 g/dL\nLeukocyte count 9,600/mm3\nSegmented neutrophils 80%\nEosinophils 1%\nLymphocytes 17%\nMonocytes 2%\nCD4+ T-lymphocytes 80/mm3 (Normal \u2265 500)\nPlatelet count 328,000/mm3\nSerum\npH 7.36\nNa+ 135 mEq/L\nCl- 101 mEq/L\nK+ 4.8 mEq/L\nHCO3- 22 mEq/L\nGlucose 95 mg/dL\nCreatinine 0.9 mg/dL\nBUN 16 mg/dL\nBilirubin, total 0.7 mg/dL\nAST 13 U/L\nALT 15 U/L\nErythrocyte sedimentation rate 10 mm/hour\nHIV test positive\nA lumbar puncture is performed and an opening pressure of 150 mm H2O is noted.", "Cerebrospinal fluid analysis shows a leukocyte count of 25/mm3 (60% lymphocytes), protein concentration of 52 mg/dL, and a glucose concentration of 37 mg/dL.", "India ink stain shows organisms with prominent capsules.", "Blood cultures are drawn."], "Treatment": ["He has allergic asthma treated with inhaled salbutamol."], "Diagnosis": ["Laboratory studies show:\nHemoglobin 13.6 g/dL\nLeukocyte count 9,600/mm3\nSegmented neutrophils 80%\nEosinophils 1%\nLymphocytes 17%\nMonocytes 2%\nCD4+ T-lymphocytes 80/mm3 (Normal \u2265 500)\nPlatelet count 328,000/mm3\nSerum\npH 7.36\nNa+ 135 mEq/L\nCl- 101 mEq/L\nK+ 4.8 mEq/L\nHCO3- 22 mEq/L\nGlucose 95 mg/dL\nCreatinine 0.9 mg/dL\nBUN 16 mg/dL\nBilirubin, total 0.7 mg/dL\nAST 13 U/L\nALT 15 U/L\nErythrocyte sedimentation rate 10 mm/hour\nHIV test positive\nA lumbar puncture is performed and an opening pressure of 150 mm H2O is noted.", "Blood cultures are drawn."], "Others": []}
{"Patient Personal Background": ["His mother had a myocardial infarction at 54 years.", "His BMI is 23 kg/m2."], "Patient Symptoms": ["There is tenderness above the left posterior calcaneus and a firm, 3-cm, skin-colored nodule that moves with the left Achilles tendon."], "Examination and Results": ["A photomicrograph from a biopsy of the nodule is shown."]}
{"Patient Personal Background": ["The patient was exclusively breastfed up to the age of 7 months.", "Supplementary feeding was started with non-starchy vegetable followed by starchy vegetables, meat, fish, eggs, and bread.", "Bread and cookies were the last product to be introduced at the age of 12 months.", "The patient\u2019s mother tried to withdraw dairy products from the patient\u2019s diet because she heard that lactose can cause such symptoms, but it did not help."], "Patient Symptoms": ["His mother says that these symptoms developed approximately 2 years ago.", "There are a few aphthous ulcers in the oral cavity."], "Examination and Results": ["The patient\u2019s vital signs include: blood pressure 90/55 mm Hg, heart rate 101/min, respiratory rate 19/min, and temperature 36.3\u2103 (97.3\u2109).", "His weight is 11 kg (24.2 lb, -2 SD) and height is 90 cm (2 ft 11 in, -1 SD).", "On physical examination, the patient\u2019s skin is pale with a papulovesicular rash on his abdomen and back.", "The abdomen is distended but no tenderness to palpation.", "No hepatosplenomegaly.", "An immunological assay is performed and shows positive anti-transglutaminase and anti-endomysial antibodies."]}
{"Patient Personal Background": ["Her height and weight are appropriate for her age, and she is up to date on all her vaccinations and has no medical complaints.", "She is doing well in school and has a part-time job stocking shelves at a clothing store.", "She was offered a higher-paying job as a cashier at the store, but she declined."], "Patient Symptoms": ["She is very shy and withdrawn with the physician.", "Afterwards, her mother asks to speak to the physician alone and expresses concern that her daughter is very socially isolated and feels lonely.", "She is also worried that her daughter is extremely sensitive to criticism, even from family.", "The daughter is interested in art and music, but hasn\u2019t participated in any extracurriculars because she says that she is untalented and thinks nobody wants to hang out with her."]}
{"Patient Personal Background": ["She has no history of serious illness.", "She is sexually active with 2 male partners and uses condoms inconsistently."], "Examination and Results": ["Vital signs are within normal limits.", "Pelvic examination shows multiple hyperkeratotic exophytic papules over the vulva.", "The lesions turn white on application of 3% acetic acid."]}
{"Patient Personal Background": ["Two weeks ago, while visiting Guatemala, she had an emergency appendectomy under general inhalational anesthesia."], "Patient Symptoms": ["Her temperature is 38.3\u00b0C (100.9\u00b0F) and blood pressure is 138/76 mm Hg.", "Examination shows jaundice and tender hepatomegaly."], "Examination and Results": ["Serum studies show:\nAlkaline phosphatase 102 U/L\nAspartate aminotransferase 760 U/L\nBilirubin\nTotal 3.8 mg/dL\nDirect 3.1 mg/dL\nAnti-HAV IgG positive\nAnti-HAV IgM negative\nAnti-HBs positive\nHBsAg negative\nAnti-HCV antibodies negative\nAbdominal ultrasonography shows an enlarged liver.", "A biopsy of the liver shows massive centrilobular necrosis."], "Treatment": ["During the surgery, she received a transfusion of 1 unit of packed red blood cells."]}
{"Patient Personal Background": ["The patient\u2019s past medical history is significant for a few episodes of acute pain crisis and a need for splenectomy 3 years ago."], "Patient Symptoms": ["Shortly after the transfusion has begun, the patient experiences fevers, chills, a burning sensation at the intravenous (IV) site, and sudden hypotension."], "Examination and Results": ["The vital signs upon arrival include: temperature 36.7\u00b0C (98.0\u00b0F), blood pressure 106/74 mm Hg, heart rate 111/min and regular, and respiratory rate 17/min.", "On physical examination, her pulses are bounding and fingernails are pale, but breath sounds remain clear.", "Oxygen saturation was initially 91% on room air and electrocardiogram (ECG) shows sinus tachycardia.", "A blood transfusion is initiated."], "Treatment": ["Shortly after the transfusion has begun, the patient experiences fevers, chills, a burning sensation at the intravenous (IV) site, and sudden hypotension."], "Others": ["Her mother denies any previous history of blood clots in her past, but she says that her mother has also had to be treated for pulmonary embolism in the recent past."]}
{"Patient Personal Background": ["She does not smoke or consume alcohol.", "Her medications include propranolol and sumatriptan."], "Patient Symptoms": ["The pain varies in location and intensity.", "She also has joint stiffness in the morning and reports fatigue throughout the day that she attributes to not sleeping well.", "She reports a tingling sensation in her lower limbs.", "Her bowel habits are unchanged but she often feels bloated."], "Examination and Results": ["Examination shows symmetric muscular tenderness at the base of the neck, over the shoulders, and in the lumbosacral area.", "Strength and deep tendon reflexes are normal.", "Laboratory studies show:\nHemoglobin 14.3 g/dL\nLeukocyte count 9300/mm3\nPlatelet count 230,000/mm3\nMean corpuscular volume 85 \u03bcm3\nErythrocyte sedimentation rate 12 mm/h\nSerum\nGlucose 92 mg/dL\nCreatinine 0.6 mg/dL\nTSH 3.1 \u03bcU/mL\nUrinalysis is within normal limits."], "Others": ["She appears healthy."]}
{"Patient Personal Background": ["He reports a 20-pack-year smoking history."], "Patient Symptoms": ["Upon asking about other symptoms, he mentions that he had a cough for the last 4 months which he attributes to his smoking.", "He says he had frequent nasal stuffiness and headaches over the last 3 months, for which he takes over-the-counter cold medications and analgesics.", "Over the last 2 months, he often felt that his face was mildly swollen, especially in the morning hours, but he did not consider it to be anything serious."], "Examination and Results": ["His temperature is 36.8\u00b0C (98.4\u00b0F), pulse is 96/min, blood pressure is 108/78 mm Hg, and the respiratory rate is 24/min.", "On physical examination, auscultation of the chest reveals rhonchi and crepitus over the right lung.", "A chest radiograph reveals a mass in the middle lobe of the right lung."], "Others": ["No significant past medical history.", "The remainder of the exam is unremarkable."]}
{"Patient Symptoms": ["He denies any inciting trauma or similar prior episodes."], "Examination and Results": ["Vital signs are stable.", "On examination, the right first toe is grossly erythematous and edematous, with range of motion limited due to pain."]}
{"Patient Symptoms": ["She describes the pain as affecting the inside part of the knee as well as the front of her knee, below the kneecap.", "She denies any inciting injury or trauma to the knee but reports that the pain is worse when she is climbing up stairs or rising from a chair."], "Examination and Results": ["Physical examination is significant for localized tenderness to palpation over the left anteromedial proximal tibia, 6 cm inferior to the joint line.", "There is no joint effusion noted.", "Valgus stress testing is negative for any pain or instability of the knee joint.", "Radiographs of the left knee are obtained and reveal only mild arthritis, without evidence of any fractures or bony lesions."]}
{"Patient Personal Background": ["She and her boyfriend had intercourse for the first time a few weeks ago."], "Patient Symptoms": ["She is tearful about the pregnancy and is very concerned."], "Examination and Results": ["She took several over the counter pregnancy tests that confirmed her pregnancy."], "Treatment": ["After extensive conversations with her physician and counseling, she decides she wants to medically abort her 6-week pregnancy."], "Others": ["Two weeks ago she missed her menstrual period."]}
{"Patient Personal Background": ["She has myopia and has been wearing corrective lenses for 10 years.", "Her vital signs are within normal limits."], "Patient Symptoms": ["Her symptoms occur only when looking sideways.", "Ten days ago, she lost her balance and fell off her bike, for which she went to a hospital."], "Examination and Results": ["A CT scan of the head at that time showed no abnormalities and she was released without further treatment.", "The pupils are equal and reactive to light.", "Her best corrected visual acuity is 20/40 in each eye.", "She has an adduction deficit in the right eye and nystagmus in the left eye when looking left; she has an adduction deficit in the left eye and nystagmus in the right eye when looking right.", "Fundoscopy reveals bilateral disc hyperemia."], "Others": ["Her only medication is an oral contraceptive."]}
{"Patient Personal Background": ["The patient has had a history of diabetes mellitus for the past 2 years which is well controlled.", "His current medications are insulin and aspirin.", "Family history is significant for coronary artery disease.", "He has an 80 pack-year history of smoking and currently smokes.", "He consumes 4 drinks per day of alcohol."], "Patient Symptoms": ["The pain subsides with rest."], "Examination and Results": ["On physical examination, his blood pressure is 144/89 mm Hg, the heart rate is 80/min and regular, the breathing rate is 25/min, and the pulse oximetry is 96%.", "Normal cardiac and lung sounds were heard on auscultation."], "Others": ["A percutaneous coronary intervention was performed in 2014."]}
{"Patient Symptoms": ["Physical examination shows pallor, tenderness to palpation over the temples, and inward deviation of the left eye."], "Examination and Results": ["Laboratory studies show an erythrocyte sedimentation rate of 65 mm/h.", "Temporal artery biopsy shows transmural granulomatous inflammation and fragmentation of the internal elastic lamina."], "Treatment": ["Treatment with high-dose intravenous corticosteroids is begun."]}
{"Patient Personal Background": ["She has been sexually active with multiple male partners over the past year and uses condoms inconsistently; she has been taking an oral contraceptive for the past 2 years.", "She has no previous history of serious illness or sexually transmitted diseases."], "Examination and Results": ["Her temperature is 37\u00b0C (98.6\u00b0F), pulse is 75/min, respirations are 12/min, and blood pressure is 122/82 mm Hg.", "Pelvic examination shows erythema of the vulva and vagina and foul-smelling, frothy, yellow-green vaginal discharge.", "The pH of the discharge is 5.8.", "Bimanual examination is unremarkable."], "Treatment": ["Three weeks ago, she had an episode of acute bacterial rhinosinusitis that was treated with a 10-day course of amoxicillin."]}
{"Patient Personal Background": ["The patient had normal development throughout childhood, is on the soccer team at school, and is not sexually active.", "Her father has hypertension and her mother has endometriosis and heavy periods."], "Patient Symptoms": ["The patient underwent menarche at age 11, and her periods were irregular every 2-3 months for two years.", "After that, her cycles became roughly regular every 28-35 days, but she has had extremely painful cramps and often has to miss school.", "The cramps are intermittent and feel like a dull ache in the center of her abdomen, and there is usually accompanying back pain.", "She reports some periods being \u201creally heavy\u201d and requires a superabsorbent pad every 6 hours for 2 days each cycle, but this does not limit her activities."], "Examination and Results": ["On exam, the patient is 5 feet 5 inches and weighs 158 pounds (BMI 26.3 kg/m^2).", "She is well appearing and has no abdominal tenderness.", "She has Tanner IV breasts and Tanner IV pubic hair, and external genitalia are normal."], "Treatment": ["The patient has been using heating pads with limited relief."], "Others": ["She denies any bowel or bladder changes."]}
{"Patient Symptoms": ["On arrival, she has a cervical collar in place and is unresponsive.", "Her pupils are dilated and not reactive to light.", "She is unresponsive to noxious stimuli."], "Examination and Results": ["Her temperature is 36.7\u00b0C (98\u00b0F), pulse is 70/min, and blood pressure is 131/76 mm Hg.", "Serum concentrations of electrolytes, urea nitrogen, and creatinine are within the reference range.", "Toxicology screening is negative.", "A CT scan of the head without contrast shows a massive intracranial bleed and a cervical spine injury at the level of C3."], "Treatment": ["She is intubated, and mechanical ventilation is begun."]}
{"Patient Symptoms": ["Her temperature is 39.4\u00b0C (103\u00b0F).", "Physical examination shows nuchal rigidity and photophobia."], "Examination and Results": ["Blood cultures are obtained and a lumbar puncture is performed.", "A Gram stain of cerebrospinal fluid shows gram-negative cocci in pairs."]}
{"Patient Personal Background": ["He had 2 myocardial infarctions at the age of 66 and 69 years and suffers from chronic heart failure."], "Patient Symptoms": ["He is lethargic and cyanotic."], "Examination and Results": ["At the time of presentation, his vital signs are as follows: blood pressure 90/50 mm Hg, heart rate 108/min, respiratory rate 29/min, and temperature 35.5\u00b0C (95.9\u00b0F).", "On physical examination, the patient sits upright.", "Lung auscultation reveals widespread bilateral fine rales.", "Cardiac examination is significant for S3, accentuation of the pulmonic component of S2, and a systolic murmur heard best at the apex of the heart."]}
{"Patient Personal Background": ["Methods:\nIn this double-blind, randomized controlled trial, patients (N=1200) with a history of coronary artery disease, myocardial infarction in the past 2 years, and a diagnosis of comorbid adult-onset asthma were recruited from cardiology clinics at a large academic medical center in Philadelphia, PA.", "Patients who were immunocompromised or had a history of recurrent infections were excluded."], "Examination and Results": ["After collecting data on changes in plaque volume, LDL-C levels, FEV1/FVC ratio, and ACQ scores from baseline to 12-month follow-up, he is curious if the changes in the aforementioned measurements are statistically significant.", "Variables measured included plaque volume, serum LDL-C levels, FEV1/FVC ratio, and Asthma Control Questionnaire (ACQ) scores, which quantified the severity of asthma symptoms.", "Plaque volume was determined by ultrasound.", "Analyses were performed from baseline to month 12.", "Results:\nAt baseline, participants in the two groups did not differ by age, gender, race, plaque volume, serum LDL-C levels, FEV1/FVC ratio, and ACQ scores (p > 0.05 for all)."], "Treatment": ["Patients were subsequently randomly assigned a 12-month course of pulmharkimab 75 mg/day, pulmharkimab 150 mg/day, or a placebo, with each group containing 400 participants."], "Others": ["Which of the following is the most appropriate statistical method to compare the groups?\"", "\"Impact of pulmharkimab on asthma control and cardiovascular disease progression in patients with coronary artery disease and comorbid asthma\nIntroduction:\nActive asthma has been found to be associated with a more than two-fold increase in the risk of myocardial infarction, even after adjusting for cardiovascular risk factors.", "It has been suggested that the inflammatory mediators and accelerated atherosclerosis characterizing systemic inflammation may increase the risk of both asthma and cardiovascular disease.", "This study evaluated the efficacy of the novel IL-1 inhibitor pulmharkimab in improving asthma and cardiovascular disease progression.", "All participants were included in analysis and analyzed in the groups to which they were randomized regardless of medication adherence.", "A total of 215 participants (18%) were lost to follow-up.", "At 12-month follow-up, the groups contained the following numbers of participants:\nPulmharkimab 75 mg/d: 388 participants\nPulmharkimab 150 mg/d: 202 participants\nPlacebo: 395 participants\nTable 1: Association between pulmharkimab and both pulmonary and cardiovascular outcomes.", "Models were adjusted for sociodemographic variables and medical comorbidities.", "All outcome variables were approximately normally distributed."]}
{"Patient Personal Background": ["The patient does not smoke.", "She drinks one to two glasses of wine on the weekends."], "Patient Symptoms": ["The palpitations are accompanied by chest pain that is sharp and localized to the left 3rd intercostal space.", "She appears nervous."], "Examination and Results": ["Her pulse is 110/min and irregularly irregular, and blood pressure is 135/85 mmHg.", "Examination shows a fine tremor on both hands and digital swelling.", "There is retraction of the left upper eyelid.", "A systolic ejection murmur is heard along the right upper sternal border.", "The extremities are warm, and pulses are 2+ bilaterally."]}
{"Patient Personal Background": ["The patient lives with his daughter and was chatting with her when suddenly his speech became distorted with random and disconnected words that made no sense."], "Patient Symptoms": ["The patient lives with his daughter and was chatting with her when suddenly his speech became distorted with random and disconnected words that made no sense.", "He seems to be physically frustrated that no one understands him."], "Examination and Results": ["Physical examination demonstrates weakness of the right arm."]}
{"Patient Personal Background": ["Currently, she takes aspirin (81 mg once daily), rosuvastatin (10 mg once daily), lisinopril (20 mg once daily), and isosorbide mononitrate (60 mg once daily).", "She has been menopausal for the last 15 years.", "The vital signs are as follows: blood pressure 135/80 mm Hg, heart rate 76/min, respiratory rate 14/min, and temperature 36.5\u2103 (97.7\u2109)."], "Patient Symptoms": ["The pain is bilateral, \u201cband-like,\u201d and extends to the neck.", "The patient rates the 4 points out of 10 on a visual scale.", "The headache is not accompanied by nausea, vomiting, photophobia, or phonophobia, and is not aggravated by movements, but gets worse when the patient coughs or laughs.", "The headache has persisted throughout the day and is usually worse in the morning an hour after she has breakfast and taken her medications."], "Examination and Results": ["The physical examination reveals S2 accentuation that is best heard in the second intercostal space at the right sternal border.", "Palpation of the paranasal sinuses is painless.", "The neurologic exam shows no focal symptoms, no pain on palpation of the trigeminal points, and no meningeal symptoms."], "Diagnosis": ["The patient was diagnosed with stage 1 arterial hypertension 2 years ago and stable angina pectoris 3 weeks ago."]}
{"Patient Personal Background": ["He states that he received all of his recommended vaccinations prior to beginning college, but has not had any vaccines in the past 13 years.", "His medical history is significant for intermittent, exercise-induced asthma.", "He has been sexually active in the past with multiple female partners."]}
{"Patient Personal Background": ["She says that she punctured her foot with a rusty nail while she was playing tennis and that the puncture wound has since progressed to a non-healing ulcer."], "Patient Symptoms": ["Over the last 2 days, she has also been experiencing a fever and drainage from the wound."], "Examination and Results": ["On presentation, she is found to have a slightly fruity smelling red ulcer with purulent drainage.", "Probing the ulcer goes all the way down to bone."]}
{"Patient Personal Background": ["He recently returned from a trip to Belize."], "Examination and Results": ["His temperature is 38.3\u00b0C (100.9\u00b0F).", "Physical examination shows scleral icterus and tender hepatomegaly.", "Serum studies show markedly elevated transaminases and anti-hepatitis A virus antibodies."], "Others": ["In this patient, infected cells express more MHC class I molecules on their surfaces."]}
{"Patient Personal Background": ["His only medication is ibuprofen for joint pain."], "Patient Symptoms": ["He has been unable to practice with his recreational soccer team and has had to rest frequently when walking to work.", "There is tenderness to palpation and stiffness of the metacarpophalangeal joints of both hands."], "Examination and Results": ["Physical examination shows tanned skin.", "Pulmonary examination shows coarse crackles in both lung fields.", "The liver is palpated 4 cm below the right costal margin."]}
{"Patient Personal Background": ["Her personal history is relevant for allergic rhinitis."], "Examination and Results": ["Physical examination shows grouped, erythematous papulovesicular lesions on her arms, torso, and abdomen."]}
{"Patient Personal Background": ["The patient is light-skinned and has a history of occasional sunburns when she does not apply sunscreen.", "Current medications include demeclocycline for malignancy-associated hyponatremia and amoxicillin for sinusitis."], "Examination and Results": ["Physical examination shows prominent erythema and a papular eruption on her forehead, cheeks, neck, and the dorsum of both hands."], "Others": ["She wore a long-sleeved shirt and was exposed to direct sunlight for about 10 minutes."]}
{"Patient Personal Background": ["His previous medical history is significant for a previous car crash in which the patient required internal fixation of a femur fracture and a corneal transplant for corneal degeneration.", "Otherwise he had no neurologic deficits prior to 6 weeks ago."], "Patient Symptoms": ["On presentation, he is conscious but does not know where he is nor how he got there.", "His wife is contacted and says that he has been getting increasingly confused over the past 6 weeks.", "This progressed from misplacing objects to getting lost in places that he knew how to navigate previously.", "Most worryingly, he has recently started forgetting the names of their children.", "In addition to these memory changes, she says that he now has rapid jerky movements of his extremities as well as coordination and balance problems.", "Finally, he has become extremely paranoid about government surveillance and has had hallucinations about secret agents in their house."], "Examination and Results": ["Physical exam reveals myoclonus and ataxia."]}
{"Patient Personal Background": ["The patient's past medical history reveals recurrent upper respiratory infections but no skin or soft tissue infections.", "The child had cardiac surgery as an infant but has otherwise been healthy."], "Patient Symptoms": ["He was in his usual state of health until 3 days ago when he began to complain of a sore throat as well as general malaise."], "Examination and Results": ["On presentation, his temperature is 100\u00b0F (37.8 \u00b0C), blood pressure is 115/72 mmHg, pulse is 65/min, and respirations are 22/min.", "Physical exam shows white plaques on the tongue and mouth.", "A scraping of this material reveals a characteristic morphology after being treated with KOH.", "Serum protein electrophoresis shows a normal distribution of bands from this patient."]}
{"Patient Personal Background": ["She has a 6-year-old daughter who was born at term after an uncomplicated pregnancy.", "She has no history of severe illness and tries to stay healthy by going to the gym an hour per day.", "Her menses occur at regular 28-day intervals and last 5 to 6 days; her last menstrual period started 2 days ago."], "Patient Symptoms": ["She says she is worried because she and her husband have been trying to conceive for more than a year with no success."], "Examination and Results": ["Analysis of her husband's semen has shown normal sperm counts and morphology.", "Physical examination shows no abnormalities."], "Treatment": ["Conception by in vitro fertilization was attempted once 3 months ago but was unsuccessful."]}
{"Patient Personal Background": ["The patient's past medical history is notable for anxiety, obesity, hypertension, and polycystic ovarian syndrome.", "She is currently not on any medications other than an exercise program with which she is non-compliant."], "Patient Symptoms": ["They found her somnolent next to her computer and scattered pill bottles over two hours ago."], "Examination and Results": ["A physical exam is performed and is within normal limits.", "Her temperature is 99.5\u00b0F (37.5\u00b0C), pulse is 82/min, blood pressure is 125/85 mmHg, respirations are 11/min, and oxygen saturation is 97% on room air."], "Others": ["The family cannot recall the types of pill bottles that they found and did not bring them to the ED.", "The patient begins communicating with the physician and states that she did take acetaminophen but it was only a few pills."]}
{"Patient Personal Background": ["The patient and his wife are asymptomatic and have no history of serious illness."], "Examination and Results": ["Genetic testing in the patient's family shows that his mother is not a carrier of the mutation that is responsible for the disease in his relatives."], "Others": ["The patient's older brother died at age 13 from heart failure and his 6-year-old nephew currently has severe muscle weakness.", "A pedigree chart of the patient's family is shown."]}
{"Patient Symptoms": ["The patient has recently gained weight and can't seem to exercise like she used to.", "She also notes that her thinking seems slow."], "Examination and Results": ["Physical examination shows thickened, dry skin.", "Serum analysis confirms the physician's suspicions."]}
{"Examination and Results": ["Physical examination shows dense breasts and a 2.5-cm rubbery, mobile mass that is nontender in the upper outer quadrant of the right breast.", "A biopsy of the mass shows rounded contour with overgrowth of fibrous and glandular tissue."]}
{"Treatment": ["His wife arrives within minutes to the hospital exclaiming that under no circumstance should he receive any blood transfusions during surgery.", "After reviewing his medical chart, you see also see an annotation indicating no blood transfusions for religious reasons."]}
{"Patient Symptoms": ["The patient has developed an upper respiratory infection while at school.", "He is coughing and has a runny nose."], "Examination and Results": ["His temperature is 37.8\u00b0 C (100.2\u00b0 F) and vital signs are within normal limits.", "Physical examination is unremarkable."]}
{"Examination and Results": ["The breast tissue in pregnant women contained an increased number of acinar glands with epithelial proliferation compared to the non-pregnant women."]}
{"Patient Personal Background": ["He has been healthy apart from an upper respiratory tract infection 6 months ago.", "He was delivered at 38 weeks' gestation.", "His immunizations are up-to-date.", "He is at the 40th percentile for height and 50th percentile for weight."], "Patient Symptoms": ["His mother noticed deformities in both of his legs since he started walking independently.", "The mother is concerned that he has a growth disorder."], "Examination and Results": ["Vital signs are within normal limits.", "Examination shows closed anterior and posterior fontanelles.", "The knees do not stay together when both the feet and ankles are placed together.", "The gait is unremarkable."], "Others": ["His 6-year-old sister was treated for developmental dysplasia of the hip.", "He can kick a ball and say a 2-word phrase.", "He plays well with other children at his day care."]}
{"Patient Personal Background": ["She is current with her Pap smears, all of which have been normal.", "She denies any recent travel or a history of trauma.", "The patient has not been sexually active for the past 2 months.", "She smokes 1 pack of cigarettes per day and drinks alcohol occasionally, but has never used illicit drugs."], "Examination and Results": ["The pelvic examination reveals a small, firm, non-tender, immobile cystic mass at the edge of the exocervical os with a yellow hue.", "The remainder of the physical examination is unremarkable."], "Others": ["The patient appears well and has no specific complaints.", "Her menstrual periods are regular and usually last 3\u20134 days.", "The patient is otherwise asymptomatic and has no other complaints."]}
{"Patient Personal Background": ["Pregnancy was complicated by polyhydramnios."], "Examination and Results": ["Apgar scores are 7 and 7 at 1 and 5 minutes, respectively.", "He is at the 2nd percentile for head circumference and 15th percentile for length.", "Examination shows a prominent posterior part of the head.", "The ears are low-set and the jaw is small and retracted.", "The fists are clenched, with overlapping second and third fingers.", "The calcaneal bones are prominent and the plantar surface of the foot shows a convex deformity.", "Abdominal examination shows an omphalocele."]}
{"Patient Personal Background": ["He has had sexual intercourse with multiple men and women over the past year and does not use barrier protection.", "His last screen for sexually transmitted diseases was 10 years ago and was normal.", "His past medical history is notable for well-controlled asthma.", "He was involved in a motorcycle accident 2 years ago and suffered multiple fractured bones in his upper and lower extremities, all of which have healed.", "He has a distant history of cocaine abuse.", "He drinks 5-6 glasses of wine per week."], "Patient Symptoms": ["On examination, he appears cachectic but is pleasant and appropriately interactive."], "Examination and Results": ["His temperature is 100.8\u00b0F (38.2\u00b0C), blood pressure is 130/75 mmHg, pulse is 85/min, and respirations are 20/min.", "An HIV differentiation assay and follow-up Western blot are performed and are positive."], "Treatment": ["The patient is started on tenofovir, abacavir, and efavirenz.", "However, the patient develops a hypersensitivity reaction to abacavir, so the decision is made to replace this medication with ritonavir."], "Diagnosis": ["An HIV differentiation assay and follow-up Western blot are performed and are positive."]}
{"Patient Personal Background": ["His past medical history is insignificant."], "Patient Symptoms": ["His symptoms are progressively getting worse over the past few months despite adequate rest and trial of over the counter analgesics.", "His back pain is constant and non-radiating in nature.", "He denies any trauma to his back."], "Examination and Results": ["On examination, there is mild tenderness over the lumbar region in the midline with an absence of paraspinal muscle tenderness.", "Straight leg raise test is negative.", "His skin and conjunctiva appear pale.", "His results are provided below.", "Complete blood count\nRBC 4.9 million cells/\u00b5L\nHemoglobin 9.8 g/dL\nHematocrit 41%\nTotal leukocyte count 6,800 cells/\u00b5L\nNeutrophils 70%\nLymphocyte 26%\nMonocytes 3%\nEosinophil 1%\nBasophils 0%\nPlatelets 230,000 cells/\u00b5L\nBasic Metabolic Panel\nSodium 136 mEq/L\nPotassium 5.1 mEq/L\nChloride 101 mEq/L\nBicarbonate 24 mEq/L\nAlbumin 3.6 mg/ dL\nUrea nitrogen 31 mg/dL\nCreatinine 2.7 mg/dL\nUric Acid 6.7 mg/dL\nCalcium 12.1 mg/dL\nGlucose 105 mg/dL\nUrinalysis shows proteinuria without any RBCs or pus cells."], "Others": ["The physician orders basic blood work."]}
{"Patient Personal Background": ["She says that her mother had osteoporosis and she is concerned that she may develop it as well.", "She takes calcium and vitamin D supplements daily."], "Patient Symptoms": ["The patient states that she has mild joint pain, which she attributes to osteoarthritis, but she notes no recent fractures."], "Examination and Results": ["After review of her DEXA scan, her physician states that she has osteopenia."]}
{"Examination and Results": ["The bacteria are found to be able to grow in a specialized culture that contains sheep blood, cystine, and potassium tellurite; the colonies are black and have a shining surface."]}
{"Patient Personal Background": ["He was delivered at term to a 32-year-old woman."], "Patient Symptoms": ["He is not able to sit upright on his own.", "His tongue protrudes beyond the teeth.", "Neck veins are distended."], "Examination and Results": ["He is at the 75th percentile for height and 25th percentile for weight.", "His temperature is 37.7\u00b0C (99.8\u00b0F), blood pressure is 110/68 mm Hg, pulse is 150/min, and respirations are 50/min.", "Crackles are heard at both lung bases.", "Cardiac examination shows an S3 gallop.", "The liver is palpated 2 cm below the right costal margin.", "Neurologic examination shows profound weakness in proximal and distal muscles of the upper and lower extremities.", "He has 2+ reflexes bilaterally.", "A chest x-ray shows cardiomegaly.", "Serum glucose is 105 mg/dL."]}
{"Examination and Results": ["Two weeks after the conditioning regimen is started, he develops a temperature of 38.5\u00b0C (101.3\u00b0F)."], "Treatment": ["Two weeks after the conditioning regimen is started, he develops a temperature of 38.5\u00b0C (101.3\u00b0F)."]}
{"Patient Personal Background": ["The patient has a past medical history of depression, anxiety, and obesity.", "The patient has a known history of medication non-compliance."], "Patient Symptoms": ["She seemed to be responding to internal stimuli when being initially interviewed.", "On physical exam the patient is poorly kempt and has an odd body odor.", "Cardiac exam is unrevealing with the exception of a friction rub."], "Examination and Results": ["Her temperature is 99.5\u00b0F (37.5\u00b0C), pulse is 112/min, blood pressure is 100/70 mmHg, respirations are 18/min, and oxygen saturation is 98% on room air.", "Inspection of her oropharynx reveals multiple ulcers.", "Since the incident, the patient has calmed down and is currently resting."], "Others": ["The patient refused to explain her behavior to the police.", "She is no longer responding to internal stimuli and is more cooperative.", "Lab values are obtained and are below."]}
{"Examination and Results": ["The complete blood count showed leukocytosis.", "Anaerobic culture of the peritoneal fluid needle aspirate showed a gram-negative pathogen."], "Treatment": ["His appendix was removed for an abscess 3 days ago."]}
{"Patient Personal Background": ["She reports that herer father has a similar condition."], "Patient Symptoms": ["Her right knee has also been stiff and slightly swollen for the past 6 weeks.", "She is overall fatigued and has difficulty moving around but has not sought medical attention until now."], "Examination and Results": ["On physical examination, the distal interphalangeal joints are swollen, warm, and painful; her nails are pitted and cracked.", "There are also rough, erythematous skin patches seen over her elbows which have been present for the last few months."], "Treatment": ["They both use hydrating creams and topical glucocorticoids with moderate benefit."]}
{"Patient Personal Background": ["She recently returned from a year of traveling abroad, but has otherwise been healthy."], "Patient Symptoms": ["She presented to the physician because she discovered blood in her sputum after coughing.", "Two weeks later, she returns with a skin rash, diarrhea, and confusion, and is given a factor to take in addition to the medications previously prescribed."], "Examination and Results": ["Based on clinical suspicion, an acid fast stain is performed showing the causative organism, and she is started on appropriate therapy."], "Treatment": ["Based on clinical suspicion, an acid fast stain is performed showing the causative organism, and she is started on appropriate therapy.", "Two weeks later, she returns with a skin rash, diarrhea, and confusion, and is given a factor to take in addition to the medications previously prescribed."]}
{"Examination and Results": ["On examination, she is found to have rebound tenderness in the lower right quadrant of her abdomen."], "Diagnosis": ["Further workup suggests ovarian cancer, which is confirmed later in the week to be stage 4 with confirmed distant metastases in the lungs and brain."]}
{"Patient Personal Background": ["He drinks 6 to 8 beers daily."], "Patient Symptoms": ["His stools are bulky, foul-smelling, and difficult to flush.", "Over the past 6 months, he has had recurrent dull epigastric pain that is triggered by meals and lasts for a few days."], "Examination and Results": ["Abdominal examination shows mild epigastric tenderness with no rebound or guarding.", "A CT scan of the abdomen is shown."]}
{"Patient Personal Background": ["He is known to be hypertensive, but noncompliant with medications for the last 20 years."], "Examination and Results": ["Physical examination reveals dry skin, ecchymoses, and conjunctival pallor.", "His blood pressure is 180/99 mm Hg, heart rate is 89/min, and respiratory rate is 17/min.", "The initial laboratory results are remarkable for hemoglobin of 10 g/dL, mean corpuscular volume of 90 \u03bcm3, platelet count of 200,000/mm3, blood urea nitrogen of 29 mg/dL, and creatinine of 2.1 mg/dL."]}
{"Patient Personal Background": ["He was born at 29 weeks via spontaneous vaginal delivery.", "He is meeting all of his milestones and is up to date with all vaccines.", "The child is breastfed exclusively."], "Patient Symptoms": ["He presents to the pediatric ward with fever, dyspnea, and cough, which he developed 3 days ago.", "His mother also reports he had poor weight gain despite a good appetite during the past 2 months as well as frequent stools with an unpleasant smell."], "Examination and Results": ["His blood pressure is 80/50 mm Hg, the heart rate is 109/min, the respiratory rate is 29/min, and the temperature is 39.1\u00b0C (102.4\u00b0F).", "The patient\u2019s weight is between the 5th and 10th percentile.", "His length is between the 50th and 75th percentile.", "The patient is sluggish and reacts torpidly to examination.", "His skin is pale and dry with decreased turgor and elasticity.", "On auscultation, there are diminished vesicular sounds and disseminated moist rales at the bases of both lungs.", "Heart sounds are normal.", "The abdomen is distended without palpable masses.", "The patient\u2019s blood analysis shows the following findings:\nComplete blood count \n Erythrocytes  3.3 x 106/mm3\n Hb  12 g/dL\n Total leukocyte count  17,500/mm3\n Neutrophils\n 59%\n Lymphocytes\n 32%\n Eosinophils\n 3%\n Monocytes\n 6%\n Basophils\n 0\nPlatelet count\n232,000/mm3\nSputum culture grows Pseudomonas aeruginosa.", "A sweat test shows chloride concentration of 85 mEq/L (elevated)."]}
{"Patient Personal Background": ["Since she started high school one year ago, her academic performance has decreased.", "She also has had difficulty finding friends at the new school."], "Patient Symptoms": ["She is afraid that her classmates will make fun of her and think that she is \u201cstupid.\u201d One month ago, when she had to give a presentation, she could not stop wondering how her classmates were going to react if she said something wrong.", "During the presentation, her heart started racing and she became flushed.", "Since this event, she avoids saying anything in class.", "She spends her breaks in the restroom because she is worried that nobody will talk to her."], "Examination and Results": ["Physical and neurologic examinations show no abnormalities.", "On mental status examination, the girl avoids eye contact and appears uncomfortable and anxious."]}
{"Patient Symptoms": ["He also \u2018can\u2019t catch his breath\u2019 at times.", "The mother also reports that he seems to be slightly shorter than other children his age."], "Examination and Results": ["His temperature is 36.6\u00b0C (97.9\u00b0F), blood pressure is 110/70 mm Hg, and respiratory rate is 14/min.", "On auscultation, a localized harsh pansystolic murmur is heard over the left sternal border at the level of the 2nd\u20133rd intercostal space.", "The murmur becomes louder when the patient is asked to squat.", "An echocardiogram is performed."]}
{"Patient Symptoms": ["She tested positive for both Kernig and Brudzinski's signs and shows signs of confusion, dyspnea, and hypotension."], "Examination and Results": ["She tested positive for both Kernig and Brudzinski's signs and shows signs of confusion, dyspnea, and hypotension.", "The blood culture results confirmed the presence of Neisseria meningitidis, and a complete blood count (CBC) revealed leukocytosis."], "Diagnosis": ["The blood culture results confirmed the presence of Neisseria meningitidis, and a complete blood count (CBC) revealed leukocytosis."]}
{"Patient Personal Background": ["His past medical history is also significant for asthma and eczema.", "He takes no medications except for omeprazole."], "Patient Symptoms": ["He feels solid food getting stuck in his chest behind the sternum when he eats.", "Drinking does not cause any difficulty swallowing.", "He has no coughing or nasal regurgitation.", "He has no hoarseness or weight loss.", "He has had heartburn for 2 years with no response to high-dose omeprazole."], "Examination and Results": ["His vital signs are within normal limits.", "Physical examination shows no abnormal findings."]}
{"Patient Personal Background": ["The patient recently underwent anesthesia for an appendectomy several months ago.", "He also has a past medical history of schizophrenia well controlled with haloperidol and is currently taking phenytoin for epilepsy.", "He is also currently taking propranolol for anxiety and hyperthyroidism."], "Patient Symptoms": ["He was at work as a construction worker when his coworkers found him down at the work site.", "He has minimal muscle tone and is incoherent when answering questions.", "The patient is covered in sweat and dirt."], "Examination and Results": ["His temperature is 106\u00b0F (41.1\u00b0C), blood pressure is 109/62 mmHg, pulse is 170/min, respirations are 23/min, and oxygen saturation is 95% on room air.", "Physical exam is notable for an altered man with a Glasgow Coma Scale of 10."]}
{"Patient Personal Background": ["He smokes a pack of cigarettes per day and drinks alcohol occasionally."], "Patient Symptoms": ["He complains of early satiety, abdominal discomfort after food intake, and abdominal bloating.", "These symptoms have been present since the patient was 52, but they were milder at that time so he paid little attention to them since.", "Tingling and decreased sensation in both lower extremities began a few months ago.", "His relatives also note that he has become excessively somnolent and forgetful."], "Examination and Results": ["His weight is 61 kg (134.5 lb), height is 181 cm (5 ft 11 in), and BMI is 18.6 kg/m2.", "His vital signs include: blood pressure 110/80 mm Hg, heart rate 89/min, respiratory rate 13/min, and temperature 36.1\u00b0C (96.9\u00b0F).", "The patient\u2019s skin is pale, thin, dry, and hypoelastic.", "Lung and heart examinations are within normal limits for his age.", "The patient\u2019s tongue is bright red with atrophic papillae.", "The abdomen is distended and tender to palpation in the epigastric area.", "Neurological examination shows symmetrical bilateral distal hypoesthesia for all sensations and decreased muscle strength in both upper and lower extremities.", "On a mini-mental status examination, the patient scores 25."], "Others": ["The patient\u2019s medical history is significant for acute hepatitis B 20 years ago.", "Lymph nodes and the thyroid gland are not enlarged."]}
{"Patient Personal Background": ["Her mother is concerned about the blood-tinged discharge but states that her daughter has been feeding and voiding well.", "The neonate was delivered at 39 weeks gestation by an uncomplicated vaginal delivery, and she and her mother were discharged home after two days.", "The prenatal course was complicated by chlamydia in the mother during the first trimester, for which she and the partner were both treated with a negative test of cure.", "The neonate\u2019s biological father is no longer involved the patient's care, but her mother\u2019s boyfriend has been caring for the baby whenever the mother rests."], "Patient Symptoms": ["Her mother is concerned about the blood-tinged discharge but states that her daughter has been feeding and voiding well."], "Examination and Results": ["At this visit, the neonate\u2019s temperature is 98.5\u00b0F (36.9\u00b0C), pulse is 138/min, and respirations are 51/min.", "She appears comfortable, and cardiopulmonary and abdominal exams are unremarkable.", "There are no bruises or marks on her skin.", "Examination of the genitals reveals no vulvar irritation or skin changes, but there is scant pink mucoid discharge at the introitus."]}
{"Patient Personal Background": ["His past medical history is notable for hypertension, diabetes, and stable angina.", "He takes lisinopril, metformin, glyburide, and aspirin.", "He has a history of intravenous drug use and was homeless in his early 30\u2019s.", "He drinks alcohol socially and has a 30 pack-year smoking history.", "His temperature is 98.6\u00b0F (37\u00b0C), blood pressure is 130/85 mmHg, pulse is 95/min, and respirations are 18/min."], "Patient Symptoms": ["He reports a 6-month history of slowly progressive tiredness associated with dull achy pain in his knees, hips, and shoulders."], "Examination and Results": ["Physical examination reveals a generally well-appearing male without evidence of ascites, peripheral edema, or jaundice."]}
{"Patient Personal Background": ["The patient\u2019s medical history is negative for similar symptoms or a thyroid disorder."], "Patient Symptoms": ["The small, round, and painless swelling, which was detected 3 weeks ago in the middle of her neck, has now increased in size.", "The swelling is associated with sweaty palms and soles, insomnia, irritability, nervousness, and fatigue; however, the patient does not complain of fever, cervical lymphadenopathy, weight loss, vision problems, or body swelling."], "Examination and Results": ["The vital signs are within normal limits.", "Local examination reveals a 3 x 3 cm round, non-tender, non-fluctuant, and non-pulsatile swelling in the anterior triangle of her neck.", "The patient carries a total white blood cell count of 10,200/mm3, including 70% neutrophils, 30% lymphocytes, and zero eosinophils.The erythrocyte sedimentation rate is 20 mm/hr (normal, 0\u201329 mm/hr)."]}
{"Patient Symptoms": ["She reports that her fingers feel stiff in the morning and the symptoms tend to improve as the day progresses."], "Examination and Results": ["Her temperature is 37\u00b0C (98.6\u00b0F), blood pressure is 120/70 mm Hg, respiratory rate is 16/min, and heart rate is 70/min.", "On physical examination, her metacarpophalangeal joints are erythematous and tender."], "Others": ["She denies any recent trauma or other inciting events.", "Family history is significant for a grandmother who suffered from fibromyalgia."]}
{"Patient Personal Background": ["He has hypertension and rheumatoid factor-positive rheumatoid arthritis.", "He does not smoke.", "He has a history of chronic alcohol abuse."], "Patient Symptoms": ["During this time he has felt like his eyes have been unusually puffy in the mornings and his urine has been frothy."], "Examination and Results": ["His temperature is 36.7\u00b0C (98\u00b0F), pulse is 80/min, and blood pressure is 148/86 mm Hg.", "Physical examination shows pallor, periorbital edema, 2+ pedal edema, and ascites.", "He has swan-neck deformities and nodules of multiple fingers and swelling and restricted range of motion of bilateral knee joints.", "Laboratory studies show:\nHemoglobin 8.2 mg/dl\nProthrombin time 12 seconds\nSerum\nAlbumin 2.8 g/dl\nTotal bilirubin 1.0 mg/dl\nAlkaline phosphatase 120 U/L\nAST 20 U/L\nALT 19 U/L\nUrea 18 mg/dl\nCreatinine 1.2 mg/dl\nUrine\nProtein 3+\nWBCs 5\u201310/hpf\nRBCs negative\nBacteria negative\nUltrasound of the liver and kidneys shows no abnormalities."], "Treatment": ["Current medications include amlodipine, methotrexate, and ibuprofen."]}
{"Patient Personal Background": ["Her past medical history is relevant for depression, personality changes, and declining work performance, for which she has been put on leave from her current job as an elementary school teacher."], "Patient Symptoms": ["On physical examination, patient has dysarthria, dystonia, and an ataxic gait."], "Examination and Results": ["Ophthalmologic examination reveals multi-colored irises with concentric rings around the periphery (findings shown in the photo).", "Sensation and motor functions are preserved."]}
{"Examination and Results": ["On examination of the oropharynx, you note a grayish-white pseudomembrane and uneven elevation of the soft palate.", "The patient displays marked enlargement of the cervical lymph nodes."]}
{"Patient Personal Background": ["He has a past medical history of asthma, depression, and anxiety.", "He is not currently taking any medications."], "Patient Symptoms": ["The patient then presents 4 months later to his primary doctor with weakness.", "The patient's strength in his upper extremities is 1/5.", "He has reduced sensation in his upper extremities as well."], "Examination and Results": ["His temperature is 99.5\u00b0F (37.5\u00b0C), blood pressure is 90/60 mmHg, pulse is 115/min, respirations are 22/min, and oxygen saturation is 99% on room air.", "The patient's cardiopulmonary exam is within normal limits.", "The patient is breathing on his own and has strong distal pulses.", "The patient's lower extremities reveal 5/5 strength with intact sensation."], "Treatment": ["Ultimately, the patient is discharged with follow up instructions after no significant fractures or injuries are found."], "Others": ["The patient was an unrestrained driver in a head-on collision.", "A chest radiograph and basic labs are ordered."]}
{"Patient Personal Background": ["She has smoked 1 pack of cigarettes daily for the last 15 years.", "Current medications include glyburide and amlodipine."], "Treatment": ["The physician prescribes a medication that decreases the production of mevalonate."]}
{"Patient Symptoms": ["Menses occur irregularly at 45 to 65-day intervals.", "Physical examination shows facial acne and growth of coarse dark hair on the face, chest, and lower back."], "Examination and Results": ["She is 159 cm (5 ft 3 in) tall and weighs 59 kg (130 lb); BMI is 23 kg/m2.", "Pelvic examination shows no abnormalities.", "Serum studies show:\nSodium 141 mEq/L\nPotassium 4.2 mEq/L\nGlucose 109 mg/dL\nCortisol (1600 h) 4 \u03bcg/dL\nProlactin 14 ng/mL\n17-hydroxyprogesterone 390 ng/dL (N=20\u2013300 ng/dL)\nTestosterone 91 ng/dL (N=8\u201360 ng/dL)\nA urine pregnancy test is negative."]}
{"Patient Personal Background": ["Current medications include aspirin, atorvastatin, hydrochlorothiazide, and metoprolol.", "Three weeks ago, he was also started on amlodipine."], "Examination and Results": ["His blood pressure ranged from 160/100 mm Hg to 150/94 mm Hg on his previous 3 visits over the past 4 months.", "His blood pressure today is 158/98 mm Hg.", "Physical examination shows no other abnormalities.", "Renal duplex ultrasonography shows 90% occlusion of the right renal artery."], "Treatment": ["Three weeks ago, he was also started on amlodipine."]}
{"Patient Personal Background": ["She has chronic migraines, hypertension, and type 2 diabetes mellitus.", "Her medications include lisinopril and metformin, but she ran out of her anti-hypertensive medications over the weekend."], "Patient Symptoms": ["When he left their lakeside cabin 6 hours before to go ice fishing and get more firewood, she did not have any symptoms.", "She is confused and oriented only to person and place.", "She recalls only one of three objects after 5 minutes.", "Her gait is unsteady."], "Examination and Results": ["Her temperature is 37.1\u00b0C (98.8\u00b0F), pulse is 110/min, respirations are 21/min, and blood pressure is 154/92 mm Hg.", "Pulse oximetry on room air shows an oxygen saturation of 98%.", "Physical examination shows no abnormalities."]}
{"Examination and Results": ["Imaging reveals transmural myocardial infarction in the posterior 1/3 of the ventricular septum."]}
{"Patient Symptoms": ["He also reports abdominal pain, intermittent nausea, and fever.", "He has not had vomiting, tenesmus, or rectal pain."], "Examination and Results": ["His vital signs are within normal limits.", "Abdominal examination reveals tenderness of the right lower abdomen without rebound tenderness.", "Rectal exam is unremarkable.", "Laboratory studies show a leukocyte count of 14,800/mm3 and an erythrocyte sedimentation rate of 51 mm/h.", "Test of the stool for occult blood and stool studies for infection are negative.", "A CT scan of the abdomen shows mural thickening and surrounding fat stranding of discrete regions of the terminal ileum and transverse colon.", "A colonoscopy is performed and biopsy specimens of the affected areas of the colon are taken."]}
{"Patient Symptoms": ["He describes the pain as dull and constant, boring in nature, and localized deep below the thigh muscle.", "He says it is worse at night."], "Examination and Results": ["Physical examination is significant for tenderness and warmth over the anterior aspect of the left thigh.", "A plain radiograph of the left femur shows increased cortical thickness with widened intercortical space.", "Laboratory studies show:\nAlkaline phosphatase\n925 U/L\nSerum calcium\n9.2 mg/dL\nSerum phosphorus 4.4 mg/dL\nFindings on bone biopsy are shown in the image."]}
{"Patient Personal Background": ["He has major depressive disorder with psychosis.", "His mother has Graves' disease.", "Current medications include sertraline and haloperidol.", "He appears uncomfortable."], "Patient Symptoms": ["He has had around 3\u20134 episodes of greenish colored vomit during this period.", "His temperature is 37.3\u00b0C (99.1\u00b0F), pulse is 87/min, and blood pressure is 118/72 mm Hg."], "Examination and Results": ["His temperature is 37.3\u00b0C (99.1\u00b0F), pulse is 87/min, and blood pressure is 118/72 mm Hg.", "The pupils are equal and reactive to light.", "The end-tidal CO2 is 85 mm Hg."], "Treatment": ["He is diagnosed with acute appendicitis and is taken to the operating room for an emergency laparoscopic appendectomy.", "Just after the appendiceal base is ligated, the patient shows muscle rigidity and profuse diaphoresis."], "Diagnosis": ["He is diagnosed with acute appendicitis and is taken to the operating room for an emergency laparoscopic appendectomy."], "Others": ["The appendix is gangrenous and perforated with purulent fluid in the pelvis."]}
{"Others": ["It passes through several stages during its maturation.", "Positive selection is an important process during maturation of T lymphocytes, and it ensures the preservation of self-major histocompatibility complex (MHC)-restricted T cells."]}
{"Patient Personal Background": ["The patient reports that he returned from active duty in Iraq 3 months ago and was adjusting to life back at home until about 7 weeks ago when he began having intense fear of loud noises and seeing sudden flashbacks to bombing attacks he endured during his time in Iraq.", "He had to take a leave from his army instructor duties as he was not able to handle the familiar settings of practice shooting ranges and sudden loud explosions during battalion training."], "Patient Symptoms": ["The patient reports that he returned from active duty in Iraq 3 months ago and was adjusting to life back at home until about 7 weeks ago when he began having intense fear of loud noises and seeing sudden flashbacks to bombing attacks he endured during his time in Iraq.", "He had to take a leave from his army instructor duties as he was not able to handle the familiar settings of practice shooting ranges and sudden loud explosions during battalion training.", "After refusing to leave his house, he was finally persuaded by his wife to visit your clinic."]}
{}
{"Patient Personal Background": ["He was diagnosed with type 2 diabetes mellitus 1 year ago.", "His only medication is metformin."], "Patient Symptoms": ["He also mentions that he has had a weight gain of 4 kg (8.8 lb)."], "Examination and Results": ["His serum glucose is 186 mg/dL and his hemoglobin A1c is 7.6%."], "Treatment": ["The physician prescribes an additional antidiabetic drug and counsels the patient on its delayed onset of action."]}
{"Patient Symptoms": ["The patient fervently denies being underweight claiming that she is \u2018a fatty\u2019 and goes on to refuse any further intravenous fluid and later, even the hospital meals."], "Examination and Results": ["Her vitals taken by the emergency medical services (EMS) include blood pressure 88/55 mm Hg, pulse 55/min."], "Treatment": ["She was given a liter of isotonic fluid while en route to the hospital."], "Others": ["At the emergency department, she is alert and oriented and is noted to be anorexic."]}
{"Patient Personal Background": ["He was diagnosed with HIV 15 years ago.", "He was taking triple antiretroviral therapy but stopped a few months ago because he was feeling well.", "He lives in Wyoming."], "Examination and Results": ["Vital signs are within normal limits.", "Cardiopulmonary examination shows no abnormalities.", "His CD4+ T-lymphocyte count is 47/mm3 (N \u2265 500)."], "Treatment": ["The patient currently refuses to restart antiretroviral therapy."]}
{"Patient Personal Background": ["He was in his normal state of health until 2 weeks ago when he went abroad on a vacation.", "During his trip he went kayaking, visited spas, interacted with local animals, and ate local foods.", "He drinks socially and has a 15-pack-year history of smoking."], "Patient Symptoms": ["Since returning he has had 3-day history of fever, cough, headache, and diarrhea."], "Examination and Results": ["On presentation his temperature is 102.3\u00b0F (39.1\u00b0C), blood pressure is 105/62 mmHg, pulse is 91/min, respirations are 18/min, and O2 saturation is 91% on room air.", "Chest exam reveals fine crackles on auscultation.", "Chest radiograph reveals patchy infiltrates in both lungs and labs reveal mild hyponatremia and mild elevation of AST/ALT levels."]}
{"Patient Personal Background": ["His past medical history is significant for infectious mononucleosis last year and type 1 diabetes mellitus for which he has an insulin pump."], "Patient Symptoms": ["He reports that he lost his balance while attempting a new trick and fell on his outstretched hands.", "He has been icing his hand and taking several tablets of ibuprofen every few hours, but the pain and swelling have not improved.", "The patient reports that he has not been able to use the hand to take notes in school."], "Examination and Results": ["On physical exam, there is mild swelling over the dorsal aspect of the hand and wrist.", "He has tenderness in the region between the extensor pollicus longus and the extensor pollicus brevis of the right hand."], "Treatment": ["He has been icing his hand and taking several tablets of ibuprofen every few hours, but the pain and swelling have not improved."]}
{"Patient Personal Background": ["Menses have occurred at 45- to 90-day intervals since menarche at the age of 15 years.", "Over the past two years, she was unable to become pregnant despite having unprotected sexual intercourse with her husband on a regular basis.", "There is no personal or family history of serious illness."], "Patient Symptoms": ["The patient reports that she was too embarrassed to discuss this issue with anyone until now.", "Examination shows oily skin and severe facial acne.", "There is abnormal pigmented hair on the upper lip and around both nipples."], "Examination and Results": ["She is 170 cm (5 ft 7 in) tall and weighs 85 kg (187 lb); BMI is 29.4 kg/m2.", "Her vital signs are within normal limits."], "Others": ["Her last menstrual period was 5 weeks ago."]}
{"Patient Personal Background": ["He has type 2 diabetes mellitus, for which he takes metformin and sitagliptin.", "He has smoked 1 pack of cigarettes daily for 20 years."], "Patient Symptoms": ["He also reports lightheadedness that started earlier in the day."], "Examination and Results": ["He appears pale and diaphoretic.", "A 12-lead ECG is shown."]}
{"Patient Symptoms": ["He complains of severe pain that prevents him from participating in physical therapy and wakes him from sleep."], "Examination and Results": ["Physical examination of the left knee shows a healing incision; there is no joint effusion, erythema, or evidence of wound dehiscence, and his gait is normal."], "Treatment": ["He was discharged with prescriptions for oxycodone and acetaminophen.", "When the physician recommends switching to ibuprofen for pain, he becomes visibly angry and demands a refill of oxycodone."], "Others": ["There were no complications."]}
{"Patient Personal Background": ["This patient also has type 2 diabetes mellitus which is well controlled with metformin."], "Patient Symptoms": ["Three months ago, she presented with complaints about facial asymmetry.", "Her daughter has noticed that her mother\u2019s mouth is droops downwards on the right side of her face and that she cannot close her right eye well.", "The same side also lacks wrinkles on the forehead.", "Since then, the patient feels like her facial muscles have gotten weaker.", "Upon being asked to close her eyes, the patient has difficulty doing so and fails to completely close her eyelids."], "Examination and Results": ["On examination, there is no loss of pain, temperature, or crude or tactile touch sensations in the whole face.", "The neurological exam is otherwise unremarkable."], "Treatment": ["She was given a course of corticosteroids, but she has still not recovered fully.", "The neurologist recommends a therapy that will help relieve her symptoms."]}
{"Patient Personal Background": ["He was treated for a neck abscess 6 months ago.", "He takes no medications.", "He has smoked one pack of cigarettes daily for 10 years and drinks two to three beers daily.", "He has been using intravenous cocaine and heroin for 6 years.", "He appears ill. His temperature is 38.6\u00b0C (101.5\u00b0F), pulse is 112/min, respirations are 20/min, and blood pressure is 110/70 mm Hg."], "Patient Symptoms": ["He has no cough.", "Examination shows track marks on both cubital fossae."], "Examination and Results": ["There are retinal hemorrhages with pale centers.", "The lungs are clear to auscultation.", "A grade 3/6 holosystolic murmur is heard best at the lower left sternal border.", "Laboratory studies show:\nHemoglobin 13.3 g/dL\nLeukocyte count 14,300/mm3\nPlatelet count 278,000/mm3\nSerum\nGlucose 96 mg/dL\nCreatinine 1.0 mg/dL\nTotal bilirubin 0.4 mg/dL\nAST 18 U/L\nALT 22 U/L\nTransthoracic echocardiography shows multiple vegetations on the tricuspid valve and moderate tricuspid regurgitation.", "Two sets of blood cultures are collected."]}
{"Patient Personal Background": ["She has no history of major medical illness."], "Examination and Results": ["Her temperature is 36\u00b0C (96.8\u00b0F), pulse is 121/min, and blood pressure is 120/78 mm Hg.", "Physical examination shows pale conjunctivae.", "A peripheral blood smear is shown."]}
{"Patient Personal Background": ["He admits to drinking alcohol almost every night since the age of 17."], "Patient Symptoms": ["He says that he often gets similar pain but less severe and that it worsens with meals.", "The pain sometimes radiates to his back.", "He recently lost 15 kg (33.6 lb) of weight secondary to his lack of appetite since his last visit 2 months ago."], "Examination and Results": ["His temperature is 37.0\u00b0 C (98.6\u00b0F), respirations are 15/min, pulse is 67/min, and blood pressure is 122/98 mm Hg.", "Physical examination reveals moderate epigastric tenderness.", "An abdominal CT scan reveals calcifications as shown by the white arrows."]}
{"Patient Personal Background": ["He is a financial director with a 15-pack-year history of smoking who tried quitting several times.", "The patient has gastrointestinal reflux disease and takes omeprazole.", "The medical history is significant for a head trauma after which he had two seizure episodes.", "He does not have a history of any other disorders.", "Currently, he is not on any antiepileptic medication."], "Treatment": ["He heard from his friend about an antidepressant that efficiently helps with smoking cessation."], "Others": ["He tried different nicotine replacement products, none of which helped him.", "He would like to try this medication, and asks his physician for an advice."]}
{"Patient Personal Background": ["She has had no prenatal care."], "Patient Symptoms": ["The abdomen is nontender, and regular contractions are felt every 2 minutes.", "There is blood on the vulva, introitus, and medial aspect of the thighs."], "Examination and Results": ["Her temperature is 37.2\u00b0C (99.0\u00b0F), pulse is 102/min, respirations are 16/min, and blood pressure is 138/82 mm Hg.", "The uterus is consistent in size with a 20-week gestation.", "Ultrasound shows complete detachment of the placenta from the uterus.", "Fetal heart tones are absent."], "Treatment": ["An emergent cesarean delivery is performed."], "Others": ["Following the procedure, the patient becomes tearful and distraught."]}
{"Patient Personal Background": ["He has not had any changes in his weight.", "He has a history of hypertension, type 2 diabetes mellitus, and chronic shoulder pain.", "He does not drink alcohol and does not smoke.", "His diet has mostly consisted of potatoes and lean meats since his wife passed away 1 year ago."], "Examination and Results": ["His pulse is 92/min and blood pressure is 135/80 mm Hg.", "Examination shows conjunctival and mucosal pallor.", "Abdominal and rectal examination shows no abnormalities.", "Neurological exam shows mild postural tremor.", "Peripheral blood smear shows red blood cells with increased zones of central pallor and anisocytosis."], "Treatment": ["Current daily medications include hydrochlorothiazide, metformin, and ibuprofen."]}
{"Others": ["Her younger brother has mild developmental delay, pale complexion, and has to limit his dietary intake of phenylalanine.", "She has no similar symptoms and is in good health.", "Her parents are healthy."]}
{"Patient Personal Background": ["He has had approximately 10 different sexual partners in the past 3 months."], "Patient Symptoms": ["He noticed the swelling a day ago while preparing for the college basketball game."], "Examination and Results": ["Synovial fluid tap shows a WBC count of 90,000 cells/mm3."]}
{}
{"Patient Personal Background": ["His neighbor says that he never really knew the patient that well and that he mostly kept to himself.", "They have been neighbors for the past 3 years at an apartment close to the hospital."], "Patient Symptoms": ["The patient appears disheveled, has a flat affect, and appears to be having auditory hallucinations.", "He suddenly seemed interested in attending all the local council meetings and social gatherings.", "He is very talkative at these events and boasts highly of himself and starts suggesting changes that the committee could make with his help.", "He gets very agitated when they deny accepting his suggestions."], "Examination and Results": ["He is alert and oriented to time, person, and place and has an intact long-term and short-term memory."], "Others": ["What worried the neighbor was a sudden change in the patient's behavior which started last week."]}
{"Patient Personal Background": ["The patient has been relatively healthy and just recently started \u201cintermittent fasting\u201d to try to lose weight.", "He recalls a similar episode 4 years ago when he was recovering from an emergency appendectomy.", "The patient denies smoking but endorses an episode of binge drinking 2 days ago.", "He is sexually active with both men and women."], "Examination and Results": ["His physical examination is unremarkable besides scleral icterus."]}
{"Patient Symptoms": ["She reports that she has had episodic tinnitus in her right ear for the past 3 years."], "Examination and Results": ["Neurologic examination shows hearing loss in the right ear.", "An MRI of the brain is shown."]}
{"Patient Symptoms": ["She says that the pain of passing the stone was excruciating and asks how she can prevent kidney stones in the future."], "Examination and Results": ["CT scan in the ED revealed a 4-mm stone occluding the right ureter.", "Pathology report on the stone states it was composed of calcium oxalate."], "Treatment": ["She was able to pass the stone without assistance over the course of 5 hours."], "Others": []}
{"Patient Personal Background": ["His father had a similar condition that was treated with medications."], "Patient Symptoms": ["He reports that certain daily activities have become more difficult to perform.", "The patient appears anxious."], "Examination and Results": ["Vital signs are within normal limits.", "Examination shows a low-amplitude tremor bilaterally when the arms are outstretched that worsens when reaching out to grab a pen.", "Muscle strength and tone is normal bilaterally.", "Deep tendon reflexes are 2+ bilaterally.", "On mental status examination, his mood is good.", "His speech is normal in rate and rhythm."]}
{"Patient Personal Background": ["He has adult polycystic kidney disease and was on maintenance hemodialysis for 2 months prior to transplantation.", "Current medications include azathioprine, cyclosporine, prednisone, and enalapril."], "Patient Symptoms": ["During the past 2 days, he has had decreasing urinary output.", "He appears lethargic."], "Examination and Results": ["He passed 5 liters of urine on the second postoperative day and serum studies showed a creatinine concentration of 2.1 mg/dL.", "His temperature is 37.8\u00b0C (100\u00b0F), pulse is 101/min, and blood pressure is 164/94 mm Hg.", "Examination shows a healing surgical incision in the right lower abdomen.", "The graft site shows tenderness to palpation.", "His blood urea nitrogen concentration is 52 mg/dL, creatinine concentration is 4.1 mg/dL.", "A biopsy of the transplanted kidney shows tubulitis.", "C4d staining is negative."]}
{"Patient Personal Background": ["She recently underwent routine screening for bone density due to a history of hypothyroidism.", "She also has a history of gastroesophageal reflux disease (GERD) that is being treated with a proton-pump inhibitor (PPI) and more recently with a histamine2 receptor antagonist (H2RA), hypertension being treated with a thiazide diuretic, depression being treated with lithium, and hormone replacement therapy."], "Examination and Results": ["Her results meet the criteria for osteopenia, with a T-score of -1.6."], "Others": ["She is concerned about progressive bone loss and the risk of fractures."]}
{"Patient Symptoms": ["On arrival, he is unconscious."], "Examination and Results": ["His respirations are 24/min, and palpable systolic blood pressure is 60 mm Hg, and pulse is 141/min and irregularly irregular.", "Examination shows multiple ecchymoses over the chest.", "There is a 3-cm (1.2-in) laceration over the abdomen and a 4-cm (1.6-in) laceration over the scalp.", "Jugular venous pressure is increased.", "Bilateral crackles are heard at the lung bases.", "Cardiac examination shows no murmurs, rubs, or gallops.", "The abdomen is soft.", "Focused assessment with sonography in trauma (FAST) is negative.", "An electrocardiogram shows absent p-waves."], "Treatment": ["Two large bore intravenous catheters are inserted and 0.9% saline infusion is begun.", "Vasopressors are administered."], "Others": ["After 5 minutes, his pulse is 160/min and palpable systolic blood pressure is 50 mm Hg.", "One hour later, the patient dies."]}
{"Patient Symptoms": ["On exam, you detect a friction rub."], "Examination and Results": ["Vital signs are stable.", "Routine labs show K 7.5 and Cr 5.1."]}
{"Patient Personal Background": ["His personal history is relevant for cigarette smoking and a sedentary lifestyle.", "He has type-2 diabetes mellitus which is under control with oral medications."], "Examination and Results": ["Upon physical examination, he is found to have a blood pressure of 130/70 mm Hg, a pulse of 72/min, a respiratory rate of 18/min, and a body temperature of 36.5\u00b0C (97.7\u00b0F).", "The rest of the examination is unremarkable except for an enlarged, nontender left supraclavicular node."]}
{"Patient Symptoms": ["She says she is now having trouble walking a full block.", "For the past week, she also has noticed bilateral swelling of the lower legs.", "She denies chest pain, fever, chills, syncope, or bloody sputum."], "Examination and Results": ["Current vitals include: temperature 37.0\u00b0C (98.6\u00b0F), pulse 63/min, blood pressure 128/91 mm Hg and respiratory rate 15/min.", "On physical examination, there is elevated jugular venous pressure, decreased breath sounds bilaterally at the lung bases, and 1+ non-pitting edema bilaterally in the lower extremities.", "A chest X-ray demonstrates a slightly enlarged cardiac silhouette."]}
{"Patient Personal Background": ["She has been living alone since the death of her husband 1 year ago."], "Patient Symptoms": ["She appears thin and has temporal wasting bilaterally."], "Examination and Results": ["Physical examination shows bruises on her lower legs, swollen gums, and petechiae on the hard palate."]}
{"Patient Symptoms": ["Upon arrival, the patient regained consciousness and complained of intense bilateral flank pain and a recent decrease in urination."], "Examination and Results": ["Urine microscopy demonstrated abundant square crystals of calcium oxalate that looked like \u201cfolded envelopes.\""]}
{"Patient Symptoms": ["He reports improvement in his symptoms and has not experienced any adverse effects."]}
{"Patient Personal Background": ["Her boyfriend says she recently returned from a trip to Southeast Asia."], "Patient Symptoms": ["She appears ill and is lethargic."], "Examination and Results": ["Her temperature is 39\u00b0C (102.2\u00b0F).", "Physical examination shows jaundice and tender hepatomegaly.", "Laboratory studies show the presence of anti-hepatitis A IgM antibodies."]}
{"Patient Personal Background": ["The patient is a current smoker and is sexually active.", "He admits to having unprotected sex with many different partners this past year.", "The patient has no significant past medical history and is not currently taking any medications."], "Patient Symptoms": ["The patient describes the pain as feeling worse in the morning.", "He says it is a general stiffness that improves when he goes to the gym and lifts weights.", "He also states that his symptoms seem to improve when he leans forward or when he is cycling."], "Examination and Results": ["On physical exam, the patient demonstrates notable kyphosis of the thoracic spine and decreased mobility of the back in all 4 directions.", "The patient\u2019s strength is 5/5 in his upper and lower extremities.", "The rest of his physical exam is within normal limits."]}
{"Patient Personal Background": ["The boy was born at 39 weeks gestation via spontaneous vaginal delivery.", "He is up to date on all vaccines and is meeting all developmental milestones.", "He was breastfed for the first 3 months and then switched to cow\u2019s milk and about two months ago she started giving him fruits and vegetables.", "Family history is noncontributory."], "Patient Symptoms": ["Generally, the boy looks pale."], "Examination and Results": ["Today, his heart rate is 120/min, respiratory rate is 40/min, blood pressure is 90/50 mm Hg, and temperature of 37.0\u00b0C (98.6\u00b0F).", "On examination, he has a heartbeat with a regular rate and rhythm and his lungs are clear to auscultation bilaterally.", "His weight and height fall within the expected range."]}
{}
{"Patient Personal Background": ["Three months later, his blood pressure appears to be adequately controlled on this therapy."], "Patient Symptoms": ["While working in his garden one afternoon, the patient is stung by a wasp and experiences a severe anaphylactic reaction that is subsequently treated with epinephrine."], "Treatment": ["While working in his garden one afternoon, the patient is stung by a wasp and experiences a severe anaphylactic reaction that is subsequently treated with epinephrine."]}
{"Patient Personal Background": ["Three years ago, he had an asthma attack that was treated with albuterol and a one-week course of steroids.", "His mother has Hashimoto's thyroiditis and had precocious puberty.", "His mother's height is 147 cm (4 ft 10 in) and his father's height is 160 cm (5 ft 3 in)."], "Patient Symptoms": ["Neither his clothing nor his shoe size have changed over the past year.", "He also frequently bumps into obstacles such as furniture and has headaches at night.", "He is always thirsty for cold water and has been urinating more frequently."], "Examination and Results": ["He is at the 5th percentile for height and 5th percentile for weight.", "His temperature is 37\u00b0C (98.6\u00b0F), pulse is 98/min, respirations are 16/min, and blood pressure is 100/64 mm Hg.", "Examination shows a soft and nontender abdomen.", "The genitals and pubic hair are both Tanner stage 1.", "Axillary hair is absent.", "Patellar reflexes are 1+ bilaterally."]}
{"Patient Personal Background": ["Her pregnancy has been uncomplicated.", "Her first child was born at term by vaginal delivery.", "She has no history of any serious illnesses.", "She does not drink alcohol or smoke cigarettes.", "Current medications include vitamin supplements."], "Patient Symptoms": ["Speculum examination demonstrates clear fluid at the cervical os."], "Examination and Results": ["Her temperature is 37.2\u00b0C (98.9\u00b0F), pulse is 70/min, respirations are 18/min, and blood pressure is 128/82 mm Hg.", "The fetal heart rate is reactive at 160/min with no decelerations.", "Tocometry shows uterine contractions.", "Nitrazine testing is positive."], "Treatment": ["She is started on indomethacin."]}
{"Patient Personal Background": ["He has a history of constipation."], "Examination and Results": ["His temperature is 39.1\u00b0C (102.4\u00b0C).", "Abdominal examination shows left lower quadrant tenderness with no guarding or rebound.", "Laboratory studies show a leukocyte count of 19,000/mm3.", "A CT scan of the abdomen shows segmental wall thickening of the descending colon with multiple diverticula and a 5.0-cm, low-attenuation pelvic lesion with air-fluid levels.", "CT-guided drainage of the fluid collection yields 250 mL of yellow-greenish fluid."], "Treatment": []}
{"Others": ["He is curious if patients with diabetes (defined as fasting serum glucose \u2265126 mg/dL on two separate readings) are at increased risk of developing open-angle glaucoma over time."]}
{"Examination and Results": ["Results:\nThe rate of exacerbations was reduced by 47% (95% confidence interval [CI], 29 to 61) among patients receiving intravenous mepolizumab and by 53% (95% CI, 37 to 65) among those receiving subcutaneous mepolizumab, as compared with those receiving placebo (p<0.001 for both comparisons).", "Exacerbations necessitating an emergency department visit or hospitalization were reduced by 32% in the group receiving intravenous mepolizumab and by 61% in the group receiving subcutaneous mepolizumab.", "At week 32, the mean increase from baseline in FEV1 was 100 ml greater in patients receiving intravenous mepolizumab than in those receiving placebo (p=0.02) and 98 ml greater in patients receiving subcutaneous mepolizumab than in those receiving placebo (p=0.03).", "The improvement from baseline in the SGRQ score was 6.4 points and 7.0 points greater in the intravenous and subcutaneous mepolizumab groups, respectively than in the placebo group, and the improvement in the ACQ-5 score was 0.42 points and 0.44 points greater in the two mepolizumab groups, respectively than in the placebo group (p<0.001 for all comparisons)."], "Treatment": ["Patients were assigned to receive mepolizumab, a humanized monoclonal antibody against interleukin-5, which was administered as either a 75-mg intravenous dose or a 100-mg subcutaneous dose or placebo every 4 weeks for 32 weeks."], "Others": ["Methods:\nIn this randomized, double-blind clinical trial we assigned 576 patients with recurrent asthma exacerbations and evidence of eosinophilic inflammation despite high doses of inhaled glucocorticoids to one of three study groups.", "The primary outcome was the rate of exacerbations.", "Other outcomes included the forced expiratory volume in 1 second (FEV1) and scores on the St. George\u2019s Respiratory Questionnaire (SGRQ) and the 5-item Asthma Control Questionnaire (ACQ-5).", "Conclusions:\nMepolizumab administered either intravenously or subcutaneously significantly reduced asthma exacerbations and was associated with improvements in markers of asthma control."]}
{"Patient Symptoms": ["She says she was only unconscious for a moment and recovered quickly.", "She reports increasing fatigue and joint pain for the past 4 months."], "Examination and Results": ["Her blood pressure is 90/60 mm Hg, and her temperature is 36.6\u00b0C (98.0\u00b0F).", "On physical examination, the patient is fully conscious.", "Her radial pulse is absent at her right wrist and 1+ at her left wrist."]}
{"Patient Personal Background": ["She has no history of serious illness.", "She is sexually active with her boyfriend and states that she has been having pain during vaginal intercourse lately."], "Patient Symptoms": ["She also reports some pain while sitting and walking.", "She is sexually active with her boyfriend and states that she has been having pain during vaginal intercourse lately.", "She appears uncomfortable."], "Examination and Results": ["Her temperature is 38\u00b0C (100.4\u00b0F), pulse is 90/min, and blood pressure 120/80 mm Hg.", "Pelvic examination shows a left-sided, tender mass surrounded by edema and erythema in the left inner labia."]}
{"Patient Personal Background": ["She was born with a disease that has led her to have recurrent upper respiratory infections throughout her life requiring antibiotic prophylaxis and chest physiotherapy as well as pancreatic enzyme replacement therapy."], "Treatment": ["She was born with a disease that has led her to have recurrent upper respiratory infections throughout her life requiring antibiotic prophylaxis and chest physiotherapy as well as pancreatic enzyme replacement therapy."], "Others": ["She marries a man (without this disease phenotype) from a population where the prevalence of this disease is 1/100."]}
{"Patient Personal Background": ["She was diagnosed with hypertension in the past and is now regularly taking antihypertensive medication (amlodipine 10 mg once daily)."], "Patient Symptoms": ["She has had a diffuse thyroid swelling for the past 4 months.", "She complains of pain in the long bones of her arms and legs for the past 3 months.", "She is slightly built, appears thin, and is anxious and apprehensive.", "Her skin is moist and warm."], "Examination and Results": ["Her weight is 45 kg (99.2 lb) and height is 146 cm (4 ft 7 in); BMI is 21.12 kg/m2.", "Her pulse is 116/min, the blood pressure is 196/102 mm Hg, the respiratory rate is 29/min, and the temperature is 37.2\u00b0C (99.0\u00b0F).", "Diffuse and firm thyromegaly is present.", "Her upper extremities exhibit fine tremors during an anxiety attack.", "The laboratory test results reveal elevated 24-hour urinary VMA and metanephrines.", "Serum epinephrine, calcitonin, and parathormone levels are also elevated.", "Hypercalcemia and hyperglycemia are also noted."]}
{"Patient Personal Background": ["He has worked as a car salesman for 15 years and worked in a shipyard before that for 22 years.", "He smoked half a pack of cigarettes daily for 13 years but stopped 25 years ago."], "Patient Symptoms": ["The cough had been initially nonproductive.", "He has not had fever or chest pain."], "Examination and Results": ["His temperature is 37.1\u00b0C (98.8\u00b0F), pulse is 86/min, respirations are 16/min, and blood pressure is 130/80 mm Hg.", "Fine expiratory crackles are heard at both lung bases.", "An x-ray of the chest shows patchy infiltrates and supradiaphragmatic pleural thickening in both lungs."], "Others": ["He is originally from China and visits his family there once every year.", "A photomicrograph from a sputum sample is shown."]}
{"Patient Personal Background": ["Her past medical history is significant for varicose veins in her lower extremities, well-controlled diabetes mellitus type 2, and a 25 pack-year smoking history.", "The patient currently takes metformin and pioglitazone."], "Patient Symptoms": ["On physical examination, the patient is pale and diaphoretic."], "Examination and Results": ["Her temperature is 37.8\u00b0C (100.0\u00b0F), the pulse is 111/min, the respirations are 18/min, and the blood pressure is 130/60 mm Hg.", "Cardiac exam is significant for an S3 gallop.", "There is erythema and swelling over multiple varicose veins in her left leg.", "Ultrasound of her left leg is positive for a deep vein thrombosis."], "Treatment": ["The patient is admitted, and anticoagulation is started with a vitamin K inhibitor."], "Diagnosis": ["Ultrasound of her left leg is positive for a deep vein thrombosis."], "Others": ["Family history is significant for her sister who died at the age of 35 because of a pulmonary embolism.", "However, despite these interventions, she dies shortly after admission."]}
{"Patient Personal Background": ["The boy has no significant medical history.", "He emigrated to the United States with his family from Nigeria 1 month ago.", "He is in the 85th percentile for height and weight, and he has been meeting all developmental milestones."], "Patient Symptoms": ["She notes that he has been treated several times with different antibiotics, but that they have not helped.", "She reports no recent history of fever, chills, or night sweats."], "Examination and Results": ["His temperature is 37.8\u2103 (100.0\u2109).", "On physical examination, the patient has a prominent 8 \u00d7 8 cm mass over the right mandible.", "The mass has partially distorted the borders of the mandible and cheek.", "The overlying skin is erythematous.", "The mass is firm, immobile, and tender.", "The contralateral side of the face shows no abnormalities.", "An oral examination shows the disruption of the ipsilateral lower teeth and oral mucosa.", "The remainder of the physical exam is unremarkable."], "Treatment": ["A biopsy of the mass is performed and a histopathologic analysis is seen in the image."]}
{"Examination and Results": ["A urinalysis revealed a high level of uric acid."], "Others": ["A family history is notable for two similar cases in male cousins on the mother's side."]}
{"Patient Personal Background": ["She has a 10-year history of hypertension and an esophageal stricture due to severe gastroesophageal reflux disease.", "She was diagnosed with endometrial hyperplasia 20 years ago and treated with medroxyprogesterone.", "Menarche started at 11 years of age and her last menstrual period was 8 years ago.", "The patient does not have any children.", "Current medications include lansoprazole and hydrochlorothiazide."], "Examination and Results": ["Her last mammography and PAP smear 6 months ago showed no abnormalities.", "Her blood pressure is 135/85 mm Hg.", "Physical examination shows no abnormalities."], "Treatment": ["Treatment is begun with a drug that prevents further bone resorption and reduces her risk of developing breast cancer."], "Others": ["Her mother died of breast cancer at the age of 45 years."]}
{"Patient Personal Background": ["Her pregnancy has been uncomplicated.", "They are planning to travel to Ethiopia next month to visit the husband's family.", "Medications include folic acid and an iron supplement."], "Examination and Results": ["Vital signs are within the normal range.", "Abdominal examination shows a uterus that is consistent with a 20-week gestation."], "Treatment": ["Medications include folic acid and an iron supplement."]}
{"Patient Personal Background": ["Past medical history is insignificant.", "He is a non-smoker and does not drink alcohol."], "Patient Symptoms": ["He states that his pain is worse a few hours after he eats."], "Examination and Results": ["The vital signs include blood pressure 120/90 mm Hg, heart rate 83/min, and temperature 37.0\u00b0C (98.6\u00b0F).", "Physical examination is insignificant except for mild epigastric tenderness.", "A metabolic panel reveals the following:\nSerum sodium 136 mEq/L\nSerum potassium 4.2 mEq/L\nCalcium 13.2 mg/dL\nBicarbonate 26 mEq/L\nUpper gastrointestinal endoscopy reveals multiple duodenal ulcers."], "Others": ["His father had similar symptoms."]}
{"Patient Personal Background": ["The patient\u2019s blood glucose levels have been difficult to control on his current insulin regimen due to poor adherence to recommended therapy, and he has had difficulty putting on weight despite eating copiously."], "Examination and Results": ["The patient is afebrile and his vital signs are within normal limits.", "His body mass index (BMI) is 19 kg/m2."]}
{"Patient Personal Background": ["Three months ago, she was in India for 3 weeks to attend a family wedding.", "She worked as a seamstress in a textile factory for 50 years.", "She has smoked one pack of cigarettes daily for 47 years.", "Her current medications include enalapril, digoxin, isosorbide, spironolactone, and metoprolol."], "Patient Symptoms": ["During this period, she also has had a 4.5-kg (10-lb) weight loss and has become increasingly short of breath with mild exertion.", "She appears thin."], "Examination and Results": ["Her temperature is 37.0\u00b0C (98.6\u00b0F), pulse is 90/min, respirations are 25/min, and blood pressure is 110/70 mm Hg.", "Pulse oximetry on room air shows an oxygen saturation of 94%.", "There is dullness to percussion and decreased breath sounds over the right lung base.", "The remainder of the examination shows no abnormalities.", "Laboratory studies show a glucose level of 90 mg/dL, serum lactate dehydrogenase of 227 U/L, and serum protein of 6.3 g/dL.", "An x-ray of the chest shows nodular pleural lesions on the right side and a moderate-sized pleural effusion.", "Thoracentesis shows 250 ml of turbid fluid."], "Treatment": ["Her current medications include enalapril, digoxin, isosorbide, spironolactone, and metoprolol."], "Diagnosis": ["She has congestive heart failure and hypertension."]}
{"Patient Personal Background": ["Menses have occurred at 30- to 90-day intervals since menarche at the age of 12 years.", "She is sexually active with her husband and they do not use condoms.", "There is no personal or family history of serious illness."], "Patient Symptoms": ["Examination shows oily skin and severe acne on the face.", "There is dark hair on the upper lip and around both nipples."], "Examination and Results": ["Her last menstrual period was 6 weeks ago.", "She is 170 cm (5 ft 7 in) tall and weighs 73 kg (161 lb); BMI is 25.3 kg/m2.", "Her vital signs are within normal limits.", "Laboratory studies show:\nDehydroepiandrosterone sulfate 6.2 \u03bcg/mL (N=0.5\u20135.4)\nFollicle-stimulating hormone 20 mIU/mL\nLuteinizing hormone 160 mIU/mL\nTestosterone 4.1 nmol/L (N < 3.5)\nA urine pregnancy test is negative."]}
{"Patient Personal Background": ["She recently joined a walking program with her friends in order to lose weight; however, she noticed that she was not able to keep up with her friends during the program.", "She has a 60-pack-year history of smoking as well as hypertension well-controlled on medication."], "Patient Symptoms": ["She recently joined a walking program with her friends in order to lose weight; however, she noticed that she was not able to keep up with her friends during the program."]}
{"Patient Personal Background": ["She does not smoke."], "Examination and Results": ["Physical examination shows mild wheezing over bilateral lung fields and enlarged supraclavicular and cervical lymph nodes.", "A CT scan of the chest is shown.", "A biopsy specimen of a cervical lymph node shows organized epithelioid histiocytes and multinucleated giant cells without focal necrosis."]}
{"Patient Personal Background": ["Menopause occurred 1 year ago.", "She attained menarche at 10 years of age.", "She has a history of hypothyroidism and type 2 diabetes mellitus.", "She has smoked 1 pack of cigarettes daily for 20 years but quit 5 years ago.", "Current medications include levothyroxine and metformin.", "She is 165 cm (5 ft 5 in) tall and weighs 86 kg (190 lb); BMI is 32 kg/m2."], "Examination and Results": ["Physical examination shows mild vaginal atrophy and a normal cervix.", "The uterus and adnexa are nontender to palpation.", "Transvaginal ultrasonography shows an endometrial thickness of 6 mm.", "Endometrial biopsy shows non-invasive proliferation of endometrial glands with no nuclear or cytological atypia."]}
{"Patient Personal Background": ["Six months ago, combined antiretroviral therapy consisting of dolutegravir, tenofovir, and emtricitabine was initiated."], "Examination and Results": ["Laboratory studies show a decrease in the CD4 count and an increase in the viral load despite ongoing treatment."], "Treatment": ["Six months ago, combined antiretroviral therapy consisting of dolutegravir, tenofovir, and emtricitabine was initiated.", "The patient is switched to a new treatment regimen, including a drug that acts by preventing viral DNA synthesis without undergoing intracellular phosphorylation."]}
{"Patient Personal Background": ["The patient\u2019s mother says that the patient was recently in northern Maine and spent most of her time during the trip outdoors."], "Patient Symptoms": ["Physical examination reveals a slight asymmetry of the facial muscles with an inability to whistle or close the right eye.", "There is also decreased taste sensation."], "Examination and Results": ["Physical examination reveals a slight asymmetry of the facial muscles with an inability to whistle or close the right eye.", "A circular red rash with central clearing is present on the trunk."]}
{"Patient Personal Background": ["Current medications include simvastatin, metformin, fenofibrate, hydrochlorothiazide, aspirin, glyburide, and lisinopril."], "Examination and Results": ["He has a blood pressure of 136/92 mm Hg and a heart rate of 69/min.", "On physical examination, his heart sounds are regular and lung sounds are clear."]}
{"Patient Symptoms": ["During the first 2 days of clinical manifestations, the parents of the child tried to control the symptoms using acetaminophen; however, the newborn continued to be ill, and blisters were noticeable around the buttocks, hands, and feet."], "Examination and Results": ["During the physical examination, the vital signs include body temperature 39.0\u00b0C (102.3\u00b0F), heart rate 130/min, and respiratory rate 45/min.", "Ears, nose, and oral mucosa preserved their integrity, while the skin presents with diffuse blanching erythema and flaccid blisters with a positive Nikolsky\u2019s sign."]}
{"Patient Personal Background": ["Her medical history is remarkable for diet-controlled type 2 diabetes mellitus and hypertension treated with hydrochlorothiazide.", "Menopause occurred at 52 years of age."], "Patient Symptoms": ["She mentions that she has tried over-the-counter lubricants, but lubricants do not seem to provide substantial relief.", "She has been sexually active with her husband until recently and reports severe pain during vaginal intercourse."], "Examination and Results": ["The physical examination reveals dry, thin, white plaque-like lesions in the vulvar area with atrophy of the labia minora.", "The clitoris appears retracted.", "The perianal skin appears pale and wrinkled."]}
{"Patient Personal Background": ["Other than SLE, her medical history is unremarkable."], "Patient Symptoms": ["She notes that she was in her usual state of health until 3 days prior to presentation when she noticed some mild tenderness around her left eye, unrelieved by any pain relievers.", "This morning when she woke up she was unable to see out of her left eye and made an appointment to come see you.", "She has had no additional symptoms other than pain and vision loss."], "Examination and Results": ["Her vital signs are all within normal limits.", "On exam, she has no vision in her left eye, but 20/30 visual acuity in her right eye.", "When you shine a light in her left eye there is no response."]}
{"Patient Personal Background": ["Her past medical history is non-contributory and she is not currently taking any medications."], "Patient Symptoms": ["She states that she was walking up the stairs at work when she felt sudden and severe abdominal pain followed by nausea and vomiting.", "The patient's symptoms persisted after ibuprofen and acetaminophen."], "Examination and Results": ["Her temperature is 99.7\u00b0F (37.6\u00b0C), blood pressure is 122/78 mmHg, pulse is 120/min, respirations are 17/min, and oxygen saturation is 98% on room air.", "Physical exam is notable for an absence of abdominal tenderness, a left adnexal mass, and left adnexal tenderness.", "A transvaginal ultrasound demonstrates free fluid surrounding the ovary with edema and the presence of doppler flow.", "A urinary pregnancy test is negative."]}
{"Patient Personal Background": ["He drinks two to four beers daily.", "He does not smoke.", "His pulse is 95/min and blood pressure is 120/70 mm Hg."], "Patient Symptoms": ["During this time, he has also had shortness of breath and palpitations on exertion.", "He has noticed blood in his stools on three separate occasions in the past 4 months."], "Examination and Results": ["Examination shows pale conjunctivae.", "The abdomen is soft with no organomegaly.", "Rectal examination is unremarkable.", "His hemoglobin concentration is 7.2 g/dL, hematocrit is 32%, and mean corpuscular volume is 68 \u03bcm3."]}
{"Patient Personal Background": ["She has no history of serious illness.", "She works as an event manager and has had more stress than usual due to a recent concert tour."], "Patient Symptoms": ["She was seated and was being tattooed on her right upper flank when she became diaphoretic, pale, and passed out.", "According to her boyfriend, the patient slipped to the floor and her arms and legs moved in a jerky fashion for a few seconds."], "Examination and Results": ["She appears well.", "Her temperature is 37\u00b0C (98.4\u00b0F), pulse is 68/min, respirations are 16/min, and blood pressure is 120/72 mm Hg.", "Her cardiopulmonary examination shows no abnormalities.", "Neurologic examination shows no focal findings.", "An ECG shows an incomplete right bundle branch block."], "Others": ["She regained consciousness within half a minute and was alert and fully oriented immediately."]}
{"Patient Symptoms": ["He has nausea and severe pain in the right shoulder.", "He is in acute distress."], "Examination and Results": ["His temperature is 37\u00b0C (98.6\u00b0F), pulse is 85/min, respirations are 15/min, and blood pressure is 135/85 mm Hg.", "Examination shows swelling and tenderness over the right clavicle and pain exacerbated by movement; range of motion is limited.", "The skin over the clavicle is intact.", "The radial pulse in the right arm is intact.", "Sensory examination of the right upper limb shows no abnormalities.", "An x\u2011ray of the chest is shown."], "Others": ["The boy was racing with his cousin when he lost control and fell onto his right side."]}
{"Patient Personal Background": ["His wife reports he has been preoccupied with gambling at the local casino."], "Patient Symptoms": ["He becomes restless and irritable when his wife attempts to restrict his gambling."], "Treatment": ["Four months ago, he was diagnosed with Parkinson disease and treatment was initiated."], "Diagnosis": ["Four months ago, he was diagnosed with Parkinson disease and treatment was initiated."]}
{"Patient Symptoms": ["She denies any sick contacts."], "Examination and Results": ["Her temperature is 101\u00b0F (38.3\u00b0C), blood pressure is 110/70 mmHg, pulse is 96/min, and respirations are 15/min.", "Physical exam reveals several oral mucosal petechiae, bleeding gums, bilateral submandibular lymphadenopathy, and hepatosplenomegaly.", "Initial laboratory workup shows the following:\n\nLeukocyte count and differential:\nLeukocyte count: 6,600/mm^3\nSegmented neutrophils: 60%\nBands: 20%\nEosinophils: 9%\nBasophils: 1%\nLymphocytes: 0%\nMonocytes: 10%\nPlatelet count: 99,000/mm^3\n\nHemoglobin: 8.1 g/dL\nHematocrit: 25%\n\nProthrombin time: 25 sec\nPartial thromboplastin time: 50 sec\nInternational normalized ratio: 1.6\nD-dimer: 2,000 \u00b5g/mL\nFibrinogen: 99 mg/dL\n\nA bone marrow biopsy demonstrates 34% myeloblasts with Auer rods that are myeloperoxidase positive."]}
{"Patient Personal Background": ["He reports that he has experienced similar symptoms multiple times over the past 5 years since he started working at his local zoo as a reptilian caretaker.", "He takes fish oil and a multivitamin daily."], "Patient Symptoms": ["Two hours prior to presentation, he developed muscle cramps and nausea.", "He has had 3 episodes of non-bloody watery stools since his symptoms started."], "Examination and Results": ["His temperature is 101\u00b0F (38.3\u00b0C), blood pressure is 130/90 mmHg, pulse is 90/min, and respirations are 17/min.", "On exam, he demonstrates sensitivity to bright light.", "A stool sample and culture demonstrates abundant non-lactose fermenting, oxidase-negative, and H2S-producing gram-negative bacilli."], "Others": ["His medical history is unremarkable.", "He is tired-appearing but alert and fully oriented."]}
{"Patient Personal Background": ["He has type 2 diabetes mellitus and hypertension.", "Current medications include ramipril and metformin."], "Patient Symptoms": ["He has had multiple falls over the past 4 months.", "Over the past 6 months, he has had progressive urinary urgency and now wears an adult diaper as is not always able to control the urge to void.", "His appetite has also decreased in this time period.", "He used to drive, but his wife convinced him to stop after she noticed that he was becoming increasingly inattentive while driving."], "Examination and Results": ["His temperature is 37.1C (98.8F), pulse is 90/min and blood pressure is 132/88 mm Hg.", "Examination shows a broad-based gait with slow and short steps.", "Neurologic examination shows no focal findings.", "On mental status examination, he is oriented to person and place but not to time.", "Attention and concentration are impaired.", "He recalls only one of three objects after 5 minutes."]}
{"Patient Personal Background": ["She lives with her sister and works as a cashier in a local retail store.", "She takes no medications."], "Patient Symptoms": ["During this period, the patient has had several episodes of dizziness as well as double vision.", "She also reports that she has lost control of her bladder on several occasions lately."], "Examination and Results": ["Her vital signs are within normal limits.", "On mental status examination, she is oriented to person and place only.", "There is moderate weakness of the upper and lower extremities.", "Sensory examination shows no abnormalities.", "Deep tendon reflexes are 3+ bilaterally.", "Babinski's sign is present bilaterally."], "Others": ["She has not had any trauma or weight changes."]}
{"Patient Personal Background": ["She has been living alone since her husband passed away 2 years ago.", "She has remained an active member of her retirement community's wine club; however, she stopped attending the meetings 3 weeks ago.", "She drinks 4-6 glasses of wine per day.", "Her BMI is 31 kg/m^2."], "Patient Symptoms": ["She is generally able to her maintain her house, but her house appears more disorganized over the past 2 weeks.", "She generally drives short distances but avoids driving long distances as she occasionally gets lost when navigating new areas.", "She feels like her balance is getting worse, but she has not fallen.", "She has noticed increased urinary urgency over the past 8 months and has had 2 episodes of incontinence.", "Her temperature is 99.8\u00b0F (37.7\u00b0C), blood pressure is 115/65 mmHg, pulse is 95/min, and respirations are 17/min.", "On examination, she is oriented to person and time but not place or situation.", "She does not seem to recognize her doctor despite knowing him for many years.", "She becomes somnolent intermittently throughout the interview.", "She can recall 0/3 words after 5 minutes.", "She has a low-frequency tremor in her right arm that increases in severity with deliberate movement."], "Examination and Results": ["Her temperature is 99.8\u00b0F (37.7\u00b0C), blood pressure is 115/65 mmHg, pulse is 95/min, and respirations are 17/min.", "On examination, she is oriented to person and time but not place or situation.", "She can recall 0/3 words after 5 minutes.", "She has a low-frequency tremor in her right arm that increases in severity with deliberate movement."], "Treatment": ["She was started on multiple medications for worsening anxiety by her psychiatrist 1 month ago."], "Others": ["Despite these changes, she reports feeling well."]}
{"Patient Personal Background": ["He takes enalapril and metformin."], "Patient Symptoms": ["He reports that he feels well and has no complaints.", "One month later, the patient returns to the physician complaining of new onset lower extremity swelling."], "Examination and Results": ["His temperature is 98.8\u00b0F (37.1\u00b0C), blood pressure is 155/90 mmHg, pulse is 80/min, and respirations are 16/min."], "Treatment": ["His physician adds another anti-hypertensive medication to the patient\u2019s regimen."]}
{"Patient Personal Background": ["A week ago, she returned from India, where she was working with an NGO to build houses in rural areas.", "She has no history of a serious illness."], "Patient Symptoms": ["Physical examination shows jaundice."], "Examination and Results": ["Her temperature is 39.3\u00b0C (102.7\u00b0F), pulse is 102/min, respirations are 22/min, and blood pressure is 112/78 mm Hg.", "The abdomen is soft and nontender.", "The remainder of the examination shows no abnormalities.", "Her hemoglobin concentration is 10 g/dL and a blood smear shows fragmented erythrocytes and occasional ring-shaped inclusion bodies within erythrocytes."], "Treatment": ["The patient took one dose of chloroquine one week before her trip.", "She also took a further dose during her trip."]}
{"Patient Personal Background": ["She eats a healthy, varied diet and exercises at the gym 4 days a week, including 20 minutes of aerobic exercise."], "Patient Symptoms": ["Although she feels generally healthy she has noticed gaining about 9 kg (20 lb) over the last year.", "On further questioning, she has also noted fatigue and constipation.", "She denies shortness of breath, chest pain, lightheadedness, or blood in her stool."], "Examination and Results": ["At the clinic, the vital signs include: pulse 52/min, blood pressure 110/72 mm Hg, and oxygen saturation 99% on room air.", "The physical exam is notable only for slightly dry skin.", "The complete blood count (CBC) is within normal limits."]}
{"Patient Personal Background": ["She has a history of bronchial asthma and bulimia nervosa.", "She works as a nurse.", "She does not smoke and drinks 1\u20132 beers on the weekend.", "Current medications include fish oil, a multivitamin, and a salbutamol inhaler."], "Patient Symptoms": ["She has had up to 12 watery stools per day.", "Sometimes she awakens at night because she has to defecate.", "She has abdominal bloating and cramps.", "She has had a 2-kg weight loss in the past month."], "Examination and Results": ["Her temperature is 36.8\u00b0C (98.2\u00b0F), pulse is 65/min, and blood pressure is 100/75 mm Hg.", "Examination shows dry mucous membranes.", "Abdominal and rectal examinations are unremarkable.", "Laboratory studies show:\nHematocrit 46%\nLeukocyte Count 6,500/mm3\nPlatelet Count 220,000/mm3\nSerum\nNa+ 136 mEq/L\nK+ 3.2 mEq/L\nCl- 102 mEq/L\nHCO3- 33 mEq/L\nMg2+ 3.3 mEq/L\nUrea nitrogen 14 mg/dL\nCreatinine 0.8 mg/dL\nAbdominal ultrasound shows no abnormalities.", "Colonoscopy shows dark colored mucosa with interspersed white spots.", "Biopsies of colonic mucosa are obtained and sent for pathological evaluation."], "Others": ["She returned from a trip to Costa Rica 7 weeks ago."]}
{"Patient Personal Background": ["He has no history of serious illness.", "He does not smoke.", "He drinks three to five beers on weekends."], "Patient Symptoms": ["He has problems getting to sleep at night and frequently falls asleep during class.", "Recently he has started skipping classes altogether.", "He goes to bed between 11 p.m. and 1 a.m. but cannot fall asleep for 2\u20133 hours.", "When he wakes up at 8:30 a.m., he feels extremely drowsy, and he tries to overcome his fatigue by drinking 2\u20133 cups of coffee a day.", "He naps at various times during the afternoon, often for more than an hour.", "He states that he has tried over-the-counter melatonin pills and exercising at 8 p.m. without success."], "Examination and Results": ["Physical examination shows no abnormalities."], "Others": ["He stopped watching videos on his smartphone at night because of suggestions from his peers."]}
{"Patient Personal Background": ["Over the past 3 years, he has been dressing all in black and wears a long black coat, even in the summer.", "The mother reports that her son has always had difficulties fitting in.", "He does not have any friends and spends most of his time in his room playing online games.", "Rather than doing his coursework, he spends most of his time reading up on paranormal phenomena, especially demons."], "Patient Symptoms": ["He is anxious at college because he is uncomfortable around other people, and his academic performance is poor.", "For example, a breeze in an enclosed room is likely the \u201cbreath of a demon\u201d."], "Examination and Results": ["Mental status examination shows laborious speech.", "The patient avoids eye contact."], "Others": ["He says that he has never seen any demons, but sometimes there are signs of their presence."]}
{"Patient Personal Background": ["He has a medical history of 25 years of heavy smoking."], "Examination and Results": ["His vitals include: heart rate 89/min, respiratory rate 27/min, and blood pressure 120/90 mm Hg.", "The physical exam shows increased resonance to percussion, decreased breath sounds, and crackles at the lung base.", "Chest radiography shows signs of pulmonary hyperinflation.", "Spirometry shows a forced expiratory volume in the first second (FEV1) of 48%, a forced vital capacity (FVC) of 85%, and an FEV1/FVC ratio of 56%."]}
{"Patient Personal Background": ["His medications include hydrochlorothiazide."], "Patient Symptoms": ["He reports that he was rocking his grandson to sleep when the symptoms began.", "He states the pain is constant and is primarily located on his right side.", "When asked to indicate the area of pain, he says that it surrounds his eye and upper forehead.", "He had one episode of vomiting.", "The patient also reports difficulty seeing out of his right eye, which he attributes to excessive tearing."], "Examination and Results": ["His temperature is 98.6\u00b0F (37\u00b0C), blood pressure is 135/91 mmHg, pulse is 72/min, and respirations are 12/min.", "Upon physical examination, the right pupil is minimally responsive to light and the globe feels firm.", "A right-sided carotid bruit is appreciated."], "Others": ["The patient\u2019s right eye is shown in Figure A."]}
{"Treatment": ["She is started on verapamil and instructed to exercise at 50% of her VO2 max while several cardiac parameters are being measured."]}
{"Patient Personal Background": ["She was delivered preterm at 35 weeks, and her medical history is significant for several ear infections over the last year.", "Her older brother has been diagnosed with attention-deficit hyperactivity disorder (ADHD), but the rest of her family history is otherwise unremarkable.", "Otherwise, the patient is energetic and started preschool 3 months ago."], "Patient Symptoms": ["The patient has become more withdrawn lately and has sometimes been ignoring her parents when asked to perform tasks at home.", "This seems to have worsened over the last 8 weeks.", "She seems distracted during the interview and responds only intermittently to the physician\u2019s directions."], "Examination and Results": ["Her temperature is 98.6\u00b0F (37\u00b0C), blood pressure is 98/62 mmHg, pulse is 97/min, and respirations are 26/min.", "The patient successfully draws a square and can stand on 1 foot.", "Her neurological examination is normal, and she is at the 50th percentile for height and weight."], "Others": ["Her language skills are unchanged from her appointment 6 months ago."]}
{"Patient Personal Background": ["He has a history of heart failure with reduced ejection fraction, obesity, diabetes, hypertension, acute coronary syndrome, atrial fibrillation, and peripheral vascular disease."], "Patient Symptoms": ["He states that his wife made him come in when he fainted today while attempting to stand up.", "He otherwise states he has noticed some visual changes, including noting a yellow tint to objects."], "Examination and Results": ["His temperature is 98.5\u00b0F (36.9\u00b0C), blood pressure is 153/91 mmHg, pulse is 40/min, respirations are 15/min, and oxygen saturation is 97% on room air.", "Physical exam reveals a frail man who is unable to ambulate secondary to lightheadedness.", "His neurological exam is otherwise non-focal.", "An ECG is performed as seen in Figure A."]}
{"Patient Personal Background": ["The patient is sexually active with multiple male partners and reports inconsistent condom use.", "She has a history of intravenous drug use and has not been to a doctor in the last 2 years."], "Patient Symptoms": ["The headache started 1 month ago.", "It is constant and \u201call over\u201d but gets worse when she is lying down or in the setting of bright lights.", "A review of systems is significant for a low-grade fever, night sweats, cough, malaise, poor appetite, and unintentional weight loss of 12 pounds in the last 2 months."], "Examination and Results": ["Her temperature is 100.4\u00b0F (38.0\u00b0C), blood pressure is 110/78 mmHg, pulse is 88/min, and respirations are 14/min with an oxygen saturation of 98% O2 on room air.", "On physical exam, pain is elicited upon passive flexion of the patient\u2019s neck.", "A CT scan shows ventricular enlargement.", "A CD4+ count is 57 cells/\u00b5L blood."]}
{"Patient Personal Background": ["The patient was born at 39 weeks and met all her developmental milestones.", "She is currently up to date on her vaccinations and did not have infections during early childhood.", "Her parents are divorced and her father has noted she does not seem to get sick when he takes care of her."], "Patient Symptoms": ["Her mother says that last night her daughter felt ill, and her condition has been worsening.", "Her daughter experienced a severe headache and had a stiff neck.", "This morning she was minimally responsive, vomited several times, and produced a small amount of dark cloudy urine."], "Examination and Results": ["Her temperature is 99.5\u00b0F (37.5\u00b0C), blood pressure is 60/35 mmHg, pulse is 190/min, respirations are 33/min, and oxygen saturation is 98% on room air."], "Treatment": ["The patient is started on intravenous fluids, vasopressors, and broad-spectrum antibiotics."], "Diagnosis": ["She presented with similar symptoms 6 weeks ago and was treated for an Escherchia coli infection.", "She also was treated for a urinary tract infection 10 weeks ago."]}
{"Patient Personal Background": ["He denies recent trauma and he has no known medical problems.", "He denies tobacco use and will often drink 6-8 beers or spirits on weekend nights."], "Patient Symptoms": ["He woke last night with sudden-onset, sharp, 10/10 non-radiating pain in his right knee."], "Examination and Results": ["His temperature is 98.6\u00b0F (37.0\u00b0C), pulse is 90/min, blood pressure is 140/90 mmHg, respirations are 16/min, and oxygen saturation is 97% on room air.", "Physical exam reveals an erythematous, edematous right knee.", "Passive extension of the knee is limited by pain.", "Synovial fluid aspiration is performed and sent for analysis, which reveals 20,000 leukocytes/mm^3, and no organisms visualized."]}
{"Patient Personal Background": ["She lives with her mother who has diabetes whose medications include metformin, insulin, lisinopril, amlodipine, and glyburide."], "Patient Symptoms": ["This has happened several times this past month with increasing frequency.", "Each time her symptoms improved with eating."], "Examination and Results": ["Her temperature is 98.0\u00b0F (36.7\u00b0C), blood pressure is 132/81 mmHg, pulse is 85/min, respirations are 16/min, and oxygen saturation is 98% on room air.", "Physical exam reveals a confused woman.", "She is moving all her extremities but follows commands poorly."], "Others": ["She is otherwise healthy.", "Laboratory studies are ordered as seen below."]}
{"Patient Personal Background": ["The patient is not aware of any medical problems and just started seeing a primary care physician last week.", "He recently used a friend's prescription for ondansetron for nausea."], "Patient Symptoms": ["He was outside tending to his lawn for several hours in the heat, when he stood up suddenly from pulling weeds and fainted.", "He denies any preceding symptoms and returned to baseline within 1 minute."], "Examination and Results": ["His temperature is 99.3\u00b0F (37.4\u00b0C), blood pressure is 142/88 mmHg, pulse is 107/min, respirations are 14/min, and oxygen saturation is 99% on room air.", "Physical exam reveals intact cranial nerves, normal strength and sensation, and a stable gait.", "His abdomen is soft and nontender.", "An ECG is performed as seen in Figure A."]}
{"Patient Symptoms": ["There were no passengers and he was awake but disoriented at the scene.", "He has multiple lacerations on his face and arms and smells of alcohol and marijuana."], "Examination and Results": ["His temperature is 97.9\u00b0F (36.6\u00b0C), blood pressure is 131/88 mmHg, pulse is 89/min, and respirations are 14/min.", "He is speaking but is confused, opens his eyes to voice commands, and follows simple commands.", "His cardiac exam is normal and his lungs are clear to auscultation bilaterally.", "He has bruising over his abdomen without any tenderness to palpation, distension, or rigidity."], "Others": ["Paramedics report that the patient was driving the car and crashed into a tree at roughly 25 miles per hour."]}
{"Patient Personal Background": ["He has no significant medical history and does not currently take any medications."], "Patient Symptoms": ["He denies having nausea, vomiting, or diarrhea."], "Examination and Results": ["His temperature is 98.6\u00b0F (37\u00b0C), blood pressure is 115/72 mmHg, pulse is 98/min, and respirations are 14/min.", "Physical exam reveals conjunctival icterus, bilateral flank tenderness, and erythema of the left leg."], "Treatment": ["He was recently diagnosed with cellulitis of his left leg, for which he was prescribed trimethoprim-sulfamethoxazole."], "Diagnosis": ["He was recently diagnosed with cellulitis of his left leg, for which he was prescribed trimethoprim-sulfamethoxazole."]}
{"Patient Personal Background": ["He reports that he traveled to Africa last year and returned from a vacation to Thailand 10 days ago.", "His immunizations are up to date, although he missed the pre-departure travel medicine consult before his trip to Thailand."], "Patient Symptoms": ["He also endorses sweats, headache behind the eyes, sore throat, muscle and joint pain, and a new rash seen in Figure A."], "Examination and Results": ["His temperature is 101.5\u00b0F (38.6\u00b0C), blood pressure is 125/80 mmHg, pulse is 105/min, and respirations are 14/min."]}
{"Patient Symptoms": ["For 2 months, she has experienced intermittent palpitations along with menstrual irregularity and hair loss.", "At home, the air conditioner is at its coldest setting, but the patient still feels overheated."], "Examination and Results": ["Her temperature is 99.5\u00b0F (37.5\u00b0C), blood pressure is 135/90 mmHg, pulse is 120/min, and respirations are 22/min.", "The patient is diaphoretic with tremulous hands, demonstrates thyromegaly, and protrusion of her eyes is noted."], "Treatment": ["She is given atenolol in the emergency department with improvement of her palpitations and is instructed to follow up with her primary doctor for further management."]}
{"Patient Personal Background": ["She was born at 38-weeks gestational age without complications.", "Her medications consist of lamotrigine and valproic acid."], "Patient Symptoms": ["Her parents have noticed the patient occasionally stiffens and spreads her arms at home."], "Examination and Results": ["She recently underwent a neurology evaluation which revealed hypsarrhythmia on electroencephalography (EEG) with a mix of slow waves, multifocal spikes, and asynchrony.", "Her temperature is 98.3\u00b0F (36.8\u00b0C), blood pressure is 90/75 mmHg, pulse is 94/min, and respirations are 22/min.", "Physical exam reveals innumerable hypopigmented macules on the skin and an irregularly shaped, thickened, and elevated plaque on the lower back."], "Treatment": ["Her medications consist of lamotrigine and valproic acid."], "Others": ["She has no other medical problems."]}
{"Patient Personal Background": ["He has a diet high in refined carbohydrates and has gained 20 pounds since starting high school."], "Patient Symptoms": ["The patient has had lesions on his face that have persisted since he was 13 years of age.", "He returns 1 month later stating that his symptoms are roughly the same."], "Examination and Results": ["Physical exam is notable for the findings in Figure A."], "Treatment": ["The patient is started on benzoyl peroxide and topical retinoids."]}
{"Patient Personal Background": ["Her medical problems consist of heart failure for which she takes furosemide, spironolactone, and metoprolol, which were continued at admission."], "Patient Symptoms": ["The headache started suddenly while she was eating dinner and she says it feels like the \u201cworst headache of my life.\u201d An emergent CT scan of the head without contrast confirms the diagnosis, and a CT angiogram identifies the source of bleeding.", "On hospital day 3, she is found to be disoriented to person, place, and time.", "She also develops nausea and vomiting."], "Examination and Results": ["Her temperature is 99.6\u00b0F (37.6\u00b0C), blood pressure is 100/60 mmHg, pulse is 112/min, and respirations are 16/min.", "Physical examination shows poor skin turgor.", "Capillary refill time is 4 seconds.", "Serum laboratory results are shown below: Na+: 120 mEq/L Cl-: 92 mEq/L K+: 3.9 mEq/L HCO3-: 26 mEq/L BUN: 32 mg/dL Creatinine: 1.0 mg/dL Serum osmolality is 265 mEq/L and urine osmolality is 340 mEq/L.", "Urine sodium is 44 mEq/L."], "Treatment": ["The patient undergoes surgical management of her condition."], "Diagnosis": ["The headache started suddenly while she was eating dinner and she says it feels like the \u201cworst headache of my life.\u201d An emergent CT scan of the head without contrast confirms the diagnosis, and a CT angiogram identifies the source of bleeding."]}
{"Treatment": ["The resident suggests performing one on the deceased patient, as the student cannot harm him."], "Others": ["A medical student rotating in the intensive care unit asked if she can practice performing intubations during her rotation.", "The resident suggests performing one on the deceased patient, as the student cannot harm him."]}
{"Patient Personal Background": ["He has no significant medical history and takes no medications."], "Patient Symptoms": ["He first felt the pain while lifting boxes at work but thought that he had just strained a muscle.", "The pain appears to be worse in the mornings and after rest.", "Exercise and physical activity appear to temporarily make the pain better."], "Examination and Results": ["His temperature is 98.6\u00b0F (37.0\u00b0C), blood pressure is 115/70 mmHg, pulse is 70/min, and respirations are 12/min.", "On physical exam, he is found to have limited flexion and extension of his spine as well as tenderness to palpation over the insertion of his patellar tendons bilaterally."], "Treatment": ["He has taken acetaminophen and ibuprofen for the pain."]}
{"Patient Personal Background": ["The patient has a medical history of obesity, type 2 diabetes mellitus, and hypertension.", "His current medications include insulin, metformin, lisinopril, and hydrochlorothiazide."], "Patient Symptoms": ["The pain is over his chest and in his left arm.", "2 days later, he complains of chest pain."], "Examination and Results": ["An ECG is performed and is seen in Figure A.", "His temperature is 99.5\u00b0F (37.5\u00b0C), pulse is 112/min, blood pressure is 100/70 mmHg, respirations are 18/min, and oxygen saturation is 95% on room air.", "A repeat ECG is performed and is seen in Figure B."], "Treatment": ["The patient is appropriately managed and is admitted to the step-down unit."]}
{"Patient Personal Background": ["He has never had any serious injuries but that he always seems to bruise easily, especially after he started playing soccer this fall."], "Patient Symptoms": ["He has dull, aching pain along his left side where he hit the ground."], "Examination and Results": ["On physical exam, the patient has extensive bruising of the lateral left thigh and tenderness to palpation.", "His temperature is 98.6\u00b0F (37\u00b0C), blood pressure is 112/74 mmHg, pulse is 82/min, and respirations are 11/min."], "Others": ["He fell sideways off the scooter as he rounded a curve in the road.", "His parents deny that he has an abnormal number of nosebleeds or bleeding from the gums.", "They have never seen blood in his stool or urine.", "His mother notes that her brother has had similar problems."]}
{"Patient Personal Background": ["He was born at home via spontaneous vaginal delivery at 37 weeks of gestation to a G1P1 mother.", "His mother did not receive prenatal care."], "Patient Symptoms": ["His parents are concerned that he is not feeding well and has lost weight over the last 2 weeks.", "He does not appear to respond to visual stimuli, and further examination reveals bilateral clouding of the lens."], "Examination and Results": ["His blood pressure is 70/44 mmHg, pulse is 151/min, and respirations are 41/min.", "His weight is 3 kg (4th percentile) compared with 3.5 kg at birth (45th percentile).", "On physical exam, he is jaundiced with an enlarged liver and spleen."]}
{"Patient Symptoms": ["Whenever he eats solids, he regurgitates them back up.", "Several hours later, the patient presents to the emergency department with chest pain and shortness of breath."], "Examination and Results": ["His temperature is 99.5\u00b0F (37.5\u00b0C), blood pressure is 130/85 mmHg, pulse is 60/min, respirations are 12/min, and oxygen saturation is 99% on room air.", "On physical exam, the patient demonstrates a normal cardiopulmonary exam.", "His physical exam demonstrates no tenderness of the neck, a normal oropharynx, palpable crepitus above the clavicles, and minor lymphadenopathy."], "Diagnosis": ["Given this patient's suspected diagnosis, the gastroenterologist performs a diagnostic test."]}
{"Patient Personal Background": ["The patient's medical history is notable for anxiety, obesity, hypertension, and polycystic ovarian syndrome.", "She is currently not on any medications.", "She was given an exercise program but she has not been compliant with these exercises."], "Patient Symptoms": ["They found her somnolent next to her computer with an empty pill bottle around 3 hours ago.", "The patient begins communicating with the physician and states that she did take acetaminophen but it was only a few pills."], "Examination and Results": ["Her temperature is 99.5\u00b0F (37.5\u00b0C), pulse is 82/min, blood pressure is 125/85 mmHg, respirations are 11/min, and oxygen saturation is 97% on room air.", "Physical exam is within normal limits."], "Others": ["The family cannot recall the types of pill bottles that they found and did not bring them to the ED.", "Her parents are certain the bottle was new."]}
{"Patient Personal Background": ["The patient is a Swedish foreign exchange student and does not speak any English.", "Her medical history and current medications are unknown."], "Patient Symptoms": ["She was hiking when she suddenly felt unable to breathe and had to take slow deep breaths to improve her symptoms."], "Examination and Results": ["Her temperature is 99.5\u00b0F (37.5\u00b0C), blood pressure is 127/68 mmHg, pulse is 120/min, respirations are 22/min, and oxygen saturation is 90% on room air.", "Physical exam is notable for poor air movement bilaterally and tachycardia."], "Treatment": ["The patient is started on treatment."]}
{"Patient Personal Background": ["He is otherwise healthy and has no medical problems or recent illness and is up to date on his vaccinations."], "Patient Symptoms": ["This has happened in the past, but his mother thought he was fabricating his symptoms.", "The mother states this episode lasted about 3 minutes and involved full-body jerking.", "After the episode, the child was non-responsive but was breathing on his own.", "He initially is unable to move his left upper and lower extremity and has a left facial droop; however, after a few minutes, he has 4/5 strength in the affected side with resolution of his facial weakness.", "The mother notes that this is similar to his past episodes."], "Examination and Results": ["He has had an MRI of the brain with no acute findings in the past.", "His temperature is 97.6\u00b0F (36.4\u00b0C), blood pressure is 100/64 mmHg, pulse is 90/min, respirations are 12/min, and oxygen saturation is 99% on room air.", "The patient is protecting his airway but is unable to answer questions.", "He is able to move the right upper and lower extremity."], "Treatment": ["She has taken him to a free health clinic to have him seen by a doctor who prescribed medication; however, she has been unable to fill the prescription."], "Others": ["The child has a history of migraine headaches with aura that resolve with ibuprofen."]}
{"Patient Personal Background": ["He is otherwise healthy and does not take any medications."], "Patient Symptoms": ["The patient\u2019s wife states she found him lethargic at home.", "He has been sick the past week with diarrhea and has been staying home from work.", "The patient has profuse, bloody diarrhea while in the emergency department.", "He continues to have diarrhea while in the emergency department."], "Examination and Results": ["His temperature is 97.5\u00b0F (36.4\u00b0C), blood pressure is 62/32 mmHg, pulse is 185/min, respirations are 25/min, and oxygen saturation is 98% on room air.", "An ECG is performed as seen in Figure A."], "Treatment": ["The patient is given 3L of ringer lactate and subsequently appears less confused, with a blood pressure of 100/70 mmHg."], "Others": ["He is able to drink oral fluids and protect his airway."]}
{"Patient Personal Background": ["He has no medical problems and takes no medications.", "His temperature is 98.4\u00b0F (36.9\u00b0C), blood pressure is 118/72 mmHg, pulse is 72/min, and respirations are 16/min."], "Patient Symptoms": ["At school, he interrupts class by making barking noises.", "His mother notes that he has been making throat-clearing noises daily for the past 2 years.", "On exam, he grimaces several times and blinks his eyes rapidly."], "Examination and Results": ["He gets along with his 2 brothers, plays turn-taking games with his friends, and completes his chores.", "His temperature is 98.4\u00b0F (36.9\u00b0C), blood pressure is 118/72 mmHg, pulse is 72/min, and respirations are 16/min.", "On exam, he grimaces several times and blinks his eyes rapidly."], "Others": ["He does not appear to be reacting to internal stimuli.", "His mood and affect are normal."]}
{"Patient Personal Background": ["His medical history is significant for IV drug use, HIV (CD4: 47/mm^3), hypertension, hyperlipidemia, diabetes mellitus, and seasonal allergies.", "He denies recent IV drug use.", "His home medications include hydrochlorothiazide, atorvastatin, metformin, cetirizine, darunavir, tenofovir, and emtricitabine."], "Patient Symptoms": ["His nasal congestion started about 1 week ago and he noticed the blurry vision this morning when he struggled to read the words on his television screen.", "He has injected conjunctiva and rhinorrhea."], "Examination and Results": ["His temperature is 100.8\u00b0F (38.2\u00b0C), blood pressure is 127/85 mmHg, pulse is 78/min, and respirations are 12/min.", "His cranial nerves are intact, and his motor and sensory neurologic exam is normal.", "A MRI of the brain is performed and can be seen in Figure A."]}
{"Patient Personal Background": ["The patient was born at 39 weeks via vaginal delivery to a G1P1 29-year-old woman.", "The patient has been breastfeeding and producing 5 stools/day."], "Examination and Results": ["His temperature is 99.5\u00b0F (37.5\u00b0C), blood pressure is 60/38 mmHg, pulse is 150/min, respirations are 24/min, and oxygen saturation is 98% on room air.", "A cardiopulmonary exam is notable for a benign flow murmur.", "A musculoskeletal exam reveals the findings shown in Figure A."], "Others": ["He is otherwise healthy."]}
{"Patient Personal Background": ["Medical history is significant for rheumatoid arthritis diagnosed approximately 10 years ago and treated with methotrexate as well as type 2 diabetes mellitus treated with metformin."], "Patient Symptoms": ["Her symptoms have progressively worsened over the course of 2 weeks and are most significant in her lower extremities.", "She also notices increased urinary frequency."], "Examination and Results": ["Her temperature is 98.6\u00b0F (37\u00b0C), blood pressure is 138/92 mmHg, pulse is 92/min, and respirations are 17/min.", "On physical exam, there is mild tenderness to palpation of the metacarpophalangeal and proximal interphalangeal joints.", "There is 4/5 power throughout the lower extremity.", "Laboratory testing is shown."], "Diagnosis": ["Approximately 1 month ago, she was diagnosed with calcium phosphate nephrolithiasis."]}
{"Patient Symptoms": ["He regurgitates a moderate amount of formula through his nose and mouth after most feeds.", "He does not seem interested in additional feeding after these episodes of regurgitation and he has become progressively more irritable around meal times.", "The patient is starting to refuse some feeds.", "His mother denies seeing blood or streaks of red in his stool and she denies any family history of food allergies or dermatological problems."], "Examination and Results": ["The patient\u2019s weight was in the 62nd percentile 4 weeks ago and he is now in the 48th percentile.", "His height and head circumference have followed similar trends.", "His temperature is 98.2\u00b0F (36.8\u00b0C), blood pressure is 72/47 mmHg, pulse is 125/min, and respirations are 27/min.", "On physical exam, the patient smiles reciprocally and can lift his head and chest when in the prone position.", "His abdomen is soft, non-tender, and non-distended."], "Others": ["The patient drinks 4 ounces of cow\u2019s milk formula every 3 hours.", "He usually stools 1 time per day and urinates up to 6 times per day."]}
{"Patient Personal Background": ["The patient was born at 38 weeks gestation via Caesarean section for cervical incompetence."], "Patient Symptoms": ["The child had a runny nose and cough for a few days last week.", "The patient\u2019s mother endorses decreased appetite during the aforementioned illness which has now returned to baseline."], "Examination and Results": ["On physical exam, the patient has scleral icterus and dark urine staining her diaper."], "Others": ["The patient\u2019s mother has no complaints.", "The patient\u2019s family history is significant for an older brother with glucose-6-phosphate dehydrogenase (G6PD) deficiency and a maternal uncle with cirrhosis secondary to chronic hepatitis B."]}
{"Patient Personal Background": ["The patient has a medical history of alcoholism and has been admitted to the hospital multiple times for withdrawal, abdominal pain, and traumatic injuries from his drinking.", "The patient states that his last drink was more than 1 year ago."], "Examination and Results": ["His temperature is 99.3\u00b0F (37.4\u00b0C), blood pressure is 115/78 mmHg, pulse is 78/min, respirations are 15/min, and oxygen saturation is 99% on room air.", "Physical exam reveals a non-tender, non-distended abdomen.", "Laboratory studies are notable for a serum calcium of 7.0 mg/dL.", "A computed tomography (CT) scan of the abdomen is performed as seen in Figure A.", "A Sudan Black stain of the patient\u2019s stool is positive."]}
{"Patient Personal Background": ["The patient was born at 39 weeks of gestation to a 30-year-old primigravid via vaginal delivery.", "The patient\u2019s mother received routine prenatal care and the pregnancy was uncomplicated.", "The patient\u2019s anatomy ultrasound at 20 weeks of gestation was unremarkable.", "The patient\u2019s mother denies any family history of genetic diseases."], "Examination and Results": ["The patient\u2019s APGAR scores were notable for poor muscle tone at both 1 and 5 minutes of life.", "The patient\u2019s birth weight is 2.6 kg (5 lb 11 oz), which is at the 5th percentile.", "His height and head circumference are in the 15th and 3rd percentile, respectively.", "His temperature is 97.1\u00b0F (36.2\u00b0C), blood pressure is 57/42 mmHg, pulse is 140/min, and respirations are 38/min.", "On physical exam, the patient has a wide nasal bridge, down slanting palpebral fissures, and widely spaced eyes.", "He has good respiratory effort with a high-pitched cry."]}
{"Patient Personal Background": ["She has a history of hypertension and hyperlipidemia for which she takes amlodipine and atorvastatin.", "She immigrated from Vietnam 6 months ago."], "Patient Symptoms": ["She has experienced these symptoms daily for the past 3 months.", "She feels bloated and has episodic loose and watery stools."], "Examination and Results": ["Her temperature is 98.6\u00b0F (37.0\u00b0C), blood pressure is 110/60 mmHg, pulse is 70/min, and respirations are 18/min.", "Physical exam reveals a thin-appearing woman in no acute distress.", "Her mucous membranes are moist.", "Cardiac and lung examinations are unremarkable.", "Laboratory results are as follows: Leukocyte count: 13,000/mm^3 Segmented neutrophils: 54% Bands: 2% Eosinophils: 6% Basophils: 0.4% Lymphocytes: 30% Monocytes: 5% A vitamin D level is 26 ng/mL (reference: >= 30 ng/mL)."]}
{"Patient Personal Background": ["The patient has a medical history of diabetes.", "He drinks 2-7 alcoholic drinks per day and has smoked 2 packs of cigarettes per day since he was 25.", "The patient uses anabolic steroids."], "Patient Symptoms": ["The patient states he has experienced these symptoms for a few weeks; however, today his hand felt so weak he dropped his cup of tea.", "He has lost 17 pounds since he last came to the emergency department 1 month ago.", "The patient states that he is experiencing a dull aching and burning pain in his right arm during the exam."], "Examination and Results": ["His temperature is 99.5\u00b0F (37.5\u00b0C), blood pressure is 177/108 mmHg, pulse is 90/min, respirations are 17/min, and oxygen saturation is 98% on room air.", "Physical exam reveals decreased sensation in the right arm and 2/5 strength in the right arm and 5/5 strength in in the left arm."], "Others": ["Symptoms are not changed with changes in head and neck position."]}
{"Patient Personal Background": ["Her husband tells the physician that he is concerned that the patient has been increasingly obsessed about her weight recently.", "She has a history of major depressive disorder for which she takes escitalopram."], "Patient Symptoms": ["She has been experiencing nausea, vomiting, and diarrhea after eating leftovers 2 days ago."], "Examination and Results": ["Her temperature is 98.6\u00b0F (37.0\u00b0C), blood pressure is 110/72 mmHg, pulse is 110/min, and respirations are 11/min.", "Physical examination is notable for dry mucous membranes and tachycardia with regular rhythm.", "Laboratory testing shows the following results:\n\nSerum:\nNa+: 135 mEq/L\nCl-: 96 mEq/L\nK+: 2.9 mEq/L\nHCO3-: 36 mEq/L\n\nVenous blood gas shows a pH of 7.52."]}
{"Patient Personal Background": ["The child has a medical history of obesity and atopic dermatitis and uses topical steroid cream.", "His birth history is unremarkable.", "His family history is notable for asthma in his older sister and irritable bowel syndrome in his father."], "Patient Symptoms": ["On exam, he appears uncomfortable, is coughing continuously, and is drooling."], "Examination and Results": ["His temperature is 98.5\u00b0F (36.9\u00b0C), pulse is 120/min, blood pressure is 90/52 mmHg, and respirations are 32/min.", "Cardiopulmonary and abdominal exams are unremarkable.", "A chest radiograph is performed and the results are shown in Figures A and B."]}
{"Patient Personal Background": ["The patient has no significant medical history."], "Patient Symptoms": ["For the past 3 months, the patient has been coughing when he drinks liquids.", "His speech also sounds different according to his wife."], "Examination and Results": ["His temperature is 98.6\u00b0F (37.0\u00b0C), blood pressure is 110/80 mmHg, pulse is 60/min, and respirations are 12/min.", "On physical exam, he is unable to fully extend his tongue, and there are fasciculations on his tongue.", "When tapping the mandible at the chin while the mouth is held open, there is pronounced upward movement of the lower jaw.", "Sensory exam reveals no deficits."]}
{"Patient Personal Background": ["The patient has a medical history of diabetes.", "He drinks 2-7 alcoholic drinks per day and has smoked 2 packs of cigarettes per day since he was 25.", "The patient uses anabolic steroids."], "Patient Symptoms": ["The patient states he has experienced these symptoms for a few weeks; however, today his hand felt so weak he dropped his cup of tea.", "He has lost 17 pounds since he last came to the emergency department 1 month ago.", "The patient states that he is experiencing a dull aching and burning pain in his right arm during the exam."], "Examination and Results": ["His temperature is 99.5\u00b0F (37.5\u00b0C), blood pressure is 177/108 mmHg, pulse is 90/min, respirations are 17/min, and oxygen saturation is 98% on room air.", "Physical exam reveals decreased sensation in the right arm and 2/5 strength in the right arm and 5/5 strength in in the left arm."], "Others": ["Symptoms are not changed with changes in head and neck position."]}
{"Patient Personal Background": ["His medical history is significant for an episode of pancreatitis 2 years ago for which he was hospitalized for several days.", "He drinks 2-3 beers on the weekend and he has never smoked.", "He has no family history of colon cancer."], "Patient Symptoms": ["He reports that he also noticed some blood mixed with his stool.", "He notes a weight loss of 8 pounds in the last 2 months with no changes in his diet or exercise habits."], "Examination and Results": ["His temperature is 97.6\u00b0F (36.4\u00b0C), blood pressure is 135/78 mmHg, pulse is 88/min, and respirations are 14/min.", "On physical exam, his abdomen is soft and non-tender to palpation.", "Bowel sounds are present, and there is no hepatomegaly."], "Others": ["The patient denies abdominal pain or any changes in his stool habits."]}
{"Patient Personal Background": ["The patient has a medical history of obesity, diabetes, diabetic nephropathy, hypertension, and a 40-pack-year smoking history.", "His current medications include atorvastatin, lisinopril, insulin, metformin, and nicotine gum."], "Patient Symptoms": ["He was riding the train home from a business conference when his symptoms began.", "The patient's right lower extremity appears mildly inflamed, and palpation of the calf elicits pain."], "Examination and Results": ["His temperature is 99.5\u00b0F (37.5\u00b0C), blood pressure is 130/87 mmHg, pulse is 120/min, respirations are 15/min, and oxygen saturation is 93% on room air.", "An ECG is ordered as seen in Figure A.", "A chest radiograph is ordered as seen in Figure B.", "Laboratory values are ordered as seen below: Serum: Na+: 137 mEq/L Cl-: 105 mEq/L K+: 4.1 mEq/L HCO3-: 24 mEq/L BUN: 22 mg/dL Glucose: 129 mg/dL Creatinine: 1.2 mg/dL Ca2+: 10.1 mg/dL AST: 11 U/L ALT: 12 U/L On physical exam, the patient appears to be in distress.", "His cardiac exam is notable for tachycardia.", "Pulmonary exam reveals bilateral air movement without any wheezes or crackles."]}
{"Patient Personal Background": ["He was last seen in the clinic several months ago when he was diagnosed with attention deficit hyperactivity disorder (ADHD).", "He hopes to play baseball in college and has begun lifting weights daily in preparation for baseball season.", "The patient has a healthy diet to fuel his exercise regimen.", "His parents have no concerns and are pleased with the recent improvement in his grades."], "Patient Symptoms": ["His chest has a normal appearance other than mild gynecomastia."], "Examination and Results": ["His temperature is 98.6\u00b0F (37\u00b0C), blood pressure is 115/71 mmHg, pulse is 72/min, and respirations are 12/min.", "On physical exam, the patient has tall stature with average muscle mass for his age.", "The patient has sparse facial hair and a moderate amount of coarse pubic hair that extends across the pubis and spares the medial thighs.", "His testes are small and firm."], "Treatment": ["He was started on methylphenidate at that time and the patient now reports improvement in his ability to concentrate in school and at home."], "Diagnosis": ["He was last seen in the clinic several months ago when he was diagnosed with attention deficit hyperactivity disorder (ADHD)."]}
{"Patient Personal Background": ["The patient has a medical history of obesity, diabetes, bipolar disorder, and tonic-clonic seizures.", "The patient has IV drug and alcohol use disorder and has presented to the ED many times for intoxication.", "Her current medications include metformin, insulin, lisinopril, and valproic acid."], "Patient Symptoms": ["She was at a rehabilitation hospital when her symptoms started."], "Examination and Results": ["Her temperature is 98.6\u00b0F (37\u00b0C), blood pressure is 115/71 mmHg, pulse is 72/min, and respirations are 12/min.", "Physical exam reveals anasarca and asymmetric lower extremity swelling."], "Treatment": ["Based on the results of a doppler ultrasound of her swollen lower extremity, heparin is started."], "Others": ["The patient is then transferred to the general medicine floor for continued management.", "Laboratory studies are shown below."]}
{"Patient Personal Background": ["The patient has a medical history of sinusitis, constipation, diabetes, and pelvic inflammatory disease.", "Her current medications include fexofenadine, oral contraceptive pills, and metformin.", "She is currently taking amoxicillin for a sinus infection.", "She smokes 1 pack of cigarettes per day and drinks 2-3 alcoholic beverages daily."], "Patient Symptoms": ["She was at home when a sudden headache began with greater severity than she had experienced in the past.", "Neurological exam reveals a confused woman who is now complaining of \"seeing double.\""], "Examination and Results": ["Her temperature is 99.5\u00b0F (37.5\u00b0C), blood pressure is 187/118 mmHg, pulse is 120/min, respirations are 17/min, and oxygen saturation is 98% on room air.", "Cardiopulmonary exam reveals mild bibasilar crackles and tachycardia.", "Abdominal exam is within normal limits."], "Others": ["She presented within 30 minutes of symptom onset.", "On physical exam, the patient is noted to be uncomfortable with the appearance shown in Figure A."]}
{"Patient Personal Background": ["The patient is otherwise healthy.", "He has no other significant medical history and does not take any medications."], "Patient Symptoms": ["He noticed this yesterday as well, but it was much scanter.", "He was celebrating his birthday last night and admits having \"too much to drink\" and vomited profusely overnight.", "He currently feels well and is not nauseous."], "Examination and Results": ["His temperature is 99.2\u00b0F (37.3\u00b0C), blood pressure is 110/75 mmHg, pulse is 82/min, respirations are 16/min, and oxygen saturation is 100% on room air.", "Physical exam reveals a nontender abdomen with normal bowel sounds.", "Rectal exam reveals grossly bloody stool."]}
{"Patient Personal Background": ["She has no medical history and has never been hospitalized."], "Patient Symptoms": ["She has been complaining of pain in her right leg for the last few days.", "The open wound remains present on the thigh with surrounding erythema and edema."], "Examination and Results": ["Her temperature is 102.2\u00b0F (39\u00b0C), blood pressure is 118/78 mmHg, pulse is 90/min, respirations are 21/min, and pulse oximetry is 99% on room air.", "MRI is consistent with osteomyelitis."], "Treatment": ["At the time of the bite, they cleaned the wound and irrigated it with sterile saline water from a first aid kit."], "Diagnosis": ["MRI is consistent with osteomyelitis."], "Others": ["Her neighbor\u2019s cat bit her last week and her parents attributed the pain to her healing bite."]}
{"Patient Personal Background": ["He has no medical history and takes no medications.", "He recently started experimenting with alcohol and marijuana that one of his friends has been stealing from their parents."], "Patient Symptoms": ["He says that the spasms usually occur after he wakes up as he is getting ready for school, and consist of disorganized jerking motions that stop after a few minutes.", "He has also noticed that they occur when he stays up late to cram last minute for exams."], "Examination and Results": ["His temperature is 98.6\u00b0F (37.0\u00b0C), blood pressure is 115/70 mmHg, pulse is 70/min, and respirations are 12/min.", "Physical exam reveals a healthy child."], "Others": ["He has not noticed any other symptoms."]}
{"Patient Symptoms": ["One week ago, he began vomiting and regurgitating breastmilk through his nose after most feedings.", "His stools over the past week have also become blood-streaked.", "The patient does not seem to be in any distress when he passes these bloody stools.", "The patient surpassed his birth weight by 2 weeks of age but has fallen 1 standard deviation on the growth curve since then.", "His temperature is 98.6\u00b0F (37\u00b0C), blood pressure is 78/47 mmHg, pulse is 115/min, and respirations are 28/min."], "Examination and Results": ["The patient is breastfed and typically feeds for 20-30 minutes every 2 hours.", "On physical exam, the patient is well-appearing.", "The patient\u2019s abdomen is soft, non-tender, and non-distended.", "A digital rectal exam reveals a small amount of blood in the rectal vault."], "Others": ["His face and back have the physical exam finding seen in Figure A."]}
{"Patient Personal Background": ["His activity level has been normal and he has been attending school until this morning.", "He has no medical history or known allergies, but he has not received any of the recommended vaccines due to parental refusal."], "Patient Symptoms": ["On examination, the child is fussy.", "Bilateral conjunctivae are injected, and there is redness on and around the tonsils."], "Examination and Results": ["His temperature is 100.3\u00b0F (37.9\u00b0C), blood pressure is 98/62 mmHg, pulse is 85/min, respirations are 22/min, and oxygen saturation is 98% on room air.", "There is no lymphadenopathy.", "Faint rhonchi are heard at the lung bases bilaterally."]}
{"Patient Personal Background": ["The patient is obese, and her only medication is an oral contraceptive pill.", "She otherwise is known to smoke cigarettes on occasion."], "Patient Symptoms": ["She was found to have altered mental status at home, and during transport to the hospital, she became pulseless."], "Examination and Results": ["Physical exam is notable for a critically ill patient with chest compressions ongoing.", "The monitor shows pulseless electrical activity.", "A bedside echocardiograph is notable for a dilated and hypokinetic right ventricle with septal bowing into a hyperkinetic left ventricle."], "Treatment": ["Cardiopulmonary resuscitation is ongoing and 2 intravenous lines are placed.", "The patient regains her pulse after several rounds of CPR and epinephrine."], "Others": ["She recently underwent Achilles tendon repair.", "Her right lower extremity is in a post-operative splint."]}
{"Patient Personal Background": ["Of note, the patient has presented to the emergency department before for a similar reason when she was struggling with online dating.", "The patient states that she struggles with her romantic relationships though she deeply desires them."], "Patient Symptoms": ["The patient states she knew her boyfriend was having sexual thoughts about the woman from the grocery store, prompting her decision to cut her own wrist.", "When interviewing the patient, she is teary and apologizes for her behavior."], "Examination and Results": ["Her temperature is 98.6\u00b0F (37\u00b0C), blood pressure is 112/71 mmHg, pulse is 73/min, and respirations are 14/min.", "On physical exam, you note a frightened young woman who is wearing a revealing dress that prominently displays her breasts."], "Treatment": ["In the emergency department, the bleeding has stopped and the patient is currently medically stable.", "You tell the patient that she will have to stay in the psychiatric emergency department for the night which makes her furious."], "Others": ["She is grateful to you for her care and regrets her actions."]}
{"Patient Personal Background": ["The patient has been breastfed since birth, and usually feeds for 30 minutes every 2-3 hours.", "Her older son had a similar problem with vomiting that resolved around 12 months of age.", "Four weeks ago, the patient\u2019s height and weight were in the 40th and 34th percentiles, respectively.", "His height and weight are now respectively in the 37th and 36th percentiles."], "Patient Symptoms": ["The patient\u2019s mother is concerned that her milk production is not keeping up with the patient\u2019s nutritional requirements.", "She reports that about 2 weeks ago the patient began regurgitating breastmilk through his nose and mouth after some feeds.", "He seems mildly upset during the episodes of regurgitation but usually settles down quickly and is hungry again soon afterwards.", "His mother has already tried limiting the volume of each feed, which seems to have reduced the frequency of regurgitation."], "Examination and Results": ["His temperature is 98.6\u00b0F (37\u00b0C), blood pressure is 72/49 mmHg, pulse is 121/min, and respirations are 32/min.", "On physical exam, the patient is cooing in his mother\u2019s lap and smiles reciprocally with her.", "He lifts his head and shoulders off the examination table when placed in the supine position.", "His abdomen is soft, non-tender and non-distended.", "Bowel sounds are normoactive."], "Treatment": ["She denies any diarrhea, hematochezia, or family history of food allergies."]}
{"Patient Personal Background": ["The first day of her last menstrual period was 7 weeks prior to presentation.", "The patient has no medical conditions and takes no medications.", "The patient asks if she should modify her current exercise regimen due to her pregnancy.", "She typically swims or uses an exercise bike for 45 minutes, 5 days a week, and plays in an office soccer league for 1 hour on 1 day per week."], "Examination and Results": ["Her temperature is 98.6\u00b0F (37.0\u00b0C), blood pressure is 110/70 mmHg, pulse is 64/min, and respirations are 17/min.", "Physical exam is notable for a nontender abdomen.", "Pelvic exam reveals a closed cervix with no adnexal or uterine tenderness.", "A urine pregnancy test is positive, and an intrauterine singleton pregnancy measuring approximately 9 weeks gestational age is visualized on transvaginal ultrasound."]}
{"Patient Personal Background": ["The patient has a medical history of asthma and seasonal allergies."], "Patient Symptoms": ["He is concerned about a rash that does not seem to be improving."], "Examination and Results": ["His temperature is 98.6\u00b0F (37.0\u00b0C), blood pressure is 137/98 mmHg, pulse is 90/min, respirations are 14/min, and oxygen saturation is 98% on room air.", "Physical exam reveals the finding in Figure A."], "Others": ["He was recently exposed to his grandfather who has vesicular lesions on his skin and is being treated.", "He has a family history of skin cancer, colon cancer, and ovarian cancer."]}
{"Patient Personal Background": ["The patient\u2019s medical history is significant for hypertension, for which he takes lisinopril.", "His family history is unknown as he was adopted.", "The patient met his mother once and never knew his father but was told he died in his 50s.", "He drinks a few glasses of wine per week and has never smoked."], "Patient Symptoms": ["His wife reports that her husband has not been himself for the last 2 months.", "Whereas he was previously outgoing and \u201cthe life of the party,\u201d the patient is now irritable and withdrawn.", "He is a partner at an accounting firm, but his colleagues are threatening to fire him if he continues to perform poorly at work.", "The patient cannot explain the recent changes to his mood and tearfully admits he fears there is something seriously wrong with him.", "His wife says that he is getting worse."], "Examination and Results": ["His temperature is 98.6\u00b0F (37\u00b0C), blood pressure is 141/87 mmHg, pulse is 81/min, and respirations are 12/min.", "On physical exam, the patient has a flat affect with a facial grimace and sudden jerky movements of his upper extremities."]}
{"Patient Personal Background": ["He does not see a primary care physician and is not currently taking any medications.", "He drinks alcohol socially and does not smoke."], "Patient Symptoms": ["The patient has presented 3 times this month with similar complaints.", "He states his shortness of breath started when he was walking from his car to a local restaurant."], "Examination and Results": ["His temperature is 99.5\u00b0F (37.5\u00b0C), pulse is 100/min, blood pressure is 130/90 mmHg, respirations are 18/min, and oxygen saturation is 96% on room air.", "On physical exam, he appears fatigued and the cardiovascular exam reveals an additional heart sound after S2.", "A pulmonary exam is notable for bilateral crackles and an abdominal exam reveals an obese abdomen without pain in any of the quadrants.", "Lower extremity pitting edema is noted bilaterally."]}
{"Patient Personal Background": ["She started treatment for a skin condition with a new oral medication 2 months prior."], "Patient Symptoms": ["She has not noticed any changes in her complexion as of yet."], "Examination and Results": ["Her temperature is 98.2\u00b0F (36.8\u00b0C), blood pressure 100/65 mmHg, pulse 87/min, and respiratory rate 14/min.", "She is oriented to person, place, and time.", "Neurological exam reveals papilledema upon examination of both eyes.", "Skin examination is notable for the findings in Figure A."]}
{"Patient Personal Background": ["He has a history of alcohol use disorder and has vomited small streaks of blood in the past, but has never undergone formal medical workup for it."], "Patient Symptoms": ["His wife states that he began vomiting bright red blood this evening while eating dinner, and has produced about 5 cups total."], "Examination and Results": ["On exam, he has bright red blood in his mouth and pharynx, and also displays a distended abdomen with a fluid wave, jaundice, scattered spider angiomas, and multiple ecchymoses.", "His temperature is 98.4\u00b0F (36.9\u00b0C), blood pressure is 98/68 mmHg, pulse is 125/min, and respirations are 22/min.", "A rapid point-of-care hemoglobin and platelet count is 8.8 g/dL and 80,000/mm^3, respectively."], "Treatment": ["The patient is given 1L of normal saline."]}
{"Patient Personal Background": ["Her medical history is significant for hyperlipidemia, mild intermittent asthma, and type 2 diabetes mellitus.", "She has never smoked and has 10-15 alcoholic drinks per week.", "She works as an aide at a nursing home."], "Patient Symptoms": ["Over the past week, she has had increasing difficulty chewing her food and progressive pain in the left side of her jaw.", "This morning, she was unable to close her mouth for several minutes after taking a bite of her breakfast."], "Examination and Results": ["Her temperature is 100.8\u00b0F (38.2\u00b0C), blood pressure is 133/74 mmHg, pulse is 105/min, and respirations are 14/min.", "On physical exam, there is a bluish hue to the skin on the lower left side of the patient\u2019s face.", "A 3x4 cm non-tender mass can be palpated inferior to the angle of the left mandible.", "Thick exudate is draining from an opening in the skin.", "The gram stain of the exudate can be seen in Figure A."], "Others": ["Two months ago, the patient had a root canal on a left molar."]}
{"Patient Personal Background": ["The child was recently adopted and little is known about his medical or family history.", "He eats a varied diet at home and with limited juice and snack foods."], "Patient Symptoms": ["The child seems to be doing well, but the patient is much larger than any of the other 3-year-olds in his preschool class.", "He appears mildly developmentally delayed.", "He appears to have poor visual acuity and is referred to an ophthalmologist, who finds downward lens subluxation of the right eye."], "Examination and Results": ["His temperature is 98.6\u00b0F (37\u00b0C), blood pressure is 101/67 mmHg, pulse is 110/min, and respirations are 24/min.", "On physical exam, the patient is in the 73rd percentile for weight, 99th percentile for height, and 86th percentile for head circumference.", "He has a fair complexion and tall stature with a prominent sternum.", "The patient also has joint hypermobility and hyperelastic skin."]}
{"Patient Personal Background": ["The patient has dementia at baseline and is minimally interactive."], "Patient Symptoms": ["This morning, she was found to be obtunded.", "No further history was provided from the nursing home, and the patient is unable to provide any history."], "Examination and Results": ["Her temperature is 95.0\u00b0F (35.0\u00b0C), blood pressure is 84/54 mmHg, pulse is 50/min, respirations are 9/min, and oxygen saturation is 98% on room air.", "Physical exam reveals an obtunded woman who only withdraws her extremities to pain.", "Her skin is cool and pale, and her hair is thin.", "There are no signs of trauma noted on exam.", "Laboratory values are notable for a whole blood sodium of 120 mEq/L."], "Treatment": ["The patient is given several intravenous boluses of fluids and her blood pressure improves to 100/60 mmHg."], "Others": ["She was last known to be normal the night before."]}
{"Patient Personal Background": ["He uses intravenous drugs and is unable to offer a history."], "Patient Symptoms": ["He was found unconscious in a park.", "Physical exam reveals an obtunded man covered in vomit, with track marks on his arm and several skin abscesses."], "Examination and Results": ["His temperature is 99.0\u00b0F (37.2\u00b0C), blood pressure is 80/40 mmHg, pulse is 156/min, and respirations are 26/min.", "Physical exam reveals an obtunded man covered in vomit, with track marks on his arm and several skin abscesses.", "As the fourth liter of fluids is finishing, the patient is noted to have jugular venous distension and an oxygen saturation of 92% on nonrebreather."], "Treatment": ["The patient is given 4 liters of Ringer lactate and intravenous antibiotics.", "He is subsequently intubated.", "The patient is started on norepinephrine, and his blood pressure is subsequently found to be 85/44 mmHg."], "Others": ["An ECG is obtained as seen in Figure A."]}
{"Patient Personal Background": ["He has hypertension and hyperlipidemia, for which he takes lisinopril and atorvastatin.", "He has never smoked cigarettes."], "Patient Symptoms": ["The mass has been slowly enlarging over the past 1 year.", "He reports no dysphagia, difficulty breathing, or changes to his voice.", "He also denies heat intolerance, palpitations, tremors, or diarrhea."], "Examination and Results": ["His temperature is 37.1\u00b0C (98.8\u00b0F), blood pressure is 130/84 mmHg, pulse is 86/min, respirations are 12/min, and oxygen saturation is 99% on room air.", "Bedside ultrasound reveals a 1x2 cm hypoechogenic nodule with microcalcifications in the right thyroid lobe, which is biopsied."], "Others": ["Pathology results are shown in Figure A."]}
{"Patient Personal Background": ["His medical problems include hypertension, hyperlipidemia, hypothyroidism, and chronic neck pain for which he takes amlodipine, hydrochlorothiazide, atorvastatin, levothyroxine, and duloxetine.", "Surgical history consists of posterior lumbar fusion and elective left total hip arthroplasty.", "He has a 90-pack-year smoking history and quit 10 years ago."], "Patient Symptoms": ["He reports these symptoms started intermittently in the middle finger after returning from a golfing trip but has progressed to being nearly constant.", "The thenar eminence, thumb, and other digits are spared.", "He reports no other symptoms."], "Examination and Results": ["The patient\u2019s temperature is 99.6\u00b0F (37.6\u00b0C), blood pressure is 134/80 mmHg, pulse is 90/min, and respirations are 16/min.", "Physical exam reveals 4/5 strength in elbow extension and wrist flexion on the right.", "He has 5/5 strength in the remainder of the motor exam on the right upper extremity and on the left upper extremity.", "The triceps reflex is 1+ on the right compared to 2+ on the left.", "There is no spasticity.", "His neck pain, which radiates down his right arm, is reproduced with axial loading during neck extension with simultaneous rightward rotation and lateral bending."]}
{"Patient Personal Background": ["The parents have no concerns at this time and note he is starting to run around and speak in 3-word sentences.", "He has no remarkable medical history and his mother had an uncomplicated full-term pregnancy and delivery."], "Examination and Results": ["He is appropriately meeting the developmental milestones for his age.", "The patient\u2019s temperature is 98.4\u00b0F (36.9\u00b0C), blood pressure is 96/52 mmHg, pulse is 102/min, and respirations are 25/min.", "He is in the 55th percentile for height and 62nd percentile for weight, which is consistent with his documented growth curves.", "Fundoscopic exam shows the finding in Figure A.", "His pediatrician continues the ocular examination and further notes that the pupils are equal, round, and reactive, extraocular movements are full, and ocular alignment appears normal."]}
{"Patient Personal Background": ["He has no past medical history and takes no medications."], "Patient Symptoms": ["The patient is unable to offer a history and repetitively asks the nurses what happened.", "He is complaining of a headache.", "A head CT scan is ordered."], "Examination and Results": ["His temperature is 97.6\u00b0F (36.4\u00b0C), blood pressure is 122/74 mmHg, pulse is 90/min, respirations are 12/min, and oxygen saturation is 98% of room air.", "Physical exam reveals a confused young man.", "Cranial nerves 2-12 are intact and the patient has normal strength and sensation.", "He demonstrates a stable gait."], "Treatment": [], "Others": ["He drove his car into a pole while speeding at night.", "He knows his name and address and is able to remember other information about himself.", "Throughout the exam, he continuously asks what happened to him."]}
{"Patient Personal Background": ["He has a history of migraine headaches, but he feels that this headache is significantly more painful than his typical migraines.", "His medical history is significant for migraines and hypertension.", "He has a 20-pack-year smoking history and a history of cocaine use.", "He drinks 5-6 beers per week."], "Patient Symptoms": ["He suddenly developed a throbbing, bitemporal headache about 5 hours ago \"out of nowhere.\"", "He has a history of migraine headaches, but he feels that this headache is significantly more painful than his typical migraines.", "He also endorses nausea and he reports that he vomited once before arrival in the emergency department."], "Examination and Results": ["His temperature is 98.6\u00b0F (37\u00b0C), blood pressure is 147/91 mmHg, pulse is 62/min, and respirations are 12/min.", "On physical exam, he appears to be in moderate distress and has pain with neck flexion.", "He has no focal neurologic deficits."], "Treatment": ["The patient took his prescribed sumatriptan with no relief of his symptoms."], "Others": ["The patient denies any recent trauma to the head.", "A head CT is performed and can be seen in Figure A."]}
{"Patient Personal Background": ["The patient\u2019s medications include aspirin and carvedilol.", "He reports that he is a smoker with a 50-pack-year history."], "Patient Symptoms": ["When it started, he felt like a \u201ccurtain was pulled down\u201d over his right eye but wasn't able to seek care immediately because it was snowing outside and he didn't want to travel in inclement weather.", "A review of systems is significant for occasional palpitations and presyncope."], "Examination and Results": ["The patient\u2019s temperature is 99\u00b0F (37.2\u00b0C), blood pressure is 112/72 mmHg, pulse is 84/min, and respirations are 14/min with an oxygen saturation of 97% on room air.", "Physical exam reveals 20/800 vision in the right eye.", "A fundoscopic exam of the right eye is shown in Figure A.", "Physical and fundoscopic examinations of the left eye are unremarkable."]}
{"Patient Personal Background": ["She is otherwise healthy and does not take any medications."], "Patient Symptoms": ["Her breast has not been tender, and she has not noticed any changes to the skin.", "Bloody discharge is expressed from the right nipple."], "Examination and Results": ["Her temperature is 36.5\u00b0C (97.7\u00b0F), blood pressure is 110/82 mmHg, pulse is 68/min, respirations are 12/min, and oxygen saturation is 99% on room air.", "Exam of the right breast reveals no mass on palpation.", "There is no axillary lymphadenopathy."]}
{"Patient Personal Background": ["He endorses a history of unprotected sex with multiple partners and intravenous drug use during a recent vacation to Mexico but has no other significant medical history.", "He drinks socially and has never smoked."], "Patient Symptoms": ["He also endorses loss of appetite and subjective fever.", "He has had vague, mild discomfort in the right upper quadrant since the start of this wrestling season."], "Examination and Results": ["His temperature is 98.6\u00b0F (37\u00b0C), blood pressure is 119/72 mmHg, pulse is 102/min, and respirations are 12/min.", "Physical exam demonstrates pain on palpation of the right lower quadrant and mild pain in the right upper quadrant.", "A CT of the abdomen confirms appendicitis.", "The scan also shows a large liver mass measuring 6 cm as seen in Figure A."], "Diagnosis": ["He has significant acne on his face, chest, and back."]}
{"Patient Personal Background": ["He is asymptomatic and has no acute complaints, has no medical problems, and takes no medications.", "He was born in the United States but moved to El Salvador at age 11 and has only recently moved back to the United States in the past year.", "He was up to date on his vaccinations prior to his move to El Salvador."], "Examination and Results": ["The patient\u2019s temperature is 98.2\u00b0F (36.8\u00b0C), blood pressure is 120/76 mmHg, pulse is 82/min, and respirations are 16/min.", "There are no rashes noted on physical exam."], "Others": ["He last received a diphtheria, tetanus, and acellular pertussis (DTaP) vaccine 14 years ago at age 5, the second dose of a meningococcal vaccine 3 years ago, and an influenza vaccine 2 months ago."]}
{"Patient Personal Background": ["The patient's mother reports that the pregnancy was uncomplicated other than an episode of sinusitis in the 3rd trimester, for which she was treated with azithromycin."], "Patient Symptoms": ["Three weeks ago, the patient began vomiting after meals.", "The vomitus appears to be normal stomach contents without streaks of red or green.", "Despite these adjustments, the vomiting has become more frequent and forceful.", "The patient is voiding about 4 times per day and his urine appears dark yellow."], "Examination and Results": ["The patient's temperature is 98.7\u00b0F (37.1\u00b0C), blood pressure is 58/41 mmHg, pulse is 166/min, and respirations are 16/min.", "On physical exam, the patient looks small for his age.", "His abdomen is soft, non-tender, and non-distended."], "Treatment": ["His parents have already tried repositioning him during mealtimes and switching his formula to eliminate cow\u2019s milk and soy."], "Others": ["He has fallen 1 standard deviation off of the growth curve."]}
{"Patient Symptoms": ["He had a similar episode about 1 month ago which resolved after a few hours.", "The pain feels like a stabbing sensation behind his right eye.", "He denies any symptoms on the left side.", "The last time he had an episode like this, his eye was tearing."], "Examination and Results": ["His temperature is 98.2\u00b0F (36.8\u00b0C), blood pressure is 120/90 mmHg, pulse is 110/min, and respirations are 12/min.", "Physical exam reveals a 2 mm pupil on the right and a 5 mm pupil on the left.", "Extraocular movements are intact bilaterally.", "The remainder of the neurologic exam is unremarkable."]}
{"Patient Personal Background": ["His past medical history is significant for human immunodeficiency virus (HIV) infection, diagnosed 15 years ago.", "The patient is intermittently compliant with his antiretroviral therapy (ART)."], "Patient Symptoms": ["He has no concerns."], "Examination and Results": ["His temperature is 99.0\u00b0F (37.2\u00b0C), blood pressure is 130/84 mmHg, pulse is 92/min, and respirations are 11/min.", "His most recent lab work showed a cluster of differentiation CD4 count of 150 cells/\u00b5L."], "Treatment": ["He received a dose of the 13-valent pneumococcal vaccine and a dose of the 23-valent pneumococcal vaccine 15 years ago, as well as a second dose of the 23-valent pneumococcal vaccine 10 years ago."]}
{"Patient Personal Background": ["Her medical problems consist of heart failure for which she takes furosemide, spironolactone, and metoprolol, which were continued at admission."], "Patient Symptoms": ["The headache started suddenly while she was eating dinner and she says it feels like the \u201cworst headache of my life.\u201d An emergent CT scan of the head without contrast confirms the diagnosis, and a CT angiogram identifies the source of bleeding.", "She also develops nausea and vomiting."], "Examination and Results": ["Her temperature is 99.6\u00b0F (37.6\u00b0C), blood pressure is 100/60 mmHg, pulse is 112/min, and respirations are 16/min.", "Physical examination shows poor skin turgor.", "Capillary refill time is 4 seconds.", "Serum laboratory results are shown below: Na+: 120 mEq/L Cl-: 92 mEq/L K+: 3.9 mEq/L HCO3-: 26 mEq/L BUN: 32 mg/dL Creatinine: 1.0 mg/dL Serum osmolality is 265 mEq/L and urine osmolality is 340 mEq/L.", "Urine sodium is 44 mEq/L."], "Treatment": ["The patient undergoes surgical management of her condition."], "Diagnosis": ["The headache started suddenly while she was eating dinner and she says it feels like the \u201cworst headache of my life.\u201d An emergent CT scan of the head without contrast confirms the diagnosis, and a CT angiogram identifies the source of bleeding."], "Others": ["On hospital day 3, she is found to be disoriented to person, place, and time."]}
{"Patient Symptoms": ["While holding her newborn, the mother endorses a headache, blurry vision, and abdominal pain."], "Examination and Results": ["Her temperature is 98.0\u00b0F (36.7\u00b0C), blood pressure is 194/104 mmHg, pulse is 100/min, respirations are 18/min, and oxygen saturation is 98% on room air.", "Physical exam reveals an uncomfortable woman.", "There is blood in her vagina and her uterus is contracted.", "Her cranial nerve exam is unremarkable and she has normal strength and sensation."], "Treatment": ["She subsequently undergoes an uncomplicated vaginal delivery.", "The child is healthy and is heated, suctioned, and stimulated."], "Others": ["Laboratory studies and a urinalysis are pending."]}
{"Patient Personal Background": ["His primary care provider was concerned and had advised him to go to the hospital, as the patient is on warfarin for atrial fibrillation."], "Patient Symptoms": ["He was seen in the emergency department 2 days ago for profuse epistaxis.", "A dark, purpuric rash is noted on his torso and extremities."], "Examination and Results": ["Upon presentation to the ED today, his temperature is 97.6\u00b0F (36.4\u00b0C), blood pressure is 64/33 mmHg, pulse is 160/min, respirations are 32/min, and oxygen saturation is 100% on room air.", "Physical exam reveals an obtunded man who cannot answer questions."], "Treatment": ["The patient\u2019s nasal packing is removed with no further bleeding.", "The patient is given IV fluids and blood cultures are drawn."], "Others": ["However, his bleeding resolved with pressure and nasal packing."]}
{"Patient Personal Background": ["Her medical history is notable for a treated episode of acute renal failure, diabetes mellitus, obesity, and hypertension.", "Her current medications include losartan, metformin, insulin, and ibuprofen.", "She also recently fell off the treadmill while exercising at the gym."], "Patient Symptoms": ["The pain is present in the morning but is nearly unbearable by the end of the day.", "The patient points to the areas that cause her pain stating that it is mostly over the groin."], "Examination and Results": ["Her temperature is 98.6\u00b0F (37\u00b0C), blood pressure is 135/91 mmHg, pulse is 72/min, and respirations are 12/min.", "On exam, an obese woman in no distress is noted.", "There is pain, decreased range of motion, and crepitus on exam of her right hip."], "Treatment": ["The patient recently started taking high doses of vitamin D as she believes that it could help her symptoms."], "Others": []}
{"Patient Personal Background": ["He just switched from being home-schooled to public school and joined the basketball team.", "He does not currently take any medications."], "Patient Symptoms": ["He has fainted several times during basketball practices.", "He did not sustain any injuries or have any prodromes prior to these episodes.", "He is usually unconscious for less than a minute."], "Examination and Results": ["He is otherwise healthy and has met all developmental milestones.", "His temperature is 97.6\u00b0F (36.4\u00b0C), blood pressure is 104/54 mmHg, pulse is 100/min, respirations are 19/min, and oxygen saturation is 98% on room air.", "Physical exam reveals a well-appearing and playful boy.", "An ECG is performed as seen in Figure A.", "An echocardiogram is ordered and pending."]}
{"Patient Symptoms": ["Her urinary leaking occurs throughout the day and night, and she often has to get up to use the bathroom while asleep.", "Exercising does not affect the loss of urine.", "She states that she often cannot make it to the bathroom in time once she senses a need to void."], "Examination and Results": ["Her urinalysis is unremarkable, and her postvoid residual volume is 40 mL.", "On pelvic examination, there is no dribbling of urine when the patient coughs.", "Physical exam is otherwise unremarkable."], "Others": ["Her last menstrual period was 2 weeks ago."]}
{"Patient Personal Background": ["His wife has noticed a tremor while he is working on his car and knows that his father died of Parkinson disease.", "His medical problems include hypertension, diabetes, and hyperlipidemia for which he takes lisinopril, metformin, and atorvastatin.", "He has 3-5 drinks of scotch per night before working on his car."], "Patient Symptoms": ["His wife has noticed a tremor while he is working on his car and knows that his father died of Parkinson disease.", "He says that the tremor is nothing to worry about and only occurs during a few activities such as pouring drinks, pointing the remote at the television, or fixing his car."], "Examination and Results": ["On physical exam, the tremor is replicated during finger to nose testing.", "Romberg sign is negative.", "Cranial nerves II-XII are intact.", "The rest of the exam is benign."], "Others": ["The patient states his wife is just overreacting."]}
{"Patient Personal Background": ["Her medical history is significant for mild intermittent asthma for which she uses an albuterol inhaler as needed.", "She is sexually active with 1 male partner.", "She recently returned from South India following a mission trip for 6 weeks."], "Patient Symptoms": ["These symptoms have been going on for 2 months.", "She has lost 6 pounds (2.7 kg) over these 2 months."], "Examination and Results": ["Her temperature is 98.6\u00b0F (37.0\u00b0C), blood pressure is 105/70 mmHg, pulse is 95/min, and respirations are 14/min.", "On examination, the patient\u2019s skin is pale.", "Labs are obtained and show the following results:\n\nLeukocyte count: 4,500/mm^3\nHemoglobin: 10.5 g/dL\nPlatelets: 110,000/mm^3\nMean corpuscular volume (MCV): 116 \u00b5m^3\nReticulocyte count: 0.5%\n\nA biopsy of the small bowel reveals blunting of villi and a mixed infiltration of lymphocytes, plasma cells, and eosinophils."]}
{"Patient Personal Background": ["She has no significant medical history.", "She takes no medication other than whey protein supplements, a multivitamin, and fish oil."], "Patient Symptoms": ["She has noticed \"twitching\" in both her upper and lower extremities over the past 3 days that have interfered with her training for a marathon.", "She has felt more fatigued over the past month."], "Examination and Results": ["Her temperature is 98.5\u00b0F (36.9\u00b0C), blood pressure is 103/71 mmHg, pulse is 105/min, respirations are 11/min, and oxygen saturation is 100% on room air.", "Physical exam reveals a thin woman with thinning hair.", "She appears pale and her mucous membranes are dry.", "Her neurological and cardiac exams are unremarkable.", "Laboratory studies are ordered as seen below.", "Hemoglobin: 10 g/dL Hematocrit: 30% Leukocyte count: 6,100/mm^3 with normal differential Platelet count: 187,500/mm^3 Serum: Na+: 130 mEq/L Cl-: 100 mEq/L K+: 2.3 mEq/L HCO3-: 28 mEq/L BUN: 40 mg/dL Glucose: 79 mg/dL Creatinine: 0.9 mg/dL Ca2+: 8.2 mg/dL Mg2+: 1.8 mg/dL Thyroid stimulating hormone (TSH): 4.0 mIU/L Free T4: 0.4 ng/dL (normal: 0.7-1.53 ng/dL) The patient is given 4 liters of lactated ringer solution and 40 mEq of potassium."], "Treatment": ["Her repeat whole blood potassium 3 hours later is 2.4 mEq/L, and her repeat BUN is 20 mEq/L.", "Another 40 mEq of potassium is administered.", "Another repeat whole blood potassium is 2.5 mEq/L."]}
{"Patient Symptoms": ["She is confused and is unable to provide any history, but complains of generalized pain.", "Physical exam reveals, a confused, ill-appearing woman."], "Examination and Results": ["Her temperature is 99.2\u00b0F (37.3\u00b0C), blood pressure is 129/64 mmHg, pulse is 63/min, respirations are 13/min, and oxygen saturation is 99% on room air.", "Lungs are clear to auscultation bilaterally.", "An electrocardiogram is obtained as shown in Figure A. Dipstick urinalysis is notable for 4+ blood and dark colored urine."], "Others": ["She was found on the floor of her apartment after her neighbor called 911."]}
{"Patient Personal Background": ["The child is sleeping at regular 2-hour intervals and feeding and stooling well."], "Patient Symptoms": ["The parents have noticed a \u201cswelling of the belly button.\u201d Cord separation occurred at 7 days of age.", "The swelling seems to come and go but is never larger than the size of a blueberry.", "They deny any drainage from the swelling."], "Examination and Results": ["Her temperature is 98.6\u00b0F (37\u00b0C), blood pressure is 68/43 mmHg, pulse is 128/min, and respirations are 32/min.", "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."]}
{"Patient Personal Background": ["The patient works as a farmer and has no concerns about his health.", "He has a medical history of hypertension and obesity.", "His current medications include lisinopril and metoprolol."], "Examination and Results": ["His temperature is 99.5\u00b0F (37.5\u00b0C), blood pressure is 177/108 mmHg, pulse is 90/min, respirations are 17/min, and oxygen saturation is 98% on room air.", "Physical exam is notable for a murmur after S2 over the left sternal border.", "The patient demonstrates a stable gait and 5/5 strength in his upper and lower extremities."]}
{"Patient Personal Background": ["He has a history of coronary artery disease and underwent an uncomplicated coronary angioplasty with stent placement 2 years ago.", "He routinely travels both domestically and internationally as a senior shipyard worker and has a 30-pack-year smoking history.", "He used to drink 4 cocktails a week.", "He has not smoke or drank alcohol in over 7 years."], "Patient Symptoms": ["His symptoms began 3 months ago.", "He has also lost 18 pounds.", "Physical exam is notable for right pupillary constriction as well as paresthesias in his right fourth and fifth digits."], "Examination and Results": ["His temperature is 99.5\u00b0F (37.7\u00b0C), blood pressure is 140/60 mmHg, pulse is 97/min, and respirations are 13/min.", "There is no pain with active shoulder rotation.", "His chest imaging is shown in Figure A."]}
{"Patient Personal Background": ["She has a medical history of hypertension for which she takes hydrochlorothiazide.", "The patient\u2019s mother had breast cancer at age 68, and her sister has endometriosis."], "Patient Symptoms": ["She states that she feels well and has no complaints."], "Examination and Results": ["Her temperature is 98.6\u00b0F (37.0\u00b0C), blood pressure is 138/74 mmHg, pulse is 80/min, and respirations are 13/min.", "Her BMI is 32.4 kg/m^2.", "A pelvic exam reveals a non-tender, 12-week-size uterus with an irregular contour.", "A transvaginal ultrasound is performed and demonstrates two intramural leiomyomas."]}
{"Patient Personal Background": ["The patient lives alone and was found unresponsive by his son.", "Generally, the patient manages his own finances, medications, and works part-time.", "He has a past medical history of hypothyroidism, depression, and diabetes."], "Patient Symptoms": ["He has not been responding to phone calls for the past 3 days.", "The patient is unable to offer a history.", "The patient is cold to the touch and moves all extremities to painful stimuli.", "His pupils are reactive and sluggish, and he does not follow commands."], "Examination and Results": ["His temperature is 88.0\u00b0F (31.1\u00b0C), blood pressure is 92/62 mmHg, pulse is 35/min, respirations are 9/min, and oxygen saturation is 92% on room air.", "There are no signs of trauma or skin infections.", "An ECG is performed as seen in Figure A."], "Treatment": ["The patient is started on IV fluids and hydrocortisone, is externally warmed, and is started on a norepinephrine drip."]}
{"Patient Personal Background": ["The patient has a medical history of asthma and seasonal allergies."], "Patient Symptoms": ["He is concerned about a rash that does not seem to be improving."], "Examination and Results": ["His temperature is 98.6\u00b0F (37.0\u00b0C), blood pressure is 137/98 mmHg, pulse is 90/min, respirations are 14/min, and oxygen saturation is 98% on room air.", "Physical exam reveals the finding in Figure A."], "Others": ["He was recently exposed to his grandfather who has vesicular lesions on his skin and is being treated.", "He has a family history of skin cancer, colon cancer, and ovarian cancer."]}
{"Patient Personal Background": ["He was born at 39 weeks gestation to a 27-year-old primigravid mother via cesarean section for cervical insufficiency.", "The pregnancy was complicated by gestational diabetes and the amniotic fluid was clear."], "Patient Symptoms": ["The patient now is exhibiting increased work of breathing and is progressively more tachypneic.", "His chest radiograph can be seen in Figure A."], "Examination and Results": ["Upon delivery, the patient had strong respiratory effort and a strong cry.", "His Apgar scores at 1 and 5 minutes were 7 and 8, respectively.", "His birth weight is 3,568 g (7 lb 14 oz).", "His temperature is 99.0\u00b0F (37.2\u00b0C), blood pressure is 60/44 mmHg, pulse is 146/min, and respirations are 72/min.", "On physical exam, the patient is grunting with nasal flaring and subcostal retractions.", "Breath sounds are decreased at the bases bilaterally.", "The patient has central cyanosis."], "Others": []}
{"Patient Personal Background": ["He states that he has been working in a hot, humid attic all day and forgot his water bottle.", "The patient has a history of hypertension being managed by his primary care doctor."], "Patient Symptoms": ["He felt dizzy when standing up and then fainted and was unconscious for roughly 1 minute.", "Physical exam reveals a diaphoretic man."], "Examination and Results": ["His temperature is 98.7\u00b0F (37.1\u00b0C), blood pressure is 149/82 mmHg, pulse is 86/min, respirations are 15/min, and oxygen saturation is 99% on room air.", "He demonstrates an unremarkable cardiopulmonary exam.", "The patient walks with a steady gait and his neurologic exam is non-focal.", "An ECG is performed as seen in Figure A."], "Treatment": ["The patient is given 2 liters of oral fluids and feels back to his baseline."], "Others": ["He awoke at his neurologic baseline afterwards."]}
{"Patient Personal Background": ["He has a history of type II diabetes mellitus and hypertension.", "He takes metformin, insulin, and lisinopril."], "Patient Symptoms": ["The pain is worse at night.", "He has associated fever and chills.", "This morning, he awoke with purulent, foul-smelling discharge on his pillow."], "Examination and Results": ["His temperature is 102.2\u00b0F (39.0\u00b0C), blood pressure is 130/87 mmHg, pulse is 110/min, and respirations are 16/min.", "The patient is toxic in appearance and in mild distress due to pain.", "Examination of the external ear reveals findings shown in Figure A. Granulation tissue and purulent drainage are noted in the external auditory canal."]}
{"Patient Personal Background": ["His medical history is significant for hypertension, hyperlipidemia, coronary artery disease, and a prior transient ischemic attack.", "His medications include atorvastatin and lisinopril."], "Patient Symptoms": ["The patient lost control of his skis and collided with a tree.", "He lost consciousness for about 30 seconds.", "When he woke up, he was mildly confused but able to ski down the rest of the mountain.", "During the ride, he became gradually more somnolent."], "Examination and Results": ["The paramedics report that at the scene the patient had a Glasgow Coma Score (GCS) of 15.", "In the emergency department, his temperature is 97.8\u00b0F (36.6\u00b0C), blood pressure is 141/84 mmHg, pulse is 71/min, and respirations are 16/min.", "He is difficult to arouse with a GCS of 7.", "A head CT is performed and can be seen in Figure A."], "Treatment": ["The patient initially denied medical treatment but his wife convinced him to be taken by ambulance to the emergency department for evaluation."]}
{"Patient Personal Background": ["He was born at 37 weeks of gestation to a 38-year-old G3P3 woman.", "The pregnancy was uncomplicated and the patient\u2019s mother refused all prenatal testing.", "The patient\u2019s 2 older siblings are both healthy."], "Patient Symptoms": ["The vomitus was described as \u201cbright green\u201d without any traces of blood.", "The patient has urinated several times since he was born but has not passed any stool.", "His abdomen is non-tender, firm, and distended."], "Examination and Results": ["His temperature is 98.6\u00b0F (37\u00b0C), blood pressure is 67/43 mmHg, pulse is 135/min, and respirations are 34/min.", "On physical exam, the patient has upslanting palpebral fissures, epicanthal folds, and a single transverse palmar crease.", "Bowel sounds are hypoactive.", "Digital rectal exam evacuates a small amount of stool and flatulence."], "Treatment": ["A nasogastric tube is placed to decompress the stomach."], "Others": ["The patient\u2019s abdominal radiograph can be seen in Figure A."]}
{"Patient Personal Background": ["The patient\u2019s older sister had her first period at age 14.", "The mother had her first period at age 13.", "The patient reports she is doing well in school and is on the varsity basketball team.", "Her medical history is significant for asthma and atopic dermatitis.", "Her medications include albuterol and topical triamcinolone."], "Examination and Results": ["Her temperature is 98\u00b0F (36.7\u00b0C), blood pressure is 111/72 mmHg, pulse is 65/min, and respirations are 14/min with an oxygen saturation of 99% on room air.", "Her body mass index (BMI) is 19 kg/m^2.", "Physical exam shows absent breast development and external genitalia at Tanner stage 1.", "Serum follicle-stimulating hormone (FSH) level is measured to be 38 mIU/mL."], "Treatment": ["Her medications include albuterol and topical triamcinolone."]}
{"Patient Personal Background": ["The patient has had 2 uncomplicated spontaneous vaginal deliveries at full term with her last child born 6 years ago.", "She has a history of generalized anxiety disorder, atopic dermatitis, and she is currently on escitalopram."], "Patient Symptoms": ["She has felt nauseous the last several mornings and has been tired for a few weeks.", "She is concerned about the risk of Down syndrome in this fetus, as her sister gave birth to an affected child at age 43."], "Examination and Results": ["Her temperature is 98.6\u00b0F (37.0\u00b0C), pulse is 70/min, blood pressure is 121/67 mmHg, and respirations are 13/min.", "The patient appears anxious, but overall comfortable, and cardiopulmonary and abdominal exams are unremarkable.", "Pelvic exam reveals normal external genitalia, a closed and soft cervix, a 10-week-sized uterus, and no adnexal masses."]}
{"Patient Personal Background": ["The child was born at 38 weeks of gestation to a 28-year-old G3P3 mother.", "The pregnancy was complicated by preeclampsia in the mother which was well-controlled throughout the pregnancy."], "Patient Symptoms": ["The mother went into spontaneous labor but the delivery was complicated by a prolonged 2nd stage of labor.", "On physical exam, she appears to be in mild distress and has a 4x5 cm ecchymotic area of swelling over the bilateral parietal bones."], "Examination and Results": ["Her temperature is 98.6\u00b0F (37\u00b0C), blood pressure is 67/43 mmHg, pulse is 135/min, and respirations are 34/min.", "Serial assessments of the child\u2019s head circumference over the next 12 hours show no change in the size of the swelling."], "Treatment": ["A vacuum-assisted vaginal delivery was eventually performed."], "Others": ["The child\u2019s Apgar scores were 8 and 9 at 1 and 5 minutes, respectively."]}
{"Treatment": ["At a teaching hospital with residents, the time to tissue plasminogen activator administration is roughly 2 hours."], "Others": ["This has led to many adverse outcomes and increased morbidity at the teaching hospital."]}
{"Patient Personal Background": ["He has a past medical history of diabetes, obesity, and hypertension.", "He had his Achilles tendon repaired 4 weeks ago and he has been less mobile."], "Patient Symptoms": ["He recently had a cold that kept him home from work for the past week.", "Physical exam is notable for dyspnea provoked by walking short distances."], "Examination and Results": ["His temperature is 99.2\u00b0F (37.3\u00b0C), blood pressure is 150/85 mmHg, pulse is 82/min, respirations are 16/min, and oxygen saturation is 100% on room air.", "Jugular venous distension is noted on exam.", "The patient\u2019s blood pressure is 130/70 mmHg during inspiration.", "A bedside echocardiogram demonstrates impaired diastolic filling with normal ventricular contractility.", "An ECG is performed as seen in Figure A."]}
{"Patient Personal Background": ["The neonate was delivered at 39 weeks gestation via an uncomplicated vaginal delivery and was discharged home after 2 days.", "The prenatal course was complicated by chlamydia in the mother during the first trimester, for which she and the partner were both treated with a confirmatory test of cure.", "The biological father is no longer involved in the patient's life, but her mother\u2019s boyfriend has been caring for the baby whenever the mother rests.", "The neonate\u2019s temperature is 98.5\u00b0F (36.9\u00b0C), blood pressure is 56/35 mmHg, pulse is 138/min, and respirations are 51/min."], "Patient Symptoms": ["Examination of the genitals reveals no vulvar irritation or skin changes but there is scant pink mucoid discharge at the introitus."], "Examination and Results": ["Her daughter has been feeding and voiding well.", "She appears comfortable, and cardiopulmonary and abdominal exams are unremarkable.", "There are no bruises or marks on her skin."]}
{"Patient Personal Background": ["He was driving under the influence of alcohol when he sustained a crash against a pole.", "His medical history is significant for hypertension but he does not take any medications."], "Patient Symptoms": ["His Glasgow coma score (GCS) on presentation is 6.", "One week later, the patient\u2019s GCS score is now 3."], "Examination and Results": ["His temperature is 98.6\u00b0F (37.0\u00b0C), blood pressure is 110/80 mmHg, pulse is 60/min, and respirations are 12/min on a ventilator.", "Initial urine toxicology is negative.", "Laboratory studies do not show significant electrolyte, acid-base, or endocrine disturbances."], "Treatment": ["The patient is admitted to the intensive care unit and appropriate care is initiated.", "Sedative and paralytic agents are withdrawn."]}
{"Patient Personal Background": ["The patient has a past medical history of atrial fibrillation and is currently taking metoprolol and warfarin."], "Patient Symptoms": ["He has never had epistaxis before and has been unable to control it with pressure, head elevation, and ice.", "There is not a clear, single bleeding vessel."], "Examination and Results": ["His temperature is 98.5\u00b0F (36.9\u00b0C), blood pressure is 123/81 mmHg, pulse is 90/min, respirations are 13/min, and oxygen saturation is 97% on room air.", "Physical exam reveals a comfortable man in no distress.", "Inspection reveals active bleeding in the anterior nares."]}
{"Patient Personal Background": ["His past medical history is notable for a myocardial infarction 7 years ago, COPD, heart failure with a left ventricular ejection fraction of 22%, obesity, diabetes, and peripheral vascular disease."], "Patient Symptoms": ["He typically has poor exercise tolerance and is only able to walk from his house to his mailbox before becoming dyspneic.", "He now has shortness of breath even at rest."], "Examination and Results": ["His temperature is 97.7\u00b0F (36.5\u00b0C), blood pressure is 124/82 mmHg, pulse is 140/min, respirations are 32/min, and oxygen saturation is 78% on room air.", "Physical exam reveals an uncomfortable man with increased work of breathing.", "He demonstrates bilateral crackles and wheezing on pulmonary exam."], "Treatment": ["The patient is started on BiPAP, and his oxygen saturation improves to 94%."], "Others": ["He had a cold recently but has no new medical problems.", "An ECG is performed, as seen in Figure A, and a chest radiograph is performed, as seen in Figure B."]}
{"Patient Personal Background": ["His only medical problem is hypertension for which he takes amlodipine.", "The patient is a non-smoker, uses alcohol infrequently, and has never used illicit drugs."], "Patient Symptoms": ["The pain started 6 hours ago when he was gardening and carrying a heavy bag.", "The pain is rated as 10/10 in severity and radiates down the posterior aspect of the right thigh.", "He reports no fevers or chills."], "Examination and Results": ["His temperature is 99.6\u00b0F (37.6\u00b0C), blood pressure is 140/70 mmHg, pulse is 90/min, and respirations are 20/min.", "Physical examination reveals 3/5 strength to hip extension, knee flexion and extension, and plantar flexion bilaterally.", "Sensation to pinprick is diminished over the posterolateral legs and lateral aspects of both feet.", "Ankle and knee reflexes are absent bilaterally.", "The patient\u2019s underwear is wet and a bladder scan reveals 800 mL of urine."]}
{"Patient Personal Background": ["He recently retired from working the day shift at a cemetery.", "The patient has a medical history of irritable bowel syndrome which is managed with fiber supplements."], "Patient Symptoms": ["When the patient retired, his goal was to finally be able to go out with his wife; however, he finds that he is unable to stay awake past 6 pm in the evening.", "His wife is disappointed that they cannot do any activities in the evening together.", "The patient has tried drinking caffeine but finds that it does not help."], "Examination and Results": ["The patient\u2019s wife claims that the patient seems to sleep peacefully, and the patient states he feels rested when he awakes.", "His temperature is 98.6\u00b0F (37\u00b0C), blood pressure is 125/83 mmHg, pulse is 87/min, and respirations are 11/min.", "The patient\u2019s neurological exam is within normal limits."]}
{"Patient Personal Background": ["She is at 12 weeks gestational age and has not received prior prenatal care.", "She has no known medical problems and takes only a prenatal multivitamin.", "She has unprotected sexual intercourse with 3 male partners."], "Patient Symptoms": ["She has mild morning sickness but no other symptoms."], "Examination and Results": ["Her temperature is 98.6\u00b0F (37.0\u00b0C), blood pressure is 118/70 mmHg, pulse is 80/min, and respirations are 18/min.", "Physical exam reveals a well-appearing woman in no acute distress.", "There are no lesions appreciated on skin exam.", "Cardiopulmonary exam is unremarkable.", "An antibody test for human immunodeficiency virus (HIV)-1/2 is positive."], "Treatment": ["The patient is started on an appropriate treatment regimen."]}
{"Patient Personal Background": ["Her medical history is significant for type 2 diabetes mellitus and hypertension for which she takes metformin and losartan."], "Patient Symptoms": ["She has been having worsening headaches and intermittent nausea over the past 5 months.", "The headaches are constant and dull, and they typically worsen when she sneezes or laughs.", "Recently, she has become increasingly nauseous and has vomited twice in the past 10 days."], "Examination and Results": ["Her temperature is 98.6\u00b0F (37.0\u00b0C), blood pressure is 115/70 mmHg, pulse is 70/min, and respirations are 12/min.", "She is noted to have papilledema on fundoscopy, but physical exam is otherwise normal.", "Her CT scan findings are presented in Figure A."]}
{"Patient Personal Background": ["The patient works on a farm and does not see a doctor often.", "He has a history of hypertension but does not take medications routinely.", "He smokes cigarettes occasionally."], "Patient Symptoms": ["He has not had any chest pain, dyspnea, or weakness during this time frame and currently feels at his baseline."], "Examination and Results": ["His temperature is 98.1\u00b0F (36.7\u00b0C), blood pressure is 152/93 mmHg, pulse is 86/min, respirations are 15/min, and oxygen saturation is 98% on room air.", "Physical exam is unremarkable and the patient walks with a stable gait and no focal weakness.", "An ECG is performed as seen in Figure A.", "Laboratory studies are ordered as seen below."]}
{"Patient Personal Background": ["Her home medications include levothyroxine, oral contraceptive pills, and topical trans-retinoin.", "She has 2 glasses of wine with dinner several nights a week and has never smoked.", "She works as a receptionist at a marketing company."], "Patient Symptoms": ["Every few weeks she has an episode of a right-sided, throbbing headache.", "The episodes began several years ago and are accompanied by nausea and bright spots in her vision.", "The headache usually subsides if she lies still in a dark, quiet room for several hours."], "Examination and Results": ["Her temperature is 98.6\u00b0F (37\u00b0C), blood pressure is 125/81 mmHg, pulse is 64/min, and respirations are 11/min.", "On physical exam, the patient has no focal neurologic deficits.", "A CT of the head is performed and shows no acute abnormalities."], "Others": ["The patient denies any weakness, numbness, or tingling during these episodes."]}
{"Patient Personal Background": ["The patient is otherwise healthy and does not take any medications."], "Patient Symptoms": ["He states his pain is 10/10.", "He is requesting medications and is crying out in pain."], "Examination and Results": ["His temperature is 98.7\u00b0F (37.1\u00b0C), blood pressure is 149/85 mmHg, pulse is 103/min, respirations are 15/min, and oxygen saturation is 99% on room air.", "Physical exam reveals swelling over his right leg and knee.", "The patient cries out in pain with passive motion of the foot at the ankle.", "A radiograph is performed as seen in Figure A."]}
{"Patient Personal Background": ["She was born at 36 weeks gestation to a 37-year-old G2P2 mother.", "The pregnancy was complicated by gestational diabetes, and all prenatal testing was unremarkable."], "Patient Symptoms": ["She was feeding well until this morning when she had several episodes of vomiting.", "The parents describe the vomitus as \u201cbright green\u201d and the patient has shown little interest in feeding since then."], "Examination and Results": ["The patient has not yet regained her birth weight and is in the 46th percentile for height and the 36th percentile for weight.", "The patient\u2019s temperature is 99.2\u00b0F (37.3\u00b0C), blood pressure is 68/46 mmHg, pulse is 132/min, and respirations are 32/min.", "On physical exam, the patient is in mild distress.", "Her abdomen is distended and firm without guarding.", "Bowel sounds are hypoactive."], "Others": ["She has no dysmorphic features.", "The patient\u2019s abdominal radiograph can be seen in Figure A and the patient\u2019s upper gastrointestinal series can be seen in Figure B."]}
{"Patient Personal Background": ["The patient is otherwise healthy and takes no medications."], "Patient Symptoms": ["He states that he has been a bit more fatigued lately but believes it is secondary to poor sleep at his new house."], "Examination and Results": ["His temperature is 98.0\u00b0F (36.7\u00b0C), blood pressure is 141/90 mmHg, pulse is 82/min, respirations are 16/min, and oxygen saturation is 98% on room air.", "Physical exam is notable only for minor pallor but is otherwise unremarkable.", "Basic laboratory studies are ordered as seen below."]}
{"Patient Personal Background": ["The patient has a medical history of polycystic ovary syndrome."], "Patient Symptoms": ["She now needs to shave her face every day or else thick hair appears.", "She also has worsening acne that started several weeks ago."], "Examination and Results": ["Her pregnancy thus far has been complicated by gestational diabetes, which is managed by diet and exercise.", "She has a male fetus based on her 20 week anatomy ultrasound.", "The patient\u2019s temperature is 98.5\u00b0F (36.9\u00b0C), blood pressure is 121/76 mmHg, pulse is 70/min, and respirations are 13/min.", "The cardiopulmonary exam is normal, and the patient\u2019s abdomen has a fundal height of 31 cm.", "A pelvic exam reveals an unremarkable closed cervix and a right-sided adnexal mass without tenderness."], "Others": ["Transvaginal ultrasound is performed and shown in Figure A."]}
{"Patient Personal Background": ["The patient has a medical history of blepharitis treated with eye cleansing and squamous cell carcinoma of the skin treated with Mohs surgery."], "Patient Symptoms": ["He has felt a mass in his eye that has persisted for the past month."], "Examination and Results": ["His temperature is 99.5\u00b0F (37.5\u00b0C), blood pressure is 157/102 mmHg, pulse is 90/min, respirations are 17/min, and oxygen saturation is 98% on room air.", "Physical exam is notable for a firm and rubbery nodule palpable inside the patient's left eyelid.", "Physical exam does not elicit any pain."]}
{"Patient Personal Background": ["She has a history of chlamydial infection in her 20's and has had 3 urinary tract infections over the past year.", "She has no other significant medical history and does not take any medications."], "Patient Symptoms": ["She states that she has had involuntary loss of urine about 4 times each day over the past 3 months.", "It is not associated with coughing or sneezing.", "The patient has not been sexually active with her husband due to pain with intercourse."], "Examination and Results": ["Her temperature is 98.6\u00b0F (37.0\u00b0C), blood pressure is 115/70 mmHg, pulse is 70/min, and respirations are 12/min.", "On physical examination, the vulvar skin is pale and atrophic with reduced elasticity and multiple areas of petechiae.", "The vaginal mucosa also has a loss of rugae and several areas of friable irritation.", "There is minimal clear vaginal discharge.", "Urinalysis is normal and fecal occult blood test is negative.", "Pelvic ultrasound reveals a small, retroverted uterus."], "Others": ["Menopause occurred at age 52."]}
{"Patient Personal Background": ["He recently started playing for his high school basketball team and generally eats healthy food.", "He has no significant medical history and takes no medications."], "Patient Symptoms": ["He feels disappointed because his voice has not changed.", "He is concerned that he is not as tall as his classmates."], "Examination and Results": ["His temperature is 98.6\u00b0F (37.0\u00b0C), blood pressure is 115/70 mmHg, pulse is 70/min, and respirations are 12/min.", "On physical examination, the patient does not have facial hair or acne.", "His height is 60 inches and his arm span is 50 inches.", "His visual fields are full and he has no cranial nerve abnormalities.", "His strength is 5/5 in bilateral upper and lower extremities.", "Chest palpation and abdominal examination are unremarkable.", "He has no pubic hair and his testicles are symmetric with a volume of 3 mL."]}
{"Patient Personal Background": ["The patient has a medical history of a suicide attempt in college, constipation, anxiety, depression, and a sunburn associated with surfing which was treated with aloe vera gel."], "Patient Symptoms": ["The pain has lasted for several months but seems to have worsened recently.", "Any activity such as opening jars, walking, or brushing her teeth is painful."], "Examination and Results": ["Her temperature is 99.5\u00b0F (37.5\u00b0C), blood pressure is 137/78 mmHg, pulse is 92/min, respirations are 14/min, and oxygen saturation is 98% on room air.", "Laboratory values are obtained and shown below."]}
{"Patient Personal Background": ["Her last menstrual period was 8 weeks ago.", "The patient has a medical history of type 1 diabetes mellitus since childhood and her home medications include insulin.", "The patient\u2019s brother is autistic but her family history is otherwise unremarkable."], "Examination and Results": ["Her hemoglobin A1c 2 weeks ago was 13.7%.", "At that time, she was also found to have microalbuminuria on routine urinalysis.", "Her temperature is 98.6\u00b0F (37.0\u00b0C), blood pressure is 124/81 mmHg, pulse is 75/min, and respirations are 14/min.", "A physical exam is unremarkable."], "Treatment": ["Her primary care provider prescribed lisinopril but the patient has not yet started taking it."]}
{"Patient Personal Background": ["As the infant is resting, vital signs are taken."], "Patient Symptoms": ["His mother notices that his face, chest, and extremities turn dusky blue during nursing.", "She also notes that he seems to be snoring loudly and breathing very quickly.", "When she removes him from her breast, he begins to cry and his color improves."], "Examination and Results": ["The delivery is uncomplicated and the neonate has Apgar scores of 9 and 9 at 1 and 5 minutes respectively.", "His temperature is 98.2\u00b0F (36.7\u00b0C), pulse is 130/min, respirations are 45/min, and oxygen saturation is 97% on room air.", "A physical exam demonstrates well-perfused skin but is notable for the facial features shown in Figure A."], "Others": ["After 15 minutes, he attempts to nurse for the 1st time.", "The neonate\u2019s prenatal course was unremarkable, and his mother has a medical history of asthma with occasional albuterol inhaler use."]}
{"Patient Personal Background": ["Her past medical history is unremarkable and she is not currently taking any medications.", "She denies drinking alcohol, smoking cigarettes, or using recreational drugs."], "Patient Symptoms": ["She has generally been feeling well, but notes feeling intermittent palpitations over the past few months.", "She attributes her palpitations to recently drinking more caffeine, but would like to obtain an electrocardiogram since her symptoms are worrisome and affecting her ability to concentrate on her career as a fitness instructor."], "Examination and Results": ["Her temperature is 36.9\u00b0C (98.4\u00b0F), blood pressure is 116/76 mmHg, pulse is 55/min, respirations are 12/min, and oxygen saturation is 98% on room air.", "Her electrocardiogram is shown in Figure A."]}
{"Patient Personal Background": ["The patient\u2019s medical history is significant for hypertension, alcohol use disorder, and chronic obstructive pulmonary disease.", "His medications include aspirin, amlodipine, and fluticasone-salmeterol.", "He drinks a glass of red wine every night with dinner and smokes a cigar on the weekends."], "Patient Symptoms": ["He is unsure when his symptoms started, but they have been affecting him for \u201ca while.\u201d It began as episodes of \u201cunsteadiness\u201d that progressed to a feeling of \u201cspinning.\u201d He cannot tell if his symptoms change with position but reports that if he does not lie down he will become nauseous.", "He also has worsening hearing loss worse on his right side."], "Examination and Results": ["His temperature is 98.6\u00b0F (37\u00b0C), blood pressure is 135/91 mmHg, pulse is 72/min, and respirations are 12/min.", "Examination shows delayed horizontal nystagmus."]}
{"Patient Personal Background": ["His medical history is significant for chronic renal failure for which he received a renal transplant 5 years prior, as well as multiple surgeries for skin cancer.", "His current medications include aspirin, atorvastatin, prednisone, tacrolimus, and mycophenolate mofetil."], "Patient Symptoms": ["The lesion has grown rapidly over the previous 2 weeks.", "He endorses trauma to the area when he accidentally scraped his hand against a window and notes that there was some bleeding."], "Examination and Results": ["His temperature is 98.6\u00b0F (37\u00b0C), blood pressure is 136/91 mmHg, pulse is 82/min, and respirations are 11/min.", "Physical exam is notable for a 2 x 2.5 cm nodular lesion of the dorsal hand as seen in Figure A."]}
{"Patient Personal Background": ["He enjoys spending time with his spouse, playing cards with his friends, and taking daily walks around his neighborhood."], "Patient Symptoms": ["His wife has noticed that he has a worsening ability to organize, plan, and exhibit impulse control over the last month.", "The patient states that he is able to complete his activities of daily living without assistance, but has some weakness of his left upper and lower extremities that began 3 months prior.", "He needs reminders from his wife about daily tasks to complete."], "Examination and Results": ["His temperature is 98.2\u00b0F (36.8\u00b0C), blood pressure is 149/87 mmHg, pulse is 87/min, and respirations are 12/min.", "Physical exam reveals an elderly man who is oriented to person, place, and time.", "He has 4/5 left-sided weakness of the upper and lower extremities and associated pronator drift of the left upper extremity.", "A mini-mental status exam reveals he is able to remember 2 out of 3 words after 4 minutes.", "He is able to appropriately draw a clock.", "A magnetic resonance imaging study of the brain is shown in Figure A."]}
{"Patient Personal Background": ["He has a medical history of anxiety, diabetes, a fracture of his foot sustained when he tripped, and a recent cold that caused him to miss work for 1 week.", "His current medications include metformin, insulin, buspirone, vitamin D, calcium, and sodium docusate."], "Patient Symptoms": ["In general, he has been in good health; however, he recently has experienced weight loss, abdominal pain, and general fatigue."], "Examination and Results": ["His temperature is 99.5\u00b0F (37.5\u00b0C), blood pressure is 150/100 mmHg, pulse is 90/min, respirations are 18/min, and oxygen saturation is 98% on room air.", "Physical exam reveals a calm gentleman.", "A mild systolic murmur is heard in the left upper sternal region.", "The rest of the physical exam is within normal limits."], "Others": ["Laboratory values are ordered as seen below."]}
{"Patient Personal Background": ["He has a history of hypertension, major depressive disorder, Raynaud disease, and chronic obstructive pulmonary disease (COPD) on 2 liters of oxygen at home.", "Current medications include lisinopril, inhaled umeclidinium-vilanterol, and as-needed albuterol.", "He drinks 4 beers a day and has smoked 1 pack of cigarettes a day for 40 years."], "Patient Symptoms": ["He began feeling the palpitations 3 days ago while eating dinner."], "Examination and Results": ["He denies chest pain, shortness of breath, or loss of consciousness.", "His temperature is 98.9\u00b0 F (37.2\u00b0 C), blood pressure is 130/85 mmHg, pulse is 125/min, and respirations are 16/min.", "Physical exam is notable for an irregular pulse and scattered end-expiratory wheezes.", "An echocardiogram performed 1 month ago showed a left ventricular ejection fraction of 60-65%.", "The patient requires 3 liters of oxygen today.", "An ECG is performed as seen in Figure A."]}
{"Patient Personal Background": ["He has a past medical history of diabetes and atrial fibrillation and is currently taking warfarin.", "His other medications are not known."], "Patient Symptoms": ["He was last seen normal 1 hour ago.", "His wife noticed that he was confused, slurring his speech, and had notable weakness that caused him to drop his cup of coffee.", "The patient is confused and not able to answer any questions.", "Facial drooping of the left lower face is noted, and the patient cannot follow any commands.", "The patient is not able to follow any commands for further neurologic evaluation but does not appear to be moving his right upper extremity."], "Examination and Results": ["His temperature is 98.0\u00b0F (36.7\u00b0C), blood pressure is 150/90 mmHg, pulse is 115/min, and respirations are 17/min."]}
{"Patient Personal Background": ["The patient is a long-time runner but states that the pain has been getting worse recently.", "The patient has a medical history of surgical repair of his Achilles tendon, ACL, and medial meniscus.", "The patient lives with his wife and they both practice a vegan lifestyle."], "Patient Symptoms": ["When running and at rest he has a burning and aching pain along the bottom of his foot that sometimes turns to numbness.", "Taking time off from training does not improve his symptoms.", "On physical exam, the patient states that he is currently not experiencing any pain in his foot but rather is experiencing numbness/tingling along the plantar surface of his foot."], "Examination and Results": ["His temperature is 98.6\u00b0F (37\u00b0C), blood pressure is 114/72 mmHg, pulse is 81/min, and respirations are 12/min.", "Strength is 5/5 and reflexes are 2+ in the lower extremities."]}
{"Patient Symptoms": ["She has not shaved in about a week.", "She has also gained about 10 pounds in the last several months, and her periods have become irregular over the last year.", "Her last menstrual period was 3 months ago."], "Examination and Results": ["Her temperature is 98.6\u00b0F (37.0\u00b0C), pulse is 72/min, blood pressure is 136/86 mmHg, and respirations are 13/min.", "Her BMI is 26 kg/m^2.", "Her skin exam reveals hirsutism along the jawline and acanthosis nigricans in the axillary folds.", "Cardiopulmonary and abdominal exams are unremarkable.", "A pelvic exam reveals normal external genitalia, a mobile and non-tender 6-week-sized uterus, and no adnexal masses or tenderness.", "Transvaginal ultrasound is performed and shown in Figure A."]}
{"Patient Personal Background": ["The patient has no significant medical history, and takes no other medication."], "Examination and Results": ["His temperature is 98.6\u00b0F (37.0\u00b0C), pulse is 130, blood pressure is 85/50, and respirations are 22.", "Primary and secondary survey and FAST exam are unremarkable for other associated injuries."], "Others": ["He was not stabbed or otherwise injured elsewhere.", "Pressure is removed from the wound, and pulsatile bleeding from the wound is noted."]}
{"Patient Personal Background": ["His medical history is significant for type 2 diabetes mellitus, hypertension, and hyperlipidemia.", "His current medications include metformin, atorvastatin, and lisinopril."], "Patient Symptoms": ["He was having dinner at home with his wife when he suddenly noticed he had difficulty eating and speaking.", "He also noticed a new-onset weakness on his left side."], "Examination and Results": ["His temperature is 98.6\u00b0F (37\u00b0C), blood pressure is 130/80 mmHg, pulse is 70/min, and respirations are 15/min.", "On examination, strength is 5/5 in the right upper and lower extremities and 3/5 in the left upper and lower extremities.", "On cranial nerve examination, his tongue deviates to the right side.", "There is also decreased sensation to light touch and vibration on the left side of his body."]}
{"Patient Personal Background": ["He has no significant medical history and takes no medications."], "Patient Symptoms": ["He first felt the pain while lifting boxes at work but thought that he had just strained a muscle.", "The pain appears to be worse in the mornings and after rest.", "Exercise and physical activity appear to temporarily make the pain better."], "Examination and Results": ["His temperature is 98.6\u00b0F (37.0\u00b0C), blood pressure is 115/70 mmHg, pulse is 70/min, and respirations are 12/min.", "On physical exam, he is found to have limited flexion and extension of his spine as well as tenderness to palpation over the insertion of his patellar tendons bilaterally."], "Treatment": ["He has taken acetaminophen and ibuprofen for the pain."]}
{"Patient Personal Background": ["He was born at 39 weeks gestation to a 38-year-old G3P3 mother.", "The pregnancy was uncomplicated, and the patient\u2019s mother received routine prenatal care.", "She declined prenatal testing.", "One of the patient\u2019s older siblings has Down syndrome."], "Patient Symptoms": ["The patient is otherwise doing well and feeding every 2 hours.", "The patient has had 2 episodes of vomiting that were described as green in color."], "Examination and Results": ["He is urinating 8-10 times per day.", "The patient's temperature is 98.2\u00b0F (36.8\u00b0C), blood pressure is 48/32 mmHg, pulse is 164/min, and respirations are 48/min.", "On physical exam, the patient is in no acute distress.", "His abdomen is firm, non-tender, and distended with hypoactive bowel sounds.", "A digital rectal exam fails to relieve the obstruction.", "An abdominal radiograph is performed and the result can be seen in Figure A."]}
{"Patient Personal Background": ["He has a medical history of diabetes and hypertension for which he is on metformin and losartan."], "Patient Symptoms": ["He states that the pain is dull in quality, started 30 minutes ago, has been gradually worsening, and is worse with exertion.", "He also endorses some shortness of breath.", "He also believes the pain is worse when leaning back and improved when leaning forward.", "His wife noticed he fainted after the pain started but regained consciousness shortly after."], "Examination and Results": ["His temperature is 99.2\u00b0F (37.3\u00b0C), blood pressure is 130/87 mmHg, pulse is 99/min, respirations are 22/min, and oxygen saturation is 100% on room air.", "Physical exam reveals an overweight man.", "A normal S1 and S2 are auscultated with clear breath sounds.", "An ECG is performed as seen in Figure A."]}
{"Patient Personal Background": ["He has no significant medical history and takes no medications.", "He exercises twice a day, often with heavy weightlifting, and eats a high-protein diet.", "He reports occasional alcohol use and remote marijuana use.", "He is sexually active with his wife and has no history of sexually transmitted infections."], "Examination and Results": ["His temperature is 99.5\u00b0F (37.5\u00b0C), blood pressure is 148/90 mmHg, pulse is 84/min, and respirations are 15/min.", "Physical exam reveals small testes and a receding hairline.", "He also has palpable tissue underneath his nipples bilaterally.", "His muscle tone is normal in his upper and lower extremities bilaterally."]}
{"Patient Personal Background": ["Pregnancy and delivery were uncomplicated.", "The family has a cat at home."], "Patient Symptoms": ["Then 1 day ago, the patient developed eyelid edema and eye redness.", "This morning, the newborn developed a thick yellow-white eye discharge."], "Examination and Results": ["The patient\u2019s rectal temperature is 99\u00b0F (37.2\u00b0C), blood pressure is 80/50 mmHg, pulse is 134/min, and respirations are 34/min with an oxygen saturation of 98% O2 on room air.", "The patient's physical exam is otherwise unrevealing."], "Others": ["The newborn had been sleeping regularly and feeding well.", "The mother denies that anyone in the house smokes.", "Figure A shows a photograph of one of the patient's eyes."]}
{"Patient Personal Background": ["He states this weekend he had a barbecue.", "The patient has a medical history of obesity, diabetes, depression, anxiety, diverticulosis, constipation, and a surgical repair of his anterior cruciate ligament.", "His current medications include metformin, insulin, lisinopril, fluoxetine, and sodium docusate."], "Patient Symptoms": ["When he was lifting a heavy object, he suddenly felt pain in his lower back.", "He describes the pain as in his buttocks but states that at times it travels down his leg.", "He states that it feels electrical and burning in nature."], "Examination and Results": ["His temperature is 98.6\u00b0F (37\u00b0C), blood pressure is 131/82 mmHg, pulse is 82/min, and respirations are 14/min.", "On physical exam, he is found to have an intact motor and sensory function in his lower extremities bilaterally.", "No clonus or Babinski sign is appreciated.", "An exam of the cranial nerves is intact bilaterally."]}
{"Patient Personal Background": ["He is up to date on his vaccinations."], "Patient Symptoms": ["Over the past several weeks, the child has been more fatigued and his parents state that \u201che always seems to be sick.\u201d They state that sometimes he complains about his bones hurting and they note that he is less playful."], "Examination and Results": ["His temperature is 102\u00b0F (38.9\u00b0C), blood pressure is 92/60 mmHg, pulse is 115/min, respirations are 23/min, and oxygen saturation is 99% on room air.", "Physical exam is notable for diffuse non-tender lymphadenopathy.", "Abdominal exam reveals hepatosplenomegaly."]}
{"Patient Personal Background": ["He is back to playing basketball for his school team without any difficulty."], "Patient Symptoms": ["The patient denies any abdominal pain, fevers, chills, nausea, vomiting, diarrhea, or constipation.", "His urine appears more amber than usual but he suspects dehydration."], "Examination and Results": ["His temperature is 98.6\u00b0F (37\u00b0C), blood pressure is 110/70 mmHg, pulse is 76/min, and respirations are 15/min.", "His physical exam is unremarkable.", "The laparoscopic incision sites are all clean without erythema.", "Urine: Epithelial cells: Scant Glucose: Negative Protein: 3+ WBC: 3/hpf Bacteria: None Leukocyte esterase: Negative Nitrites: Negative The patient is told to return in 3 days for a follow-up appointment; however, his urinalysis at that time is similar."], "Others": ["He eats solids and drinks liquids without difficulty.", "The pediatrician orders a urinalysis, which is notable for the following."]}
{"Patient Personal Background": ["She returned from a recent missionary trip to South America 12 months prior where she endorsed eating a local delicacy as well as a period of fevers and eyelid swelling during her stay."], "Patient Symptoms": ["She endorses decreased exercise tolerance as well as intermittent palpitations."], "Examination and Results": ["Her temperature is 99.1\u00b0F (37.3\u00b0C), pulse is 95/min, blood pressure is 130/85 mmHg, respirations are 15/min, and oxygen saturation is 97% on room air.", "Physical exam is notable for a laterally displaced point of maximal impulse as well as a 2/6 diastolic murmur radiating to the axilla.", "A blood smear is shown in Figure A."]}
{"Patient Personal Background": ["He recently was released from prison.", "He attributes this to intravenous drug use in prison."], "Patient Symptoms": ["He has felt very fatigued and has had a cough.", "He has lost roughly 15 pounds over the past 3 weeks."], "Examination and Results": ["His temperature is 99.5\u00b0F (37.5\u00b0C), blood pressure is 127/68 mmHg, pulse is 100/min, respirations are 18/min, and oxygen saturation is 98% on room air.", "QuantiFERON gold testing is positive."], "Treatment": ["The patient is started on appropriate treatment."]}
{"Patient Personal Background": ["The patient has a medical history of a suicide attempt and alcohol abuse.", "He is not currently taking any medications.", "The patient admits to using heroin and cocaine and drinking 5-8 alcoholic drinks per day.", "His temperature is 103\u00b0F (39.4\u00b0C), blood pressure is 92/59 mmHg, pulse is 110/min, respirations are 20/min, and oxygen saturation is 96% on room air."], "Patient Symptoms": ["The patient has felt unwell for the past week and has felt subjectively febrile."], "Examination and Results": ["Cardiopulmonary exam is notable for a systolic murmur heard best along the left sternal border.", "Dermatologic exam reveals scarring in the antecubital fossa.", "IV fluids are administered and the blood pressure is subsequently 120/70 mmHg."], "Treatment": []}
{"Patient Personal Background": ["The patient has never been pregnant and previously used a copper intrauterine device (IUD) for contraception, but she had the IUD removed 1 year ago because it worsened her menorrhagia.", "She has now been using combined oral contraceptive pills (OCPs) for nearly 1 year.", "The patient reports improvement in her menorrhagia on the OCPs but denies any improvement in her pain.", "Her medical history is otherwise unremarkable."], "Patient Symptoms": ["She reports that for the last several years, she has had chronic pain that is worse just before her menstrual period.", "Over the past 2 months, she has also had worsening pain during intercourse.", "She denies dysuria, vaginal discharge, or vaginal pruritus.", "The patient reports improvement in her menorrhagia on the OCPs but denies any improvement in her pain."], "Examination and Results": ["Her temperature is 98.0\u00b0F (36.7\u00b0C), blood pressure is 124/73 mmHg, pulse is 68/min, and respirations are 12/min.", "The patient has pain with lateral displacement of the cervix on pelvic exam.", "A pelvic ultrasound shows no abnormalities, and a urine pregnancy test is negative."]}
{"Patient Personal Background": ["He has no health concerns and has not seen a physician in years.", "The patient has a medical history of depression treated with fluoxetine and lithium."], "Examination and Results": ["His temperature is 99.5\u00b0F (37.5\u00b0C), blood pressure is 122/78 mmHg, pulse is 90/min, respirations are 13/min, and oxygen saturation is 98% on room air.", "Physical exam is notable for the finding in Figure A."]}
{"Patient Personal Background": ["He has a medical history of asthma."], "Patient Symptoms": ["His symptoms started last night and have persisted.", "He occasionally has migraine headaches, but he has not had a headache like this in the past.", "He reports associated nausea, vomiting, fevers, and neck pain."], "Examination and Results": ["His temperature is 100.4\u00b0F (38.0\u00b0C), blood pressure is 110/60 mmHg, pulse is 95/min, respirations are 17/min, and oxygen saturation is 98% on room air.", "On physical exam, he appears uncomfortable.", "Neurologic exam reveals no focal deficits.", "There is pain with passive neck flexion.", "No edema or rashes are noted.", "Lungs are clear to auscultation bilaterally."], "Treatment": ["Lumbar puncture is performed and CSF results are obtained as shown below."]}
{"Patient Symptoms": ["Review of systems is notable for a 12-pound unintentional weight loss and intermittent loose stools."], "Examination and Results": ["Her temperature is 37.2\u00b0C (98.9\u00b0F), blood pressure is 100/72 mmHg, pulse is 72/min, respirations are 12/min, and oxygen saturation is 100% on room air.", "Her abdomen is soft, mildly diffusely tender to deep palpation, and non-distended.", "She is found to have the finding on colonoscopy in Figure A. Serum perinuclear antineutrophil cytoplasmic antibodies (p-ANCA) are positive."], "Others": ["She has a family history notable for a father with coronary artery disease and a mother with primary sclerosing cholangitis."]}
{"Patient Personal Background": ["She denies pain, but reports her right eye \u201cfeels funny.\u201d The patient\u2019s medical history is significant for a previous myocardial infarction, hypertension, and osteoporosis.", "Her current medications include aspirin, metoprolol, rosuvastatin, lisinopril, and alendronate."], "Patient Symptoms": ["She was in her usual state of health until waking up this morning unable to see out of her right eye.", "She denies pain, but reports her right eye \u201cfeels funny.\u201d The patient\u2019s medical history is significant for a previous myocardial infarction, hypertension, and osteoporosis."], "Examination and Results": ["Her temperature is 98\u00b0F (36.7\u00b0C), blood pressure is 145/86 mmHg, pulse is 62/min, and respirations are 12/min with an oxygen saturation of 98% on room air.", "The patient's pupils are symmetric in size and equally reactive to light with accommodation.", "A fundoscopic exam of the right eye is shown in Figure A.", "The left optic fundus is unremarkable."]}
{"Patient Symptoms": ["She has felt tired and unwilling to engage in any activities lately.", "She states that her limbs feel heavy all the time and that completing any activity takes tremendous effort.", "She no longer finds any happiness in activities that she previously enjoyed.", "She struggles to sleep and at times can't sleep for several days.", "She returns 1 week later stating that her symptoms have not improved.", "She is requesting help as her performance at work and school is suffering."], "Examination and Results": ["Her temperature is 99.5\u00b0F (37.5\u00b0C), blood pressure is 115/72 mmHg, pulse is 60/min, respirations are 13/min, and oxygen saturation is 98% on room air."], "Treatment": ["The patient is started on appropriate first-line therapy and sent home."]}
{"Patient Personal Background": ["His past medical history is notable for hypertension, type 2 diabetes mellitus, and hyperlipidemia.", "His medications include amlodipine, atorvastatin, and metformin."], "Patient Symptoms": ["For the past few months, he has pain in his chest with physical activity.", "The pain goes away after he takes a break.", "He reports no chest pain while he is resting, and the pain is not worsening."], "Examination and Results": ["His temperature is 36.5\u00b0C (97.7\u00b0F), blood pressure is 132/80 mmHg, pulse is 74/min, respirations are 14/min, and oxygen saturation is 98% on room air.", "He has a regular rate and rhythm, normal S1 and S2, and no murmurs, rubs, or gallops.", "His anterior, lateral, and posterior chest are non-tender to palpation.", "His electrocardiogram is shown in Figure A. Troponin I level is < 0.017 ng/mL."]}
{"Patient Personal Background": ["He has a medical history significant for high blood pressure, hyperlipidemia, and seasonal allergies with no prior surgical history.", "He has no history of tobacco use.", "He moved from India 7 years prior to presentation.", "He currently lives in Oregon and has not left the west coast since moving.", "His temperature is 99\u00b0F (37.2\u00b0C), blood pressure is 100/70 mmHg, pulse is 76/min, and respirations are 16/min."], "Patient Symptoms": ["He has had a chronic cough and a 20 pound unintentional weight loss over the past 6 months."], "Examination and Results": ["His physical exam is significant for hyperpigmentation of the oral mucosa and temporal muscle wasting.", "Radiography of the abdomen demonstrates bilateral adrenal calcifications."]}
{"Patient Personal Background": ["He has a medical history of obesity and anxiety and is not currently taking any medications."], "Examination and Results": ["His temperature is 104\u00b0F (40\u00b0C), blood pressure is 147/88 mmHg, pulse is 200/min, respirations are 33/min, and oxygen saturation is 99% on room air.", "Physical exam reveals dry mucous membranes, hot flushed skin, and inappropriate responses to the physician's questions."], "Others": ["Laboratory values are ordered as seen below."]}
{"Patient Personal Background": ["Since then, he has been on valproic acid but the seizure activity remains unchanged.", "He was recently enrolled in daycare because she could no longer care for him full-time."], "Patient Symptoms": ["She reports that occasionally he \u201csuddenly drops\u201d when running around the house.", "Since then, the seizure activity has increased and the daycare facility also noted concerns over his lack of response to voice commands.", "A physical exam is significant for lack of response to auditory stimulation.", "The patient is then startled when a door is closed quickly and he suddenly loses consciousness."], "Examination and Results": ["His temperature is 98.6\u00b0F (37\u00b0C), blood pressure is 105/52 mmHg, pulse is 110/min, and respirations are 25/min.", "An EEG is performed, which is unrevealing.", "An ECG is quickly performed and is shown in Figure B."], "Others": ["She says that his first seizure occurred 1 year ago.", "Family history is significant for a cousin who died suddenly at a young age.", "An ECG is shown in Figure A."]}
{"Patient Personal Background": ["His past medical history is significant for previous myocardial infarction, a 30-pack-year smoking history, gastroesophageal reflux disease, and poorly controlled hypertension.", "The patient\u2019s only home medication is omeprazole."], "Examination and Results": ["His temperature is 98.6\u00b0F (37\u00b0C), blood pressure is 140/90 mmHg, pulse is 90/min, respirations are 30/min, and oxygen saturation is 88% on room air.", "Physical exam is significant for a jugular venous pressure of 15 cm, an S3 heart sound, bibasilar crackles, and 2+ pitting edema to the knees bilaterally.", "His abdomen is soft and non-tender.", "His neurological exam is nonfocal and he walks with a steady gait."]}
{"Patient Personal Background": ["He is brought in by his home care nurse, who reports that the patient has a history of myasthenia gravis and frequent urinary tract infections.", "His temperature is 99.0\u00b0F (37.2\u00b0C), blood pressure is 128/78 mmHg, pulse is 92/min, and respirations are 28/min with an oxygen saturation of 86% O2 on room air."], "Patient Symptoms": ["The patient was in his normal state of health until 5 days ago when he developed a urinary tract infection.", "This morning, he experienced poor grip strength and progressive difficulty breathing.", "The patient has gray-blue skin, hypophonia, weak upper extremities, and normal leg strength."], "Examination and Results": ["His temperature is 99.0\u00b0F (37.2\u00b0C), blood pressure is 128/78 mmHg, pulse is 92/min, and respirations are 28/min with an oxygen saturation of 86% O2 on room air.", "The patient has gray-blue skin, hypophonia, weak upper extremities, and normal leg strength.", "An arterial blood gas is drawn with results as shown below:\n\nPO2: 55 mmHg\nPCO2: 60 mmHg\npH: 7.30\n\nThe patient is intubated."], "Treatment": ["He was receiving gentamicin infusions for his infections."]}
{"Patient Personal Background": ["Her mother is concerned that the patient is a picky eater and refuses to eat vegetables.", "She drinks milk with meals and has juice sparingly.", "She goes to sleep easily at night and usually sleeps for 11-12 hours.", "The patient has trouble falling asleep for naps but does nap for 1-2 hours a few times per week.", "She is doing well in daycare and enjoys parallel play with the other children."], "Examination and Results": ["Her mother reports that she can walk downstairs with both feet on each step.", "She has a vocabulary of 10-25 words that she uses in the form of 1 word commands.", "She is in the 42nd percentile for height and 48th percentile for weight, which is consistent with her growth curves.", "Her temperature is 98.6\u00b0F (37\u00b0C), blood pressure is 92/56 mmHg, pulse is 106/min, and respirations are 23/min.", "On physical exam, she appears well nourished.", "She can copy a line and throw a ball."]}
{"Patient Personal Background": ["He has a history of obesity, hypertension, type 2 diabetes mellitus, and depression.", "His current medications include metformin, aspirin, rosuvastatin, lisinopril, and fluoxetine.", "He has a 25-pack-year smoking history and drinks 1 glass of wine a day."], "Examination and Results": ["His temperature is 98.6\u00b0F (37.0\u00b0C), blood pressure is 115/70 mmHg, pulse is 70/min, and respirations are 12/min.", "On physical exam, he has a 1.2 x 1.7 cm ulcer on the plantar surface of his left metatarsal head."]}
{"Patient Personal Background": ["He has a history of diabetes, obesity, and hypertension but does not see a physician for his underlying conditions."], "Patient Symptoms": ["His symptoms lasted 20 minutes but by the time he arrived at the emergency department he was symptom-free.", "The patient denies any preceding symptoms."], "Examination and Results": ["His temperature is 99.2\u00b0F (37.3\u00b0C), blood pressure is 140/85 mmHg, pulse is 82/min, respirations are 16/min, and oxygen saturation is 100% on room air.", "Physical exam reveals normal vision, strength, and sensation with a stable gait.", "Finger-nose testing and tandem gait are unremarkable.", "A CT scan of the head is performed and is unremarkable."]}
{"Patient Personal Background": ["The patient was born at 29 weeks gestation to a G1P1 mother.", "Her postnatal course was complicated by a prolonged neonatal intensive care unit stay for neonatal respiratory distress syndrome (NRDS).", "Since discharge from the hospital, her mother reports that the patient has been doing well without health problems.", "She has been gaining weight appropriately."], "Examination and Results": ["Her temperature is 98.6\u00b0F (37.0\u00b0C), blood pressure is 80/50 mmHg, pulse is 120/min, and respirations are 25/min."], "Diagnosis": ["Her postnatal course was complicated by a prolonged neonatal intensive care unit stay for neonatal respiratory distress syndrome (NRDS)."], "Others": ["The patient's mother asks the pediatrician about potentially delaying the 2-month vaccine doses due to the baby's medical history.", "Which of the following is the correct vaccination plan for this infant in terms of the vaccinations below?"]}
{"Patient Personal Background": ["The patient's medical history is notable for diabetes which was managed during her pregnancy with insulin."], "Patient Symptoms": ["The patient is fatigued but states that she is doing well.", "Currently, she is complaining that her vagina hurts.", "The next morning, the patient experiences chills and a light red voluminous discharge from her vagina.", "She states that she feels pain and cramps in her abdomen."], "Examination and Results": ["Her temperature is 99.5\u00b0F (37.5\u00b0C), blood pressure is 107/68 mmHg, pulse is 97/min, respirations are 16/min, and oxygen saturation is 98% on room air."], "Others": ["Laboratory values are obtained and shown below."]}
{"Patient Personal Background": ["Her medical history includes type 2 diabetes mellitus which is well-controlled with metformin."], "Patient Symptoms": ["Initially, she attributed her mother's forgetfulness and word-finding difficulties to normal aging, but over the past few years, her mother's memory has worsened, her mood has grown more irritable, and her mother has been found wandering the neighborhood unsure of how to get home."], "Examination and Results": ["On exam, her temperature is 98.2\u00b0F (36.8\u00b0C), blood pressure is 115/82 mmHg, pulse is 73/min, respirations are 12/min, and oxygen saturation is 99% on room air.", "Cardiopulmonary exam reveals normal S1 and S2, no murmurs, and clear lungs bilaterally.", "She scores 16/30 on the Montreal Cognitive Assessment (MoCA) test."]}
{"Patient Personal Background": ["She is sexually active and uses condoms."], "Patient Symptoms": ["She states that it started 1 day ago and has not improved with hygiene products.", "She does not complain of any abdominal or pelvic pain but states she has some mild burning when urinating."], "Examination and Results": ["Her temperature is 97.6\u00b0F (36.4\u00b0C), blood pressure is 111/74 mmHg, pulse is 81/min, respirations are 12/min, and oxygen saturation is 98% on room air.", "Physical exam is notable for thick, white discharge from the cervix.", "There is no cervical motion or adnexal tenderness or masses.", "Some whitish discharge is noted from the urethra.", "A urine pregnancy test is negative."]}
{"Patient Personal Background": ["Her medical history is significant for type 2 diabetes mellitus, hypertension, and osteoporosis for which she takes metformin, enalapril, and alendronate.", "She was found to have a deep vein thrombosis of her left leg 3 months prior to presentation."], "Patient Symptoms": ["She noticed her symptoms while in the bathtub at home.", "She has never had symptoms like this before.", "Over the previous several months she has had episodes of joint swelling and pain in her hands as well as redness, burning pain, and swelling of her hands and feet."], "Examination and Results": ["Her temperature is 98.6\u00b0F (37.0\u00b0C), pulse is 80/min, blood pressure is 135/85 mmHg, and respirations are 13/min.", "Physical exam is notable for a woman in discomfort with excoriations over the skin on her forearms.", "Laboratory tests are shown below."]}
{"Patient Personal Background": ["Her mother fears that her daughter may have caught measles."], "Patient Symptoms": ["The patient has had headaches in the past but this is the worst headache of her life.", "Her symptoms started yesterday and have been getting progressively worse.", "The patient states that the pain is mostly on the left side of her head."], "Examination and Results": ["Her temperature is 98.6\u00b0F (37\u00b0C), blood pressure is 123/74 mmHg, pulse is 85/min, and respirations are 13/min.", "On exam, the patient is an obese girl who is clutching her head with the light in the room turned off.", "Her neurological exam is within normal limits.", "Fundoscopic exam reveals mild bilateral papilledema.", "An MRI of the head is obtained and reveals cerebral edema.", "A lumbar puncture reveals an increased opening pressure with a normal glucose level."], "Treatment": ["There has been a recent outbreak of measles at the patient\u2019s school and the patient\u2019s mother has been trying to give her daughter medicine to prevent her from getting sick."]}
{"Patient Personal Background": ["She has been compliant with her medications, which include albuterol, metformin, glyburide, and atorvastatin."], "Patient Symptoms": ["She thinks that her husband is having sex with other women because they have not had sex over the past year.", "She feels that her co-workers also disrespect her for her weight and constant sweat stains around her armpits and chest.", "She has noticed that the sweat stains get itchy and induce a burning sensation unless she showers or changes her shirt."], "Examination and Results": ["Her temperature is 98.6\u00b0F (37\u00b0C), blood pressure is 128/85 mmHg, pulse is 91/min, and respirations are 11/min.", "On physical exam, the patient has a flat affect, with moist oral mucosa and nasal polyps.", "She denies sinus tenderness.", "Her neck is thick with a posterior cervical fat pad.", "During cardiac auscultation, the finding in Figure A is noted below her breasts."]}
{"Patient Personal Background": ["The child was born at 39 weeks gestation to a 34-year-old G2P2 mother by vacuum-assisted vaginal delivery after prolonged labor.", "The mother was diagnosed during this pregnancy with gestational diabetes mellitus and received prenatal care throughout.", "All prenatal screening was normal and the 20-week anatomy ultrasound was unremarkable."], "Patient Symptoms": ["She denies that the lump was present at birth and is concerned about an infection."], "Examination and Results": ["His birth weight was 3.8 kg (8.4 lb) and his length and head circumference are at the 40th and 60th percentiles, respectively.", "His temperature is 98.6\u00b0F (37\u00b0C), blood pressure is 65/42 mmHg, pulse is 131/min, and respirations are 36/min.", "On physical exam, the child is in no acute distress.", "He has a 3x3 cm fluctuant swelling over the right parietal bone that does not cross the midline.", "There is no discoloration of the overlying scalp."]}
{"Patient Personal Background": ["She has no significant medical history, is up to date on all vaccinations, and her last tetanus shot was 3 years ago."], "Examination and Results": ["On arrival, her temperature is 36.7\u00b0C (98\u00b0F), blood pressure is 82/63 mmHg, pulse is 120/min, respirations are 20/min, and oxygen saturation is 97% on 2L oxygen nasal cannula.", "On physical exam, there are extensive ecchymoses and abrasions along her left posterior ribs and left flank.", "A CT scan of the abdomen is obtained, which is shown in Figure A."]}
{"Patient Personal Background": ["The patient has a medical history of asthma and his only medication is albuterol."], "Examination and Results": ["His temperature is 98.0\u00b0F (36.6\u00b0C), blood pressure is 120/70 mmHg, pulse is 105/min, and respirations are 17/min.", "Exam was significant for pulsatile bleeding from a clean-cut wound on his right second finger.", "Radiography of the hand revealed a complete amputation of the right finger from the distal interphalangeal joint."], "Treatment": ["The teacher applied dressings and pressure to the patient's injured digit and immediately transported the patient to the emergency department.", "The wound was cleaned, compression applied, analgesics administered, and the hand surgeons were notified."], "Others": ["He arrived within 20 minutes of the accident.", "The teacher states that he left the amputated finger in the classroom, but the principal would be transporting it to the hospital."]}
{"Patient Personal Background": ["His past medical history is notable for hypertension and atrial fibrillation treated with metoprolol, apixaban, and lisinopril."], "Patient Symptoms": ["At home, the patient thought he was simply dehydrated, but he rapidly began to have trouble speaking.", "When his wife noted this she brought him into the hospital.", "On arrival to the emergency department, the patient is not responding to verbal stimuli and only withdraws his left upper extremity and lower extremity to pain.", "The patient has a seizure and subsequently demonstrates agonal breathing.", "He no longer responds to painful stimuli."], "Examination and Results": ["His temperature is 99.0\u00b0F (37.2\u00b0C), blood pressure is 170/100 mmHg, pulse is 95/min, and respirations are 16/min.", "A fingerstick blood glucose is 122 mg/dL."]}
{"Patient Personal Background": ["The patient has a medical history of type 2 diabetes mellitus, depression, anxiety, and irritable bowel syndrome.", "Her current medications include metformin, glyburide, escitalopram, and psyllium husks."], "Patient Symptoms": ["The pain was initially a 4/10 in severity but has increased recently to a 6/10 prompting her to come in.", "On exam, the patient is an obese woman with pain upon palpation of the right upper quadrant."], "Examination and Results": ["Her temperature is 99.2\u00b0F (37.3\u00b0C), pulse of 95/min, blood pressure of 135/90 mmHg, respirations of 15/min with 98% oxygen saturation on room air.", "Initial labs are are below:\n\nNa+: 140 mEq/L\nK+: 4.0 mEq/L\nCl-: 100 mEq/L\nHCO3-: 24 mEq/L\nAST: 100 U/L\nALT: 110 U/L\nAmylase: 30 U/L\nAlkaline phosphatase: 125 U/L\n\nBilirubin\nTotal: 2.5 mg/dL\nDirect: 1.8 mg/dL\n\nThe patient is sent for a right upper quadrant ultrasound demonstrating an absence of stones, no pericholecystic fluid, a normal gallbladder contour and no abnormalities noted in the common bile duct.", "MRCP with secretin infusion is performed demonstrating patent biliary and pancreatic ductal systems."]}
{"Patient Personal Background": ["The patient has a history of depression and multiple suicide attempts.", "He takes fluoxetine as well as over-the-counter pain medications for a recent muscle strain.", "He exercises regularly and recently has started making his own beer at home."], "Patient Symptoms": ["He has become gradually more confused over the past several days.", "His wife also notes he has had diarrhea, nausea and vomiting, and abdominal pain for the past week."], "Examination and Results": ["His temperature is 98.3\u00b0F (36.8\u00b0C), blood pressure is 107/75 mmHg, pulse is 110/min, respirations are 22/min, and oxygen saturation is 99% on room air.", "Physical exam reveals a confused man with a garlic odor on his breath and the finding in Figure A. Cardiopulmonary exam reveals a rapid heart rate with no murmurs and clear breath sounds."], "Others": ["He works in a large industrial compound that manufactures semiconductors."]}
{"Patient Personal Background": ["The father\u2019s brother died of sickle cell anemia at an early age.", "Parental studies reveal that both mother and father are carriers of the sickle cell gene."], "Examination and Results": ["The patient's temperature is 98.6\u00b0F (37.0\u00b0C), blood pressure is 80/45 mmHg, pulse is 130/min, and respirations are 25/min.", "The results are shown in Figure A."], "Others": ["The physician decides to repeat testing for the patient and his 3-year-old sister.", "The physician begins counseling the family."]}
{"Patient Personal Background": ["Overall he is doing well.", "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.", "His medical history is significant for hypertension and diabetes for which he takes lisinopril and metformin."], "Patient Symptoms": ["Despite this, the patient claims that he feels less well-rested when he wakes up in the morning.", "The patient states that he used to sleep 9 hours a night in his youth and felt excellent.", "Now he sleeps 7 hours a night and doesn\u2019t feel as well rested as he used to."], "Examination and Results": ["His temperature is 98.6\u00b0F (37\u00b0C), blood pressure is 131/85 mmHg, pulse is 71/min, and respirations are 12/min.", "His neurological exam is within normal limits.", "The patient is muscular and has a healthy weight with a pleasant demeanor."], "Treatment": ["His medical history is significant for hypertension and diabetes for which he takes lisinopril and metformin."], "Others": ["The patient\u2019s wife states that he seems to sleep peacefully.", "He denies feeling fatigued or tired currently."]}
{"Patient Personal Background": ["He has no past medical history and takes no medications."], "Patient Symptoms": ["He states he has a constant sensation that the room is spinning.", "He is now having trouble walking and has been vomiting intermittently.", "His dizziness is constant and unchanged with performance of the Dix-Hallpike maneuver."], "Examination and Results": ["His temperature is 98.0\u00b0F (36.7\u00b0C), blood pressure is 122/84 mmHg, pulse is 80/min, respirations are 16/min, and oxygen saturation is 98% on room air.", "Physical exam reveals a young man who is vomiting.", "His gait is ataxic and he exhibits rightward nystagmus.", "The head impulse test reveals a corrective saccade and there is no skew deviation."]}
{"Patient Personal Background": ["Pregnancy and delivery were uncomplicated but the mother had limited prenatal care during the third trimester."], "Patient Symptoms": ["The mother reports that the patient has developed a cough and nasal discharge.", "Upon visual examination of the eyes, mucoid ocular discharge and eyelid swelling are noted."], "Examination and Results": ["Immediately after delivery, the baby was given silver nitrate drops and vitamin K. His temperature is 99\u00b0F (37.2\u00b0C), blood pressure is 81/52 mmHg, pulse is 135/min, and respirations are 36/min with an oxygen saturation of 98% O2 on room air.", "A fluorescein test is negative.", "On lung exam, scattered crackles are appreciated.", "A chest radiograph is performed that shows hyperinflation with bilateral infiltrates."], "Treatment": ["Immediately after delivery, the baby was given silver nitrate drops and vitamin K. His temperature is 99\u00b0F (37.2\u00b0C), blood pressure is 81/52 mmHg, pulse is 135/min, and respirations are 36/min with an oxygen saturation of 98% O2 on room air."]}
{"Patient Symptoms": ["She was found on the floor of her apartment after her neighbor called 911.", "She is confused and is unable to provide any history, but complains of generalized pain."], "Examination and Results": ["Her temperature is 99.2\u00b0F (37.3\u00b0C), blood pressure is 129/64 mmHg, pulse is 63/min, respirations are 13/min, and oxygen saturation is 99% on room air.", "Physical exam reveals, a confused, ill-appearing woman.", "Lungs are clear to auscultation bilaterally.", "An electrocardiogram is obtained as shown in Figure A. Dipstick urinalysis is notable for 4+ blood and dark colored urine."]}
{"Patient Personal Background": ["Menarche was at age 12 and she had regular periods up until 2 years ago.", "She is otherwise healthy, participates in multiple school sports teams, and has been training rigorously for upcoming competitions.", "She denies alcohol use, smoking, and recreational drugs.", "She is not sexually active and does not take oral contraceptives."], "Patient Symptoms": ["At that time, her periods became less regular until around 7 months ago when they ceased altogether."], "Examination and Results": ["Her temperature is 36.7\u00b0C (98\u00b0F), blood pressure is 121/80 mmHg, pulse is 62/min, respirations are 11/min, oxygen saturation is 100% on room air, and BMI is 20 kg/m^2.", "Her pelvic exam reveals an anteverted uterus, no adnexal masses, a normal-appearing cervix with no cervical motion tenderness, and normal vaginal anatomy."]}
{"Patient Symptoms": ["Physical exam reveals sparse hair that is falling out throughout the patient\u2019s body.", "He has a rash by the corners of his mouth.", "The patient has multiple loose bowel movements and on day 6 the patient\u2019s surgical wound does not appear to be healing."], "Examination and Results": ["The patient is intoxicated and is unable to offer further history.", "His temperature is 97.5\u00b0F (36.4\u00b0C), blood pressure is 92/52 mmHg, pulse is 145/min, respirations are 33/min, and oxygen saturation is 90% on room air."], "Treatment": ["He is intubated to protect his airway, given 2 units of packed red blood cells, and sent to the operating room for an exploratory laparotomy.", "The patient is subsequently admitted to the intensive care unit."], "Others": ["He is extubated the next day and appears well.", "His vitals are within normal limits.", "It is held together only by the sutures with minimal underlying healing."]}
{"Patient Personal Background": ["His medical history is otherwise notable for hypertension and hyperlipidemia.", "His only home medication is pravastatin.", "The patient smokes half a pack per day of cigarettes and drinks 2-3 beers throughout the day.", "His family history is significant for Parkinson disease in his father."], "Patient Symptoms": ["For the last several years he has noticed this \"shaking\" when he brushes his teeth and prepares a cup of coffee in the morning.", "The shaking then gradually improves over the course of the day."], "Examination and Results": ["On physical exam, his temperature is 98.6\u00b0F (37.0\u00b0C), blood pressure is 159/84, pulse is 74/min, and respirations are 12/min.", "He has a high-frequency bilateral hand tremor elicited on finger-to-nose testing."]}
{"Patient Personal Background": ["He was born at 37 weeks gestation to a 39-year-old G3P3 mother.", "The mother initially labored at home with a midwife but was transferred to the hospital for failure to progress.", "The mother declined all prenatal screening tests during this pregnancy."], "Examination and Results": ["His temperature is 98.6\u00b0F (37\u00b0C), blood pressure is 63/41 mmHg, pulse is 133/min, and respirations are 39/min.", "His Apgar scores were 7 and 8 at 1 and 5 minutes, respectively.", "His weight is 3.0 kg (6.6 lb), and his height and his head circumference are in the 30th and 40th percentiles, respectively.", "On physical exam, he is found to have a 3 cm full-thickness defect in the abdominal wall to the right of the umbilicus with evisceration of a loop of the bowel."], "Treatment": ["The abdominal defect is immediately covered in sterile saline dressings and an orogastric tube and 2 peripheral intravenous lines are placed."], "Others": ["The infant was eventually delivered via Caesarean section."]}
{"Patient Personal Background": ["His parents report that he is feeding and stooling well and they have just started experimenting with solid foods.", "The patient was noted to be developmentally appropriate for his age at his last visit 2 months ago."], "Patient Symptoms": ["His parents are concerned because a few weeks ago he started rolling from back to front in addition to front to back, but he now struggles when placed on his back.", "In the examination room, he is able to roll from front to back but cannot roll from back to front.", "He is not able to sit without support and makes no attempt at bouncing when supported in a standing position."], "Examination and Results": ["On physical exam, the patient seems well-nourished and has no dysmorphic features.", "His temperature is 98.6\u00b0F (37\u00b0C), blood pressure is 77/49 mmHg, pulse is 112/min, and respirations are 24/min.", "The patient\u2019s abdomen is non-tender and soft without hepatosplenomegaly.", "His patellar reflexes are 4+ bilaterally."]}
{"Patient Personal Background": ["His medical and surgical history is significant for the reconstruction of a torn anterior cruciate ligament in his right knee.", "His family history is significant for a mother with \u201cthyroid problems\u201d and a father with coronary artery disease.", "The patient is an information technology specialist at a local company.", "He is sexually active with men.", "His temperature is 98.6\u00b0F (37.0\u00b0C), blood pressure is 124/82 mmHg, pulse is 71/min, and respirations are 12/min."], "Examination and Results": ["He feels well and has no complaints.", "On physical exam, the patient is tall and slender with a BMI of 21 kg/m2.", "A single nodule can be palpated on the patient\u2019s thyroid.", "He has palpable cervical lymphadenopathy.", "On cardiac exam, he has a normal S1/S2 with no murmurs, rubs, or gallops, and his lungs are clear bilaterally.", "His abdomen is soft and non-tender without hepatosplenomegaly."], "Others": ["A physical exam of the perioral region can be seen in Figure A."]}
{"Patient Personal Background": ["She denies any recent travel, new sexual partners, or antibiotic use."], "Examination and Results": ["Physical examination reveals multiple clustered vesicles and shallow ulcers in the vulvar region.", "A Tzanck smear shows multinucleated giant cells."]}
{"Patient Personal Background": ["Her family history is notable for hypothyroidism in her mother.", "She does not smoke cigarettes, stopped drinking alcohol prior to pregnancy, and does not use drugs."], "Patient Symptoms": ["She first presented 4 weeks ago with bilateral hand tremors.", "She reports mild improvement in her symptoms but continues to experience sweating and palpitations."], "Examination and Results": ["At that time, she was found to have a thyroid-stimulating hormone (TSH) concentration <0.01 mU/L and an elevated free T4.", "Her temperature is 97.6\u00b0F (36.4\u00b0C), blood pressure is 113/70 mmHg, pulse is 126/min, and respirations are 18/min.", "On physical exam, she appears anxious, mildly diaphoretic and has a non-tender prominence on her neck which is shown in Figure A."], "Treatment": ["She was started on propranolol and propylthiouracil.", "The dosage of both medications has been titrated to the maximum dose."]}
{"Patient Personal Background": ["His medical history is pertinent for intravenous drug use.", "He has no past surgical history."], "Patient Symptoms": ["The pain is localized to 1 spot in his lower back and is worse with physical activity."], "Examination and Results": ["His temperature is 36.8\u00b0C (98.2\u00b0F), blood pressure is 118/90 mmHg, pulse is 92/min, respirations are 13/min, and oxygen saturation is 99% on room air.", "On physical exam, he has midline back tenderness to palpation at L2-L3.", "Laboratory workup reveals an erythrocyte sedimentation rate of 112 mm/h and C-reactive protein of 10 mg/dL."]}
{"Patient Personal Background": ["She has a history of hypertension, hyperlipidemia, and diabetes.", "Her medications are lisinopril, amlodipine, atorvastatin, and metformin.", "She is a non-smoker and drinks 3-4 standard drinks per week."], "Patient Symptoms": ["She has no complaints and is asymptomatic."], "Examination and Results": ["Her temperature is 98.2\u00b0F (36.8\u00b0C), blood pressure is 142/84 mmHg, pulse is 82/min, and respirations are 16/min.", "On physical exam, a solid, immobile neck mass is palpated inferior to the cricoid cartilage to the left of midline.", "An ultrasound is obtained and shows a 1.2 cm hypoechoic mass with microcalcifications.", "Serum thyroid-stimulating hormone (TSH) concentration is 7.2 \u00b5U/mL."], "Others": ["There is no family history of malignancy."]}
{"Patient Personal Background": ["He has a history of depression which is well managed with fluoxetine.", "He has a past medical history of diabetes and notes that his home blood glucose readings have been higher lately."], "Patient Symptoms": ["He states that since starting the medication, his sexual drive has increased, yet he is unable to achieve orgasm.", "As a result, he refuses to take the medication anymore."], "Examination and Results": ["His temperature is 98.3\u00b0F (36.8\u00b0C), blood pressure is 127/82 mmHg, pulse is 88/min, respirations are 14/min, and oxygen saturation is 99% on room air.", "Physical exam reveals an obese man in no acute distress with a normal affect and non-focal neurologic exam."], "Treatment": ["The physician agrees to change the patient\u2019s antidepressant."]}
{"Patient Personal Background": ["The patient has a medical history of obesity, anxiety, and constipation.", "He is currently not taking any medications and has not filled his prescriptions for over 1 year."], "Patient Symptoms": ["He has been taking his medications and resting.", "The patient states he feels better since the incident."], "Examination and Results": ["An ECG is obtained and is seen in Figure A.", "At this visit, his temperature is 99.5\u00b0F (37.5\u00b0C), blood pressure is 130/87 mmHg, pulse is 80/min, respirations are 11/min, and oxygen saturation is 96% on room air."], "Treatment": ["The patient is managed appropriately and is discharged on atorvastatin, metoprolol, aspirin, clopidogrel, and sodium docusate."], "Others": ["The patient visits his primary care physician 4 weeks later and claims to be doing better."]}
{"Patient Personal Background": ["His medical history is otherwise significant for hypertension and diabetes mellitus, for which he takes metformin and lisinopril."], "Patient Symptoms": ["His dyspnea began 1 hour ago while he was sitting in a chair watching television.", "He also endorses lightheadedness and fatigue but denies chest pain."], "Examination and Results": ["His temperature is 98.8\u00b0F (37.1\u00b0C), blood pressure is 85/54 mmHg, pulse is 48/min, and respirations are 22/min.", "On physical exam, he appears to be in moderate distress.", "He has normal cardiac sounds with an irregular rhythm.", "His lungs are clear to auscultation bilaterally, and his electrocardiogram can be seen in Figure A."], "Treatment": ["The patient is given an initial dose of atropine but this has no effect."], "Others": ["Two weeks ago, he had a mitral valve repair for mitral insufficiency secondary to myxomatous degeneration."]}
{"Patient Personal Background": ["The patient is breastfed, has been feeding well every 2 hours, and is urinating over 8 times per day.", "He was born at 35 weeks gestation to a 27-year-old G4P4 mother.", "The patient is of Ashkenazi Jewish descent and the patient\u2019s parents refused all prenatal genetic testing.", "The pregnancy was uncomplicated until the patient\u2019s mother had a spontaneous rupture of membranes at 35 weeks of gestation.", "The patient\u2019s 3 older siblings are all healthy."], "Patient Symptoms": ["On physical exam, he appears to be in moderate distress."], "Examination and Results": ["The patient\u2019s temperature is 98.2\u00b0F (36.8\u00b0C), blood pressure is 48/32 mmHg, pulse is 164/min, and respirations are 48/min.", "He has no dysmorphic features, and his abdomen is distended and non-tender.", "Bowel sounds are absent."]}
{"Patient Personal Background": ["He admits to occasional cocaine and marijuana use.", "Otherwise, the patient has no significant medical history and is not taking any medications."], "Patient Symptoms": ["During this past week, he has been unable to properly study and prepare for final exams because he is exhausted.", "He has been going to bed early but is unable to get a good night\u2019s sleep."], "Examination and Results": ["His temperature is 98.6\u00b0F (37\u00b0C), blood pressure is 115/71 mmHg, pulse is 72/min, and respirations are 12/min.", "On physical exam, the patient is a tired and anxious appearing young man.", "His neurological exam is within normal limits."], "Others": ["The patient states that he fears he will fail his courses if he does not come up with a solution."]}
{"Patient Personal Background": ["He has a history of hypertension, hyperlipidemia, and depression.", "He currently takes amlodipine and atorvastatin and is compliant with his medications.", "He has a 45-pack-year smoking history, but he does not drink alcohol or use any illicit drugs."], "Patient Symptoms": ["He was eating dinner when he started feeling severe pain in his abdomen that made him lose his appetite.", "He denies any diarrhea or hematochezia and says the pain is not affected by movement.", "During evaluation, the patient becomes diaphoretic and pale and reports that he feels fatigued."], "Examination and Results": ["His temperature is 98.6\u00b0F (37\u00b0C), his blood pressure is 110/64 mmHg, pulse is 97/min, and respirations are 15/min.", "Physical exam is notable for diffuse abdominal tenderness without rigidity or guarding.", "Repeat blood pressure is 87/50 and pulse is 127."], "Treatment": ["Intravenous fluid boluses are administered."]}
{"Patient Personal Background": ["The patient was born at 39 weeks of gestation via spontaneous vaginal delivery.", "He is up to date with routine vaccinations."], "Patient Symptoms": ["His mother is concerned about his vision, as she noticed him squinting while watching television.", "When focusing on the pediatrician's penlight, the patient's left eye wanders."], "Examination and Results": ["He is able to walk alone, speak 3 words, and scribble with a crayon.", "His temperature is 98.6\u00b0F (37.0\u00b0C), blood pressure is 80/55 mmHg, pulse is 105/min, and respirations are 25/min.", "On exam, his pupils are round and reactive to light.", "However, when the right eye is covered, the left eye refocuses on the light.", "The rest of his neurological exam, including extraocular movements, is within normal limits."], "Others": ["A photograph of his eyes is shown in Figure A."]}
{"Patient Symptoms": ["Her mother reports that the patient began having \u201cexplosive\u201d diarrhea 6 hours ago.", "The patient has little interest in feeding since leaving the hospital after her birth and has not yet regained her birth weight.", "The patient passed meconium on the 3rd day of life."], "Examination and Results": ["Her temperature is 101.8\u00b0F (38.8\u00b0C), blood pressure is 58/37 mmHg, pulse is 148/min, and respirations are 38/min.", "On physical exam, the patient appears to be in moderate distress.", "She has no dysmorphic features and she has a normal S1/S2 without any murmurs, rubs, or gallops.", "Her abdomen is firm and distended.", "A digital rectal exam reveals a tight anal sphincter and precipitates a release of gas and liquid stool."], "Treatment": ["Her immediate postnatal period was otherwise significant for 2 episodes of bilious vomiting that resolved with the temporary use of a nasogastric tube and expulsion of stool during a digital rectal exam."], "Others": ["Her abdominal radiograph can be seen in Figure A."]}
{"Patient Personal Background": ["She has a medical history of generalized anxiety disorder and hypothyroidism for which she takes escitalopram and levothyroxine.", "She had a Roux-en-Y gastric bypass 5 years ago.", "She has been in a monogamous relationship with her husband for the last 15 years and uses a copper intrauterine device."], "Patient Symptoms": ["She feels more irritable with her husband and children and does not find pleasure in creating art anymore.", "Over the last 2 weeks, she has been sleeping approximately 5 hours a night and had a fall while walking in her home with the lights off."], "Examination and Results": ["Physical examination is notable for a depressed affect.", "Pupils are equal, round, and reactive to light and accommodation.", "She has 4/5 strength in the bilateral lower extremities and brisk patellar reflexes."], "Others": ["She denies any head trauma or loss of consciousness associated with the fall."]}
{"Patient Symptoms": ["The patient was found on a mountain trail non-responsive.", "Dark bullae are noted on the patient's extremities."], "Examination and Results": ["His temperature is 91\u00b0F (32.8\u00b0C), blood pressure is 103/61 mmHg, pulse is 60/min, respirations are 11/min, and oxygen saturation is 97% on room air.", "An ECG is performed as seen in Figure A."], "Treatment": ["The patient is placed under a warm air circulator, and his extremities are bathed in warm water."], "Others": ["His mental status rapidly improves with warming.", "Laboratory studies are ordered and are pending."]}
{"Patient Personal Background": ["He has no significant medical history and takes no medications.", "He recently returned from summer camp."], "Patient Symptoms": ["He has had headache and fever for the last 2 days, and this morning he was confused and had difficulty answering questions.", "He also developed a rash this morning."], "Examination and Results": ["His temperature is 104\u00b0F (40\u00b0C), pulse is 120/min, blood pressure is 105/60 mmHg, and respirations are 22/min.", "On exam, flexion of the neck causes flexion of the hips and knees.", "Fundoscopic exam reveals no papilledema."], "Others": ["Examination of the patient's rash is shown in Figure A."]}
{"Patient Personal Background": ["His past medical history is notable for diabetes and obesity.", "He has smoked 1 pack of cigarettes per day for the past 30 years."], "Patient Symptoms": ["His symptoms started at work when he was lifting boxes.", "He states that he currently feels crushing pressure over his chest.", "He is given nitroglycerin, with minimal improvement in his symptoms."], "Examination and Results": ["His temperature is 97.9\u00b0F (36.6\u00b0C), blood pressure is 155/99 mmHg, pulse is 110/min, respirations are 22/min, and oxygen saturation is 98% on room air.", "Physical exam reveals an uncomfortable, diaphoretic man.", "His heart and breath sounds are unremarkable.", "The patient\u2019s chest pain is worse when the ECG in the emergency department is taken, compared to the one taken in triage."], "Treatment": ["He is given aspirin and an ECG is performed in triage, as seen in Figure A.", "He is given nitroglycerin, with minimal improvement in his symptoms.", "A troponin level is drawn."], "Others": ["A repeat ECG in the emergency department is performed, also seen in Figure A."]}
{"Patient Personal Background": ["She has a history of obesity, hypertension, and depression for which she takes losartan and sertraline.", "She has smoked 1 pack of cigarettes per day for 30 years."], "Examination and Results": ["Her temperature is 99.5\u00b0F (37.5\u00b0C), blood pressure is 148/90 mmHg, pulse is 84/min, and respirations are 15/min.", "Physical exam is unremarkable, including no costovertebral or suprapubic tenderness to palpation."]}
{"Patient Personal Background": ["The patient has a past medical history of obesity, poorly controlled diabetes, hypertension, and peripheral vascular disease."], "Patient Symptoms": ["He states that ever since his wife died 4 months ago, he has been eating and sleeping more and no longer engages in any activities he once enjoyed such as hiking or fishing.", "He feels guilty for not spending more time with his wife before she died.", "He was recently fired for making several major bookkeeping mistakes at work as an accountant as he had trouble focusing.", "The patient is requesting oxycodone at this appointment as he states he has burning pain in his legs that feels worse now than it has in years past.", "His affect seems depressed."], "Examination and Results": ["His temperature is 98.7\u00b0F (37.1\u00b0C), blood pressure is 129/82 mmHg, pulse is 83/min, respirations are 15/min, and oxygen saturation is 99% on room air.", "Physical exam reveals a stable gait and reduced sensation symmetrically over the lower extremities.", "He complains of electric pain when touching his lower extremities."]}
{"Patient Personal Background": ["Her medical history is notable for hypertension and hyperlipidemia for which she takes amlodipine and atorvastatin.", "She traveled recently and has no sick contacts."], "Patient Symptoms": ["On exam, her abdomen is soft, non-distended, and non-tender to palpation; however she has diffuse discomfort upon palpation of the abdomen with no rebound, rigidity, or guarding."], "Examination and Results": ["Her temperature is 37.0\u00b0C (98.6\u00b0F), blood pressure is 118/82 mmHg, pulse is 98/min, respirations are 14/min, and oxygen saturation is 98% on room air."], "Treatment": ["She recently completed a course of clindamycin 2 weeks ago for a tooth infection."]}
{"Patient Personal Background": ["She experienced menarche at age 12 and has regular periods."], "Patient Symptoms": ["She states that she has had recurrent bouts of mood swings, bloating, and abdominal pain that occur together approximately every 4 weeks.", "She states that when these symptoms occur, she gets into frequent arguments at work, is unable to concentrate, and sleeps longer than usual.", "Furthermore, she has episodes of extreme anxiety during these periods, leading her to take off time from work.", "She notes that these symptoms are causing distress in her interpersonal relationships as well."], "Examination and Results": ["Her temperature is 98.2\u00b0F (36.8\u00b0C), blood pressure is 100/70 mmHg, pulse is 75/min, and respirations are 12/min.", "Physical exam reveals a nontender abdomen.", "Pelvic exam reveals a closed cervix with no cervical motion or adnexal tenderness.", "Her cardiopulmonary and neurological exams are unremarkable."], "Others": ["She has no past medical history and takes no medications."]}
{"Patient Personal Background": ["She has had regular menses since menarche, and her last menstrual period ended 8 days ago.", "She has no significant medical history."], "Examination and Results": ["Her temperature is 98.6\u00b0F (37\u00b0C), blood pressure is 114/71 mmHg, pulse is 81/min, and respirations are 12/min.", "A physical exam is unremarkable.", "A urine pregnancy test is negative."], "Treatment": ["She had unprotected sexual intercourse earlier that morning and requests emergency contraception.", "The patient asks for an emergency contraceptive pill and would prefer that her parents not be notified about her visit."]}
{"Patient Personal Background": ["She has not had time for regular check-ups.", "She exercises 3-4 times a week and consumes red meat sparingly.", "She drank and smoked cigarettes socially with coworkers but never at home or on vacation.", "Her family history is notable for coronary artery disease on her father's side and colon cancer on her mother's side.", "She last had a colonoscopy 5 years ago that revealed no abnormal findings."], "Patient Symptoms": ["She wakes up with achy wrists and elbows that she suspects is from years of using a computer keyboard."], "Examination and Results": ["Her temperature is 99\u00b0F (37.2\u00b0C), blood pressure is 125/83 mmHg, pulse is 82/min, respirations are 12/min, and oxygen saturation is 99% on room air.", "Her physical exam is grossly unremarkable."]}
{"Patient Personal Background": ["He has a history of a seizure disorder."], "Patient Symptoms": ["He was running a marathon but became confused halfway through the race.", "He arrives unable to coherently answer questions and is not sure where he is."], "Examination and Results": ["His temperature is 105\u00b0F (40.6\u00b0C), blood pressure is 116/68 mmHg, pulse is 167/min, respirations are 29/min, and oxygen saturation is 99% on room air.", "Physical exam reveals a confused man who is moving all 4 extremities and is protecting his airway.", "During the exam, he develops a tonic-clonic seizure, which lasts 1 minute and then terminates on its own.", "A urine dipstick is positive for red blood cells."], "Treatment": ["The patient is given intravenous fluids, and basic laboratory studies are drawn and pending."]}
{"Patient Personal Background": ["He was noted to have surpassed his birth weight at his last office visit 1 week ago."], "Patient Symptoms": ["His parents report that he suddenly started vomiting this morning and has shown no interest in feeding since then.", "They describe the vomitus as green and without any traces of blood."], "Examination and Results": ["His temperature is 97.6\u00b0F (36.4\u00b0C), blood pressure is 78/56 mmHg, pulse is 148/min, and respirations are 44/min.", "On physical exam, the patient is in mild distress.", "He has no dysmorphic features, and his mucous membranes are dry.", "His abdomen is soft and distended.", "Bowel sounds are hypoactive.", "An abdominal radiograph is performed as in Figure A."]}
{"Patient Personal Background": ["He has no medical problems and takes no medications."], "Patient Symptoms": ["He was riding his bicycle when he fell onto his outstretched right hand.", "He immediately clutched his right elbow in pain and began crying.", "He refuses to move his elbow."], "Examination and Results": ["His temperature is 98.4\u00b0F (36.9\u00b0C), blood pressure is 108/64 mmHg, pulse is 100/min, and respirations are 20/min.", "On exam, the boy is holding his right wrist with his left hand and cries upon palpation of a region that is 2 cm proximal to his elbow.", "The radial head is palpated just distal to the lateral epicondyle.", "He is unable to make a pincer with his right thumb and index finger.", "When asked to hold a pen between his right thumb and index fingers, he drops it.", "The radial pulse is diminished on the right."]}
{"Patient Personal Background": ["He currently takes no medications."], "Patient Symptoms": ["He was walking in the park about 45 minutes prior to arrival when the patient stumbled and fell.", "He had sudden weakness in his left leg and was unable to grasp a handrail with his left hand."], "Examination and Results": ["His temperature is 98.0\u00b0F (36.6\u00b0C), blood pressure is 128/89 mmHg, pulse is 130/min, and respirations are 18/min.", "On exam, he has 3/5 strength in the left upper and lower extremities and a left-sided facial droop.", "A non-contrast CT scan of the head is performed, which suggests parenchymal ischemia in the distribution of the right middle cerebral artery."], "Treatment": ["He is given intravenous alteplase with rapid improvement in his strength deficits and facial asymmetry."], "Others": ["An ECG is performed, as shown in Figure A."]}
{"Patient Symptoms": ["He was in class when he suddenly fainted and became unresponsive."], "Examination and Results": ["An autopsy is performed and is notable for no clear abnormalities.", "The patient\u2019s laboratory studies were unremarkable from a visit to the pediatrician 3 weeks ago.", "A previous ECG is seen in Figure A."], "Treatment": ["His teacher began chest compressions and he has received epinephrine and defibrillation from paramedics while in transport."], "Others": ["On arrival, the patient remains pulseless and is pronounced dead."]}
{"Patient Personal Background": ["The patient lives alone and drinks 7 alcoholic beverages per day and smokes 1-2 packs of cigarettes per day for the past 40 years."], "Patient Symptoms": ["He has felt very weak every morning with his symptoms persisting throughout the day.", "He notes minor improvement when he rides his bike but otherwise has not noticed any change in his symptoms with rest or ibuprofen use.", "The patient has lost 12 pounds recently and has had a chronic cough."], "Examination and Results": ["His temperature is 99.5\u00b0F (37.5\u00b0C), blood pressure is 177/108 mmHg, pulse is 93/min, respirations are 17/min, and oxygen saturation is 92% on room air.", "A chest radiograph is ordered as seen in Figure A."]}
{"Patient Symptoms": ["Examination reveals an ill-appearing intubated patient.", "Significant bruising is noted over the abdomen."], "Examination and Results": ["On arrival to the emergency department, his temperature is 98.6\u00b0F (37.0\u00b0C), pulse is 130/min, blood pressure is 80/50 mmHg, respirations are 22/min, and oxygen saturation is 97%.", "Endotracheal tube placement is confirmed with end tidal CO2, and bilateral breath sounds are present.", "No external bleeding or wounds are noted on exam.", "Pulses are present in all extremities but are weak and rapid.", "Significant bruising is noted over the abdomen.", "The pelvis is stable."], "Treatment": ["He was intubated and 2 large bore IVs were placed in the field with administration of 2 liters of lactated ringer's solution while en route.", "Infusion of packed red blood cells is initiated."]}
{"Patient Personal Background": ["He has a medical history of obesity and smokes regularly."], "Patient Symptoms": ["The patient states that his symptoms have been worsening over the past week.", "He also has experienced abdominal pain and diarrhea.", "He states that the rash is painful."], "Examination and Results": ["His temperature is 97.5\u00b0F (36.4\u00b0C), blood pressure is 142/82 mmHg, pulse is 85/min, respirations are 15/min, and oxygen saturation is 98% on room air.", "Physical exam is notable for an erythematous rash with papules and plaques on the patient's face, torso, and extremities.", "A fingerstick blood glucose is unable to accurately read his blood glucose and gives a reading of > 500 mg/dL."]}
{"Patient Personal Background": ["His temperature is 98.5\u00b0F (36.9\u00b0C), blood pressure is 153/89 mmHg, pulse is 90/min, respirations are 11/min, and oxygen saturation is 97% on room air."], "Patient Symptoms": ["He states that this has happened to him multiple times, particularly when he changes body position from sitting to standing, exerts himself, or turns his head quickly.", "He says that he notes numbness, vertigo, and sometimes even trouble with speaking immediately prior to fainting.", "The episodes usually last 1-5 minutes.", "When he wakes up, he is mildly confused but typically returns to baseline within a minute.", "However, when he is asked to stand up and start walking, he experiences the same numbness and tingling and feels like he may faint."], "Examination and Results": ["The patient has a past medical history of diabetes, dyslipidemia, and hypertension.", "The patient's neurological exam is unremarkable."]}
{"Patient Personal Background": ["He is otherwise healthy and takes no medications."], "Patient Symptoms": ["He states he has had profuse, watery diarrhea for the past 24 hours.", "He notes that eating and drinking make him defecate more, thus he has been refraining from drinking."], "Examination and Results": ["His temperature is 97.7\u00b0F (36.5\u00b0C), blood pressure is 84/64 mmHg, pulse is 130/min, respirations are 17/min, and oxygen saturation is 99% on room air.", "Physical exam reveals dry mucous membranes with an otherwise benign exam."], "Treatment": ["The patient is given 1L of normal saline and drinks 1L of oral fluids."]}
{"Patient Personal Background": ["She has no significant medical history and takes no medications."], "Patient Symptoms": ["Her rash has progressed and the skin on her hands is \"peeling.\"", "A diffuse, macular, erythematous rash is noted with desquamation over the patient's hands as shown in Figure A.", "The patient's nasal packing is removed revealing copious, foul-smelling, purulent discharge."], "Examination and Results": ["Her temperature is 102\u00b0F (38.9\u00b0C), blood pressure is 84/54 mmHg, pulse is 160/min, respirations are 22/min, and oxygen saturation is 99% on room air.", "Exam reveals an ill-appearing woman.", "Bilateral conjunctivitis is noted."], "Treatment": ["She had nasal septoplasty performed 1 week prior and has had nasal packing in place since that time."]}
{"Patient Symptoms": ["The patient reports pain localized to the posterior elbow and refuses to attempt elbow extension secondary to pain and swelling."]}
{"Patient Personal Background": ["Her periods are regular.", "She enjoys a diverse diet and takes levothyroxine."], "Patient Symptoms": ["Her vision has been steadily declining over the past 2 years and she thinks she needs a prescription for glasses.", "She further complains that her lips and feet feel numb."], "Examination and Results": ["Her blood pressure is 110/70 mmHg, pulse is 80/min, and respirations are 12/min.", "She is alert and oriented.", "Her pupils are equal, round, and reactive to light, but appear opacified.", "Extraocular movements are intact, albeit slow.", "Her visual acuity is decreased bilaterally.", "The remainder of her physical exam is unremarkable.", "Her basic metabolic panel is shown below: Na+: 139 mEq/L Cl-: 100 mEq/L K+: 4.9 mEq/L HCO3-: 25 mEq/L BUN: 10 mg/dL Glucose: 110 mg/dL Creatinine: 0.8 mg/dL Thyroid-stimulating hormone: 1.5 \u00b5U/mL Ca2+: 7.0 mEq/L Phosphorus: 6.5 mEq/L Albumin: 3.6 mg/dL The patient's ECG is shown in Figure A."], "Treatment": ["She enjoys a diverse diet and takes levothyroxine."]}
{"Patient Personal Background": ["The patient has a medical history of Hashimoto thyroiditis and takes levothyroxine daily.", "Her mother has type 1 diabetes mellitus."], "Patient Symptoms": ["She has had only 2 periods in the last year.", "She feels flushed without provocation and is experiencing occasional dyspareunia with post-coital spotting.", "She has also had more frequent headaches than usual."], "Examination and Results": ["Her temperature is 98.5\u00b0F (36.9\u00b0C), pulse is 70/min, blood pressure is 118/76 mmHg, and respirations are 13/min.", "Cardiopulmonary and abdominal exams are unremarkable.", "The patient has Tanner 5 breasts and pubic hair.", "A pelvic exam reveals a normal cervix, an anteverted uterus without tenderness, and no adnexal masses."]}
{"Patient Symptoms": ["The patient states that when he left for work this morning he was certain that he had closed the door to his pantry.", "Upon returning home, he saw that the door to his pantry was wide open.", "The patient is certain that his neighbors have been tampering with his food and potentially poisoned him.", "He further states that he knows they have been trying to break into his house and steal his things.", "He has tried multiple times to get them evicted from the building to no avail.", "It is for this reason that he is certain that they are trying to get their revenge upon him.", "He storms out of the office angrily, stating that he deserves the best in medical care."], "Examination and Results": ["His temperature is 98.6\u00b0F (37\u00b0C), blood pressure is 115/71 mmHg, pulse is 72/min, and respirations are 12/min."], "Treatment": ["The patient is outraged at this news and requests a competent doctor who is not colluding with his enemies."], "Others": ["The physician performs a physical exam and tells the patient that he thinks there is nothing to be concerned about, but that he should call him or come into the office if he experiences any symptoms."]}
{"Patient Personal Background": ["According to her boyfriend, the patient has a medical history of bipolar disorder for which she takes lithium, as well as chronic lower back pain for which she sees a pain specialist."], "Examination and Results": ["Her temperature is 100.5\u00b0F (38.1\u00b0C), blood pressure is 102/78 mmHg, pulse is 127/min, respirations are 19/min, and oxygen saturation is 99% on room air.", "An ECG is performed as seen in Figure A."], "Others": ["Her boyfriend found her at home next to a suicide note and brought her into the emergency department."]}
{"Patient Personal Background": ["He recently moved to the United States to work in construction.", "He drinks alcohol 1-2 times per week and has never smoked.", "He denies any family history of cancer.", "His temperature is 98.6\u00b0F (37\u00b0C), blood pressure is 114/72 mmHg, pulse is 82/min, and respirations are 12/min."], "Patient Symptoms": ["He has had the cough for several years but it has been getting worse over the last few months.", "He has lost 10 pounds in the last 3 months along with darker stools which he believes is caused by a Western diet."], "Examination and Results": ["On physical exam, his lungs are clear to auscultation bilaterally without wheezing.", "His abdomen is soft and non-distended.", "He has no tenderness to palpation and bowel sounds are present.", "He denies any difficulty swallowing or feeling of food getting stuck in his throat."]}
{"Patient Personal Background": ["The patient lives in a foster home and has been admitted many times.", "The patient is in the 25th percentile for height and weight which has been constant since birth.", "The patient has a history of tricuspid stenosis."], "Patient Symptoms": ["Since birth, the patient has had repeated episodes of pain/pressure over her frontal sinuses and a chronic cough that produces mucus."], "Examination and Results": ["Her temperature is 99.5\u00b0F (37.5\u00b0C), blood pressure is 90/58 mmHg, pulse is 120/min, respirations are 18/min, and oxygen saturation is 94% on room air.", "Physical exam is notable for bruises along the patient's shins which the guardians state are from playing soccer."], "Treatment": ["She was recently treated with amoxicillin for an infection."], "Others": ["Her guardians state that the patient has normal bowel movements and has been gaining weight appropriately.", "She also recently had magnetic resonance imaging (MRI) of her chest which demonstrated dilation of her airways.", "The rest of the exam is deferred because the patient starts crying."]}
{"Patient Personal Background": ["The patient was born at 36 weeks gestation to a 26-year-old primigravid mother via cesarean section for cervical incompetence.", "The patient has been exclusively breastfed since birth, and his mother reports that he feeds for 20-30 minutes every 2 hours."], "Patient Symptoms": ["The patient urinates 7 times per day and has begun passing 2-3 stools per day that his mother describes as \u201cgrainy\u201d and the color of \u201cmustard.\u201d His birth weight was 3670 g (8 lb 1 oz), and his current weight is 3487 (7 lb 11 oz).", "On physical exam, the patient\u2019s anterior fontanelle is soft and flat, and his eyes are moderately icteric."], "Examination and Results": ["His temperature is 97.1\u00b0F (36.2\u00b0C), blood pressure is 57/42 mmHg, pulse is 140/min, and respirations are 38/min.", "On physical exam, the patient\u2019s anterior fontanelle is soft and flat, and his eyes are moderately icteric.", "His abdomen is soft and non-distended."], "Others": ["The patient required no resuscitation at birth and both mother and child were discharged from the hospital at 2 days of life.", "The patient has the physical exam finding seen in Figure A.", "His diaper can be seen in Figure B."]}
{"Patient Personal Background": ["The patient was diagnosed with gestational diabetes after routine screening in the 2nd trimester and has been started on insulin after unsuccessful attempts at lifestyle management.", "She also has migraines and gastroesophageal reflux disorder.", "The patient has a 15-pack-year smoking history but quit smoking in her 1st month of pregnancy.", "She denies alcohol or drug use."], "Patient Symptoms": ["Yesterday she had several episodes of diarrhea and vomited once after attending a company picnic 2 days ago.", "She is worried that she is dehydrated but otherwise feels well and has recovered from her gastrointestinal illness."], "Examination and Results": ["Her temperature is 98.5\u00b0F (36.9\u00b0C), blood pressure is 122/82 mmHg, pulse is 84/min, and respirations are 14/min."], "Treatment": ["She took loperamide with symptomatic relief."], "Others": ["A representative portion of the NST is shown in Figure A."]}
{"Patient Personal Background": ["The patient lives alone and works in a health food store."], "Patient Symptoms": ["He states that he typically can converse with animals via telepathy but is having trouble right now due to the weather.", "He has begun taking an assortment of Peruvian herbs to little avail.", "When obtaining the patient's medical history, there are several times he attempts to telepathically connect with the animals in the vicinity."], "Examination and Results": ["His temperature is 98.6\u00b0F (37\u00b0C), blood pressure is 115/71 mmHg, pulse is 72/min, and respirations are 12/min.", "On physical exam, you note a healthy young man who is dressed in an all-burlap ensemble."], "Treatment": ["Otherwise, he is not currently taking any medications.", "He has begun taking an assortment of Peruvian herbs to little avail."], "Others": ["He states that his symptoms have persisted for the past 8 months."]}
{"Patient Personal Background": ["He has a medical history of hypertension, diabetes, and obesity."], "Patient Symptoms": ["On the 2nd day of his hospitalization, the patient has abdominal pain.", "He is requesting pain medication for his abdominal pain."], "Examination and Results": ["His temperature is 98.6\u00b0F (37.0\u00b0C), blood pressure is 177/118 mmHg, pulse is 127/min, respirations are 11/min, and oxygen saturation is 98% on room air.", "An ECG is performed and notable for ST elevation in leads II, III, and aVF.", "His serum lipase is 272 U/L and his creatinine is 1.6 mg/dL."], "Treatment": ["The patient is treated appropriately and transferred to the medical floor."], "Others": ["A physical exam is notable for the finding in Figure A."]}
{"Patient Symptoms": ["He was found lying down at a bus stop unresponsive.", "On arrival, the patient has slurred speech and is somnolent.", "The patient is easily arousable to voice and sternal rub but falls asleep rapidly."], "Examination and Results": ["His temperature is 98.0\u00b0F (36.7\u00b0C), blood pressure is 130/80 mmHg, pulse is 80/min, and respirations are 12/min with a saturation of 97% on room air.", "Physical exam reveals a sleeping man with miotic pupils.", "He has decreased bowel sounds.", "He is able to state his name and knows that he is at the hospital and has an otherwise normal neurologic exam."], "Others": ["Further is unable to be elicited."]}
{"Patient Personal Background": ["The patient is a software engineer and enjoys hiking, going to nightclubs, and dancing."], "Patient Symptoms": ["His symptoms started a few weeks ago but have been worsening.", "Sometimes he notes blood on the toilet paper.", "He has to strain to have bowel movements and has trouble defecating secondary to pain."], "Examination and Results": ["His temperature is 98.1\u00b0F (36.7\u00b0C), blood pressure is 112/83 mmHg, pulse is 83/min, respirations are 13/min, and oxygen saturation is 98% on room air.", "Physical exam reveals a small, superficial fissure that is lateral to the anus and lateral to the midline."], "Others": ["He is generally healthy and does not smoke."]}
{"Patient Personal Background": ["He denies any recent travel or sick contacts and infrequently smokes cigarettes."], "Patient Symptoms": ["For the last week, his cough has been progressively worsening, and he has been noticing blood in his sputum."], "Examination and Results": ["His temperature today is 102\u00b0F (38.9\u00b0C), blood pressure is 130/90 mmHg, pulse is 100/min, and respirations are 20/min.", "A radiograph of the chest demonstrates new nodules in the left upper lobe and hilar adenopathy."], "Others": ["Approximately 5 weeks ago, he presented with similar symptoms and was found to have a right upper lobe lung infiltrate, a CD4 count of 40/mm^3, and an HIV viral load of 115,000 copies/mL.", "He was appropriately treated and discharged home.", "Four weeks after initiation of treatment, his CD4 count was over 400/mm^3 and HIV viral load was negligible."]}
{"Patient Personal Background": ["He has a medical history of hypertension, diabetes, and obesity."], "Patient Symptoms": ["On the 2nd day of his hospitalization, the patient has abdominal pain.", "He is requesting pain medication for his abdominal pain."], "Examination and Results": ["His temperature is 98.6\u00b0F (37.0\u00b0C), blood pressure is 177/118 mmHg, pulse is 127/min, respirations are 11/min, and oxygen saturation is 98% on room air.", "An ECG is performed and notable for ST elevation in leads II, III, and aVF.", "His serum lipase is 272 U/L and his creatinine is 1.6 mg/dL."], "Treatment": ["The patient is treated appropriately and transferred to the medical floor."], "Others": ["A physical exam is notable for the finding in Figure A."]}
{"Patient Personal Background": ["His medical history includes type 1 diabetes mellitus and an episode of herpes zoster on his right flank 1 year ago.", "His only home medication is insulin."], "Patient Symptoms": ["He reports that he has headaches at night several times a week.", "He first developed these headaches over 1 year ago, but they started up again 3 weeks ago.", "The episodes start suddenly and feel like a stabbing, electrical pain over his left eye.", "He also reports tearing of the left eye during these episodes.", "The headaches self-resolve over the course of 2-3 hours, but the patient complains that he is avoiding going to sleep for fear of waking up in pain."], "Examination and Results": ["His temperature is 98.6\u00b0F (37\u00b0C), blood pressure is 112/69 mmHg, pulse is 61/min, and respirations are 14/min.", "On physical exam, his extraocular muscles are intact and his eyes are not injected.", "A CT of the head and sinuses shows no acute abnormalities."]}
{"Patient Personal Background": ["He recently went camping and hiking in the woods.", "The patient drinks 1-2 beers per day and smokes 1 pack of cigarettes per day.", "He is currently sexually active with multiple partners and does not use condoms.", "The patient was discharged 1 week ago for pneumonia which was treated with azithromycin; however, he feels that his symptoms may be returning.", "His temperature is 99.5\u00b0F (37.5\u00b0C), blood pressure is 157/78 mmHg, pulse is 90/min, respirations are 15/min, and oxygen saturation is 98% on room air."], "Patient Symptoms": ["He felt itchy recently, then noticed skin lesions that broke out prompting him to come to the emergency department.", "His temperature is 99.5\u00b0F (37.5\u00b0C), blood pressure is 157/78 mmHg, pulse is 90/min, respirations are 15/min, and oxygen saturation is 98% on room air."], "Examination and Results": ["Physical exam reveals the findings in Figure A on the patient's arm.", "The skin lesions are thick and do not break when pressure is applied."]}
{"Patient Personal Background": ["His medical history is significant for chronic hepatitis C infection, hypertension, type 2 diabetes mellitus, and heart failure.", "The patient works as a butcher at a local meat processing shop and is sexually active with several partners.", "He does not use barrier protection.", "His temperature is 98.6\u00b0F (37.0\u00b0C), pulse is 90/min, blood pressure is 155/95 mmHg, and respirations are 12/min."], "Patient Symptoms": ["He first noticed the rash 2 weeks prior and he endorses intermittent itchiness from the rash."], "Examination and Results": ["On physical exam, his skin has the finding shown in Figure A.", "Fine, lace-like white lines are also noted on the patient\u2019s buccal mucosa."]}
{"Patient Personal Background": ["The patient has a medical history of obesity and prediabetes with a hemoglobin A1c of 6.0% last year."], "Patient Symptoms": ["She has started to develop pimples on her face and back over the last several months.", "Her last menstrual period was over 3 months ago and her periods have been irregular over the last year.", "She has been gaining weight recently."], "Examination and Results": ["Her temperature is 98.5\u00b0F (36.9\u00b0C), pulse is 80/min, blood pressure is 139/88 mmHg, and respirations are 13/min.", "Cardiopulmonary exam is unremarkable, and the patient\u2019s abdomen appears slightly distended but exhibits no tenderness to palpation.", "The patient\u2019s face has coarse stubble along the jawline and on the upper lip, and there is similar hair along the midline of her lower abdomen.", "A pelvic exam reveals mild clitoromegaly, a normal anteverted uterus, and a large left adnexal mass that is mildly tender.", "Her laboratory test results are shown below:\n\nHemoglobin: 13.9 g/dL\nLeukocyte count: 8,000 cells/mm^3\nPlatelet count: 142,000/mm^3\n\nDHEAS: 73 ug/dL (Normal: 145-395 ug/dL)\nTestosterone: 256 ng/dL\n17-hydroxyprogesterone: 214 ng/dL (Normal: < 200 ng/dL)\n\nUltrasound findings are shown in Figure A."]}
{"Diagnosis": ["Analyzing only those subjects who responded throughout the entire period, it is determined that opioid use disorder only minimally impairs individuals in their daily functioning."], "Others": ["Individuals are surveyed using a validated method and followed up in 6-month intervals for 5 years.", "At the end of the study period, 40% of individuals have replied to the survey throughout the entire period."]}
{"Patient Personal Background": ["She was formerly an executive at a software company but had to retire due to frequent memory lapses.", "Her medical problems include hypertension and chronic obstructive pulmonary disease for which she takes amlodipine, albuterol, ipratropium, and a fluticasone inhaler."], "Patient Symptoms": ["On occasion, she becomes difficult to understand and her speech becomes disorganized.", "She also frequently sees \"small people\" and animals on the dining room table, which is disturbing to her."], "Examination and Results": ["Her temperature is 98.6\u00b0F (37\u00b0C), blood pressure is 120/80 mmHg, pulse is 80/min, and respirations are 12/min.", "Physical exam is notable for slowed movements and difficulty with balance at rest, which were not present at her wellness visit 1 year ago."]}
{"Patient Personal Background": ["His mother's pregnancy, labor, delivery, and his neonatal course have been unremarkable."], "Patient Symptoms": ["Several times a day, he experiences paroxysmal episodes of crying, bending at the waist, and jerking of the arms and legs.", "These episodes last 1-2 seconds, but occur in clusters every 20-30 seconds for several minutes.", "He is rolling over less frequently than before, has worse head control, and no longer smiles socially."], "Examination and Results": ["His temperature is 98.6\u00b0F (37\u00b0C), blood pressure is 92/46 mmHg, pulse is 115/min, and respirations are 34/min.", "On examination, no dysmorphic features are noted.", "A 24-hour electroencephalography (EEG) is performed, during which the patient has one of these spells.", "A chaotic pattern of slowing and multifocal epileptiform charges is seen."]}
{"Patient Personal Background": ["The patient\u2019s medical history is significant for depression.", "She was recently switched from phenelzine to fluoxetine."], "Patient Symptoms": ["When he said her name or waved his hand in front of her, she did not respond.", "When he tried to move her, she would remain in whatever position she was placed.", "She resists any attempt to change her position.", "The patient remains mute and ignores any external stimuli."], "Examination and Results": ["Her temperature is 99\u00b0F (37.2\u00b0C), blood pressure is 122/79 mmHg, pulse is 68/min, and respirations are 12/min with an oxygen saturation of 98% on room air."], "Others": ["The patient is lying on the bed with her left arm raised and pointing at the ceiling."]}
{"Patient Personal Background": ["He reports that he is a mailman, and his closed fist was bitten by a dog while he was delivering mail yesterday.", "His last tetanus vaccine was 3 years ago.", "He has no medical history and takes no medications."], "Patient Symptoms": ["He reports pain but denies fevers, chills, drainage, or any other symptoms."], "Examination and Results": ["His temperature is 98.6\u00b0F (37.0\u00b0C), pulse is 80/min, blood pressure is 125/75 mmHg, and respirations are 16/min."], "Others": ["The dog is up to date on vaccinations.", "Examination of the patient's right hand is shown in Figure A."]}
{"Patient Personal Background": ["She works as a mail carrier and is nearing retirement.", "She has a medical history of anxiety, depression, irritable bowel syndrome, and dysmenorrhea.", "She is not currently taking any medications."], "Patient Symptoms": ["When she goes to bed at night, she has an urge to get up out of bed and walk around.", "The patient often wakes her husband when she does this which irritates him.", "There is a perpetual uneasiness and feeling of a need to move at night which is relieved by getting up and walking around.", "The patient denies symptoms during the day."], "Examination and Results": ["Her temperature is 99.5\u00b0F (37.5\u00b0C), blood pressure is 157/98 mmHg, pulse is 80/min, respirations are 17/min, and oxygen saturation is 98% on room air.", "Physical exam reveals 5/5 strength in the upper and lower extremities, 2+ reflexes in the upper and lower extremities, a stable gait pattern, and normal sensation.", "Cardiopulmonary and abdominal exams are within normal limits."]}
{"Patient Personal Background": ["He has a history of human immunodeficiency virus (HIV) infection being treated with bictegravir, emtricitabine, and tenofovir.", "He does not smoke tobacco and drinks alcohol socially."], "Patient Symptoms": ["He was found by his roommate to be disoriented this morning.", "He had complained of a right-sided headache for the past 5 days."], "Examination and Results": ["His last CD4 cell count was 500/mm^3.", "His temperature is 104.2\u00b0F (40.1\u00b0C), blood pressure is 110/70 mmHg, pulse is 110/min, and respirations are 22/min.", "Examination reveals 3/5 strength to right shoulder abduction and elbow flexion/extension and 4/5 strength to right hip flexion/extension.", "The remainder of the strength exam on the right and left sides is normal.", "Neck flexion does not elicit pain, and there are no tongue lacerations.", "During the exam, the patient\u2019s eyes are seen to roll backward with repeated flexion/extension of his extremities and loss of urine."]}
{"Patient Symptoms": ["He wakes up screaming in pain due to an electrocardiogram lead having caused a significant thermal burn circumferentially around his left leg.", "Overnight, the nurse continued to increase the patient's midazolam infusion rate, but she also noticed that his left toes were cold to the touch with significant edema."], "Examination and Results": ["His temperature is now 100\u00b0F (37.8\u00b0C), blood pressure is 110/75 mmHg, pulse is 80/min, respirations are 10/min and oxygen saturation is 95% on 2 liters nasal cannula.", "No dorsalis pedis or posterior tibial pulses are detected on the left lower extremity.", "A delta pressure of 25 mmHg is obtained in the left leg."], "Treatment": ["He is admitted to the medical intensive care unit for continuous electroencephalogram monitoring while on a midazolam infusion for seizure suppression and supportive care for his burn.", "Overnight, the nurse continued to increase the patient's midazolam infusion rate, but she also noticed that his left toes were cold to the touch with significant edema."]}
{"Patient Personal Background": ["She is presenting late to prenatal care due to significant anxiety about her pregnancy, as she and her husband had struggled with infertility for several years prior to conceiving.", "She also had an appendectomy at age 15 for appendicitis.", "She is a Ph.D. student and her husband is a physician."], "Patient Symptoms": ["She has had nausea and vomiting for about 2 months, tender and swollen breasts, and cravings for foods she typically does not eat."], "Examination and Results": ["Her temperature is 98.5\u00b0F (36.9\u00b0C), pulse is 75/min, blood pressure is 122/76 mmHg, and respirations are 13/min.", "A physical exam is notable for abdominal distension but is otherwise unremarkable.", "Ultrasound is shown in Figure A, and urine human chorionic gonadotropin is negative in the office."], "Others": ["She took a pregnancy test about 10 weeks ago and was too nervous to read the result immediately.", "After 24 hours, she saw that it was positive.", "The patient\u2019s affect is normal and she is pleasant and excited about her pregnancy."]}
{"Patient Personal Background": ["He has a history of a distal radius fracture 2 years ago from falling off a ladder.", "He drinks 3 alcoholic beverages weekly and denies illicit drug use."], "Patient Symptoms": ["He was working on a home improvement project the day prior to presentation when the pain started.", "He describes the pain as \"achy and sore.\"", "It is not positional and does not radiate.", "He denies fevers, chills, paresthesias, and bowel or bladder incontinence."], "Examination and Results": ["The patient\u2019s temperature is 98.4\u00b0F (36.9\u00b0C), blood pressure is 124/80 mmHg, pulse is 90/min, and respirations are 16/min.", "His body mass index (BMI) is 22.4 kg/m^2.", "There is tenderness to palpation of his paravertebral lumbar region bilaterally.", "Perineal and dermatomal sensation is symmetric and intact.", "Strength is 5/5 to knee flexion/extension and ankle dorsiflexion/plantarflexion.", "Patellar and Achilles reflexes are 2+ bilaterally.", "Raising either leg while the patient is in the supine position does not elicit any pain."]}
{"Patient Personal Background": ["The patient has a history of diabetes and is followed closely by an endocrinologist."], "Patient Symptoms": ["Today, he experienced a headache with blurry vision, thus prompting his presentation.", "Otherwise, he has lost 10 pounds over the past month."], "Examination and Results": ["His temperature is 100\u00b0F (37.8\u00b0C), blood pressure is 122/90 mmHg, pulse is 84/min, respirations are 16/min, and oxygen saturation is 99% on room air.", "Physical exam is notable for a thin man but is otherwise unremarkable.", "His visual acuity is 20/100 in both eyes, though he says that he normally has 20/20 vision.", "His gait is mildly ataxic as well, but his neurological exam is otherwise nonfocal."], "Others": ["Laboratory studies are ordered as seen below."]}
{"Patient Personal Background": ["He has no known medical history and takes no medications."], "Patient Symptoms": ["The pain starts in his chest and moves into his back, arms, and abdomen.", "He describes the pain as tearing."], "Examination and Results": ["His temperature is 37.0\u00b0C (98.6\u00b0F), pulse is 130/min, blood pressure is 210/145 mmHg, respirations are 22/min, and pulse oximetry is 98% on room air.", "Exam reveals a diaphoretic, anxious-appearing man.", "Pulses are diminished over the left wrist when compared to the right.", "A chest radiograph is obtained as shown in Figure A."]}
{"Patient Personal Background": ["Two months ago, he was started on citalopram after several weeks of depressed mood, loss of interest in activities, depressed appetite, and inability to sleep."], "Patient Symptoms": ["Two months ago, he was started on citalopram after several weeks of depressed mood, loss of interest in activities, depressed appetite, and inability to sleep.", "Today, he reports minimal improvement in his symptoms.", "He denies thoughts of suicide or self-harm.", "Exam reveals a depressed, tired appearing man."], "Examination and Results": ["His temperature is 98.6\u00b0F (37.0\u00b0C), pulse is 80/min, blood pressure is 120/80 mmHg, respirations are 22/min, and oxygen saturation is 97% on room air."], "Treatment": ["Two months ago, he was started on citalopram after several weeks of depressed mood, loss of interest in activities, depressed appetite, and inability to sleep."]}
{"Patient Personal Background": ["The patient has a medical history of type 2 diabetes mellitus, obesity, and hypertension.", "His current medications include metformin, insulin, lisinopril, and hydrochlorothiazide.", "The patient leads a sedentary life in which he tends to stay home and watch television.", "He does not engage in any physical or strenuous activity.", "His temperature is 98.6\u00b0F (37\u00b0C), blood pressure is 138/85 mmHg, pulse is 75/min, and respirations are 12/min."], "Patient Symptoms": ["He has been having trouble combing his hair and reaching objects that are high on the shelf."], "Examination and Results": ["On physical exam, the patient has decreased passive and active range of motion of his shoulder.", "The strength of the patient's upper extremity is 4/5 limited by pain."]}
{"Patient Personal Background": ["The patient is otherwise healthy and does not take any medications."], "Patient Symptoms": ["He was punched in the eye and is having pain and blurry vision."], "Examination and Results": ["His temperature is 98.1\u00b0F (36.7\u00b0C), blood pressure is 132/84 mmHg, pulse is 103/min, respirations are 17/min, and oxygen saturation is 98% on room air.", "Physical exam is notable for conjunctival injection of the patient\u2019s left eye as shown in Figure A.", "Visual acuity reveals 20/20 vision in his right eye and 20/40 vision in his left.", "His left pupil is sluggish to constrict when compared to the right.", "A fluorescein stain is unremarkable and tonometry reveals a pressure of 45 mmHg in the left eye."]}
{"Patient Personal Background": ["Her medical history is notable for depression, anxiety, and gonococcal urethritis that was appropriately treated.", "She is sexually active and does not use condoms.", "She admits to drinking at least 5 standard alcoholic drinks a day.", "The patient also recently lost a large amount of weight for a fitness show she planned on entering.", "The patient's current medications include oral contraceptive pills, fluoxetine, alprazolam, ibuprofen, acetaminophen, and folate."], "Patient Symptoms": ["The pain has been dull and progressive, but became suddenly worse while she was exercising.", "On abdominal exam you note diffuse tenderness with 10/10 pain upon palpation of the right upper quadrant."], "Examination and Results": ["Her temperature is 99.5\u00b0F (37.5\u00b0C), blood pressure is 80/40 mmHg, pulse is 110/minute, and respirations are 15/minute with an oxygen saturation of 96% on room air.", "On physical exam, you note an athletic young woman with burly shoulders, a thick neck, and acne on her forehead and back."], "Treatment": ["Intravenous fluids are started and labs are sent."], "Others": ["A urinary \u00df-hCG has been ordered."]}
{"Patient Personal Background": ["He has never smoked cigarettes but does have a history of opiate use prior to incarceration.", "He does not take any medications."], "Patient Symptoms": ["He noticed a gradual weight loss over the past year despite no changes to his diet or physical activity."], "Examination and Results": ["His temperature is 100.8\u00b0F (38.2\u00b0C), blood pressure is 142/88 mmHg, pulse is 78/min, and respirations are 12/min.", "Physical exam reveals a thin, ill-appearing man.", "Pulmonary auscultation reveals faint, inspiratory crackles in the right upper lobe.", "His chest radiograph is shown in Figure A."]}
{"Patient Personal Background": ["They order the patient\u2019s home medications including clobazam; however, they accidentally order clonazepam."], "Patient Symptoms": ["Subsequently, the patient is over-sedated and has to be transferred to the ICU for airway monitoring."], "Treatment": ["They order the patient\u2019s home medications including clobazam; however, they accidentally order clonazepam."]}
{"Patient Personal Background": ["The patient is otherwise healthy and does not take any medications."], "Patient Symptoms": ["He initially experienced pain which is currently well controlled with acetaminophen."], "Examination and Results": ["His temperature is 98.5\u00b0F (36.9\u00b0C), blood pressure is 123/79 mmHg, pulse is 90/min, respirations are 11/min, and oxygen saturation is 97% on room air.", "Physical exam is notable for the finding in Figure A.", "A radiograph of the affected digits shows a smooth cortex without disruption of the bone."], "Treatment": ["He initially experienced pain which is currently well controlled with acetaminophen."]}
{"Patient Personal Background": ["The patient has engaged in unprotected intercourse with 12 different partners.", "She has a medical history of asthma, IV drug abuse, and depression.", "She has 1 to 2 alcoholic drinks per day.", "She feels ashamed of her behavior and is requesting treatment for her condition and advice for safe sex."], "Patient Symptoms": ["The patient presents to the emergency department 3 days later with a complaint of a rash.", "She states that every time she has sex a rash has emerged on her skin."], "Examination and Results": ["Her temperature is 99.5\u00b0F (37.5\u00b0C), blood pressure is 127/68 mmHg, pulse is 91/min, respirations are 14/min, and oxygen saturation is 98% on room air.", "A physical exam is notable for the finding in Figure A."], "Treatment": ["The patient is given antibiotics and is advised on safe sex practices."]}
{"Patient Personal Background": ["He has no known medical allergies.", "He smokes 1 pack of cigarettes per day and denies alcohol or illicit drug use."], "Patient Symptoms": ["Today, he reports that he became sunburned this morning within an hour of beginning his workday, despite wearing appropriate sunscreen.", "On exam, there is a blistering erythematous rash on the arms and shoulders."], "Examination and Results": ["His temperature is 98.6\u00b0F (37.0\u00b0C), blood pressure is 125/70 mmHg, pulse is 65/min, and respirations are 12/min.", "The previous skin lesion appears unchanged."], "Treatment": ["At that time, he was prescribed treatment for the lesion and instructed to follow up as necessary."], "Others": ["He was seen 4 days ago for a new lesion on his arm that had been present for 1 week prior to that visit.", "A photograph of the lesion is shown in Figure A.", "He has a medical history significant for type 2 diabetes mellitus that is controlled with metformin."]}
{"Patient Personal Background": ["The patient is otherwise doing well in school and enjoys playing basketball.", "His medical history is otherwise significant for scoliosis which is managed by an orthopedic surgeon.", "His family history is significant for a mother with type 2 diabetes mellitus and a father who underwent aortic valve replacement last year."], "Patient Symptoms": ["Over the past several months, he has had increasing difficulty seeing the board from the back of the classroom at school."], "Examination and Results": ["His temperature is 98.6\u00b0F (37\u00b0C), blood pressure is 115/71 mmHg, pulse is 72/min, and respirations are 12/min.", "On physical exam, the patient is tall for his age and has long arms.", "He has 20 degrees of thoracic scoliosis, which is stable from previous exams.", "On slit-lamp examination, the patient is found to have bilateral upward lens subluxation and is prescribed corrective lenses."]}
{"Patient Personal Background": ["The patient has a medical history of diabetes and hypertension.", "His current medications include insulin, metformin, and lisinopril."], "Patient Symptoms": ["For the past month, he has felt abnormally tired and today noticed his vision is blurry.", "The patient also endorses increased sweating at night and new-onset headaches.", "He currently feels dizzy.", "A neurological exam is notable for decreased sensation in the patient's hands and feet.", "He also complains of numbness and tingling pain in his extremities that has been persistent during this time."], "Examination and Results": ["His temperature is 99.5\u00b0F (37.5\u00b0C), blood pressure is 157/98 mmHg, pulse is 90/min, respirations are 17/min, and oxygen saturation is 98% on room air.", "A cardiopulmonary exam is within normal limits.", "HEENT exam reveals non-tender posterior and anterior chain lymphadenopathy.", "Abdominal exam reveals splenomegaly and hepatomegaly.", "There are large, non-tender palpable lymph nodes in the patient's inguinal region.", "The dermatologic exam is notable for multiple bruises on his upper and lower extremities."]}
{"Patient Personal Background": ["The medical student has had a negative HIV serology from the beginning of medical school 2 years ago.", "She is monogamous with one male partner and denies any intravenous drug use."], "Examination and Results": ["The source patient was recently diagnosed with HIV and has a CD4 count of 550 cells/\u00b5L.", "His most recent viral load is 1,800,000 copies/mL, and he was started on HAART 3 days ago."], "Treatment": ["She was drawing blood from an HIV-positive patient when she stuck herself percutaneously while capping the needle.", "His most recent viral load is 1,800,000 copies/mL, and he was started on HAART 3 days ago."], "Diagnosis": ["The source patient was recently diagnosed with HIV and has a CD4 count of 550 cells/\u00b5L."], "Others": ["She immediately washed the puncture wound with saline."]}
{"Patient Personal Background": ["He has no other significant medical history and does not take any medications.", "He has smoked 1 pack of cigarettes a day for 35 years and drinks 3 beers per week.", "He is sexually active with his wife."], "Patient Symptoms": ["He denies any hemoptysis, facial pain, rhinorrhea, or night sweats."], "Examination and Results": ["His temperature is 101.7\u00b0F (38.7\u00b0C), blood pressure is 127/85, pulse is 102/min, and respirations are 22/min.", "Physical exam is notable for decreased breath sounds on the right side without wheezing and increased dullness to percussion on the right side.", "A chest radiograph is ordered and reveals a consolidation in the right middle lobe."], "Others": ["The patient reported similar symptoms 2 months ago.", "Chest radiograph performed at the time was notable for a right middle lobe consolidation.", "He was diagnosed with lobar pneumonia and completed a 7-day course of antibiotics with complete resolution of his symptoms."]}
{"Patient Personal Background": ["His parents report that he is doing well in school and has many friends.", "The parents have so far managed the condition using herbal teas and essential oils but have not sought formal medical care."], "Patient Symptoms": ["Their only concern is that he has a \u201cdifficult stomach.\u201d Every few months, he complains of intermittent abdominal pain that takes several days to pass.", "He occasionally misses school due to the pain.", "There is blood in his stool during these episodes.", "These symptoms have persisted for many years.", "On physical exam, the patient is thin with conjunctival pallor."], "Examination and Results": ["His temperature is 98.2\u00b0F (36.8\u00b0C), blood pressure is 106/61 mmHg, pulse is 88/min, and respirations are 12/min.", "He has lost 10 pounds since his annual visit the year before and is the same height.", "His sclerae are anicteric and his abdomen is soft and non-tender without hepatosplenomegaly.", "He undergoes an abdominal CT that shows disease affecting the terminal ileum."], "Others": ["He also has the findings seen in Figure A."]}
{"Patient Symptoms": ["She had a headache that was present for a few hours before subsiding 2 days ago, and then today she developed a headache that was sudden in onset and at maximal intensity within minutes.", "She has never had a headache like this in the past."], "Examination and Results": ["Her temperature is 99.0\u00b0F (37.2\u00b0C), blood pressure is 157/99 mmHg, pulse is 90/min, respirations are 16/min, and oxygen saturation is 99% on room air.", "On exam, she has pain with passive and active movement of the neck.", "No focal neurologic deficits are appreciated.", "A non-contrast head CT is obtained as shown in Figure A."]}
{"Patient Personal Background": ["His medical history is notable for a kidney stone 6 months ago.", "The patient does not take any medications.", "He is a non-smoker and does not drink alcohol or use recreational drugs.", "His family history is significant for osteoarthritis in his father who is 78.", "His temperature is 98.6\u00b0F (37\u00b0C), blood pressure is 133/84 mmHg, pulse is 84/min, and respirations are 15/min."], "Patient Symptoms": ["He is otherwise healthy and denies fever, chills, or recent trauma."], "Examination and Results": ["His body mass index is 27 kg/m^2.", "Physical examination shows a swollen and tender joint with overlying erythema.", "Diagnostic arthrocentesis is performed and shows a leukocyte count of 30,000/mm^3 with 85% neutrophils.", "Polarized microscopy of the synovial fluid is shown in Figure A."], "Others": ["He underwent a dental procedure to extract an infected wisdom tooth 3 weeks ago."]}
{"Patient Personal Background": ["She was born at 38-weeks gestational age without complications.", "Her medications consist of lamotrigine and valproic acid."], "Patient Symptoms": ["Her parents have noticed the patient occasionally stiffens and spreads her arms at home."], "Examination and Results": ["She recently underwent a neurology evaluation which revealed hypsarrhythmia on electroencephalography (EEG) with a mix of slow waves, multifocal spikes, and asynchrony.", "Her temperature is 98.3\u00b0F (36.8\u00b0C), blood pressure is 90/75 mmHg, pulse is 94/min, and respirations are 22/min.", "Physical exam reveals innumerable hypopigmented macules on the skin and an irregularly shaped, thickened, and elevated plaque on the lower back."], "Others": ["She has no other medical problems."]}
{"Patient Personal Background": ["The patient has not seen a physician in 30 years and recalls being current on most of his vaccinations.", "A few years ago, he went to the emergency department due to abdominal pain and was found to have increased liver enzymes due to excessive alcohol use and incidental gallstones.", "The patient has a 50 pack-year smoking history.", "His temperature is 99.5\u00b0F (37.5\u00b0C), blood pressure is 161/108 mmHg, pulse is 90/min, respirations are 17/min, and oxygen saturation is 95% on room air."], "Patient Symptoms": ["For the past several months, he has felt progressively weaker and has lost 25 pounds with intermittent abdominal pain."], "Examination and Results": ["Physical exam reveals an emaciated man.", "The patient has a negative Murphy sign and his abdomen is non-tender.", "Cardiopulmonary exam is within normal limits."]}
{"Patient Personal Background": ["Her last menstrual period was 7 weeks ago.", "She has no other past medical history and takes no medications.", "She uses a copper intrauterine device and is in a monogamous relationship."], "Patient Symptoms": ["The pain is most pronounced in the lower abdomen and has gotten worse over the past day."], "Examination and Results": ["Her temperature is 99\u00b0F (37.2\u00b0C), blood pressure is 79/50 mmHg, pulse is 135/min, and respirations are 20/min.", "Physical examination is notable for diffuse abdominal tenderness upon palpation.", "Pelvic examination demonstrates uterine and adnexal tenderness and uterine bleeding.", "Laboratory studies are shown below:\n\nHemoglobin: 9.5 g/dL\nLeukocyte count: 6,000/mm^3\nSerum beta-human chorionic gonadotropin (hCG): 2,700 IU/L\n\nThe patient is started on intravenous fluids."], "Treatment": [], "Others": ["She denies any recent abdominal or vaginal trauma."]}
{"Patient Personal Background": ["He drinks a glass of wine with dinner every night and took up scuba diving 2 months ago but otherwise does not exercise.", "His temperature is 97.5\u00b0F (36.4\u00b0C), blood pressure is 124/68 mmHg, pulse is 82/min, and respirations are 16/min."], "Patient Symptoms": ["The pain started a year ago and has progressed.", "He now has 8/10 pain when climbing stairs or rising from a seated position.", "He localizes the pain to the front of his groin."], "Examination and Results": ["He denies any erythema or swelling.", "His body mass index (BMI) is 18.1 kg/m^2.", "Physical exam reveals left groin pain at the terminal ranges of hip abduction and internal rotation.", "There is no point tenderness.", "A radiograph is obtained as in Figure A."]}
{"Patient Symptoms": ["Approximately 20 minutes after receiving the medication, he developed pain and stiffness in his neck and eventually was unable to move his neck.", "His neck is rotated to the right and is unable to return to midline."], "Examination and Results": ["His temperature is 98.6\u00b0F (37.0\u00b0C), pulse is 90/min, blood pressure is 130/80 mmHg, respirations are 16/min, and oxygen saturation is 98% on room air.", "Examination reveals an uncomfortable appearing man.", "Examination of the patient is shown in Figure A."], "Treatment": ["He underwent a laparoscopic appendectomy and was treated for post-operative nausea and vomiting with metoclopramide."], "Others": []}
{"Patient Personal Background": ["His only medical history includes an appendectomy that he underwent as a child, and he takes no daily medications."], "Patient Symptoms": ["He states that he has not passed gas or had a bowel movement in 4 days and his pain has worsened and become constant over the past 2 hours."], "Examination and Results": ["His temperature is 38.5\u00b0C (101.3\u00b0F), blood pressure is 92/60 mmHg, pulse is 138/min, and respirations are 25/min.", "His pulse oximetry is 99% on room air.There are no cardiopulmonary abnormalities on auscultation.", "His abdomen is distended and tender in all quadrants, with guarding and rebound present.", "He also has increased bowel sounds throughout."]}
{"Patient Personal Background": ["She has hypertension for which she takes hydrochlorothiazide and had a recent asthma flare requiring a prednisone taper.", "She does not drink alcohol or smoke."], "Patient Symptoms": ["Her pain is 7/10 in severity, non-radiating, and not relieved by rest.", "She has never experienced this pain in the past and denies fever, night sweats, unintentional weight loss, and bowel or bladder incontinence."], "Examination and Results": ["Her temperature is 98.6\u00b0F (37.0\u00b0C), blood pressure is 120/80 mmHg, pulse is 90/min, and respirations are 18/min.", "Physical exam reveals an uncomfortable middle-aged woman in no acute distress.", "There is no tenderness to palpation of the spinous processes.", "Flexion of the hip with the knee extended while the patient is supine does not elicit any pain, nor does forced dorsiflexion of the foot at terminal hip extension.", "She has 5/5 strength to hip flexion, extension, abduction, and adduction; knee flexion and extension; and ankle dorsiflexion and plantarflexion bilaterally.", "Bilateral patellar and Achilles reflexes are 2+."]}
{"Patient Symptoms": ["His mother reports he was eating well until 1 week ago when he began vomiting after breastfeeding.", "His mother has tried increasing the frequency of feeds and decreasing the amount of each feed, but the vomiting seems to be getting worse.", "The patient now vomits after every feed.", "The vomitus looks like breast milk."], "Examination and Results": ["He is now in the 60th percentile for weight and 68th percentile for height.", "His temperature is 98.2\u00b0F (36.8\u00b0C), blood pressure is 58/37 mmHg, pulse is 144/min, and respirations are 34/min.", "On physical exam, the patient has dry mucous membranes.", "His abdomen is soft and non-distended."], "Others": ["The patient\u2019s mother is exclusively breastfeeding and would prefer not to switch to formula but worries that the patient is not getting the nutrition he needs.", "Two weeks ago, the patient was in the 75th percentile for weight and 70th for height."]}
{"Patient Personal Background": ["The patient has a history of coronary artery disease with a drug-eluting stent placed 1 year ago, obesity, hypertension, and dyslipidemia."], "Patient Symptoms": ["He has had severe nausea, vomiting, and diarrhea for the past 3 days.", "Today, his wife noticed that he was confused.", "He denies chest pain or dyspnea, but complains of diffuse abdominal pain."], "Examination and Results": ["His temperature is 99.0\u00b0F (37.2\u00b0C), blood pressure is 100/60 mmHg, pulse is 105/min, and respirations are 22/min.", "Physical exam reveals a confused man with dry mucous membranes.", "His abdomen is diffusely tender to palpation.", "Laboratory studies are ordered and notable for the following:\n\nSerum:\nNa+: 147 mEq/L\nCl-: 112 mEq/L\nK+: 3.5 mEq/L\nHCO3-: 14 mEq/L\nBUN: 80 mg/dL\nGlucose: 100 mg/dL\nCreatinine: 2.1 mg/dL\nTroponin: 0.10 mcg/L (normal < 0.01 mcg/L)\n\nAn ECG is ordered and is pending."]}
{"Patient Personal Background": ["Her mother reports that she is eating well at home and sleeping well throughout the night."], "Examination and Results": ["She can jump and walk up and down stairs with both feet on each step.", "In the doctor\u2019s office, the patient builds a 6-cube tower and imitates a circle.", "She seems to have a vocabulary of over 50 words that she uses in 2-word sentences.", "The patient enjoys playing near other children and sometimes argues over toys with her older brother.", "Her temperature is 98.6\u00b0F (37\u00b0C), blood pressure is 92/56 mmHg, pulse is 106/min, and respirations are 23/min.", "On physical exam, she appears well developed and well nourished, and she is following along her growth curves."], "Diagnosis": ["The child is assessed as developmentally normal."]}
{"Patient Personal Background": ["He denies any diarrhea or change in his stools.", "He drinks 5-6 beers on the weekend and has a 20 pack-year smoking history.", "He denies any family history of cancer."], "Patient Symptoms": ["He says that the pain \u201ccomes and goes\u201d throughout the day and usually lasts 20-30 minutes per episode.", "The pain is above his umbilicus.", "He denies any feeling of regurgitation or nighttime cough but endorses nausea.", "He used to eat 3 large meals per day but has found that eating smaller meals more frequently improves his pain."], "Examination and Results": ["His temperature is 98.6\u00b0F (37\u00b0C), blood pressure is 117/72 mmHg, pulse is 72/min, and respirations are 13/min.", "On physical exam, he is tender to palpation above the umbilicus.", "Bowel sounds are present.", "A stool guaiac test is positive."], "Treatment": ["He tried ibuprofen with food and thinks it helped."], "Diagnosis": ["The patient undergoes an endoscopy with a biopsy to diagnose his condition."], "Others": ["He has gained 4 pounds since his last appointment 3 months ago.", "He has no known medical history."]}
{"Patient Personal Background": ["His medications include aspirin, lisinopril, metformin, and sulfasalazine."], "Patient Symptoms": ["He reports that the dyspnea started 2 months ago after he had the flu.", "At first, the difficulty breathing occurred whenever he went up and down 1 flight of stairs, but the dyspnea progressively worsened since then.", "This morning, he developed chest pain and difficulty breathing while sitting at the kitchen table."], "Examination and Results": ["His temperature is 97\u00b0F (36.1\u00b0C), blood pressure is 130/78 mmHg, pulse is 88/min, and respirations are 14/min with an oxygen saturation of 97% O2 on room air.", "On physical exam, jugular venous distension during both inspiration and expiration, mild abdominal distention, and 2+ bilateral lower extremity edema is noted.", "A chest radiograph is obtained and the result is shown in Figure A."]}
{"Patient Personal Background": ["She has a medical history of anxiety and is not currently taking any medications."], "Patient Symptoms": ["She has a general aching/pain in her joints that lasts all day.", "The pain is constant and is not relieved by rest or activity.", "She also has pain in her hands at times and occasionally notices trouble swallowing when she is eating."], "Examination and Results": ["Her temperature is 98.6\u00b0F (37\u00b0C), blood pressure is 115/72 mmHg, pulse is 74/min, and respirations are 11/min.", "On physical exam, the patient is a healthy young woman with a sunburn.", "Her hands are mildly edematous with the findings in Figure A."]}
{"Patient Personal Background": ["He has a medical history of asthma."], "Patient Symptoms": ["His symptoms started last night and have persisted.", "He occasionally has migraine headaches, but he has not had a headache like this in the past.", "He reports associated nausea, vomiting, fevers, and neck pain."], "Examination and Results": ["His temperature is 100.4\u00b0F (38.0\u00b0C), blood pressure is 110/60 mmHg, pulse is 95/min, respirations are 17/min, and oxygen saturation is 98% on room air.", "On physical exam, he appears uncomfortable.", "Neurologic exam reveals no focal deficits.", "There is pain with passive neck flexion.", "No edema or rashes are noted.", "Lungs are clear to auscultation bilaterally."], "Treatment": ["Lumbar puncture is performed and CSF results are obtained as shown below."]}
{"Patient Personal Background": ["He has a history of anxiety managed with fluoxetine and lorazepam.", "He also has hypertension but does not take any medications."], "Patient Symptoms": ["Today, his symptoms have been persistent despite taking his medications.", "He says that he feels lightheaded and can\u2019t walk."], "Examination and Results": ["His temperature is 98.7\u00b0F (37.1\u00b0C), blood pressure is 120/72 mmHg, pulse is 183/min, respirations are 25/min, and oxygen saturation is 99% on room air.", "Physical exam reveals a somnolent and uncomfortable man.", "His pulse is rapid and regular.", "An ECG is performed as seen in Figure A."]}
{"Patient Personal Background": ["Her medical history is significant for hypertension treated with lifestyle modification and gastroesophageal reflux disease (GERD)."], "Patient Symptoms": ["She noticed the weakness approximately 3 months ago.", "It has gotten progressively worse since that time.", "She has also noticed increasing difficulty combing her hair, standing from a seated position, and experiences muscle aches."], "Examination and Results": ["Her temperature is 98.6\u00b0F (37.0\u00b0C), blood pressure is 130/65 mmHg, pulse is 80/min, and respirations are 16/min.", "She has 3/5 strength to shoulder abduction and hip flexion bilaterally.", "Her strength is 5/5 to wrist extension and ankle plantar flexion.", "No skin rashes are noted."]}
{"Patient Personal Background": ["The patient has an unknown medical history and is currently not on any medications.", "She is not sexually active and does not intend to become pregnant in the near future."], "Patient Symptoms": ["The patient's teacher describes her as occasionally \"daydreaming\" for periods of time during where the patient does not respond or participate in school activities.", "The only other concern that the patient's mother has is that, upon awakening, she notices that sometimes the patient's arm will jerk back and forth.", "The patient states she is not doing this intentionally."], "Examination and Results": ["Her temperature is 98.6\u00b0F (37\u00b0C), blood pressure is 112/74 mmHg, pulse is 63/min, and respirations are 11/min.", "On physical exam, you note a young, healthy girl whose neurological exam is within normal limits."], "Others": ["Nothing has helped the patient change her behavior, including parent-teacher conferences or punishment.", "The patient has no other concerns."]}
{"Patient Personal Background": ["He denies any recent travel or sick contacts and infrequently smokes cigarettes.", "Approximately 5 weeks ago, he presented with similar symptoms and was found to have a right upper lobe lung infiltrate, a CD4 count of 40/mm^3, and an HIV viral load of 115,000 copies/mL."], "Patient Symptoms": ["For the last week, his cough has been progressively worsening, and he has been noticing blood in his sputum."], "Examination and Results": ["His temperature today is 102\u00b0F (38.9\u00b0C), blood pressure is 130/90 mmHg, pulse is 100/min, and respirations are 20/min.", "A radiograph of the chest demonstrates new nodules in the left upper lobe and hilar adenopathy."], "Treatment": ["He was appropriately treated and discharged home."]}
{"Patient Personal Background": ["The patient has a medical history of diabetes mellitus that is well-controlled with insulin and metformin.", "She has been admitted multiple times for hypoglycemia secondary to missing meals."], "Patient Symptoms": ["She feels fatigued, depressed, and has gained 10 pounds which she attributes to feeling too weak to go to the gym.", "She was recently treated for an ear infection with an antibiotic which she completed 3 weeks ago, and experienced a rash which she believes was an allergic reaction to her treatment."], "Examination and Results": ["Her temperature is 99.5\u00b0F (37.5\u00b0C), blood pressure is 127/68 mmHg, pulse is 80/min, respirations are 17/min, and oxygen saturation is 98% on room air.", "Physical exam is notable for 2/5 strength in the patient's upper and lower extremities, sparse fine hair on her body, and a rash on her face and arms.", "Serum: Na+: 139 mEq/L K+: 3.3 mEq/L Cl-: 100 mEq/L HCO3-: 25 mEq/L BUN: 20 mg/dL Glucose: 70 mg/dL Creatinine: 1.1 mg/dL Ca2+: 10.2 mg/dL AST: 12 U/L ALT: 10 U/L A muscle biopsy is obtained as seen in Figure A."], "Treatment": ["She was recently treated for an ear infection with an antibiotic which she completed 3 weeks ago, and experienced a rash which she believes was an allergic reaction to her treatment."], "Others": ["Laboratory values are ordered as seen below."]}
{"Patient Personal Background": ["She was in her usual state of health until 6 weeks ago when she was hospitalized for bacterial pneumonia.", "She often babbles but sometimes does make identifiable sounds like \u201cdada\u201d and \u201cbaba.\u201d They recently started feeding her mushy cereal, which she seems to like but occasionally spits up.", "She has started teething and sometimes becomes \u201cfussy.\u201d Vital signs are within normal limits."], "Patient Symptoms": ["She often babbles but sometimes does make identifiable sounds like \u201cdada\u201d and \u201cbaba.\u201d They recently started feeding her mushy cereal, which she seems to like but occasionally spits up.", "She has started teething and sometimes becomes \u201cfussy.\u201d Vital signs are within normal limits."], "Examination and Results": ["A physical examination is unremarkable.", "The patient\u2019s father brought a 4-week follow-up chest radiograph taken at the hospital, as shown in Figure A."], "Treatment": ["She received amoxicillin and had a resolution of her symptoms."], "Others": ["Her father reports that she seems \u201cback to normal.\u201d She can roll over by herself and can sit up without support."]}
{"Patient Personal Background": ["The patient has no significant medical history.", "He does have a 33-pack-year smoking history and drinks 4 to 5 alcoholic drinks per day."], "Patient Symptoms": ["The patient has felt steadily more fatigued over the past month and has lost 22 pounds without effort.", "Today, he fainted prompting his presentation."], "Examination and Results": ["His temperature is 99.5\u00b0F (37.5\u00b0C), blood pressure is 100/58 mmHg, pulse is 100/min, respirations are 17/min, and oxygen saturation is 98% on room air.", "The patient is very thin and appears pale.", "Stool fecal occult blood testing is positive.", "A CT scan of the abdomen is performed demonstrating a mass in the colon with multiple metastatic lesions scattered throughout the abdomen."], "Diagnosis": ["The patient is informed of his diagnosis of metastatic colon cancer."], "Others": ["When the patient conveys the information to his family, he focuses his efforts on discussing the current literature in the field and the novel therapies that have been invented.", "He demonstrates his likely mortality outcome which he calculated using the results of a large multi-center study."]}
{"Patient Personal Background": ["He started taking fluoxetine 3 weeks ago when he was diagnosed with major depressive disorder after a divorce.", "His other medications include albuterol."], "Patient Symptoms": ["Since then, he notes that his symptoms are roughly unchanged.", "Physical exam reveals a depressed affect."], "Examination and Results": ["His temperature is 99.3\u00b0F (37.4\u00b0C), blood pressure is 132/88 mmHg, pulse is 77/min, respirations are 14/min, and oxygen saturation is 99% on room air.", "His neurologic exam is non-focal.", "A serum thyroid stimulating hormone (TSH) resulted from his last visit and is noted to be 4.8 \u00b5U/mL (normal: 0.5-5 \u00b5U/mL)."], "Diagnosis": ["He started taking fluoxetine 3 weeks ago when he was diagnosed with major depressive disorder after a divorce."]}
{"Patient Personal Background": ["The patient is otherwise healthy and has no other medical problems."], "Patient Symptoms": ["The symptoms began towards the end of running a marathon and persisted after finishing the race."], "Examination and Results": ["His temperature is 98.0\u00b0F (36.7\u00b0C), blood pressure is 105/71 mmHg, pulse is 113/min, respirations are 19/min, and oxygen saturation is 98% on room air.", "Physical exam reveals a distended and tender abdomen.", "A radiograph is performed as seen in Figure A."]}
{"Patient Symptoms": ["She states that she feels well apart from the discomfort of that sensation."], "Examination and Results": ["Her temperature is 97.9\u00b0F (36.6\u00b0C), blood pressure is 124/84 mmHg, pulse is 180/min, respirations are 22/min, and oxygen saturation is 98% on room air.", "An ECG is obtained as seen in Figure A."], "Treatment": ["After unsuccessful attempts at vagal maneuvers, the emergency physician administers an IV medication.", "The effect of the medication wears off in seconds."]}
{"Patient Personal Background": ["The patient works as a farmer and gardens in his spare time.", "He has a medical history of poorly managed type 2 diabetes mellitus and irritable bowel syndrome.", "His current medications include lisinopril, metformin, insulin, fiber supplements, and a multivitamin."], "Patient Symptoms": ["In addition, he complains of a cut on his scalp that is not seeming to heal."], "Examination and Results": ["On physical exam, there is a calm, obese gentleman.", "The patient's glucose journal reveals an average blood glucose of 175 mg/dL.", "His temperature is 98.8\u00b0F (37.1\u00b0C), blood pressure is 134/86 mmHg, pulse is 80/min, and respirations are 13/min.", "On inspection of the patient's scalp, the finding in Figure B is noted."], "Treatment": ["The patient is sent home and instructed to keep a blood glucose journal."], "Others": ["Inspection of the patient's scalp reveals the finding shown in Figure A.", "Three months later, the patient returns with his glucose journal."]}
{"Patient Personal Background": ["Aside from occasional shin splints, she has a relatively unremarkable medical history.", "She takes oral contraceptive pills and a multivitamin daily.", "Her periods have been regular, occurring once every 28 to 30 days with normal flow.", "She is sexually active with 2 partners, who use condoms routinely.", "Her prior pap smear was performed last year and was normal."], "Examination and Results": ["Her temperature is 36.7\u00b0C (98\u00b0F), blood pressure is 115/80 mmHg, pulse is 65/min, respirations are 12/min, and oxygen saturation is 100% on room air.", "Her physical exam is within normal limits."], "Others": ["All of her age appropriate immunizations are up to date.", "Her mother has diabetes and coronary artery disease, and her father passed away at age 45 after being diagnosed with colon cancer at age 40.", "Her grand-aunt underwent bilateral mastectomies after being diagnosed with breast cancer at age 60."]}
{"Patient Personal Background": ["The patient has a medical history of IV drug use, diabetes mellitus, oral cold sores, hypertension, renal failure, and dyslipidemia.", "The patient's current medications include lisinopril, atorvastain, insulin, and aspirin.", "Prior to the procedure, he was also on dialysis."], "Examination and Results": ["His temperature is 98.5\u00b0F (36.9\u00b0C), blood pressure is 121/76 mmHg, pulse is 70/min, and respirations are 13/min."], "Treatment": ["The previous day, the patient had a renal transplant from a matched donor.", "The patient is started on cyclosporine."], "Others": ["He is currently recovering and doing well.", "The patient successfully recovers over the next few days."]}
{"Patient Personal Background": ["He has a medical history of hypertension, glaucoma, and osteoarthritis in his left knee that requires him to walk with a cane.", "He takes hydrochlorothiazide, timolol eyedrops, and occasional acetaminophen."], "Patient Symptoms": ["The patient initially became less talkative than usual before starting to confuse her with her sister.", "The patient also could not remember what day of the week it was and he was out of groceries and likely had been for several days when visited.", "The patient is unable to provide a clear history.", "The patient is lethargic but arousable, oriented only to person, and disheveled."], "Examination and Results": ["His temperature is 98.5\u00b0 F (36.9\u00b0 C), blood pressure is 122/74 mmHg, pulse is 75/min, and respirations are 14/min.", "Neurologic exam reveals intact cranial nerves, 1+ deep tendon reflexes throughout, and 4/5 strength in all extremities.", "There is a 3 x 5 cm green-blue area of ecchymosis on the lateral aspect of his left knee.", "A CT of the head without contrast is performed and shown in Figure A."], "Others": ["While she was talking to him, he fell asleep and was difficult to rouse."]}
{"Patient Personal Background": ["The patient is a non-smoker and has a history of GERD for which she takes antacids."], "Patient Symptoms": ["She states she has had a cough for the past week.", "She also has abdominal pain and trouble focusing that has been worsening and has lost 5 pounds recently.", "Her gastroesophageal reflux disease (GERD) has been poorly controlled recently."], "Examination and Results": ["Her temperature is 98.6\u00b0F (37\u00b0C), blood pressure is 115/71 mmHg, pulse is 72/min, and respirations are 12/min.", "A physical exam is within normal limits."]}
{"Patient Personal Background": ["His medical history is significant for gastroesophageal reflux disease for which he takes omeprazole.", "He has no family history of neurologic disease."], "Patient Symptoms": ["He was normal until around 3 months ago when he started forgetting important meetings and misplacing items around the house.", "One month ago, the patient was fired from his job as a software engineer after attempting to grope a coworker.", "The patient expresses frustration that he is no longer able to concentrate enough to enjoy his hobby of solving puzzles."], "Examination and Results": ["His temperature is 98.6\u00b0F (37.0\u00b0C), blood pressure is 120/75 mmHg, pulse is 70/min, and respirations are 16/min.", "During the examination, the patient\u2019s cell phone rings unexpectedly causing the patient to suddenly jerk his arms and legs.", "Further diagnostic investigation is performed which reveals an elevated 14-3-3 protein on cerebrospinal fluid analysis."]}
{"Patient Personal Background": ["He was the driver in a head-on collision and was not wearing a seatbelt.", "His medical history is unknown."], "Patient Symptoms": ["The patient is acutely intoxicated and is attempting to attack the nurses."], "Examination and Results": ["His temperature is 97.6\u00b0F (36.4\u00b0C), blood pressure is 74/34 mmHg, pulse is 180/min, respirations are 32/min, and oxygen saturation is 98% on room air.", "Physical exam is notable for jugular venous distension.", "An electrocardiogram (ECG) is performed as seen in Figure A."], "Treatment": ["Soon after presentation, he is sedated, paralyzed, and intubated."]}
{"Patient Personal Background": ["The patient had a myocardial infarction 6 months ago, and she now has multiple drug-eluting stents.", "Her medical history is otherwise significant for rheumatoid arthritis and migraines.", "Her home medications include methotrexate, atorvastatin, clopidogrel, and aspirin."], "Patient Symptoms": ["She often feels lightheaded and like she may \u201cpass out\u201d but never actually loses consciousness."], "Examination and Results": ["Her temperature is 98.6\u00b0F (37\u00b0C), blood pressure is 118/75 mmHg, pulse is 92/min, and respirations are 12/min.", "On physical exam, she has an irregular heartbeat with normal cardiac sounds.", "Her abdomen is non-distended and she has mild lower extremity edema."], "Others": ["Her ECG upon discharge from that hospitalization was normal.", "Her current ECG can be seen in Figure A."]}
{"Patient Personal Background": ["He has a medical history of type 2 diabetes mellitus, hypertension, depression, obesity, and a myocardial infarction 7 years ago.", "The patient's prescribed medications are metoprolol, aspirin, lisinopril, hydrochlorothiazide, fluoxetine, metformin, and insulin.", "The patient has not been filling his prescriptions regularly and can not remember what medications he has been taking."], "Examination and Results": ["His temperature is 99.5\u00b0F (37.5\u00b0C), pulse is 96/min, blood pressure is 180/120 mmHg, respirations are 18/min, and oxygen saturation is 97% on room air."]}
{"Patient Personal Background": ["He has a medical history significant for hypertension that is well-controlled with lisinopril.", "He had an uncomplicated appendectomy when he was 23 years old.", "He has no family history of gastrointestinal malignancy."], "Patient Symptoms": ["He describes the blood as bright red wisps that float on the surface of the stool.", "He has no pain with bowel movements but notes on occasion he may strain.", "He does not endorse fatigue, fever, constipation, diarrhea, nausea, vomiting, abdominal pain, weight loss, or dyspnea."], "Examination and Results": ["His last colonoscopy was 3 years prior to presentation and was benign.", "His temperature is 98.6\u00b0F (37.0\u00b0C), blood pressure is 140/90 mmHg, pulse is 76/min, and respirations are 16/min.", "On physical exam, the patient's abdomen is soft, non-distended, and non-tender with normal bowel sounds and without organomegaly or masses.", "The anus is patent without fissures, hemorrhoids, or skin tags."]}
{"Patient Symptoms": ["Over the past 2 days, the patient\u2019s stools have become looser and streaked with blood.", "The patient has also regurgitated several of her feedings in the last few days.", "Neither the vomit nor bloody stools have seemed to bother the patient."], "Examination and Results": ["The patient is breastfed every 2-3 hours and voids 10-12 times daily.", "The patient\u2019s weight continues to trend along the 50th percentile.", "The patient\u2019s temperature is 98.4\u00b0F (36.9\u00b0C), blood pressure is 66/51 mmHg, pulse is 127/min, and respirations are 26/min.", "On physical exam, the patient appears well nourished and is cooing.", "Her abdomen is soft and non-tender.", "Physical exam reveals the finding seen in Figure A."], "Others": ["The patient previously had several soft stools per day that ranged in color from mustard yellow to dark green."]}
{"Patient Personal Background": ["He has experienced similar symptoms before."], "Patient Symptoms": ["Today, he was hit in the face with a football, followed by significant swelling of his lips and tongue.", "The patient speaks with a muffled voice."], "Examination and Results": ["His temperature is 98.1\u00b0F (36.7\u00b0C), blood pressure is 120/83 mmHg, pulse is 80/min, respirations are 16/min, and oxygen saturation is 98% on room air.", "Physical exam reveals swollen lips and a protruding, enlarged tongue.", "His breath sounds are clear."], "Others": ["He demonstrates no rash and his abdomen is soft and nontender."]}
{"Examination and Results": [], "Treatment": ["She is started on verapamil and instructed to exercise at 50% of her VO2 max while several cardiac parameters are being measured."]}
{"Patient Personal Background": ["The patient was born at 39 weeks and met all her developmental milestones.", "She is currently up to date on her vaccinations and did not have infections during early childhood.", "Her parents are divorced and her father has noted she does not seem to get sick when he takes care of her."], "Patient Symptoms": ["Her mother says that last night her daughter felt ill, and her condition has been worsening.", "Her daughter experienced a severe headache and had a stiff neck.", "This morning she was minimally responsive, vomited several times, and produced a small amount of dark cloudy urine.", "The patient was born at 39 weeks and met all her developmental milestones."], "Examination and Results": ["Her temperature is 99.5\u00b0F (37.5\u00b0C), blood pressure is 60/35 mmHg, pulse is 190/min, respirations are 33/min, and oxygen saturation is 98% on room air."], "Treatment": ["The patient is started on intravenous fluids, vasopressors, and broad-spectrum antibiotics."], "Others": ["She presented with similar symptoms 6 weeks ago and was treated for an Escherchia coli infection.", "She also was treated for a urinary tract infection 10 weeks ago."]}
{"Patient Personal Background": ["She was born at 38-weeks gestational age without complications.", "Her medications consist of lamotrigine and valproic acid."], "Patient Symptoms": ["Her parents have noticed the patient occasionally stiffens and spreads her arms at home."], "Examination and Results": ["She recently underwent a neurology evaluation which revealed hypsarrhythmia on electroencephalography (EEG) with a mix of slow waves, multifocal spikes, and asynchrony.", "Her temperature is 98.3\u00b0F (36.8\u00b0C), blood pressure is 90/75 mmHg, pulse is 94/min, and respirations are 22/min.", "Physical exam reveals innumerable hypopigmented macules on the skin and an irregularly shaped, thickened, and elevated plaque on the lower back."], "Treatment": ["Her medications consist of lamotrigine and valproic acid."], "Others": ["She has no other medical problems."]}
{"Patient Personal Background": ["He has a diet high in refined carbohydrates and has gained 20 pounds since starting high school."], "Patient Symptoms": ["The patient has had lesions on his face that have persisted since he was 13 years of age."], "Examination and Results": ["Physical exam is notable for the findings in Figure A."], "Treatment": ["The patient is started on benzoyl peroxide and topical retinoids."]}
{"Patient Personal Background": ["Her medical problems consist of heart failure for which she takes furosemide, spironolactone, and metoprolol, which were continued at admission."], "Patient Symptoms": ["The headache started suddenly while she was eating dinner and she says it feels like the \u201cworst headache of my life.\u201d An emergent CT scan of the head without contrast confirms the diagnosis, and a CT angiogram identifies the source of bleeding.", "On hospital day 3, she is found to be disoriented to person, place, and time.", "She also develops nausea and vomiting."], "Examination and Results": ["Her temperature is 99.6\u00b0F (37.6\u00b0C), blood pressure is 100/60 mmHg, pulse is 112/min, and respirations are 16/min.", "Physical examination shows poor skin turgor.", "Capillary refill time is 4 seconds.", "Serum laboratory results are shown below: Na+: 120 mEq/L Cl-: 92 mEq/L K+: 3.9 mEq/L HCO3-: 26 mEq/L BUN: 32 mg/dL Creatinine: 1.0 mg/dL Serum osmolality is 265 mEq/L and urine osmolality is 340 mEq/L."], "Treatment": ["The patient undergoes surgical management of her condition."], "Diagnosis": ["The headache started suddenly while she was eating dinner and she says it feels like the \u201cworst headache of my life.\u201d An emergent CT scan of the head without contrast confirms the diagnosis, and a CT angiogram identifies the source of bleeding."]}
{"Patient Personal Background": ["The patient was born at 39 weeks via vaginal delivery to a G1P1 29-year-old woman."], "Patient Symptoms": ["The patient has been breastfeeding and producing 5 stools/day."], "Examination and Results": ["His temperature is 99.5\u00b0F (37.5\u00b0C), blood pressure is 60/38 mmHg, pulse is 150/min, respirations are 24/min, and oxygen saturation is 98% on room air.", "A cardiopulmonary exam is notable for a benign flow murmur.", "A musculoskeletal exam reveals the findings shown in Figure A."], "Others": ["He is otherwise healthy."]}
{"Patient Personal Background": ["The patient was born at 38 weeks gestation via Caesarean section for cervical incompetence."], "Patient Symptoms": ["The child had a runny nose and cough for a few days last week.", "The patient\u2019s mother endorses decreased appetite during the aforementioned illness which has now returned to baseline."], "Examination and Results": ["On physical exam, the patient has scleral icterus and dark urine staining her diaper."], "Others": ["The patient\u2019s mother has no complaints.", "The patient\u2019s family history is significant for an older brother with glucose-6-phosphate dehydrogenase (G6PD) deficiency and a maternal uncle with cirrhosis secondary to chronic hepatitis B."]}
{"Patient Personal Background": ["The patient was born at 39 weeks of gestation to a 30-year-old primigravid via vaginal delivery.", "The patient\u2019s mother received routine prenatal care and the pregnancy was uncomplicated.", "The patient\u2019s anatomy ultrasound at 20 weeks of gestation was unremarkable.", "The patient\u2019s mother denies any family history of genetic diseases."], "Patient Symptoms": ["The patient\u2019s APGAR scores were notable for poor muscle tone at both 1 and 5 minutes of life."], "Examination and Results": ["The patient\u2019s birth weight is 2.6 kg (5 lb 11 oz), which is at the 5th percentile.", "His height and head circumference are in the 15th and 3rd percentile, respectively.", "His temperature is 97.1\u00b0F (36.2\u00b0C), blood pressure is 57/42 mmHg, pulse is 140/min, and respirations are 38/min.", "On physical exam, the patient has a wide nasal bridge, down slanting palpebral fissures, and widely spaced eyes."], "Others": ["He has good respiratory effort with a high-pitched cry."]}
{"Patient Personal Background": ["The patient has a medical history of diabetes.", "He drinks 2-7 alcoholic drinks per day and has smoked 2 packs of cigarettes per day since he was 25.", "The patient uses anabolic steroids."], "Patient Symptoms": ["The patient states he has experienced these symptoms for a few weeks; however, today his hand felt so weak he dropped his cup of tea.", "He has lost 17 pounds since he last came to the emergency department 1 month ago.", "The patient states that he is experiencing a dull aching and burning pain in his right arm during the exam."], "Examination and Results": ["His temperature is 99.5\u00b0F (37.5\u00b0C), blood pressure is 177/108 mmHg, pulse is 90/min, respirations are 17/min, and oxygen saturation is 98% on room air.", "Physical exam reveals decreased sensation in the right arm and 2/5 strength in the right arm and 5/5 strength in in the left arm."], "Others": ["Symptoms are not changed with changes in head and neck position."]}
{"Patient Personal Background": ["The patient has a medical history of diabetes.", "He drinks 2-7 alcoholic drinks per day and has smoked 2 packs of cigarettes per day since he was 25.", "The patient uses anabolic steroids."], "Patient Symptoms": ["The patient states he has experienced these symptoms for a few weeks; however, today his hand felt so weak he dropped his cup of tea.", "He has lost 17 pounds since he last came to the emergency department 1 month ago.", "The patient states that he is experiencing a dull aching and burning pain in his right arm during the exam."], "Examination and Results": ["His temperature is 99.5\u00b0F (37.5\u00b0C), blood pressure is 177/108 mmHg, pulse is 90/min, respirations are 17/min, and oxygen saturation is 98% on room air.", "Physical exam reveals decreased sensation in the right arm and 2/5 strength in the right arm and 5/5 strength in in the left arm."], "Others": ["Symptoms are not changed with changes in head and neck position."]}
{"Patient Personal Background": ["The patient has a medical history of obesity, diabetes, diabetic nephropathy, hypertension, and a 40-pack-year smoking history.", "His current medications include atorvastatin, lisinopril, insulin, metformin, and nicotine gum."], "Patient Symptoms": ["He was riding the train home from a business conference when his symptoms began.", "The patient's right lower extremity appears mildly inflamed, and palpation of the calf elicits pain."], "Examination and Results": ["His temperature is 99.5\u00b0F (37.5\u00b0C), blood pressure is 130/87 mmHg, pulse is 120/min, respirations are 15/min, and oxygen saturation is 93% on room air.", "An ECG is ordered as seen in Figure A.", "A chest radiograph is ordered as seen in Figure B.", "Laboratory values are ordered as seen below: Serum: Na+: 137 mEq/L Cl-: 105 mEq/L K+: 4.1 mEq/L HCO3-: 24 mEq/L BUN: 22 mg/dL Glucose: 129 mg/dL Creatinine: 1.2 mg/dL Ca2+: 10.1 mg/dL AST: 11 U/L ALT: 12 U/L On physical exam, the patient appears to be in distress.", "His cardiac exam is notable for tachycardia.", "Pulmonary exam reveals bilateral air movement without any wheezes or crackles."]}
{"Patient Personal Background": ["He has a family history of skin cancer, colon cancer, and ovarian cancer.", "The patient has a medical history of asthma and seasonal allergies."], "Patient Symptoms": ["He is concerned about a rash that does not seem to be improving.", "He was recently exposed to his grandfather who has vesicular lesions on his skin and is being treated."], "Examination and Results": ["His temperature is 98.6\u00b0F (37.0\u00b0C), blood pressure is 137/98 mmHg, pulse is 90/min, respirations are 14/min, and oxygen saturation is 98% on room air.", "Physical exam reveals the finding in Figure A."]}
{"Patient Personal Background": ["His medical problems include hypertension, hyperlipidemia, hypothyroidism, and chronic neck pain for which he takes amlodipine, hydrochlorothiazide, atorvastatin, levothyroxine, and duloxetine.", "Surgical history consists of posterior lumbar fusion and elective left total hip arthroplasty.", "He has a 90-pack-year smoking history and quit 10 years ago."], "Patient Symptoms": ["He reports these symptoms started intermittently in the middle finger after returning from a golfing trip but has progressed to being nearly constant.", "The thenar eminence, thumb, and other digits are spared.", "He reports no other symptoms."], "Examination and Results": ["The patient\u2019s temperature is 99.6\u00b0F (37.6\u00b0C), blood pressure is 134/80 mmHg, pulse is 90/min, and respirations are 16/min.", "Physical exam reveals 4/5 strength in elbow extension and wrist flexion on the right.", "He has 5/5 strength in the remainder of the motor exam on the right upper extremity and on the left upper extremity.", "The triceps reflex is 1+ on the right compared to 2+ on the left.", "There is no spasticity.", "His neck pain, which radiates down his right arm, is reproduced with axial loading during neck extension with simultaneous rightward rotation and lateral bending."]}
{"Patient Personal Background": ["Her medical problems consist of heart failure for which she takes furosemide, spironolactone, and metoprolol, which were continued at admission."], "Patient Symptoms": ["The headache started suddenly while she was eating dinner and she says it feels like the \u201cworst headache of my life.\u201d An emergent CT scan of the head without contrast confirms the diagnosis, and a CT angiogram identifies the source of bleeding.", "On hospital day 3, she is found to be disoriented to person, place, and time.", "She also develops nausea and vomiting."], "Examination and Results": ["Her temperature is 99.6\u00b0F (37.6\u00b0C), blood pressure is 100/60 mmHg, pulse is 112/min, and respirations are 16/min.", "Physical examination shows poor skin turgor.", "Capillary refill time is 4 seconds.", "Serum laboratory results are shown below: Na+: 120 mEq/L Cl-: 92 mEq/L K+: 3.9 mEq/L HCO3-: 26 mEq/L BUN: 32 mg/dL Creatinine: 1.0 mg/dL Serum osmolality is 265 mEq/L and urine osmolality is 340 mEq/L.", "Urine sodium is 44 mEq/L."], "Treatment": ["The patient undergoes surgical management of her condition."]}
{"Patient Personal Background": ["His medical problems include hypertension, diabetes, and hyperlipidemia for which he takes lisinopril, metformin, and atorvastatin.", "He has 3-5 drinks of scotch per night before working on his car."], "Patient Symptoms": ["His wife has noticed a tremor while he is working on his car and knows that his father died of Parkinson disease.", "He says that the tremor is nothing to worry about and only occurs during a few activities such as pouring drinks, pointing the remote at the television, or fixing his car."], "Examination and Results": ["On physical exam, the tremor is replicated during finger to nose testing.", "Romberg sign is negative.", "Cranial nerves II-XII are intact.", "The rest of the exam is benign."], "Others": ["The patient states his wife is just overreacting."]}
{"Patient Symptoms": ["She was found on the floor of her apartment after her neighbor called 911.", "She is confused and is unable to provide any history, but complains of generalized pain."], "Examination and Results": ["Her temperature is 99.2\u00b0F (37.3\u00b0C), blood pressure is 129/64 mmHg, pulse is 63/min, respirations are 13/min, and oxygen saturation is 99% on room air.", "Physical exam reveals, a confused, ill-appearing woman.", "Lungs are clear to auscultation bilaterally.", "An electrocardiogram is obtained as shown in Figure A. Dipstick urinalysis is notable for 4+ blood and dark colored urine."]}
{"Patient Personal Background": ["The patient works as a farmer and has no concerns about his health.", "He has a medical history of hypertension and obesity.", "His current medications include lisinopril and metoprolol."], "Examination and Results": ["His temperature is 99.5\u00b0F (37.5\u00b0C), blood pressure is 177/108 mmHg, pulse is 90/min, respirations are 17/min, and oxygen saturation is 98% on room air.", "Physical exam is notable for a murmur after S2 over the left sternal border.", "The patient demonstrates a stable gait and 5/5 strength in his upper and lower extremities."]}
{"Patient Personal Background": ["The patient has a medical history of asthma and seasonal allergies."], "Patient Symptoms": ["He is concerned about a rash that does not seem to be improving."], "Examination and Results": ["His temperature is 98.6\u00b0F (37.0\u00b0C), blood pressure is 137/98 mmHg, pulse is 90/min, respirations are 14/min, and oxygen saturation is 98% on room air.", "Physical exam reveals the finding in Figure A."], "Others": ["He was recently exposed to his grandfather who has vesicular lesions on his skin and is being treated.", "He has a family history of skin cancer, colon cancer, and ovarian cancer."]}
{"Patient Personal Background": ["The patient\u2019s older sister had her first period at age 14.", "The mother had her first period at age 13.", "The patient reports she is doing well in school and is on the varsity basketball team.", "Her medical history is significant for asthma and atopic dermatitis.", "Her medications include albuterol and topical triamcinolone."], "Examination and Results": ["Her temperature is 98\u00b0F (36.7\u00b0C), blood pressure is 111/72 mmHg, pulse is 65/min, and respirations are 14/min with an oxygen saturation of 99% on room air.", "Her body mass index (BMI) is 19 kg/m^2.", "Physical exam shows absent breast development and external genitalia at Tanner stage 1.", "Serum follicle-stimulating hormone (FSH) level is measured to be 38 mIU/mL."], "Treatment": ["Her medications include albuterol and topical triamcinolone."]}
{"Patient Personal Background": ["The patient has a medical history of blepharitis treated with eye cleansing and squamous cell carcinoma of the skin treated with Mohs surgery."], "Patient Symptoms": ["He has felt a mass in his eye that has persisted for the past month."], "Examination and Results": ["His temperature is 99.5\u00b0F (37.5\u00b0C), blood pressure is 157/102 mmHg, pulse is 90/min, respirations are 17/min, and oxygen saturation is 98% on room air.", "Physical exam is notable for a firm and rubbery nodule palpable inside the patient's left eyelid.", "Physical exam does not elicit any pain."]}
{"Patient Personal Background": ["He has a medical history of anxiety, diabetes, a fracture of his foot sustained when he tripped, and a recent cold that caused him to miss work for 1 week.", "His current medications include metformin, insulin, buspirone, vitamin D, calcium, and sodium docusate."], "Patient Symptoms": ["In general, he has been in good health; however, he recently has experienced weight loss, abdominal pain, and general fatigue."], "Examination and Results": ["His temperature is 99.5\u00b0F (37.5\u00b0C), blood pressure is 150/100 mmHg, pulse is 90/min, respirations are 18/min, and oxygen saturation is 98% on room air.", "Physical exam reveals a calm gentleman.", "A mild systolic murmur is heard in the left upper sternal region.", "The rest of the physical exam is within normal limits.", "Laboratory values are ordered as seen below."]}
{"Patient Personal Background": ["His medical history is significant for type 2 diabetes mellitus, hypertension, and hyperlipidemia.", "His current medications include metformin, atorvastatin, and lisinopril."], "Patient Symptoms": ["He was having dinner at home with his wife when he suddenly noticed he had difficulty eating and speaking.", "He also noticed a new-onset weakness on his left side."], "Examination and Results": ["His temperature is 98.6\u00b0F (37\u00b0C), blood pressure is 130/80 mmHg, pulse is 70/min, and respirations are 15/min.", "On examination, strength is 5/5 in the right upper and lower extremities and 3/5 in the left upper and lower extremities.", "On cranial nerve examination, his tongue deviates to the right side.", "There is also decreased sensation to light touch and vibration on the left side of his body."]}
{"Patient Personal Background": ["He is back to playing basketball for his school team without any difficulty."], "Patient Symptoms": ["The patient denies any abdominal pain, fevers, chills, nausea, vomiting, diarrhea, or constipation.", "His urine appears more amber than usual but he suspects dehydration."], "Examination and Results": ["His temperature is 98.6\u00b0F (37\u00b0C), blood pressure is 110/70 mmHg, pulse is 76/min, and respirations are 15/min.", "His physical exam is unremarkable.", "The laparoscopic incision sites are all clean without erythema.", "Urine: Epithelial cells: Scant Glucose: Negative Protein: 3+ WBC: 3/hpf Bacteria: None Leukocyte esterase: Negative Nitrites: Negative The patient is told to return in 3 days for a follow-up appointment; however, his urinalysis at that time is similar."], "Others": ["He eats solids and drinks liquids without difficulty.", "The pediatrician orders a urinalysis, which is notable for the following."]}
{"Patient Personal Background": ["The patient has a medical history of a suicide attempt and alcohol abuse.", "He is not currently taking any medications.", "The patient admits to using heroin and cocaine and drinking 5-8 alcoholic drinks per day.", "His temperature is 103\u00b0F (39.4\u00b0C), blood pressure is 92/59 mmHg, pulse is 110/min, respirations are 20/min, and oxygen saturation is 96% on room air."], "Patient Symptoms": ["The patient has felt unwell for the past week and has felt subjectively febrile."], "Examination and Results": ["Cardiopulmonary exam is notable for a systolic murmur heard best along the left sternal border.", "Dermatologic exam reveals scarring in the antecubital fossa.", "IV fluids are administered and the blood pressure is subsequently 120/70 mmHg."], "Treatment": []}
{"Patient Personal Background": ["He has no health concerns and has not seen a physician in years.", "The patient has a medical history of depression treated with fluoxetine and lithium."], "Examination and Results": ["His temperature is 99.5\u00b0F (37.5\u00b0C), blood pressure is 122/78 mmHg, pulse is 90/min, respirations are 13/min, and oxygen saturation is 98% on room air.", "Physical exam is notable for the finding in Figure A."]}
{"Patient Personal Background": ["He has a medical history of asthma."], "Patient Symptoms": ["His symptoms started last night and have persisted.", "He occasionally has migraine headaches, but he has not had a headache like this in the past.", "He reports associated nausea, vomiting, fevers, and neck pain."], "Examination and Results": ["His temperature is 100.4\u00b0F (38.0\u00b0C), blood pressure is 110/60 mmHg, pulse is 95/min, respirations are 17/min, and oxygen saturation is 98% on room air.", "On physical exam, he appears uncomfortable.", "Neurologic exam reveals no focal deficits.", "There is pain with passive neck flexion.", "No edema or rashes are noted.", "Lungs are clear to auscultation bilaterally."], "Treatment": ["Lumbar puncture is performed and CSF results are obtained as shown below."]}
{"Patient Symptoms": ["She has felt tired and unwilling to engage in any activities lately.", "She states that her limbs feel heavy all the time and that completing any activity takes tremendous effort.", "She no longer finds any happiness in activities that she previously enjoyed.", "She struggles to sleep and at times can't sleep for several days.", "She returns 1 week later stating that her symptoms have not improved.", "She is requesting help as her performance at work and school is suffering."], "Examination and Results": ["Her temperature is 99.5\u00b0F (37.5\u00b0C), blood pressure is 115/72 mmHg, pulse is 60/min, respirations are 13/min, and oxygen saturation is 98% on room air."], "Treatment": ["The patient is started on appropriate first-line therapy and sent home."]}
{"Patient Personal Background": ["He has a medical history of obesity and anxiety and is not currently taking any medications."], "Examination and Results": ["His temperature is 104\u00b0F (40\u00b0C), blood pressure is 147/88 mmHg, pulse is 200/min, respirations are 33/min, and oxygen saturation is 99% on room air.", "Physical exam reveals dry mucous membranes, hot flushed skin, and inappropriate responses to the physician's questions.", "Laboratory values are ordered as seen below."]}
{"Patient Symptoms": ["She was found on the floor of her apartment after her neighbor called 911.", "She is confused and is unable to provide any history, but complains of generalized pain."], "Examination and Results": ["Her temperature is 99.2\u00b0F (37.3\u00b0C), blood pressure is 129/64 mmHg, pulse is 63/min, respirations are 13/min, and oxygen saturation is 99% on room air.", "Physical exam reveals, a confused, ill-appearing woman.", "Lungs are clear to auscultation bilaterally.", "An electrocardiogram is obtained as shown in Figure A. Dipstick urinalysis is notable for 4+ blood and dark colored urine."]}
{"Patient Personal Background": ["His medical history is otherwise notable for hypertension and hyperlipidemia.", "His only home medication is pravastatin.", "The patient smokes half a pack per day of cigarettes and drinks 2-3 beers throughout the day.", "His family history is significant for Parkinson disease in his father."], "Patient Symptoms": ["For the last several years he has noticed this \"shaking\" when he brushes his teeth and prepares a cup of coffee in the morning.", "The shaking then gradually improves over the course of the day."], "Examination and Results": ["On physical exam, his temperature is 98.6\u00b0F (37.0\u00b0C), blood pressure is 159/84, pulse is 74/min, and respirations are 12/min.", "He has a high-frequency bilateral hand tremor elicited on finger-to-nose testing."]}
{"Patient Personal Background": ["She denies any recent travel, new sexual partners, or antibiotic use."], "Examination and Results": ["Physical examination reveals multiple clustered vesicles and shallow ulcers in the vulvar region.", "A Tzanck smear shows multinucleated giant cells."]}
{"Patient Personal Background": ["He recently returned from summer camp.", "He has no significant medical history and takes no medications."], "Patient Symptoms": ["He has had headache and fever for the last 2 days, and this morning he was confused and had difficulty answering questions.", "He also developed a rash this morning."], "Examination and Results": ["His temperature is 104\u00b0F (40\u00b0C), pulse is 120/min, blood pressure is 105/60 mmHg, and respirations are 22/min.", "On exam, flexion of the neck causes flexion of the hips and knees.", "Fundoscopic exam reveals no papilledema."], "Others": ["Examination of the patient's rash is shown in Figure A."]}
{"Patient Personal Background": ["The patient lives alone and drinks 7 alcoholic beverages per day and smokes 1-2 packs of cigarettes per day for the past 40 years."], "Patient Symptoms": ["He has felt very weak every morning with his symptoms persisting throughout the day.", "He notes minor improvement when he rides his bike but otherwise has not noticed any change in his symptoms with rest or ibuprofen use.", "The patient has lost 12 pounds recently and has had a chronic cough."], "Examination and Results": ["His temperature is 99.5\u00b0F (37.5\u00b0C), blood pressure is 177/108 mmHg, pulse is 93/min, respirations are 17/min, and oxygen saturation is 92% on room air.", "A chest radiograph is ordered as seen in Figure A."]}
{"Patient Personal Background": ["The patient lives in a foster home and has been admitted many times.", "The patient is in the 25th percentile for height and weight which has been constant since birth.", "The patient has a history of tricuspid stenosis."], "Patient Symptoms": ["Since birth, the patient has had repeated episodes of pain/pressure over her frontal sinuses and a chronic cough that produces mucus."], "Examination and Results": ["Her temperature is 99.5\u00b0F (37.5\u00b0C), blood pressure is 90/58 mmHg, pulse is 120/min, respirations are 18/min, and oxygen saturation is 94% on room air.", "Physical exam is notable for bruises along the patient's shins which the guardians state are from playing soccer."], "Treatment": ["She was recently treated with amoxicillin for an infection."], "Others": ["Her guardians state that the patient has normal bowel movements and has been gaining weight appropriately.", "The rest of the exam is deferred because the patient starts crying."]}
{"Patient Personal Background": ["He has a medical history of hypertension, diabetes, and obesity."], "Patient Symptoms": ["On the 2nd day of his hospitalization, the patient has abdominal pain.", "He is requesting pain medication for his abdominal pain."], "Examination and Results": ["His temperature is 98.6\u00b0F (37.0\u00b0C), blood pressure is 177/118 mmHg, pulse is 127/min, respirations are 11/min, and oxygen saturation is 98% on room air.", "An ECG is performed and notable for ST elevation in leads II, III, and aVF.", "His serum lipase is 272 U/L and his creatinine is 1.6 mg/dL.", "A physical exam is notable for the finding in Figure A."], "Treatment": ["The patient is treated appropriately and transferred to the medical floor."]}
{"Patient Personal Background": ["He denies any recent travel or sick contacts and infrequently smokes cigarettes.", "Approximately 5 weeks ago, he presented with similar symptoms and was found to have a right upper lobe lung infiltrate, a CD4 count of 40/mm^3, and an HIV viral load of 115,000 copies/mL."], "Patient Symptoms": ["For the last week, his cough has been progressively worsening, and he has been noticing blood in his sputum."], "Examination and Results": ["His temperature today is 102\u00b0F (38.9\u00b0C), blood pressure is 130/90 mmHg, pulse is 100/min, and respirations are 20/min.", "A radiograph of the chest demonstrates new nodules in the left upper lobe and hilar adenopathy."], "Treatment": ["He was appropriately treated and discharged home."]}
{"Patient Personal Background": ["He has a medical history of hypertension, diabetes, and obesity."], "Patient Symptoms": ["On the 2nd day of his hospitalization, the patient has abdominal pain.", "He is requesting pain medication for his abdominal pain."], "Examination and Results": ["His temperature is 98.6\u00b0F (37.0\u00b0C), blood pressure is 177/118 mmHg, pulse is 127/min, respirations are 11/min, and oxygen saturation is 98% on room air.", "An ECG is performed and notable for ST elevation in leads II, III, and aVF.", "His serum lipase is 272 U/L and his creatinine is 1.6 mg/dL."], "Treatment": ["The patient is treated appropriately and transferred to the medical floor."], "Others": ["A physical exam is notable for the finding in Figure A."]}
{"Patient Personal Background": ["The patient\u2019s medical history is significant for depression.", "She was recently switched from phenelzine to fluoxetine."], "Patient Symptoms": ["When he said her name or waved his hand in front of her, she did not respond.", "When he tried to move her, she would remain in whatever position she was placed.", "She resists any attempt to change her position.", "The patient remains mute and ignores any external stimuli."], "Examination and Results": ["Her temperature is 99\u00b0F (37.2\u00b0C), blood pressure is 122/79 mmHg, pulse is 68/min, and respirations are 12/min with an oxygen saturation of 98% on room air."], "Others": ["The patient is lying on the bed with her left arm raised and pointing at the ceiling."]}
{"Patient Personal Background": ["She works as a mail carrier and is nearing retirement.", "She has a medical history of anxiety, depression, irritable bowel syndrome, and dysmenorrhea.", "She is not currently taking any medications."], "Patient Symptoms": ["When she goes to bed at night, she has an urge to get up out of bed and walk around.", "The patient often wakes her husband when she does this which irritates him.", "There is a perpetual uneasiness and feeling of a need to move at night which is relieved by getting up and walking around.", "The patient denies symptoms during the day."], "Examination and Results": ["Her temperature is 99.5\u00b0F (37.5\u00b0C), blood pressure is 157/98 mmHg, pulse is 80/min, respirations are 17/min, and oxygen saturation is 98% on room air.", "Physical exam reveals 5/5 strength in the upper and lower extremities, 2+ reflexes in the upper and lower extremities, a stable gait pattern, and normal sensation.", "Cardiopulmonary and abdominal exams are within normal limits."]}
{"Patient Symptoms": ["He wakes up screaming in pain due to an electrocardiogram lead having caused a significant thermal burn circumferentially around his left leg.", "Overnight, the nurse continued to increase the patient's midazolam infusion rate, but she also noticed that his left toes were cold to the touch with significant edema."], "Examination and Results": ["His temperature is now 100\u00b0F (37.8\u00b0C), blood pressure is 110/75 mmHg, pulse is 80/min, respirations are 10/min and oxygen saturation is 95% on 2 liters nasal cannula.", "No dorsalis pedis or posterior tibial pulses are detected on the left lower extremity.", "A delta pressure of 25 mmHg is obtained in the left leg."], "Treatment": ["He is admitted to the medical intensive care unit for continuous electroencephalogram monitoring while on a midazolam infusion for seizure suppression and supportive care for his burn.", "Overnight, the nurse continued to increase the patient's midazolam infusion rate, but she also noticed that his left toes were cold to the touch with significant edema."]}
{"Patient Personal Background": ["He has no known medical history and takes no medications."], "Patient Symptoms": ["The pain starts in his chest and moves into his back, arms, and abdomen.", "He describes the pain as tearing."], "Examination and Results": ["His temperature is 37.0\u00b0C (98.6\u00b0F), pulse is 130/min, blood pressure is 210/145 mmHg, respirations are 22/min, and pulse oximetry is 98% on room air.", "Exam reveals a diaphoretic, anxious-appearing man.", "Pulses are diminished over the left wrist when compared to the right.", "A chest radiograph is obtained as shown in Figure A."]}
{"Patient Symptoms": ["She had a headache that was present for a few hours before subsiding 2 days ago, and then today she developed a headache that was sudden in onset and at maximal intensity within minutes.", "She has never had a headache like this in the past."], "Examination and Results": ["Her temperature is 99.0\u00b0F (37.2\u00b0C), blood pressure is 157/99 mmHg, pulse is 90/min, respirations are 16/min, and oxygen saturation is 99% on room air.", "On exam, she has pain with passive and active movement of the neck.", "No focal neurologic deficits are appreciated.", "A non-contrast head CT is obtained as shown in Figure A."]}
{"Patient Personal Background": ["She was born at 38-weeks gestational age without complications.", "Her medications consist of lamotrigine and valproic acid."], "Patient Symptoms": ["Her parents have noticed the patient occasionally stiffens and spreads her arms at home."], "Examination and Results": ["She recently underwent a neurology evaluation which revealed hypsarrhythmia on electroencephalography (EEG) with a mix of slow waves, multifocal spikes, and asynchrony.", "Her temperature is 98.3\u00b0F (36.8\u00b0C), blood pressure is 90/75 mmHg, pulse is 94/min, and respirations are 22/min.", "Physical exam reveals innumerable hypopigmented macules on the skin and an irregularly shaped, thickened, and elevated plaque on the lower back."], "Others": ["She has no other medical problems."]}
{"Patient Personal Background": ["The patient has not seen a physician in 30 years and recalls being current on most of his vaccinations.", "A few years ago, he went to the emergency department due to abdominal pain and was found to have increased liver enzymes due to excessive alcohol use and incidental gallstones.", "The patient has a 50 pack-year smoking history.", "His temperature is 99.5\u00b0F (37.5\u00b0C), blood pressure is 161/108 mmHg, pulse is 90/min, respirations are 17/min, and oxygen saturation is 95% on room air."], "Patient Symptoms": ["For the past several months, he has felt progressively weaker and has lost 25 pounds with intermittent abdominal pain."], "Examination and Results": ["Physical exam reveals an emaciated man.", "The patient has a negative Murphy sign and his abdomen is non-tender.", "Cardiopulmonary exam is within normal limits."]}
{"Patient Personal Background": ["He has a medical history of asthma."], "Patient Symptoms": ["His symptoms started last night and have persisted.", "He occasionally has migraine headaches, but he has not had a headache like this in the past.", "He reports associated nausea, vomiting, fevers, and neck pain."], "Examination and Results": ["His temperature is 100.4\u00b0F (38.0\u00b0C), blood pressure is 110/60 mmHg, pulse is 95/min, respirations are 17/min, and oxygen saturation is 98% on room air.", "On physical exam, he appears uncomfortable.", "Neurologic exam reveals no focal deficits.", "There is pain with passive neck flexion.", "No edema or rashes are noted.", "Lungs are clear to auscultation bilaterally."], "Treatment": ["Lumbar puncture is performed and CSF results are obtained as shown below."]}
{"Patient Personal Background": ["He denies any recent travel or sick contacts and infrequently smokes cigarettes.", "Approximately 5 weeks ago, he presented with similar symptoms and was found to have a right upper lobe lung infiltrate, a CD4 count of 40/mm^3, and an HIV viral load of 115,000 copies/mL."], "Patient Symptoms": ["For the last week, his cough has been progressively worsening, and he has been noticing blood in his sputum."], "Examination and Results": ["His temperature today is 102\u00b0F (38.9\u00b0C), blood pressure is 130/90 mmHg, pulse is 100/min, and respirations are 20/min.", "A radiograph of the chest demonstrates new nodules in the left upper lobe and hilar adenopathy."], "Others": ["He was appropriately treated and discharged home.", "Four weeks after initiation of treatment, his CD4 count was over 400/mm^3 and HIV viral load was negligible."]}
{"Patient Personal Background": ["The patient has a medical history of diabetes mellitus that is well-controlled with insulin and metformin.", "She has been admitted multiple times for hypoglycemia secondary to missing meals."], "Patient Symptoms": ["She feels fatigued, depressed, and has gained 10 pounds which she attributes to feeling too weak to go to the gym.", "She was recently treated for an ear infection with an antibiotic which she completed 3 weeks ago, and experienced a rash which she believes was an allergic reaction to her treatment."], "Examination and Results": ["Her temperature is 99.5\u00b0F (37.5\u00b0C), blood pressure is 127/68 mmHg, pulse is 80/min, respirations are 17/min, and oxygen saturation is 98% on room air.", "Physical exam is notable for 2/5 strength in the patient's upper and lower extremities, sparse fine hair on her body, and a rash on her face and arms.", "Serum: Na+: 139 mEq/L K+: 3.3 mEq/L Cl-: 100 mEq/L HCO3-: 25 mEq/L BUN: 20 mg/dL Glucose: 70 mg/dL Creatinine: 1.1 mg/dL Ca2+: 10.2 mg/dL AST: 12 U/L ALT: 10 U/L A muscle biopsy is obtained as seen in Figure A."], "Others": ["Laboratory values are ordered as seen below."]}
{"Patient Personal Background": ["She was in her usual state of health until 6 weeks ago when she was hospitalized for bacterial pneumonia."], "Patient Symptoms": ["Her father reports that she seems \u201cback to normal.\u201d She can roll over by herself and can sit up without support.", "She often babbles but sometimes does make identifiable sounds like \u201cdada\u201d and \u201cbaba.\u201d They recently started feeding her mushy cereal, which she seems to like but occasionally spits up.", "She has started teething and sometimes becomes \u201cfussy.\u201d Vital signs are within normal limits."], "Examination and Results": ["A physical examination is unremarkable.", "The patient\u2019s father brought a 4-week follow-up chest radiograph taken at the hospital, as shown in Figure A."], "Treatment": ["She received amoxicillin and had a resolution of her symptoms."]}
{"Patient Personal Background": ["The patient is otherwise healthy and has no other medical problems."], "Patient Symptoms": ["The symptoms began towards the end of running a marathon and persisted after finishing the race.", "Physical exam reveals a distended and tender abdomen."], "Examination and Results": ["His temperature is 98.0\u00b0F (36.7\u00b0C), blood pressure is 105/71 mmHg, pulse is 113/min, respirations are 19/min, and oxygen saturation is 98% on room air.", "A radiograph is performed as seen in Figure A."]}
{"Patient Personal Background": ["His medical history is significant for gastroesophageal reflux disease for which he takes omeprazole.", "He has no family history of neurologic disease."], "Patient Symptoms": ["He was normal until around 3 months ago when he started forgetting important meetings and misplacing items around the house.", "One month ago, the patient was fired from his job as a software engineer after attempting to grope a coworker.", "The patient expresses frustration that he is no longer able to concentrate enough to enjoy his hobby of solving puzzles."], "Examination and Results": ["His temperature is 98.6\u00b0F (37.0\u00b0C), blood pressure is 120/75 mmHg, pulse is 70/min, and respirations are 16/min.", "During the examination, the patient\u2019s cell phone rings unexpectedly causing the patient to suddenly jerk his arms and legs.", "Further diagnostic investigation is performed which reveals an elevated 14-3-3 protein on cerebrospinal fluid analysis."]}
{"Patient Personal Background": ["The patient has a medical history of poorly managed diabetes, constipation, anxiety, dyslipidemia, and hypertension."], "Patient Symptoms": ["He decided to come in when his symptoms worsened.", "He feels that his symptoms are exacerbated with large fatty meals and when he drinks alcohol."], "Examination and Results": ["His temperature is 99.5\u00b0F (37.5\u00b0C), blood pressure is 197/128 mmHg, pulse is 100/min, respirations are 17/min, and oxygen saturation is 95% on room air.", "Physical exam reveals a systolic murmur heard loudest along the left upper sternal border.", "Abdominal exam reveals an obese, tympanitic and distended abdomen with a 3 cm scar in the right lower quadrant.", "Vascular exam reveals weak pulses in the lower extremities."], "Others": ["His wife recently returned from a cruise with symptoms of vomiting and diarrhea."]}
{"Patient Personal Background": ["The patient has a medical history of blepharitis treated with eye cleansing and squamous cell carcinoma of the skin treated with Mohs surgery."], "Patient Symptoms": ["He has felt a mass in his eye that has persisted for the past month."], "Examination and Results": ["His temperature is 99.5\u00b0F (37.5\u00b0C), blood pressure is 157/102 mmHg, pulse is 90/min, respirations are 17/min, and oxygen saturation is 98% on room air.", "Physical exam is notable for a firm and rubbery nodule palpable inside the patient's left eyelid.", "Physical exam does not elicit any pain."]}
{"Patient Personal Background": ["His medical history is significant for hyperlipidemia and poorly controlled hypertension.", "His current medications include atorvastatin and amlodipine."], "Patient Symptoms": ["On cranial nerve exam, his left pupil is 6 mm in diameter compared to 3 mm on the right.", "His left eye is displaced laterally and downward and he also has left-sided ptosis.", "Strength is 2/5 in the right upper and right lower extremities and 5/5 in the left upper and left lower extremities.", "He has marked right-sided dysdiadochokinesia."], "Examination and Results": ["His temperature is 98.6\u00b0F (37.0\u00b0C), blood pressure is 175/95 mmHg, pulse is 90/min, respirations are 16/min.", "Sensation is intact throughout."]}
{"Patient Personal Background": ["The patient has engaged in unprotected intercourse with 12 different partners.", "She has a medical history of asthma, IV drug abuse, and depression.", "She has 1 to 2 alcoholic drinks per day."], "Patient Symptoms": ["She feels ashamed of her behavior and is requesting treatment for her condition and advice for safe sex.", "She states that every time she has sex a rash has emerged on her skin."], "Examination and Results": ["Her temperature is 99.5\u00b0F (37.5\u00b0C), blood pressure is 127/68 mmHg, pulse is 91/min, respirations are 14/min, and oxygen saturation is 98% on room air.", "A physical exam is notable for the finding in Figure A."], "Treatment": ["The patient is given antibiotics and is advised on safe sex practices."], "Others": ["The patient presents to the emergency department 3 days later with a complaint of a rash."]}
{"Patient Personal Background": ["The patient is a Swedish foreign exchange student and does not speak any English.", "Her medical history and current medications are unknown."], "Patient Symptoms": ["She was hiking when she suddenly felt unable to breathe and had to take slow deep breaths to improve her symptoms."], "Examination and Results": ["Her temperature is 99.5\u00b0F (37.5\u00b0C), blood pressure is 127/68 mmHg, pulse is 120/min, respirations are 22/min, and oxygen saturation is 90% on room air.", "Physical exam is notable for poor air movement bilaterally and tachycardia."], "Treatment": ["The patient is started on treatment."]}
{"Patient Personal Background": ["He recently was released from prison.", "He attributes this to intravenous drug use in prison."], "Patient Symptoms": ["He has felt very fatigued and has had a cough.", "He has lost roughly 15 pounds over the past 3 weeks."], "Examination and Results": ["His temperature is 99.5\u00b0F (37.5\u00b0C), blood pressure is 127/68 mmHg, pulse is 100/min, respirations are 18/min, and oxygen saturation is 98% on room air.", "QuantiFERON gold testing is positive."], "Treatment": ["The patient is started on appropriate treatment."]}
{"Patient Personal Background": ["The patient has a medical history of a suicide attempt in college, constipation, anxiety, depression, and a sunburn associated with surfing which was treated with aloe vera gel."], "Patient Symptoms": ["The pain has lasted for several months but seems to have worsened recently.", "Any activity such as opening jars, walking, or brushing her teeth is painful."], "Examination and Results": ["Her temperature is 99.5\u00b0F (37.5\u00b0C), blood pressure is 137/78 mmHg, pulse is 92/min, respirations are 14/min, and oxygen saturation is 98% on room air.", "Laboratory values are obtained and shown below."]}
{"Patient Personal Background": ["His mother's pregnancy, labor, delivery, and his neonatal course have been unremarkable."], "Patient Symptoms": ["Several times a day, he experiences paroxysmal episodes of crying, bending at the waist, and jerking of the arms and legs.", "He is rolling over less frequently than before, has worse head control, and no longer smiles socially."], "Examination and Results": ["His temperature is 98.6\u00b0F (37\u00b0C), blood pressure is 92/46 mmHg, pulse is 115/min, and respirations are 34/min.", "On examination, no dysmorphic features are noted.", "A 24-hour electroencephalography (EEG) is performed, during which the patient has one of these spells.", "A chaotic pattern of slowing and multifocal epileptiform charges is seen."]}
{"Patient Personal Background": ["His medical history is notable for a kidney stone 6 months ago.", "The patient does not take any medications.", "He is a non-smoker and does not drink alcohol or use recreational drugs.", "His family history is significant for osteoarthritis in his father who is 78.", "His temperature is 98.6\u00b0F (37\u00b0C), blood pressure is 133/84 mmHg, pulse is 84/min, and respirations are 15/min."], "Patient Symptoms": ["He is otherwise healthy and denies fever, chills, or recent trauma."], "Examination and Results": ["His body mass index is 27 kg/m^2.", "Physical examination shows a swollen and tender joint with overlying erythema.", "Diagnostic arthrocentesis is performed and shows a leukocyte count of 30,000/mm^3 with 85% neutrophils.", "Polarized microscopy of the synovial fluid is shown in Figure A."]}
{"Patient Personal Background": ["The patient has no significant medical history."], "Patient Symptoms": ["For the past 3 months, the patient has been coughing when he drinks liquids.", "His speech also sounds different according to his wife."], "Examination and Results": ["His temperature is 98.6\u00b0F (37.0\u00b0C), blood pressure is 110/80 mmHg, pulse is 60/min, and respirations are 12/min.", "On physical exam, he is unable to fully extend his tongue, and there are fasciculations on his tongue.", "When tapping the mandible at the chin while the mouth is held open, there is pronounced upward movement of the lower jaw.", "Sensory exam reveals no deficits."]}
{"Patient Personal Background": ["He was driving under the influence of alcohol when he sustained a crash against a pole.", "His medical history is significant for hypertension but he does not take any medications."], "Patient Symptoms": ["One week later, the patient\u2019s GCS score is now 3."], "Examination and Results": ["His temperature is 98.6\u00b0F (37.0\u00b0C), blood pressure is 110/80 mmHg, pulse is 60/min, and respirations are 12/min on a ventilator.", "His Glasgow coma score (GCS) on presentation is 6.", "Initial urine toxicology is negative.", "Laboratory studies do not show significant electrolyte, acid-base, or endocrine disturbances."], "Treatment": ["The patient is admitted to the intensive care unit and appropriate care is initiated.", "Sedative and paralytic agents are withdrawn."]}
{"Patient Personal Background": ["He has no medical history and takes no medications.", "He recently started experimenting with alcohol and marijuana that one of his friends has been stealing from their parents."], "Patient Symptoms": ["He says that the spasms usually occur after he wakes up as he is getting ready for school, and consist of disorganized jerking motions that stop after a few minutes.", "He has also noticed that they occur when he stays up late to cram last minute for exams."], "Examination and Results": ["His temperature is 98.6\u00b0F (37.0\u00b0C), blood pressure is 115/70 mmHg, pulse is 70/min, and respirations are 12/min.", "Physical exam reveals a healthy child."], "Others": ["He has not noticed any other symptoms."]}
{"Patient Personal Background": ["His only medical problem is hypertension for which he takes amlodipine.", "The patient is a non-smoker, uses alcohol infrequently, and has never used illicit drugs."], "Patient Symptoms": ["The pain started 6 hours ago when he was gardening and carrying a heavy bag.", "The pain is rated as 10/10 in severity and radiates down the posterior aspect of the right thigh."], "Examination and Results": ["He reports no fevers or chills.", "His temperature is 99.6\u00b0F (37.6\u00b0C), blood pressure is 140/70 mmHg, pulse is 90/min, and respirations are 20/min.", "Physical examination reveals 3/5 strength to hip extension, knee flexion and extension, and plantar flexion bilaterally.", "Sensation to pinprick is diminished over the posterolateral legs and lateral aspects of both feet.", "Ankle and knee reflexes are absent bilaterally.", "The patient\u2019s underwear is wet and a bladder scan reveals 800 mL of urine."]}
{"Patient Personal Background": ["She has not had time for regular check-ups.", "She exercises 3-4 times a week and consumes red meat sparingly.", "She drank and smoked cigarettes socially with coworkers but never at home or on vacation.", "Her family history is notable for coronary artery disease on her father's side and colon cancer on her mother's side.", "She last had a colonoscopy 5 years ago that revealed no abnormal findings."], "Patient Symptoms": ["She wakes up with achy wrists and elbows that she suspects is from years of using a computer keyboard."], "Examination and Results": ["Her temperature is 99\u00b0F (37.2\u00b0C), blood pressure is 125/83 mmHg, pulse is 82/min, respirations are 12/min, and oxygen saturation is 99% on room air.", "Her physical exam is grossly unremarkable."], "Others": ["She completed menopause at age 52."]}
{"Patient Symptoms": ["Whenever he eats solids, he regurgitates them back up.", "Several hours later, the patient presents to the emergency department with chest pain and shortness of breath."], "Examination and Results": ["His temperature is 99.5\u00b0F (37.5\u00b0C), blood pressure is 130/85 mmHg, pulse is 60/min, respirations are 12/min, and oxygen saturation is 99% on room air.", "On physical exam, the patient demonstrates a normal cardiopulmonary exam.", "His physical exam demonstrates no tenderness of the neck, a normal oropharynx, palpable crepitus above the clavicles, and minor lymphadenopathy."], "Diagnosis": ["Given this patient's suspected diagnosis, the gastroenterologist performs a diagnostic test."]}
{"Patient Personal Background": ["She has hypertension for which she takes hydrochlorothiazide and had a recent asthma flare requiring a prednisone taper.", "She does not drink alcohol or smoke."], "Patient Symptoms": ["Her pain is 7/10 in severity, non-radiating, and not relieved by rest.", "She has never experienced this pain in the past and denies fever, night sweats, unintentional weight loss, and bowel or bladder incontinence."], "Examination and Results": ["Her temperature is 98.6\u00b0F (37.0\u00b0C), blood pressure is 120/80 mmHg, pulse is 90/min, and respirations are 18/min.", "Physical exam reveals an uncomfortable middle-aged woman in no acute distress.", "There is no tenderness to palpation of the spinous processes.", "Flexion of the hip with the knee extended while the patient is supine does not elicit any pain, nor does forced dorsiflexion of the foot at terminal hip extension.", "She has 5/5 strength to hip flexion, extension, abduction, and adduction; knee flexion and extension; and ankle dorsiflexion and plantarflexion bilaterally.", "Bilateral patellar and Achilles reflexes are 2+."]}
{"Patient Symptoms": ["Approximately 20 minutes after receiving the medication, he developed pain and stiffness in his neck and eventually was unable to move his neck.", "His neck is rotated to the right and is unable to return to midline."], "Examination and Results": ["His temperature is 98.6\u00b0F (37.0\u00b0C), pulse is 90/min, blood pressure is 130/80 mmHg, respirations are 16/min, and oxygen saturation is 98% on room air.", "Examination reveals an uncomfortable appearing man.", "Examination of the patient is shown in Figure A."], "Treatment": ["He underwent a laparoscopic appendectomy and was treated for post-operative nausea and vomiting with metoclopramide."], "Others": []}
{"Patient Personal Background": ["According to her boyfriend, the patient has a medical history of bipolar disorder for which she takes lithium, as well as chronic lower back pain for which she sees a pain specialist."], "Patient Symptoms": ["Her boyfriend found her at home next to a suicide note and brought her into the emergency department."], "Examination and Results": ["Her temperature is 100.5\u00b0F (38.1\u00b0C), blood pressure is 102/78 mmHg, pulse is 127/min, respirations are 19/min, and oxygen saturation is 99% on room air.", "An ECG is performed as seen in Figure A."]}
{"Patient Personal Background": ["He has a history of human immunodeficiency virus (HIV) infection being treated with bictegravir, emtricitabine, and tenofovir.", "He does not smoke tobacco and drinks alcohol socially."], "Patient Symptoms": ["He was found by his roommate to be disoriented this morning.", "He had complained of a right-sided headache for the past 5 days."], "Examination and Results": ["His last CD4 cell count was 500/mm^3.", "His temperature is 104.2\u00b0F (40.1\u00b0C), blood pressure is 110/70 mmHg, pulse is 110/min, and respirations are 22/min.", "Examination reveals 3/5 strength to right shoulder abduction and elbow flexion/extension and 4/5 strength to right hip flexion/extension.", "The remainder of the strength exam on the right and left sides is normal.", "Neck flexion does not elicit pain, and there are no tongue lacerations.", "During the exam, the patient\u2019s eyes are seen to roll backward with repeated flexion/extension of his extremities and loss of urine."]}
{"Patient Personal Background": ["She has no significant medical history.", "She takes no medication other than whey protein supplements, a multivitamin, and fish oil."], "Patient Symptoms": ["She has noticed \"twitching\" in both her upper and lower extremities over the past 3 days that have interfered with her training for a marathon.", "She has felt more fatigued over the past month."], "Examination and Results": ["Her temperature is 98.5\u00b0F (36.9\u00b0C), blood pressure is 103/71 mmHg, pulse is 105/min, respirations are 11/min, and oxygen saturation is 100% on room air.", "Physical exam reveals a thin woman with thinning hair.", "She appears pale and her mucous membranes are dry.", "Her neurological and cardiac exams are unremarkable.", "Laboratory studies are ordered as seen below.", "Hemoglobin: 10 g/dL Hematocrit: 30% Leukocyte count: 6,100/mm^3 with normal differential Platelet count: 187,500/mm^3 Serum: Na+: 130 mEq/L Cl-: 100 mEq/L K+: 2.3 mEq/L HCO3-: 28 mEq/L BUN: 40 mg/dL Glucose: 79 mg/dL Creatinine: 0.9 mg/dL Ca2+: 8.2 mg/dL Mg2+: 1.8 mg/dL Thyroid stimulating hormone (TSH): 4.0 mIU/L Free T4: 0.4 ng/dL (normal: 0.7-1.53 ng/dL) The patient is given 4 liters of lactated ringer solution and 40 mEq of potassium."], "Treatment": ["Her repeat whole blood potassium 3 hours later is 2.4 mEq/L, and her repeat BUN is 20 mEq/L.", "Another repeat whole blood potassium is 2.5 mEq/L."], "Others": ["Another 40 mEq of potassium is administered.", "The patient\u2019s muscle spasms persist."]}
{"Patient Personal Background": ["He has no medical problems and takes no medications."], "Patient Symptoms": ["He was riding his bicycle when he fell onto his outstretched right hand.", "He immediately clutched his right elbow in pain and began crying.", "He refuses to move his elbow.", "He is unable to make a pincer with his right thumb and index finger.", "When asked to hold a pen between his right thumb and index fingers, he drops it."], "Examination and Results": ["His temperature is 98.4\u00b0F (36.9\u00b0C), blood pressure is 108/64 mmHg, pulse is 100/min, and respirations are 20/min.", "On exam, the boy is holding his right wrist with his left hand and cries upon palpation of a region that is 2 cm proximal to his elbow.", "The radial head is palpated just distal to the lateral epicondyle.", "The radial pulse is diminished on the right."]}
{"Patient Symptoms": ["Review of systems is notable for a 12-pound unintentional weight loss and intermittent loose stools."], "Examination and Results": ["Her temperature is 37.2\u00b0C (98.9\u00b0F), blood pressure is 100/72 mmHg, pulse is 72/min, respirations are 12/min, and oxygen saturation is 100% on room air.", "Her abdomen is soft, mildly diffusely tender to deep palpation, and non-distended.", "She is found to have the finding on colonoscopy in Figure A. Serum perinuclear antineutrophil cytoplasmic antibodies (p-ANCA) are positive."], "Others": ["She has a family history notable for a father with coronary artery disease and a mother with primary sclerosing cholangitis."]}
{"Patient Personal Background": ["He was noted to have surpassed his birth weight at his last office visit 1 week ago."], "Patient Symptoms": ["His parents report that he suddenly started vomiting this morning and has shown no interest in feeding since then.", "They describe the vomitus as green and without any traces of blood.", "On physical exam, the patient is in mild distress."], "Examination and Results": ["His temperature is 97.6\u00b0F (36.4\u00b0C), blood pressure is 78/56 mmHg, pulse is 148/min, and respirations are 44/min.", "He has no dysmorphic features, and his mucous membranes are dry.", "His abdomen is soft and distended.", "Bowel sounds are hypoactive.", "An abdominal radiograph is performed as in Figure A."], "Others": ["Prior to today, the patient was feeding, voiding, and stooling well."]}
{"Patient Personal Background": ["Her medical history is significant for type 2 diabetes mellitus and hypertension for which she takes metformin and losartan."], "Patient Symptoms": ["She has been having worsening headaches and intermittent nausea over the past 5 months.", "The headaches are constant and dull, and they typically worsen when she sneezes or laughs.", "Recently, she has become increasingly nauseous and has vomited twice in the past 10 days."], "Examination and Results": ["Her temperature is 98.6\u00b0F (37.0\u00b0C), blood pressure is 115/70 mmHg, pulse is 70/min, and respirations are 12/min.", "She is noted to have papilledema on fundoscopy, but physical exam is otherwise normal.", "Her CT scan findings are presented in Figure A."]}
{"Patient Personal Background": ["She was formerly an executive at a software company but had to retire due to frequent memory lapses.", "Her medical problems include hypertension and chronic obstructive pulmonary disease for which she takes amlodipine, albuterol, ipratropium, and a fluticasone inhaler."], "Patient Symptoms": ["On occasion, she becomes difficult to understand and her speech becomes disorganized.", "She also frequently sees \"small people\" and animals on the dining room table, which is disturbing to her."], "Examination and Results": ["Her temperature is 98.6\u00b0F (37\u00b0C), blood pressure is 120/80 mmHg, pulse is 80/min, and respirations are 12/min.", "Physical exam is notable for slowed movements and difficulty with balance at rest, which were not present at her wellness visit 1 year ago."]}
{"Patient Personal Background": ["Her medical history is notable for a treated episode of acute renal failure, diabetes mellitus, obesity, and hypertension.", "The patient recently started taking high doses of vitamin D as she believes that it could help her symptoms.", "Her temperature is 98.6\u00b0F (37\u00b0C), blood pressure is 135/91 mmHg, pulse is 72/min, and respirations are 12/min."], "Patient Symptoms": ["The pain is present in the morning but is nearly unbearable by the end of the day.", "The patient points to the areas that cause her pain stating that it is mostly over the groin."], "Examination and Results": ["On exam, an obese woman in no distress is noted.", "There is pain, decreased range of motion, and crepitus on exam of her right hip."], "Others": ["Her current medications include losartan, metformin, insulin, and ibuprofen.", "She also recently fell off the treadmill while exercising at the gym."]}
{"Patient Personal Background": ["He reports that he is a mailman, and his closed fist was bitten by a dog while he was delivering mail yesterday.", "He has no medical history and takes no medications."], "Patient Symptoms": ["He reports pain but denies fevers, chills, drainage, or any other symptoms."], "Examination and Results": ["His temperature is 98.6\u00b0F (37.0\u00b0C), pulse is 80/min, blood pressure is 125/75 mmHg, and respirations are 16/min."], "Others": ["The dog is up to date on vaccinations.", "His last tetanus vaccine was 3 years ago."]}
{"Patient Personal Background": ["Her mother is concerned that the patient is a picky eater and refuses to eat vegetables.", "She drinks milk with meals and has juice sparingly.", "She goes to sleep easily at night and usually sleeps for 11-12 hours.", "The patient has trouble falling asleep for naps but does nap for 1-2 hours a few times per week.", "She is doing well in daycare and enjoys parallel play with the other children.", "Her mother reports that she can walk downstairs with both feet on each step.", "She has a vocabulary of 10-25 words that she uses in the form of 1 word commands.", "She is in the 42nd percentile for height and 48th percentile for weight, which is consistent with her growth curves."], "Examination and Results": ["Her temperature is 98.6\u00b0F (37\u00b0C), blood pressure is 92/56 mmHg, pulse is 106/min, and respirations are 23/min.", "On physical exam, she appears well nourished.", "She can copy a line and throw a ball."]}
{"Patient Personal Background": ["Two months ago, he was started on citalopram after several weeks of depressed mood, loss of interest in activities, depressed appetite, and inability to sleep."], "Patient Symptoms": ["Two months ago, he was started on citalopram after several weeks of depressed mood, loss of interest in activities, depressed appetite, and inability to sleep.", "Today, he reports minimal improvement in his symptoms.", "He denies thoughts of suicide or self-harm.", "Exam reveals a depressed, tired appearing man."], "Examination and Results": ["His temperature is 98.6\u00b0F (37.0\u00b0C), pulse is 80/min, blood pressure is 120/80 mmHg, respirations are 22/min, and oxygen saturation is 97% on room air."], "Treatment": ["Two months ago, he was started on citalopram after several weeks of depressed mood, loss of interest in activities, depressed appetite, and inability to sleep."]}
{"Examination and Results": ["On arrival to the emergency department, his temperature is 98.6\u00b0F (37.0\u00b0C), pulse is 130/min, blood pressure is 80/50 mmHg, respirations are 22/min, and oxygen saturation is 97%.", "Examination reveals an ill-appearing intubated patient.", "Endotracheal tube placement is confirmed with end tidal CO2, and bilateral breath sounds are present.", "No external bleeding or wounds are noted on exam.", "Pulses are present in all extremities but are weak and rapid.", "Significant bruising is noted over the abdomen.", "The pelvis is stable.", "Infusion of packed red blood cells is initiated."], "Treatment": ["He was intubated and 2 large bore IVs were placed in the field with administration of 2 liters of lactated ringer's solution while en route."]}
{"Patient Personal Background": ["She was born at 36 weeks gestation to a 37-year-old G2P2 mother.", "The pregnancy was complicated by gestational diabetes, and all prenatal testing was unremarkable."], "Patient Symptoms": ["She was feeding well until this morning when she had several episodes of vomiting.", "The parents describe the vomitus as \u201cbright green\u201d and the patient has shown little interest in feeding since then."], "Examination and Results": ["The patient has not yet regained her birth weight and is in the 46th percentile for height and the 36th percentile for weight.", "The patient\u2019s temperature is 99.2\u00b0F (37.3\u00b0C), blood pressure is 68/46 mmHg, pulse is 132/min, and respirations are 32/min.", "On physical exam, the patient is in mild distress.", "Her abdomen is distended and firm without guarding.", "Bowel sounds are hypoactive."], "Others": ["She has no dysmorphic features.", "The patient\u2019s abdominal radiograph can be seen in Figure A and the patient\u2019s upper gastrointestinal series can be seen in Figure B."]}
{"Patient Personal Background": ["His medical and surgical history is significant for the reconstruction of a torn anterior cruciate ligament in his right knee.", "His family history is significant for a mother with \u201cthyroid problems\u201d and a father with coronary artery disease.", "The patient is an information technology specialist at a local company.", "He is sexually active with men.", "His temperature is 98.6\u00b0F (37.0\u00b0C), blood pressure is 124/82 mmHg, pulse is 71/min, and respirations are 12/min."], "Examination and Results": ["He feels well and has no complaints.", "On physical exam, the patient is tall and slender with a BMI of 21 kg/m2.", "A single nodule can be palpated on the patient\u2019s thyroid.", "He has palpable cervical lymphadenopathy.", "On cardiac exam, he has a normal S1/S2 with no murmurs, rubs, or gallops, and his lungs are clear bilaterally.", "His abdomen is soft and non-tender without hepatosplenomegaly."], "Others": ["A physical exam of the perioral region can be seen in Figure A."]}
{"Patient Personal Background": ["The patient has a medical history of obesity and prediabetes with a hemoglobin A1c of 6.0% last year."], "Patient Symptoms": ["She has started to develop pimples on her face and back over the last several months.", "Her last menstrual period was over 3 months ago and her periods have been irregular over the last year.", "She has been gaining weight recently."], "Examination and Results": ["Her temperature is 98.5\u00b0F (36.9\u00b0C), pulse is 80/min, blood pressure is 139/88 mmHg, and respirations are 13/min.", "Cardiopulmonary exam is unremarkable, and the patient\u2019s abdomen appears slightly distended but exhibits no tenderness to palpation.", "The patient\u2019s face has coarse stubble along the jawline and on the upper lip, and there is similar hair along the midline of her lower abdomen.", "A pelvic exam reveals mild clitoromegaly, a normal anteverted uterus, and a large left adnexal mass that is mildly tender.", "Her laboratory test results are shown below:\n\nHemoglobin: 13.9 g/dL\nLeukocyte count: 8,000 cells/mm^3\nPlatelet count: 142,000/mm^3\n\nDHEAS: 73 ug/dL (Normal: 145-395 ug/dL)\nTestosterone: 256 ng/dL\n17-hydroxyprogesterone: 214 ng/dL (Normal: < 200 ng/dL)\n\nUltrasound findings are shown in Figure A."]}
{"Patient Personal Background": ["The patient\u2019s medical history is significant for hypertension, alcohol use disorder, and chronic obstructive pulmonary disease.", "His medications include aspirin, amlodipine, and fluticasone-salmeterol.", "He drinks a glass of red wine every night with dinner and smokes a cigar on the weekends."], "Patient Symptoms": ["He is unsure when his symptoms started, but they have been affecting him for \u201ca while.\u201d It began as episodes of \u201cunsteadiness\u201d that progressed to a feeling of \u201cspinning.\u201d He cannot tell if his symptoms change with position but reports that if he does not lie down he will become nauseous.", "He also has worsening hearing loss worse on his right side."], "Examination and Results": ["His temperature is 98.6\u00b0F (37\u00b0C), blood pressure is 135/91 mmHg, pulse is 72/min, and respirations are 12/min.", "Examination shows delayed horizontal nystagmus."]}
{"Patient Personal Background": ["The patient has a medical history of Hashimoto thyroiditis and takes levothyroxine daily.", "Her mother has type 1 diabetes mellitus."], "Patient Symptoms": ["She has had only 2 periods in the last year.", "She feels flushed without provocation and is experiencing occasional dyspareunia with post-coital spotting.", "She has also had more frequent headaches than usual."], "Examination and Results": ["Her temperature is 98.5\u00b0F (36.9\u00b0C), pulse is 70/min, blood pressure is 118/76 mmHg, and respirations are 13/min.", "Cardiopulmonary and abdominal exams are unremarkable.", "The patient has Tanner 5 breasts and pubic hair.", "A pelvic exam reveals a normal cervix, an anteverted uterus without tenderness, and no adnexal masses."]}
{"Patient Personal Background": ["He denies recent trauma and he has no known medical problems.", "He denies tobacco use and will often drink 6-8 beers or spirits on weekend nights."], "Patient Symptoms": ["He woke last night with sudden-onset, sharp, 10/10 non-radiating pain in his right knee."], "Examination and Results": ["His temperature is 98.6\u00b0F (37.0\u00b0C), pulse is 90/min, blood pressure is 140/90 mmHg, respirations are 16/min, and oxygen saturation is 97% on room air.", "Physical exam reveals an erythematous, edematous right knee.", "Passive extension of the knee is limited by pain.", "Synovial fluid aspiration is performed and sent for analysis, which reveals 20,000 leukocytes/mm^3, and no organisms visualized.", "Microscopic examination of synovial fluid is shown in Figure A."]}
{"Patient Personal Background": ["The patient has a medical history of sinusitis, constipation, diabetes, and pelvic inflammatory disease.", "Her current medications include fexofenadine, oral contraceptive pills, and metformin.", "She is currently taking amoxicillin for a sinus infection.", "She smokes 1 pack of cigarettes per day and drinks 2-3 alcoholic beverages daily."], "Patient Symptoms": ["She was at home when a sudden headache began with greater severity than she had experienced in the past.", "She presented within 30 minutes of symptom onset.", "Neurological exam reveals a confused woman who is now complaining of \"seeing double.\""], "Examination and Results": ["Her temperature is 99.5\u00b0F (37.5\u00b0C), blood pressure is 187/118 mmHg, pulse is 120/min, respirations are 17/min, and oxygen saturation is 98% on room air.", "On physical exam, the patient is noted to be uncomfortable with the appearance shown in Figure A.", "Cardiopulmonary exam reveals mild bibasilar crackles and tachycardia.", "Abdominal exam is within normal limits."]}
{"Patient Personal Background": ["The patient's medical history is notable for diabetes which was managed during her pregnancy with insulin."], "Patient Symptoms": ["The patient is fatigued but states that she is doing well.", "Currently, she is complaining that her vagina hurts.", "The next morning, the patient experiences chills and a light red voluminous discharge from her vagina.", "She states that she feels pain and cramps in her abdomen."], "Examination and Results": ["Her temperature is 99.5\u00b0F (37.5\u00b0C), blood pressure is 107/68 mmHg, pulse is 97/min, respirations are 16/min, and oxygen saturation is 98% on room air."], "Others": ["Laboratory values are obtained and shown below."]}
{"Patient Personal Background": ["The patient had a myocardial infarction 6 months ago, and she now has multiple drug-eluting stents.", "Her medical history is otherwise significant for rheumatoid arthritis and migraines.", "Her home medications include methotrexate, atorvastatin, clopidogrel, and aspirin."], "Patient Symptoms": ["She often feels lightheaded and like she may \u201cpass out\u201d but never actually loses consciousness.", "Her abdomen is non-distended and she has mild lower extremity edema."], "Examination and Results": ["She denies dyspnea on exertion or orthopnea.", "Her temperature is 98.6\u00b0F (37\u00b0C), blood pressure is 118/75 mmHg, pulse is 92/min, and respirations are 12/min.", "On physical exam, she has an irregular heartbeat with normal cardiac sounds.", "Her current ECG can be seen in Figure A."], "Others": ["Her ECG upon discharge from that hospitalization was normal."]}
{"Patient Personal Background": ["The patient has a medical history of diabetes and hypertension.", "His current medications include insulin, metformin, and lisinopril."], "Patient Symptoms": ["For the past month, he has felt abnormally tired and today noticed his vision is blurry.", "The patient also endorses increased sweating at night and new-onset headaches.", "He currently feels dizzy.", "A neurological exam is notable for decreased sensation in the patient's hands and feet.", "He also complains of numbness and tingling pain in his extremities that has been persistent during this time."], "Examination and Results": ["His temperature is 99.5\u00b0F (37.5\u00b0C), blood pressure is 157/98 mmHg, pulse is 90/min, respirations are 17/min, and oxygen saturation is 98% on room air.", "A cardiopulmonary exam is within normal limits.", "HEENT exam reveals non-tender posterior and anterior chain lymphadenopathy.", "Abdominal exam reveals splenomegaly and hepatomegaly.", "There are large, non-tender palpable lymph nodes in the patient's inguinal region.", "The dermatologic exam is notable for multiple bruises on his upper and lower extremities."]}
{"Patient Personal Background": ["The parents have no concerns at this time and note he is starting to run around and speak in 3-word sentences.", "He has no remarkable medical history and his mother had an uncomplicated full-term pregnancy and delivery."], "Examination and Results": ["He is appropriately meeting the developmental milestones for his age.", "The patient\u2019s temperature is 98.4\u00b0F (36.9\u00b0C), blood pressure is 96/52 mmHg, pulse is 102/min, and respirations are 25/min.", "He is in the 55th percentile for height and 62nd percentile for weight, which is consistent with his documented growth curves.", "Fundoscopic exam shows the finding in Figure A.", "His pediatrician continues the ocular examination and further notes that the pupils are equal, round, and reactive, extraocular movements are full, and ocular alignment appears normal."]}
{"Patient Personal Background": ["The patient is otherwise healthy and does not take any medications."], "Patient Symptoms": ["He states his pain is 10/10.", "He is requesting medications and is crying out in pain."], "Examination and Results": ["His temperature is 98.7\u00b0F (37.1\u00b0C), blood pressure is 149/85 mmHg, pulse is 103/min, respirations are 15/min, and oxygen saturation is 99% on room air.", "Physical exam reveals swelling over his right leg and knee.", "The patient cries out in pain with passive motion of the foot at the ankle.", "A radiograph is performed as seen in Figure A."]}
{"Patient Personal Background": ["He recently went camping and hiking in the woods.", "The patient drinks 1-2 beers per day and smokes 1 pack of cigarettes per day.", "He is currently sexually active with multiple partners and does not use condoms.", "His temperature is 99.5\u00b0F (37.5\u00b0C), blood pressure is 157/78 mmHg, pulse is 90/min, respirations are 15/min, and oxygen saturation is 98% on room air."], "Patient Symptoms": ["He felt itchy recently, then noticed skin lesions that broke out prompting him to come to the emergency department.", "His temperature is 99.5\u00b0F (37.5\u00b0C), blood pressure is 157/78 mmHg, pulse is 90/min, respirations are 15/min, and oxygen saturation is 98% on room air."], "Examination and Results": ["Physical exam reveals the findings in Figure A on the patient's arm.", "The skin lesions are thick and do not break when pressure is applied."]}
{"Patient Personal Background": ["She has a medical history of generalized anxiety disorder and hypothyroidism for which she takes escitalopram and levothyroxine.", "She had a Roux-en-Y gastric bypass 5 years ago.", "She has been in a monogamous relationship with her husband for the last 15 years and uses a copper intrauterine device."], "Patient Symptoms": ["She feels more irritable with her husband and children and does not find pleasure in creating art anymore.", "Over the last 2 weeks, she has been sleeping approximately 5 hours a night and had a fall while walking in her home with the lights off.", "Pupils are equal, round, and reactive to light and accommodation."], "Examination and Results": ["Physical examination is notable for a depressed affect.", "She has 4/5 strength in the bilateral lower extremities and brisk patellar reflexes."], "Others": ["She denies any head trauma or loss of consciousness associated with the fall."]}
{"Patient Personal Background": ["He has no other significant medical history and does not take any medications.", "He has smoked 1 pack of cigarettes a day for 35 years and drinks 3 beers per week.", "He is sexually active with his wife."], "Patient Symptoms": ["He denies any hemoptysis, facial pain, rhinorrhea, or night sweats."], "Examination and Results": ["His temperature is 101.7\u00b0F (38.7\u00b0C), blood pressure is 127/85, pulse is 102/min, and respirations are 22/min.", "Physical exam is notable for decreased breath sounds on the right side without wheezing and increased dullness to percussion on the right side.", "A chest radiograph is ordered and reveals a consolidation in the right middle lobe."], "Others": ["The patient reported similar symptoms 2 months ago.", "Chest radiograph performed at the time was notable for a right middle lobe consolidation.", "He was diagnosed with lobar pneumonia and completed a 7-day course of antibiotics with complete resolution of his symptoms."]}
{"Patient Personal Background": ["The patient is otherwise healthy and does not take any medications."], "Patient Symptoms": ["He initially experienced pain which is currently well controlled with acetaminophen."], "Examination and Results": ["His temperature is 98.5\u00b0F (36.9\u00b0C), blood pressure is 123/79 mmHg, pulse is 90/min, respirations are 11/min, and oxygen saturation is 97% on room air.", "Physical exam is notable for the finding in Figure A.", "A radiograph of the affected digits shows a smooth cortex without disruption of the bone."], "Treatment": ["He initially experienced pain which is currently well controlled with acetaminophen."]}
{"Patient Personal Background": ["He has a history of coronary artery disease and underwent an uncomplicated coronary angioplasty with stent placement 2 years ago.", "He routinely travels both domestically and internationally as a senior shipyard worker and has a 30-pack-year smoking history.", "He used to drink 4 cocktails a week.", "He has not smoke or drank alcohol in over 7 years."], "Patient Symptoms": ["His symptoms began 3 months ago.", "He has also lost 18 pounds.", "Physical exam is notable for right pupillary constriction as well as paresthesias in his right fourth and fifth digits."], "Examination and Results": ["His temperature is 99.5\u00b0F (37.7\u00b0C), blood pressure is 140/60 mmHg, pulse is 97/min, and respirations are 13/min.", "There is no pain with active shoulder rotation.", "His chest imaging is shown in Figure A."]}
{"Patient Personal Background": ["He has a history of a seizure disorder."], "Patient Symptoms": ["He was running a marathon but became confused halfway through the race.", "He arrives unable to coherently answer questions and is not sure where he is."], "Examination and Results": ["His temperature is 105\u00b0F (40.6\u00b0C), blood pressure is 116/68 mmHg, pulse is 167/min, respirations are 29/min, and oxygen saturation is 99% on room air.", "Physical exam reveals a confused man who is moving all 4 extremities and is protecting his airway.", "During the exam, he develops a tonic-clonic seizure, which lasts 1 minute and then terminates on its own.", "A urine dipstick is positive for red blood cells."], "Treatment": ["The patient is given intravenous fluids, and basic laboratory studies are drawn and pending."]}
{"Patient Personal Background": ["The patient has a medical history of asthma which is well-controlled with albuterol."], "Patient Symptoms": ["Since then, the patient has developed a nasal discharge with worsening pain.", "Inspection of the patient's nose reveals a unilateral purulent discharge mixed with blood."], "Examination and Results": ["His temperature is 99.5\u00b0F (37.5\u00b0C), blood pressure is 90/48 mmHg, pulse is 124/min, respirations are 17/min, and oxygen saturation is 98% on room air.", "The cardiopulmonary exam is within normal limits.", "The rest of the patient's exam is within normal limits."], "Treatment": ["Initially, the pediatrician prescribed decongestants and sent the patient home."]}
{"Patient Personal Background": ["The patient has no significant medical history.", "He does have a 33-pack-year smoking history and drinks 4 to 5 alcoholic drinks per day."], "Patient Symptoms": ["The patient has felt steadily more fatigued over the past month and has lost 22 pounds without effort.", "Today, he fainted prompting his presentation."], "Examination and Results": ["His temperature is 99.5\u00b0F (37.5\u00b0C), blood pressure is 100/58 mmHg, pulse is 100/min, respirations are 17/min, and oxygen saturation is 98% on room air.", "The patient is very thin and appears pale.", "Stool fecal occult blood testing is positive.", "A CT scan of the abdomen is performed demonstrating a mass in the colon with multiple metastatic lesions scattered throughout the abdomen."], "Diagnosis": ["The patient is informed of his diagnosis of metastatic colon cancer."], "Others": ["When the patient conveys the information to his family, he focuses his efforts on discussing the current literature in the field and the novel therapies that have been invented.", "He demonstrates his likely mortality outcome which he calculated using the results of a large multi-center study."]}
{"Patient Personal Background": ["Medical history is significant for rheumatoid arthritis diagnosed approximately 10 years ago and treated with methotrexate as well as type 2 diabetes mellitus treated with metformin."], "Patient Symptoms": ["Her symptoms have progressively worsened over the course of 2 weeks and are most significant in her lower extremities.", "She also notices increased urinary frequency."], "Examination and Results": ["Her temperature is 98.6\u00b0F (37\u00b0C), blood pressure is 138/92 mmHg, pulse is 92/min, and respirations are 17/min.", "On physical exam, there is mild tenderness to palpation of the metacarpophalangeal and proximal interphalangeal joints.", "There is 4/5 power throughout the lower extremity.", "Laboratory testing is shown."], "Diagnosis": ["Approximately 1 month ago, she was diagnosed with calcium phosphate nephrolithiasis."]}
{"Patient Personal Background": ["The father\u2019s brother died of sickle cell anemia at an early age.", "Parental studies reveal that both mother and father are carriers of the sickle cell gene."], "Examination and Results": ["The patient's temperature is 98.6\u00b0F (37.0\u00b0C), blood pressure is 80/45 mmHg, pulse is 130/min, and respirations are 25/min.", "The physician begins counseling the family."], "Others": ["The physician decides to repeat testing for the patient and his 3-year-old sister.", "The results are shown in Figure A."]}
{"Patient Personal Background": ["He has no known medical history.", "He drinks 5-6 beers on the weekend and has a 20 pack-year smoking history.", "He denies any family history of cancer."], "Patient Symptoms": ["He says that the pain \u201ccomes and goes\u201d throughout the day and usually lasts 20-30 minutes per episode.", "The pain is above his umbilicus.", "He denies any feeling of regurgitation or nighttime cough but endorses nausea.", "He used to eat 3 large meals per day but has found that eating smaller meals more frequently improves his pain."], "Examination and Results": ["His temperature is 98.6\u00b0F (37\u00b0C), blood pressure is 117/72 mmHg, pulse is 72/min, and respirations are 13/min.", "On physical exam, he is tender to palpation above the umbilicus.", "Bowel sounds are present.", "A stool guaiac test is positive."], "Others": ["He tried ibuprofen with food and thinks it helped.", "He has gained 4 pounds since his last appointment 3 months ago.", "He denies any diarrhea or change in his stools.", "The patient undergoes an endoscopy with a biopsy to diagnose his condition."]}
{"Patient Personal Background": ["The patient has no significant medical history, and takes no other medication."], "Examination and Results": ["His temperature is 98.6\u00b0F (37.0\u00b0C), pulse is 130, blood pressure is 85/50, and respirations are 22.", "Primary and secondary survey and FAST exam are unremarkable for other associated injuries.", "Pressure is removed from the wound, and pulsatile bleeding from the wound is noted."], "Others": ["He was not stabbed or otherwise injured elsewhere."]}
{"Patient Personal Background": ["The patient has a medical history of IV drug use, diabetes mellitus, oral cold sores, hypertension, renal failure, and dyslipidemia.", "The patient's current medications include lisinopril, atorvastain, insulin, and aspirin.", "Prior to the procedure, he was also on dialysis."], "Examination and Results": ["His temperature is 98.5\u00b0F (36.9\u00b0C), blood pressure is 121/76 mmHg, pulse is 70/min, and respirations are 13/min."], "Treatment": ["The previous day, the patient had a renal transplant from a matched donor.", "The patient is started on cyclosporine."], "Others": ["He is currently recovering and doing well.", "The patient successfully recovers over the next few days."]}
{"Patient Personal Background": ["She is otherwise healthy, participates in multiple school sports teams, and has been training rigorously for upcoming competitions.", "She denies alcohol use, smoking, and recreational drugs.", "She is not sexually active and does not take oral contraceptives."], "Patient Symptoms": ["Menarche was at age 12 and she had regular periods up until 2 years ago.", "At that time, her periods became less regular until around 7 months ago when they ceased altogether."], "Examination and Results": ["Her temperature is 36.7\u00b0C (98\u00b0F), blood pressure is 121/80 mmHg, pulse is 62/min, respirations are 11/min, oxygen saturation is 100% on room air, and BMI is 20 kg/m^2.", "Her pelvic exam reveals an anteverted uterus, no adnexal masses, a normal-appearing cervix with no cervical motion tenderness, and normal vaginal anatomy."]}
{"Patient Personal Background": ["He recently moved to the United States to work in construction.", "He drinks alcohol 1-2 times per week and has never smoked.", "He denies any family history of cancer."], "Patient Symptoms": ["He has had the cough for several years but it has been getting worse over the last few months.", "He has lost 10 pounds in the last 3 months along with darker stools which he believes is caused by a Western diet."], "Examination and Results": ["His temperature is 98.6\u00b0F (37\u00b0C), blood pressure is 114/72 mmHg, pulse is 82/min, and respirations are 12/min.", "On physical exam, his lungs are clear to auscultation bilaterally without wheezing.", "His abdomen is soft and non-distended.", "He has no tenderness to palpation and bowel sounds are present."], "Others": ["He denies any difficulty swallowing or feeling of food getting stuck in his throat."]}
{"Patient Personal Background": ["She has a male fetus based on her 20 week anatomy ultrasound.", "The patient has a medical history of polycystic ovary syndrome."], "Patient Symptoms": ["She now needs to shave her face every day or else thick hair appears.", "She also has worsening acne that started several weeks ago."], "Examination and Results": ["Her pregnancy thus far has been complicated by gestational diabetes, which is managed by diet and exercise.", "The patient\u2019s temperature is 98.5\u00b0F (36.9\u00b0C), blood pressure is 121/76 mmHg, pulse is 70/min, and respirations are 13/min.", "The cardiopulmonary exam is normal, and the patient\u2019s abdomen has a fundal height of 31 cm.", "A pelvic exam reveals an unremarkable closed cervix and a right-sided adnexal mass without tenderness.", "Transvaginal ultrasound is performed and shown in Figure A."]}
{"Patient Personal Background": ["She has no medical history and has never been hospitalized."], "Patient Symptoms": ["She has been complaining of pain in her right leg for the last few days.", "The open wound remains present on the thigh with surrounding erythema and edema."], "Examination and Results": ["Her temperature is 102.2\u00b0F (39\u00b0C), blood pressure is 118/78 mmHg, pulse is 90/min, respirations are 21/min, and pulse oximetry is 99% on room air.", "MRI is consistent with osteomyelitis."], "Treatment": ["At the time of the bite, they cleaned the wound and irrigated it with sterile saline water from a first aid kit."], "Diagnosis": ["MRI is consistent with osteomyelitis."], "Others": ["Her neighbor\u2019s cat bit her last week and her parents attributed the pain to her healing bite."]}
{"Patient Personal Background": ["The patient was born to a G1P1 mother at 39 weeks gestation.", "The mother had diabetes that was managed with exercise and insulin during the pregnancy.", "The mother has never been vaccinated and did not follow routine prenatal care."], "Patient Symptoms": ["The newborn's temperature is 99.5\u00b0F (37.5\u00b0C), blood pressure is 70/30 mmHg, pulse is 160/min, respirations are 27/min, and oxygen saturation is 80% on room air."], "Examination and Results": ["The initial workup of the patient includes a chest radiograph seen in Figure A as well as lab values as seen below.", "Hemoglobin: 14 g/dL Hematocrit: 42% Leukocyte count: 6,500/mm^3 with normal differential Platelet count: 197,000/mm^3 Serum: Na+: 139 mEq/L Cl-: 101 mEq/L K+: 4.3 mEq/L HCO3-: 24 mEq/L BUN: 12 mg/dL Glucose: 99 mg/dL Creatinine: 0.5 mg/dL Ca2+: 10.0 mg/dL AST: 12 U/L ALT: 10 U/L An electrocardiogram is obtained as seen in Figure B."]}
{"Patient Personal Background": ["The child has a medical history of obesity and atopic dermatitis and uses topical steroid cream.", "His birth history is unremarkable."], "Patient Symptoms": ["On exam, he appears uncomfortable, is coughing continuously, and is drooling."], "Examination and Results": ["His temperature is 98.5\u00b0F (36.9\u00b0C), pulse is 120/min, blood pressure is 90/52 mmHg, and respirations are 32/min.", "Cardiopulmonary and abdominal exams are unremarkable.", "A chest radiograph is performed and the results are shown in Figures A and B."], "Others": ["His family history is notable for asthma in his older sister and irritable bowel syndrome in his father."]}
{"Patient Symptoms": ["Physical exam reveals sparse hair that is falling out throughout the patient\u2019s body.", "He has a rash by the corners of his mouth.", "The patient has multiple loose bowel movements and on day 6 the patient\u2019s surgical wound does not appear to be healing.", "It is held together only by the sutures with minimal underlying healing."], "Examination and Results": ["His temperature is 97.5\u00b0F (36.4\u00b0C), blood pressure is 92/52 mmHg, pulse is 145/min, respirations are 33/min, and oxygen saturation is 90% on room air.", "His vitals are within normal limits.", "It is held together only by the sutures with minimal underlying healing."], "Treatment": ["He is intubated to protect his airway, given 2 units of packed red blood cells, and sent to the operating room for an exploratory laparotomy.", "The patient is subsequently admitted to the intensive care unit."], "Others": ["The patient is intoxicated and is unable to offer further history.", "He is extubated the next day and appears well."]}
{"Patient Personal Background": ["Aside from occasional shin splints, she has a relatively unremarkable medical history.", "She takes oral contraceptive pills and a multivitamin daily.", "Her periods have been regular, occurring once every 28 to 30 days with normal flow.", "She is sexually active with 2 partners, who use condoms routinely.", "Her mother has diabetes and coronary artery disease, and her father passed away at age 45 after being diagnosed with colon cancer at age 40."], "Examination and Results": ["Her temperature is 36.7\u00b0C (98\u00b0F), blood pressure is 115/80 mmHg, pulse is 65/min, respirations are 12/min, and oxygen saturation is 100% on room air.", "Her physical exam is within normal limits."], "Others": ["All of her age appropriate immunizations are up to date.", "Her prior pap smear was performed last year and was normal.", "Her grand-aunt underwent bilateral mastectomies after being diagnosed with breast cancer at age 60."]}
{"Patient Personal Background": ["She has no significant medical history and takes no medications."], "Patient Symptoms": ["Her rash has progressed and the skin on her hands is \"peeling.\"", "A diffuse, macular, erythematous rash is noted with desquamation over the patient's hands as shown in Figure A.", "Bilateral conjunctivitis is noted.", "The patient's nasal packing is removed revealing copious, foul-smelling, purulent discharge."], "Examination and Results": ["Her temperature is 102\u00b0F (38.9\u00b0C), blood pressure is 84/54 mmHg, pulse is 160/min, respirations are 22/min, and oxygen saturation is 99% on room air.", "Exam reveals an ill-appearing woman."], "Treatment": ["She had nasal septoplasty performed 1 week prior and has had nasal packing in place since that time."]}
{"Patient Symptoms": ["Over the past 2 days, the patient\u2019s stools have become looser and streaked with blood.", "The patient has also regurgitated several of her feedings in the last few days.", "Neither the vomit nor bloody stools have seemed to bother the patient."], "Examination and Results": ["The patient is breastfed every 2-3 hours and voids 10-12 times daily.", "The patient previously had several soft stools per day that ranged in color from mustard yellow to dark green.", "The patient\u2019s weight continues to trend along the 50th percentile.", "The patient\u2019s temperature is 98.4\u00b0F (36.9\u00b0C), blood pressure is 66/51 mmHg, pulse is 127/min, and respirations are 26/min.", "On physical exam, the patient appears well nourished and is cooing.", "Her abdomen is soft and non-tender.", "Physical exam reveals the finding seen in Figure A."]}
{"Patient Personal Background": ["The patient is breastfed, has been feeding well every 2 hours, and is urinating over 8 times per day.", "He was born at 35 weeks gestation to a 27-year-old G4P4 mother.", "The patient is of Ashkenazi Jewish descent and the patient\u2019s parents refused all prenatal genetic testing.", "The pregnancy was uncomplicated until the patient\u2019s mother had a spontaneous rupture of membranes at 35 weeks of gestation.", "The patient\u2019s 3 older siblings are all healthy."], "Patient Symptoms": ["He has no dysmorphic features, and his abdomen is distended and non-tender.", "Bowel sounds are absent."], "Examination and Results": ["The patient\u2019s temperature is 98.2\u00b0F (36.8\u00b0C), blood pressure is 48/32 mmHg, pulse is 164/min, and respirations are 48/min.", "On physical exam, he appears to be in moderate distress."]}
{"Patient Personal Background": ["She is presenting late to prenatal care due to significant anxiety about her pregnancy, as she and her husband had struggled with infertility for several years prior to conceiving.", "The patient has a past medical history of bulimia nervosa but has not been symptomatic in 2 years.", "She also had an appendectomy at age 15 for appendicitis.", "She is a Ph.D. student and her husband is a physician."], "Patient Symptoms": ["She has had nausea and vomiting for about 2 months, tender and swollen breasts, and cravings for foods she typically does not eat.", "She took a pregnancy test about 10 weeks ago and was too nervous to read the result immediately."], "Examination and Results": ["Her temperature is 98.5\u00b0F (36.9\u00b0C), pulse is 75/min, blood pressure is 122/76 mmHg, and respirations are 13/min.", "The patient\u2019s affect is normal and she is pleasant and excited about her pregnancy.", "A physical exam is notable for abdominal distension but is otherwise unremarkable.", "Ultrasound is shown in Figure A, and urine human chorionic gonadotropin is negative in the office."], "Others": ["After 24 hours, she saw that it was positive."]}
{"Patient Personal Background": ["He has no significant medical history and does not currently take any medications."], "Patient Symptoms": ["He denies having nausea, vomiting, or diarrhea."], "Examination and Results": ["His temperature is 98.6\u00b0F (37\u00b0C), blood pressure is 115/72 mmHg, pulse is 98/min, and respirations are 14/min.", "Physical exam reveals conjunctival icterus, bilateral flank tenderness, and erythema of the left leg."], "Treatment": ["He was recently diagnosed with cellulitis of his left leg, for which he was prescribed trimethoprim-sulfamethoxazole."], "Diagnosis": ["He was recently diagnosed with cellulitis of his left leg, for which he was prescribed trimethoprim-sulfamethoxazole."]}
{"Patient Personal Background": ["He has a history of type II diabetes mellitus and hypertension.", "He takes metformin, insulin, and lisinopril."], "Patient Symptoms": ["The pain is worse at night.", "He has associated fever and chills.", "This morning, he awoke with purulent, foul-smelling discharge on his pillow."], "Examination and Results": ["His temperature is 102.2\u00b0F (39.0\u00b0C), blood pressure is 130/87 mmHg, pulse is 110/min, and respirations are 16/min.", "The patient is toxic in appearance and in mild distress due to pain.", "Examination of the external ear reveals findings shown in Figure A. Granulation tissue and purulent drainage are noted in the external auditory canal."], "Others": ["Physical exam is otherwise unremarkable."]}
{"Patient Personal Background": ["The patient has been breastfed since birth, and usually feeds for 30 minutes every 2-3 hours.", "Her older son had a similar problem with vomiting that resolved around 12 months of age.", "Four weeks ago, the patient\u2019s height and weight were in the 40th and 34th percentiles, respectively."], "Patient Symptoms": ["The patient\u2019s mother is concerned that her milk production is not keeping up with the patient\u2019s nutritional requirements.", "She reports that about 2 weeks ago the patient began regurgitating breastmilk through his nose and mouth after some feeds.", "He seems mildly upset during the episodes of regurgitation but usually settles down quickly and is hungry again soon afterwards.", "His mother has already tried limiting the volume of each feed, which seems to have reduced the frequency of regurgitation.", "She denies any diarrhea, hematochezia, or family history of food allergies."], "Examination and Results": ["His height and weight are now respectively in the 37th and 36th percentiles.", "His temperature is 98.6\u00b0F (37\u00b0C), blood pressure is 72/49 mmHg, pulse is 121/min, and respirations are 32/min.", "On physical exam, the patient is cooing in his mother\u2019s lap and smiles reciprocally with her.", "He lifts his head and shoulders off the examination table when placed in the supine position.", "His abdomen is soft, non-tender and non-distended.", "Bowel sounds are normoactive."]}
{"Patient Personal Background": ["He currently takes no medications."], "Patient Symptoms": ["He was walking in the park about 45 minutes prior to arrival when the patient stumbled and fell.", "He had sudden weakness in his left leg and was unable to grasp a handrail with his left hand."], "Examination and Results": ["His temperature is 98.0\u00b0F (36.6\u00b0C), blood pressure is 128/89 mmHg, pulse is 130/min, and respirations are 18/min.", "On exam, he has 3/5 strength in the left upper and lower extremities and a left-sided facial droop.", "A non-contrast CT scan of the head is performed, which suggests parenchymal ischemia in the distribution of the right middle cerebral artery.", "An ECG is performed, as shown in Figure A."], "Treatment": ["He is given intravenous alteplase with rapid improvement in his strength deficits and facial asymmetry."]}
{"Patient Personal Background": ["Her mother reports that she is eating well at home and sleeping well throughout the night."], "Examination and Results": ["She can jump and walk up and down stairs with both feet on each step.", "In the doctor\u2019s office, the patient builds a 6-cube tower and imitates a circle.", "She seems to have a vocabulary of over 50 words that she uses in 2-word sentences.", "The patient enjoys playing near other children and sometimes argues over toys with her older brother.", "Her temperature is 98.6\u00b0F (37\u00b0C), blood pressure is 92/56 mmHg, pulse is 106/min, and respirations are 23/min.", "On physical exam, she appears well developed and well nourished, and she is following along her growth curves."], "Diagnosis": ["The child is assessed as developmentally normal."]}
{"Patient Personal Background": ["She has been compliant with her medications, which include albuterol, metformin, glyburide, and atorvastatin."], "Patient Symptoms": ["She thinks that her husband is having sex with other women because they have not had sex over the past year.", "She feels that her co-workers also disrespect her for her weight and constant sweat stains around her armpits and chest.", "She has noticed that the sweat stains get itchy and induce a burning sensation unless she showers or changes her shirt."], "Examination and Results": ["Her temperature is 98.6\u00b0F (37\u00b0C), blood pressure is 128/85 mmHg, pulse is 91/min, and respirations are 11/min.", "On physical exam, the patient has a flat affect, with moist oral mucosa and nasal polyps.", "She denies sinus tenderness.", "Her neck is thick with a posterior cervical fat pad.", "During cardiac auscultation, the finding in Figure A is noted below her breasts."]}
{"Patient Personal Background": ["She has a history of hypertension and hyperlipidemia for which she takes amlodipine and atorvastatin.", "She immigrated from Vietnam 6 months ago."], "Patient Symptoms": ["She has experienced these symptoms daily for the past 3 months.", "She feels bloated and has episodic loose and watery stools."], "Examination and Results": ["Her temperature is 98.6\u00b0F (37.0\u00b0C), blood pressure is 110/60 mmHg, pulse is 70/min, and respirations are 18/min.", "Physical exam reveals a thin-appearing woman in no acute distress.", "Her mucous membranes are moist.", "Cardiac and lung examinations are unremarkable.", "Laboratory results are as follows: Leukocyte count: 13,000/mm^3 Segmented neutrophils: 54% Bands: 2% Eosinophils: 6% Basophils: 0.4% Lymphocytes: 30% Monocytes: 5% A vitamin D level is 26 ng/mL (reference: >= 30 ng/mL)."]}
{"Patient Personal Background": ["His medical history is pertinent for intravenous drug use.", "He has no past surgical history."], "Patient Symptoms": ["The pain is localized to 1 spot in his lower back and is worse with physical activity."], "Examination and Results": ["His temperature is 36.8\u00b0C (98.2\u00b0F), blood pressure is 118/90 mmHg, pulse is 92/min, respirations are 13/min, and oxygen saturation is 99% on room air.", "On physical exam, he has midline back tenderness to palpation at L2-L3.", "Laboratory workup reveals an erythrocyte sedimentation rate of 112 mm/h and C-reactive protein of 10 mg/dL."]}
{"Patient Personal Background": ["Her medical history is notable for medullary thyroid cancer status post total thyroidectomy.", "She enjoys a diverse diet and takes levothyroxine."], "Patient Symptoms": ["Her vision has been steadily declining over the past 2 years and she thinks she needs a prescription for glasses.", "She further complains that her lips and feet feel numb."], "Examination and Results": ["Her blood pressure is 110/70 mmHg, pulse is 80/min, and respirations are 12/min.", "She is alert and oriented.", "Her pupils are equal, round, and reactive to light, but appear opacified.", "Extraocular movements are intact, albeit slow.", "Her visual acuity is decreased bilaterally.", "The remainder of her physical exam is unremarkable."]}
{"Patient Personal Background": ["The patient has had 2 uncomplicated spontaneous vaginal deliveries at full term with her last child born 6 years ago.", "She has a history of generalized anxiety disorder, atopic dermatitis, and she is currently on escitalopram."], "Patient Symptoms": ["She has felt nauseous the last several mornings and has been tired for a few weeks."], "Examination and Results": ["Her temperature is 98.6\u00b0F (37.0\u00b0C), pulse is 70/min, blood pressure is 121/67 mmHg, and respirations are 13/min.", "The patient appears anxious, but overall comfortable, and cardiopulmonary and abdominal exams are unremarkable.", "Pelvic exam reveals normal external genitalia, a closed and soft cervix, a 10-week-sized uterus, and no adnexal masses."], "Others": ["She is concerned about the risk of Down syndrome in this fetus, as her sister gave birth to an affected child at age 43."]}
{"Patient Personal Background": ["He has hypertension and hyperlipidemia, for which he takes lisinopril and atorvastatin.", "He has never smoked cigarettes."], "Patient Symptoms": ["The mass has been slowly enlarging over the past 1 year.", "He reports no dysphagia, difficulty breathing, or changes to his voice.", "He also denies heat intolerance, palpitations, tremors, or diarrhea."], "Examination and Results": ["His temperature is 37.1\u00b0C (98.8\u00b0F), blood pressure is 130/84 mmHg, pulse is 86/min, respirations are 12/min, and oxygen saturation is 99% on room air.", "Bedside ultrasound reveals a 1x2 cm hypoechogenic nodule with microcalcifications in the right thyroid lobe, which is biopsied."], "Others": ["Pathology results are shown in Figure A."]}
{"Patient Personal Background": ["Her daughter has been feeding and voiding well.", "The neonate was delivered at 39 weeks gestation via an uncomplicated vaginal delivery and was discharged home after 2 days.", "The prenatal course was complicated by chlamydia in the mother during the first trimester, for which she and the partner were both treated with a confirmatory test of cure.", "The biological father is no longer involved in the patient's life, but her mother\u2019s boyfriend has been caring for the baby whenever the mother rests."], "Patient Symptoms": ["Examination of the genitals reveals no vulvar irritation or skin changes but there is scant pink mucoid discharge at the introitus."], "Examination and Results": ["The neonate\u2019s temperature is 98.5\u00b0F (36.9\u00b0C), blood pressure is 56/35 mmHg, pulse is 138/min, and respirations are 51/min.", "She appears comfortable, and cardiopulmonary and abdominal exams are unremarkable.", "There are no bruises or marks on her skin.", "Examination of the genitals reveals no vulvar irritation or skin changes but there is scant pink mucoid discharge at the introitus."]}
{"Patient Personal Background": ["He was born at 39 weeks gestation to a 38-year-old G3P3 mother.", "The pregnancy was uncomplicated, and the patient\u2019s mother received routine prenatal care.", "She declined prenatal testing.", "One of the patient\u2019s older siblings has Down syndrome."], "Patient Symptoms": ["The patient is otherwise doing well and feeding every 2 hours.", "He is urinating 8-10 times per day.", "The patient has had 2 episodes of vomiting that were described as green in color."], "Examination and Results": ["The patient's temperature is 98.2\u00b0F (36.8\u00b0C), blood pressure is 48/32 mmHg, pulse is 164/min, and respirations are 48/min.", "On physical exam, the patient is in no acute distress.", "His abdomen is firm, non-tender, and distended with hypoactive bowel sounds.", "A digital rectal exam fails to relieve the obstruction.", "An abdominal radiograph is performed and the result can be seen in Figure A."]}
{"Patient Personal Background": ["He was born at home via spontaneous vaginal delivery at 37 weeks of gestation to a G1P1 mother.", "His mother did not receive prenatal care."], "Patient Symptoms": ["His parents are concerned that he is not feeding well and has lost weight over the last 2 weeks."], "Examination and Results": ["His blood pressure is 70/44 mmHg, pulse is 151/min, and respirations are 41/min.", "His weight is 3 kg (4th percentile) compared with 3.5 kg at birth (45th percentile).", "On physical exam, he is jaundiced with an enlarged liver and spleen.", "He does not appear to respond to visual stimuli, and further examination reveals bilateral clouding of the lens."]}
{"Patient Symptoms": ["His mother reports he was eating well until 1 week ago when he began vomiting after breastfeeding.", "His mother has tried increasing the frequency of feeds and decreasing the amount of each feed, but the vomiting seems to be getting worse.", "The patient now vomits after every feed.", "The vomitus looks like breast milk.", "The patient\u2019s mother is exclusively breastfeeding and would prefer not to switch to formula but worries that the patient is not getting the nutrition he needs."], "Examination and Results": ["Two weeks ago, the patient was in the 75th percentile for weight and 70th for height.", "He is now in the 60th percentile for weight and 68th percentile for height.", "His temperature is 98.2\u00b0F (36.8\u00b0C), blood pressure is 58/37 mmHg, pulse is 144/min, and respirations are 34/min.", "On physical exam, the patient has dry mucous membranes.", "His abdomen is soft and non-distended."]}
{"Patient Personal Background": ["She is at 12 weeks gestational age and has not received prior prenatal care.", "She has no known medical problems and takes only a prenatal multivitamin.", "She has unprotected sexual intercourse with 3 male partners."], "Patient Symptoms": ["She has mild morning sickness but no other symptoms."], "Examination and Results": ["Her temperature is 98.6\u00b0F (37.0\u00b0C), blood pressure is 118/70 mmHg, pulse is 80/min, and respirations are 18/min.", "Physical exam reveals a well-appearing woman in no acute distress.", "There are no lesions appreciated on skin exam.", "Cardiopulmonary exam is unremarkable.", "An antibody test for human immunodeficiency virus (HIV)-1/2 is positive."], "Treatment": ["The patient is started on an appropriate treatment regimen."]}
{"Patient Personal Background": ["She started treatment for a skin condition with a new oral medication 2 months prior."], "Patient Symptoms": ["She has not noticed any changes in her complexion as of yet."], "Examination and Results": ["Her temperature is 98.2\u00b0F (36.8\u00b0C), blood pressure 100/65 mmHg, pulse 87/min, and respiratory rate 14/min.", "She is oriented to person, place, and time.", "Neurological exam reveals papilledema upon examination of both eyes.", "Skin examination is notable for the findings in Figure A."]}
{"Patient Personal Background": ["He was born at 37 weeks gestation to a 39-year-old G3P3 mother.", "The mother initially labored at home with a midwife but was transferred to the hospital for failure to progress.", "The mother declined all prenatal screening tests during this pregnancy."], "Examination and Results": ["His temperature is 98.6\u00b0F (37\u00b0C), blood pressure is 63/41 mmHg, pulse is 133/min, and respirations are 39/min.", "His Apgar scores were 7 and 8 at 1 and 5 minutes, respectively.", "His weight is 3.0 kg (6.6 lb), and his height and his head circumference are in the 30th and 40th percentiles, respectively.", "On physical exam, he is found to have a 3 cm full-thickness defect in the abdominal wall to the right of the umbilicus with evisceration of a loop of the bowel."], "Treatment": ["The abdominal defect is immediately covered in sterile saline dressings and an orogastric tube and 2 peripheral intravenous lines are placed."], "Others": ["The infant was eventually delivered via Caesarean section."]}
{"Patient Personal Background": ["Her medical history is significant for hypertension treated with lifestyle modification and gastroesophageal reflux disease (GERD)."], "Patient Symptoms": ["She noticed the weakness approximately 3 months ago.", "It has gotten progressively worse since that time.", "She has also noticed increasing difficulty combing her hair, standing from a seated position, and experiences muscle aches."], "Examination and Results": ["Her temperature is 98.6\u00b0F (37.0\u00b0C), blood pressure is 130/65 mmHg, pulse is 80/min, and respirations are 16/min.", "She has 3/5 strength to shoulder abduction and hip flexion bilaterally.", "Her strength is 5/5 to wrist extension and ankle plantar flexion.", "No skin rashes are noted."]}
{"Patient Symptoms": ["One week ago, he began vomiting and regurgitating breastmilk through his nose after most feedings.", "His stools over the past week have also become blood-streaked.", "The patient does not seem to be in any distress when he passes these bloody stools."], "Examination and Results": ["The patient is breastfed and typically feeds for 20-30 minutes every 2 hours.", "The patient surpassed his birth weight by 2 weeks of age but has fallen 1 standard deviation on the growth curve since then.", "His temperature is 98.6\u00b0F (37\u00b0C), blood pressure is 78/47 mmHg, pulse is 115/min, and respirations are 28/min.", "On physical exam, the patient is well-appearing.", "The patient\u2019s abdomen is soft, non-tender, and non-distended.", "A digital rectal exam reveals a small amount of blood in the rectal vault."], "Others": ["His face and back have the physical exam finding seen in Figure A."]}
{"Patient Personal Background": ["The patient's mother reports that the pregnancy was uncomplicated other than an episode of sinusitis in the 3rd trimester, for which she was treated with azithromycin."], "Patient Symptoms": ["Three weeks ago, the patient began vomiting after meals.", "The vomitus appears to be normal stomach contents without streaks of red or green.", "Despite these adjustments, the vomiting has become more frequent and forceful.", "He has fallen 1 standard deviation off of the growth curve."], "Examination and Results": ["The patient is voiding about 4 times per day and his urine appears dark yellow.", "The patient's temperature is 98.7\u00b0F (37.1\u00b0C), blood pressure is 58/41 mmHg, pulse is 166/min, and respirations are 16/min.", "On physical exam, the patient looks small for his age.", "His abdomen is soft, non-tender, and non-distended."], "Treatment": ["His parents have already tried repositioning him during mealtimes and switching his formula to eliminate cow\u2019s milk and soy."]}
{"Patient Symptoms": ["The patient drinks 4 ounces of cow\u2019s milk formula every 3 hours.", "He regurgitates a moderate amount of formula through his nose and mouth after most feeds.", "He does not seem interested in additional feeding after these episodes of regurgitation and he has become progressively more irritable around meal times.", "The patient is starting to refuse some feeds."], "Examination and Results": ["He usually stools 1 time per day and urinates up to 6 times per day.", "The patient\u2019s weight was in the 62nd percentile 4 weeks ago and he is now in the 48th percentile.", "His height and head circumference have followed similar trends.", "His temperature is 98.2\u00b0F (36.8\u00b0C), blood pressure is 72/47 mmHg, pulse is 125/min, and respirations are 27/min.", "His abdomen is soft, non-tender, and non-distended."], "Others": ["His mother denies seeing blood or streaks of red in his stool and she denies any family history of food allergies or dermatological problems.", "On physical exam, the patient smiles reciprocally and can lift his head and chest when in the prone position."]}
{"Patient Symptoms": ["She has not shaved in about a week.", "She has also gained about 10 pounds in the last several months, and her periods have become irregular over the last year.", "Her last menstrual period was 3 months ago."], "Examination and Results": ["Her temperature is 98.6\u00b0F (37.0\u00b0C), pulse is 72/min, blood pressure is 136/86 mmHg, and respirations are 13/min.", "Her BMI is 26 kg/m^2.", "Her skin exam reveals hirsutism along the jawline and acanthosis nigricans in the axillary folds.", "Cardiopulmonary and abdominal exams are unremarkable.", "A pelvic exam reveals normal external genitalia, a mobile and non-tender 6-week-sized uterus, and no adnexal masses or tenderness.", "Transvaginal ultrasound is performed and shown in Figure A."]}
{"Patient Personal Background": ["Her medical history is significant for type 2 diabetes mellitus, hypertension, and osteoporosis for which she takes metformin, enalapril, and alendronate.", "She was found to have a deep vein thrombosis of her left leg 3 months prior to presentation."], "Patient Symptoms": ["She noticed her symptoms while in the bathtub at home.", "She has never had symptoms like this before.", "Over the previous several months she has had episodes of joint swelling and pain in her hands as well as redness, burning pain, and swelling of her hands and feet."], "Examination and Results": ["Her temperature is 98.6\u00b0F (37.0\u00b0C), pulse is 80/min, blood pressure is 135/85 mmHg, and respirations are 13/min.", "Physical exam is notable for a woman in discomfort with excoriations over the skin on her forearms.", "Laboratory tests are shown below."]}
{"Patient Personal Background": ["He was born at 39 weeks gestation to a 27-year-old primigravid mother via cesarean section for cervical insufficiency.", "The pregnancy was complicated by gestational diabetes and the amniotic fluid was clear."], "Patient Symptoms": ["The patient now is exhibiting increased work of breathing and is progressively more tachypneic.", "Breath sounds are decreased at the bases bilaterally.", "The patient has central cyanosis."], "Examination and Results": ["Upon delivery, the patient had strong respiratory effort and a strong cry.", "His Apgar scores at 1 and 5 minutes were 7 and 8, respectively.", "His birth weight is 3,568 g (7 lb 14 oz).", "His temperature is 99.0\u00b0F (37.2\u00b0C), blood pressure is 60/44 mmHg, pulse is 146/min, and respirations are 72/min.", "On physical exam, the patient is grunting with nasal flaring and subcostal retractions.", "Breath sounds are decreased at the bases bilaterally."], "Others": ["His chest radiograph can be seen in Figure A."]}
{"Patient Personal Background": ["The patient was born at 36 weeks gestation to a 26-year-old primigravid mother via cesarean section for cervical incompetence.", "The patient has been exclusively breastfed since birth, and his mother reports that he feeds for 20-30 minutes every 2 hours."], "Patient Symptoms": ["The patient urinates 7 times per day and has begun passing 2-3 stools per day that his mother describes as \u201cgrainy\u201d and the color of \u201cmustard.\u201d His birth weight was 3670 g (8 lb 1 oz), and his current weight is 3487 (7 lb 11 oz)."], "Examination and Results": ["His temperature is 97.1\u00b0F (36.2\u00b0C), blood pressure is 57/42 mmHg, pulse is 140/min, and respirations are 38/min.", "On physical exam, the patient\u2019s anterior fontanelle is soft and flat, and his eyes are moderately icteric.", "His abdomen is soft and non-distended."], "Others": ["The patient required no resuscitation at birth and both mother and child were discharged from the hospital at 2 days of life.", "The patient has the physical exam finding seen in Figure A.", "His diaper can be seen in Figure B."]}
{"Patient Personal Background": ["His medical history is significant for chronic hepatitis C infection, hypertension, type 2 diabetes mellitus, and heart failure.", "The patient works as a butcher at a local meat processing shop and is sexually active with several partners.", "He does not use barrier protection.", "His temperature is 98.6\u00b0F (37.0\u00b0C), pulse is 90/min, blood pressure is 155/95 mmHg, and respirations are 12/min."], "Patient Symptoms": ["He first noticed the rash 2 weeks prior and he endorses intermittent itchiness from the rash."], "Examination and Results": ["On physical exam, his skin has the finding shown in Figure A.", "Fine, lace-like white lines are also noted on the patient\u2019s buccal mucosa."]}
{"Patient Personal Background": ["He has no significant medical history and takes no medications."], "Patient Symptoms": ["He first felt the pain while lifting boxes at work but thought that he had just strained a muscle.", "The pain appears to be worse in the mornings and after rest.", "Exercise and physical activity appear to temporarily make the pain better."], "Examination and Results": ["His temperature is 98.6\u00b0F (37.0\u00b0C), blood pressure is 115/70 mmHg, pulse is 70/min, and respirations are 12/min.", "On physical exam, he is found to have limited flexion and extension of his spine as well as tenderness to palpation over the insertion of his patellar tendons bilaterally."], "Treatment": ["He has taken acetaminophen and ibuprofen for the pain."]}
{"Patient Personal Background": ["He has a medical history of type 2 diabetes mellitus, hypertension, depression, obesity, and a myocardial infarction 7 years ago.", "The patient's prescribed medications are metoprolol, aspirin, lisinopril, hydrochlorothiazide, fluoxetine, metformin, and insulin.", "The patient has not been filling his prescriptions regularly and can not remember what medications he has been taking."], "Examination and Results": ["His temperature is 99.5\u00b0F (37.5\u00b0C), pulse is 96/min, blood pressure is 180/120 mmHg, respirations are 18/min, and oxygen saturation is 97% on room air."]}
{"Patient Personal Background": ["As the infant is resting, vital signs are taken."], "Patient Symptoms": ["His mother notices that his face, chest, and extremities turn dusky blue during nursing.", "She also notes that he seems to be snoring loudly and breathing very quickly.", "When she removes him from her breast, he begins to cry and his color improves.", "The neonate\u2019s prenatal course was unremarkable, and his mother has a medical history of asthma with occasional albuterol inhaler use."], "Examination and Results": ["The delivery is uncomplicated and the neonate has Apgar scores of 9 and 9 at 1 and 5 minutes respectively.", "His temperature is 98.2\u00b0F (36.7\u00b0C), pulse is 130/min, respirations are 45/min, and oxygen saturation is 97% on room air.", "A physical exam demonstrates well-perfused skin but is notable for the facial features shown in Figure A."], "Others": ["After 15 minutes, he attempts to nurse for the 1st time."]}
{"Patient Personal Background": ["The patient works as a farmer and gardens in his spare time.", "He has a medical history of poorly managed type 2 diabetes mellitus and irritable bowel syndrome.", "His current medications include lisinopril, metformin, insulin, fiber supplements, and a multivitamin."], "Patient Symptoms": ["In addition, he complains of a cut on his scalp that is not seeming to heal."], "Examination and Results": ["On physical exam, there is a calm, obese gentleman.", "The patient's glucose journal reveals an average blood glucose of 175 mg/dL.", "His temperature is 98.8\u00b0F (37.1\u00b0C), blood pressure is 134/86 mmHg, pulse is 80/min, and respirations are 13/min.", "On inspection of the patient's scalp, the finding in Figure B is noted."], "Others": ["Inspection of the patient's scalp reveals the finding shown in Figure A.", "The patient is sent home and instructed to keep a blood glucose journal.", "Three months later, the patient returns with his glucose journal."]}
{"Patient Personal Background": ["He recently retired from working the day shift at a cemetery.", "The patient has a medical history of irritable bowel syndrome which is managed with fiber supplements."], "Patient Symptoms": ["When the patient retired, his goal was to finally be able to go out with his wife; however, he finds that he is unable to stay awake past 6 pm in the evening.", "His wife is disappointed that they cannot do any activities in the evening together.", "The patient has tried drinking caffeine but finds that it does not help."], "Examination and Results": ["The patient\u2019s wife claims that the patient seems to sleep peacefully, and the patient states he feels rested when he awakes.", "His temperature is 98.6\u00b0F (37\u00b0C), blood pressure is 125/83 mmHg, pulse is 87/min, and respirations are 11/min.", "The patient\u2019s neurological exam is within normal limits."]}
{"Patient Symptoms": ["The parents have noticed a \u201cswelling of the belly button.\u201d Cord separation occurred at 7 days of age.", "The swelling seems to come and go but is never larger than the size of a blueberry."], "Examination and Results": ["The child is sleeping at regular 2-hour intervals and feeding and stooling well.", "Her temperature is 98.6\u00b0F (37\u00b0C), blood pressure is 68/43 mmHg, pulse is 128/min, and respirations are 32/min.", "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."], "Others": ["They deny any drainage from the swelling."]}
{"Patient Personal Background": ["The child was recently adopted and little is known about his medical or family history.", "He eats a varied diet at home and with limited juice and snack foods."], "Patient Symptoms": ["The child seems to be doing well, but the patient is much larger than any of the other 3-year-olds in his preschool class.", "He appears mildly developmentally delayed.", "He appears to have poor visual acuity and is referred to an ophthalmologist, who finds downward lens subluxation of the right eye."], "Examination and Results": ["His temperature is 98.6\u00b0F (37\u00b0C), blood pressure is 101/67 mmHg, pulse is 110/min, and respirations are 24/min.", "On physical exam, the patient is in the 73rd percentile for weight, 99th percentile for height, and 86th percentile for head circumference.", "He has a fair complexion and tall stature with a prominent sternum.", "The patient also has joint hypermobility and hyperelastic skin."]}
{"Patient Personal Background": ["The patient is otherwise doing well in school and enjoys playing basketball.", "His medical history is otherwise significant for scoliosis which is managed by an orthopedic surgeon.", "His family history is significant for a mother with type 2 diabetes mellitus and a father who underwent aortic valve replacement last year."], "Patient Symptoms": ["Over the past several months, he has had increasing difficulty seeing the board from the back of the classroom at school."], "Examination and Results": ["His temperature is 98.6\u00b0F (37\u00b0C), blood pressure is 115/71 mmHg, pulse is 72/min, and respirations are 12/min.", "On physical exam, the patient is tall for his age and has long arms.", "He has 20 degrees of thoracic scoliosis, which is stable from previous exams.", "On slit-lamp examination, the patient is found to have bilateral upward lens subluxation and is prescribed corrective lenses."]}
{"Patient Personal Background": ["Her medical history includes type 2 diabetes mellitus which is well-controlled with metformin."], "Patient Symptoms": ["Initially, she attributed her mother's forgetfulness and word-finding difficulties to normal aging, but over the past few years, her mother's memory has worsened, her mood has grown more irritable, and her mother has been found wandering the neighborhood unsure of how to get home."], "Examination and Results": ["On exam, her temperature is 98.2\u00b0F (36.8\u00b0C), blood pressure is 115/82 mmHg, pulse is 73/min, respirations are 12/min, and oxygen saturation is 99% on room air.", "Cardiopulmonary exam reveals normal S1 and S2, no murmurs, and clear lungs bilaterally.", "She scores 16/30 on the Montreal Cognitive Assessment (MoCA) test."]}
{"Patient Personal Background": ["The child was born at 38 weeks of gestation to a 28-year-old G3P3 mother.", "The pregnancy was complicated by preeclampsia in the mother which was well-controlled throughout the pregnancy."], "Patient Symptoms": ["The mother went into spontaneous labor but the delivery was complicated by a prolonged 2nd stage of labor."], "Examination and Results": ["Her temperature is 98.6\u00b0F (37\u00b0C), blood pressure is 67/43 mmHg, pulse is 135/min, and respirations are 34/min.", "On physical exam, she appears to be in mild distress and has a 4x5 cm ecchymotic area of swelling over the bilateral parietal bones.", "Serial assessments of the child\u2019s head circumference over the next 12 hours show no change in the size of the swelling."], "Treatment": ["A vacuum-assisted vaginal delivery was eventually performed."], "Others": ["The child\u2019s Apgar scores were 8 and 9 at 1 and 5 minutes, respectively."]}
{"Patient Personal Background": ["The child was born at 39 weeks gestation to a 34-year-old G2P2 mother by vacuum-assisted vaginal delivery after prolonged labor.", "The mother was diagnosed during this pregnancy with gestational diabetes mellitus and received prenatal care throughout.", "All prenatal screening was normal and the 20-week anatomy ultrasound was unremarkable."], "Patient Symptoms": ["She denies that the lump was present at birth and is concerned about an infection."], "Examination and Results": ["His birth weight was 3.8 kg (8.4 lb) and his length and head circumference are at the 40th and 60th percentiles, respectively.", "His temperature is 98.6\u00b0F (37\u00b0C), blood pressure is 65/42 mmHg, pulse is 131/min, and respirations are 36/min.", "On physical exam, the child is in no acute distress.", "He has a 3x3 cm fluctuant swelling over the right parietal bone that does not cross the midline.", "There is no discoloration of the overlying scalp."]}
{"Patient Personal Background": ["His medical history is significant for an episode of pancreatitis 2 years ago for which he was hospitalized for several days.", "He drinks 2-3 beers on the weekend and he has never smoked.", "He has no family history of colon cancer."], "Patient Symptoms": ["He reports that he also noticed some blood mixed with his stool.", "The patient denies abdominal pain or any changes in his stool habits.", "He notes a weight loss of 8 pounds in the last 2 months with no changes in his diet or exercise habits."], "Examination and Results": ["His temperature is 97.6\u00b0F (36.4\u00b0C), blood pressure is 135/78 mmHg, pulse is 88/min, and respirations are 14/min.", "On physical exam, his abdomen is soft and non-tender to palpation.", "Bowel sounds are present, and there is no hepatomegaly."]}
{"Patient Symptoms": ["The patient reports pain localized to the posterior elbow and refuses to attempt elbow extension secondary to pain and swelling."]}
{"Patient Personal Background": ["Overall he is doing well.", "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.", "Now he sleeps 7 hours a night and doesn\u2019t feel as well rested as he used to.", "His medical history is significant for hypertension and diabetes for which he takes lisinopril and metformin."], "Patient Symptoms": ["Despite this, the patient claims that he feels less well-rested when he wakes up in the morning.", "The patient states that he used to sleep 9 hours a night in his youth and felt excellent.", "The patient\u2019s wife states that he seems to sleep peacefully."], "Examination and Results": ["His temperature is 98.6\u00b0F (37\u00b0C), blood pressure is 131/85 mmHg, pulse is 71/min, and respirations are 12/min.", "His neurological exam is within normal limits.", "The patient is muscular and has a healthy weight with a pleasant demeanor."], "Others": ["He denies feeling fatigued or tired currently."]}
{"Patient Personal Background": ["She has a medical history of anxiety and is not currently taking any medications."], "Patient Symptoms": ["She has a general aching/pain in her joints that lasts all day.", "The pain is constant and is not relieved by rest or activity.", "She also has pain in her hands at times and occasionally notices trouble swallowing when she is eating."], "Examination and Results": ["Her temperature is 98.6\u00b0F (37\u00b0C), blood pressure is 115/72 mmHg, pulse is 74/min, and respirations are 11/min.", "On physical exam, the patient is a healthy young woman with a sunburn.", "Her hands are mildly edematous with the findings in Figure A."]}
{"Patient Personal Background": ["He is brought in by his home care nurse, who reports that the patient has a history of myasthenia gravis and frequent urinary tract infections.", "His temperature is 99.0\u00b0F (37.2\u00b0C), blood pressure is 128/78 mmHg, pulse is 92/min, and respirations are 28/min with an oxygen saturation of 86% O2 on room air."], "Patient Symptoms": ["The patient was in his normal state of health until 5 days ago when he developed a urinary tract infection.", "This morning, he experienced poor grip strength and progressive difficulty breathing."], "Examination and Results": ["The patient has gray-blue skin, hypophonia, weak upper extremities, and normal leg strength.", "An arterial blood gas is drawn with results as shown below:\n\nPO2: 55 mmHg\nPCO2: 60 mmHg\npH: 7.30\n\nThe patient is intubated."], "Treatment": ["He was receiving gentamicin infusions for his infections."]}
{"Patient Symptoms": ["Her mother reports that the patient began having \u201cexplosive\u201d diarrhea 6 hours ago.", "The patient has little interest in feeding since leaving the hospital after her birth and has not yet regained her birth weight.", "Her immediate postnatal period was otherwise significant for 2 episodes of bilious vomiting that resolved with the temporary use of a nasogastric tube and expulsion of stool during a digital rectal exam.", "The patient passed meconium on the 3rd day of life."], "Examination and Results": ["Her temperature is 101.8\u00b0F (38.8\u00b0C), blood pressure is 58/37 mmHg, pulse is 148/min, and respirations are 38/min.", "On physical exam, the patient appears to be in moderate distress.", "She has no dysmorphic features and she has a normal S1/S2 without any murmurs, rubs, or gallops.", "Her abdomen is firm and distended.", "A digital rectal exam reveals a tight anal sphincter and precipitates a release of gas and liquid stool."], "Others": ["Her abdominal radiograph can be seen in Figure A."]}
{"Patient Personal Background": ["He was born at 37 weeks of gestation to a 38-year-old G3P3 woman.", "The pregnancy was uncomplicated and the patient\u2019s mother refused all prenatal testing.", "The patient\u2019s 2 older siblings are both healthy."], "Patient Symptoms": ["The vomitus was described as \u201cbright green\u201d without any traces of blood.", "The patient has urinated several times since he was born but has not passed any stool.", "His abdomen is non-tender, firm, and distended."], "Examination and Results": ["His temperature is 98.6\u00b0F (37\u00b0C), blood pressure is 67/43 mmHg, pulse is 135/min, and respirations are 34/min.", "On physical exam, the patient has upslanting palpebral fissures, epicanthal folds, and a single transverse palmar crease.", "Bowel sounds are hypoactive.", "Digital rectal exam evacuates a small amount of stool and flatulence."], "Treatment": ["A nasogastric tube is placed to decompress the stomach."], "Others": ["The patient\u2019s abdominal radiograph can be seen in Figure A."]}
{"Patient Personal Background": ["His medications include aspirin, lisinopril, metformin, and sulfasalazine."], "Patient Symptoms": ["He reports that the dyspnea started 2 months ago after he had the flu.", "At first, the difficulty breathing occurred whenever he went up and down 1 flight of stairs, but the dyspnea progressively worsened since then.", "This morning, he developed chest pain and difficulty breathing while sitting at the kitchen table."], "Examination and Results": ["His temperature is 97\u00b0F (36.1\u00b0C), blood pressure is 130/78 mmHg, pulse is 88/min, and respirations are 14/min with an oxygen saturation of 97% O2 on room air.", "On physical exam, jugular venous distension during both inspiration and expiration, mild abdominal distention, and 2+ bilateral lower extremity edema is noted.", "A chest radiograph is obtained and the result is shown in Figure A."]}
{"Patient Personal Background": ["He does not see a primary care physician and is not currently taking any medications.", "He drinks alcohol socially and does not smoke."], "Patient Symptoms": ["The patient has presented 3 times this month with similar complaints.", "He states his shortness of breath started when he was walking from his car to a local restaurant."], "Examination and Results": ["His temperature is 99.5\u00b0F (37.5\u00b0C), pulse is 100/min, blood pressure is 130/90 mmHg, respirations are 18/min, and oxygen saturation is 96% on room air.", "On physical exam, he appears fatigued and the cardiovascular exam reveals an additional heart sound after S2.", "A pulmonary exam is notable for bilateral crackles and an abdominal exam reveals an obese abdomen without pain in any of the quadrants.", "Lower extremity pitting edema is noted bilaterally."]}
{"Patient Personal Background": ["The patient has a medical history of obesity, type 2 diabetes mellitus, and hypertension.", "His current medications include insulin, metformin, lisinopril, and hydrochlorothiazide."], "Patient Symptoms": ["The pain is over his chest and in his left arm.", "2 days later, he complains of chest pain."], "Examination and Results": ["An ECG is performed and is seen in Figure A.", "His temperature is 99.5\u00b0F (37.5\u00b0C), pulse is 112/min, blood pressure is 100/70 mmHg, respirations are 18/min, and oxygen saturation is 95% on room air.", "A repeat ECG is performed and is seen in Figure B."], "Treatment": ["The patient is appropriately managed and is admitted to the step-down unit."]}
{"Patient Personal Background": ["He was last seen in the clinic several months ago when he was diagnosed with attention deficit hyperactivity disorder (ADHD).", "He hopes to play baseball in college and has begun lifting weights daily in preparation for baseball season.", "The patient has a healthy diet to fuel his exercise regimen.", "His parents have no concerns and are pleased with the recent improvement in his grades."], "Examination and Results": ["His temperature is 98.6\u00b0F (37\u00b0C), blood pressure is 115/71 mmHg, pulse is 72/min, and respirations are 12/min.", "On physical exam, the patient has tall stature with average muscle mass for his age.", "He has no dysmorphic features.", "His chest has a normal appearance other than mild gynecomastia.", "The patient has sparse facial hair and a moderate amount of coarse pubic hair that extends across the pubis and spares the medial thighs.", "His testes are small and firm."], "Treatment": ["He was started on methylphenidate at that time and the patient now reports improvement in his ability to concentrate in school and at home."], "Diagnosis": ["He was last seen in the clinic several months ago when he was diagnosed with attention deficit hyperactivity disorder (ADHD)."]}
{"Patient Personal Background": ["Otherwise, he is not currently taking any medications.", "The patient lives alone and works in a health food store."], "Patient Symptoms": ["He states that he typically can converse with animals via telepathy but is having trouble right now due to the weather.", "He states that his symptoms have persisted for the past 8 months."], "Examination and Results": ["His temperature is 98.6\u00b0F (37\u00b0C), blood pressure is 115/71 mmHg, pulse is 72/min, and respirations are 12/min.", "On physical exam, you note a healthy young man who is dressed in an all-burlap ensemble."], "Treatment": ["He has begun taking an assortment of Peruvian herbs to little avail."], "Others": ["When obtaining the patient's medical history, there are several times he attempts to telepathically connect with the animals in the vicinity."]}
{"Patient Personal Background": ["The patient's medical history is notable for anxiety, obesity, hypertension, and polycystic ovarian syndrome.", "She is currently not on any medications.", "She was given an exercise program but she has not been compliant with these exercises."], "Patient Symptoms": ["They found her somnolent next to her computer with an empty pill bottle around 3 hours ago."], "Examination and Results": ["Her temperature is 99.5\u00b0F (37.5\u00b0C), pulse is 82/min, blood pressure is 125/85 mmHg, respirations are 11/min, and oxygen saturation is 97% on room air.", "Physical exam is within normal limits."], "Others": ["The family cannot recall the types of pill bottles that they found and did not bring them to the ED.", "The patient begins communicating with the physician and states that she did take acetaminophen but it was only a few pills.", "Her parents are certain the bottle was new."]}
{"Patient Personal Background": ["The patient is a long-time runner but states that the pain has been getting worse recently.", "The patient has a medical history of surgical repair of his Achilles tendon, ACL, and medial meniscus.", "The patient lives with his wife and they both practice a vegan lifestyle."], "Patient Symptoms": ["The patient is a long-time runner but states that the pain has been getting worse recently.", "When running and at rest he has a burning and aching pain along the bottom of his foot that sometimes turns to numbness.", "Taking time off from training does not improve his symptoms.", "On physical exam, the patient states that he is currently not experiencing any pain in his foot but rather is experiencing numbness/tingling along the plantar surface of his foot."], "Examination and Results": ["His temperature is 98.6\u00b0F (37\u00b0C), blood pressure is 114/72 mmHg, pulse is 81/min, and respirations are 12/min.", "On physical exam, the patient states that he is currently not experiencing any pain in his foot but rather is experiencing numbness/tingling along the plantar surface of his foot.", "Strength is 5/5 and reflexes are 2+ in the lower extremities."], "Others": ["He is currently not taking any medications."]}
{"Patient Personal Background": ["The patient is sexually active with multiple male partners and reports inconsistent condom use.", "She has a history of intravenous drug use and has not been to a doctor in the last 2 years."], "Patient Symptoms": ["The headache started 1 month ago.", "It is constant and \u201call over\u201d but gets worse when she is lying down or in the setting of bright lights.", "A review of systems is significant for a low-grade fever, night sweats, cough, malaise, poor appetite, and unintentional weight loss of 12 pounds in the last 2 months."], "Examination and Results": ["Her temperature is 100.4\u00b0F (38.0\u00b0C), blood pressure is 110/78 mmHg, pulse is 88/min, and respirations are 14/min with an oxygen saturation of 98% O2 on room air.", "On physical exam, pain is elicited upon passive flexion of the patient\u2019s neck.", "A CT scan shows ventricular enlargement.", "A CD4+ count is 57 cells/\u00b5L blood."]}
{"Patient Personal Background": ["He recently started playing for his high school basketball team and generally eats healthy food.", "He has no significant medical history and takes no medications."], "Patient Symptoms": ["He feels disappointed because his voice has not changed.", "He is concerned that he is not as tall as his classmates."], "Examination and Results": ["His temperature is 98.6\u00b0F (37.0\u00b0C), blood pressure is 115/70 mmHg, pulse is 70/min, and respirations are 12/min.", "On physical examination, the patient does not have facial hair or acne.", "His height is 60 inches and his arm span is 50 inches.", "His visual fields are full and he has no cranial nerve abnormalities.", "His strength is 5/5 in bilateral upper and lower extremities.", "Chest palpation and abdominal examination are unremarkable.", "He has no pubic hair and his testicles are symmetric with a volume of 3 mL."]}
{"Patient Personal Background": ["The patient has a medical history of type 2 diabetes mellitus, obesity, and hypertension.", "His current medications include metformin, insulin, lisinopril, and hydrochlorothiazide.", "The patient leads a sedentary life in which he tends to stay home and watch television.", "He does not engage in any physical or strenuous activity.", "His temperature is 98.6\u00b0F (37\u00b0C), blood pressure is 138/85 mmHg, pulse is 75/min, and respirations are 12/min."], "Patient Symptoms": ["He has been having trouble combing his hair and reaching objects that are high on the shelf."], "Examination and Results": ["On physical exam, the patient has decreased passive and active range of motion of his shoulder.", "The strength of the patient's upper extremity is 4/5 limited by pain."]}
{"Patient Personal Background": ["The patient was diagnosed with gestational diabetes after routine screening in the 2nd trimester and has been started on insulin after unsuccessful attempts at lifestyle management.", "She also has migraines and gastroesophageal reflux disorder.", "The patient has a 15-pack-year smoking history but quit smoking in her 1st month of pregnancy.", "She denies alcohol or drug use."], "Patient Symptoms": ["Yesterday she had several episodes of diarrhea and vomited once after attending a company picnic 2 days ago.", "She is worried that she is dehydrated but otherwise feels well and has recovered from her gastrointestinal illness."], "Examination and Results": ["Her temperature is 98.5\u00b0F (36.9\u00b0C), blood pressure is 122/82 mmHg, pulse is 84/min, and respirations are 14/min."], "Treatment": ["She took loperamide with symptomatic relief."], "Others": ["A representative portion of the NST is shown in Figure A."]}
{"Patient Personal Background": ["She is otherwise healthy and does not take any medications."], "Patient Symptoms": ["Her breast has not been tender, and she has not noticed any changes to the skin.", "Bloody discharge is expressed from the right nipple."], "Examination and Results": ["Her temperature is 36.5\u00b0C (97.7\u00b0F), blood pressure is 110/82 mmHg, pulse is 68/min, respirations are 12/min, and oxygen saturation is 99% on room air.", "Exam of the right breast reveals no mass on palpation.", "There is no axillary lymphadenopathy."]}
{"Patient Personal Background": ["He has never had any serious injuries but that he always seems to bruise easily, especially after he started playing soccer this fall.", "His parents deny that he has an abnormal number of nosebleeds or bleeding from the gums.", "They have never seen blood in his stool or urine.", "His mother notes that her brother has had similar problems."], "Patient Symptoms": ["He has dull, aching pain along his left side where he hit the ground."], "Examination and Results": ["His temperature is 98.6\u00b0F (37\u00b0C), blood pressure is 112/74 mmHg, pulse is 82/min, and respirations are 11/min.", "On physical exam, the patient has extensive bruising of the lateral left thigh and tenderness to palpation."], "Others": ["He fell sideways off the scooter as he rounded a curve in the road."]}
{"Patient Personal Background": ["His parents report that he is feeding and stooling well and they have just started experimenting with solid foods.", "The patient was noted to be developmentally appropriate for his age at his last visit 2 months ago."], "Patient Symptoms": ["His parents are concerned because a few weeks ago he started rolling from back to front in addition to front to back, but he now struggles when placed on his back.", "In the examination room, he is able to roll from front to back but cannot roll from back to front.", "He is not able to sit without support and makes no attempt at bouncing when supported in a standing position."], "Examination and Results": ["On physical exam, the patient seems well-nourished and has no dysmorphic features.", "His temperature is 98.6\u00b0F (37\u00b0C), blood pressure is 77/49 mmHg, pulse is 112/min, and respirations are 24/min.", "The patient\u2019s abdomen is non-tender and soft without hepatosplenomegaly.", "His patellar reflexes are 4+ bilaterally."]}
{"Patient Personal Background": ["She says that his first seizure occurred 1 year ago.", "Since then, he has been on valproic acid but the seizure activity remains unchanged.", "He was recently enrolled in daycare because she could no longer care for him full-time.", "Since then, the seizure activity has increased and the daycare facility also noted concerns over his lack of response to voice commands."], "Patient Symptoms": ["She reports that occasionally he \u201csuddenly drops\u201d when running around the house.", "Family history is significant for a cousin who died suddenly at a young age.", "The patient is then startled when a door is closed quickly and he suddenly loses consciousness."], "Examination and Results": ["His temperature is 98.6\u00b0F (37\u00b0C), blood pressure is 105/52 mmHg, pulse is 110/min, and respirations are 25/min.", "A physical exam is significant for lack of response to auditory stimulation.", "An EEG is performed, which is unrevealing."], "Treatment": ["Since then, he has been on valproic acid but the seizure activity remains unchanged."], "Others": ["An ECG is shown in Figure A.", "An ECG is quickly performed and is shown in Figure B."]}
{"Patient Personal Background": ["His medical history is otherwise significant for hypertension and diabetes mellitus, for which he takes metformin and lisinopril."], "Patient Symptoms": ["His dyspnea began 1 hour ago while he was sitting in a chair watching television.", "He also endorses lightheadedness and fatigue but denies chest pain."], "Examination and Results": ["His temperature is 98.8\u00b0F (37.1\u00b0C), blood pressure is 85/54 mmHg, pulse is 48/min, and respirations are 22/min.", "On physical exam, he appears to be in moderate distress.", "He has normal cardiac sounds with an irregular rhythm.", "His lungs are clear to auscultation bilaterally, and his electrocardiogram can be seen in Figure A."], "Treatment": ["The patient is given an initial dose of atropine but this has no effect."], "Others": ["Two weeks ago, he had a mitral valve repair for mitral insufficiency secondary to myxomatous degeneration."]}
{"Patient Personal Background": ["The patient has never been pregnant and previously used a copper intrauterine device (IUD) for contraception, but she had the IUD removed 1 year ago because it worsened her menorrhagia.", "She has now been using combined oral contraceptive pills (OCPs) for nearly 1 year.", "The patient reports improvement in her menorrhagia on the OCPs but denies any improvement in her pain."], "Patient Symptoms": ["She reports that for the last several years, she has had chronic pain that is worse just before her menstrual period.", "Over the past 2 months, she has also had worsening pain during intercourse.", "She denies dysuria, vaginal discharge, or vaginal pruritus."], "Examination and Results": ["Her temperature is 98.0\u00b0F (36.7\u00b0C), blood pressure is 124/73 mmHg, pulse is 68/min, and respirations are 12/min.", "The patient has pain with lateral displacement of the cervix on pelvic exam.", "A pelvic ultrasound shows no abnormalities, and a urine pregnancy test is negative."], "Others": ["Her medical history is otherwise unremarkable."]}
{"Patient Personal Background": ["The medical student has had a negative HIV serology from the beginning of medical school 2 years ago.", "She is monogamous with one male partner and denies any intravenous drug use."], "Examination and Results": ["His most recent viral load is 1,800,000 copies/mL, and he was started on HAART 3 days ago."], "Treatment": ["She immediately washed the puncture wound with saline."], "Others": ["She was drawing blood from an HIV-positive patient when she stuck herself percutaneously while capping the needle."]}
{"Patient Personal Background": ["The patient has a medical history of asthma and his only medication is albuterol."], "Patient Symptoms": ["Exam was significant for pulsatile bleeding from a clean-cut wound on his right second finger."], "Examination and Results": ["His temperature is 98.0\u00b0F (36.6\u00b0C), blood pressure is 120/70 mmHg, pulse is 105/min, and respirations are 17/min.", "Radiography of the hand revealed a complete amputation of the right finger from the distal interphalangeal joint.", "The wound was cleaned, compression applied, analgesics administered, and the hand surgeons were notified."], "Treatment": ["The teacher applied dressings and pressure to the patient's injured digit and immediately transported the patient to the emergency department.", "The teacher states that he left the amputated finger in the classroom, but the principal would be transporting it to the hospital."], "Others": ["He arrived within 20 minutes of the accident."]}
{"Patient Personal Background": ["The patient has a history of depression and multiple suicide attempts.", "He takes fluoxetine as well as over-the-counter pain medications for a recent muscle strain.", "He exercises regularly and recently has started making his own beer at home.", "His temperature is 98.3\u00b0F (36.8\u00b0C), blood pressure is 107/75 mmHg, pulse is 110/min, respirations are 22/min, and oxygen saturation is 99% on room air."], "Patient Symptoms": ["He has become gradually more confused over the past several days.", "His wife also notes he has had diarrhea, nausea and vomiting, and abdominal pain for the past week."], "Examination and Results": ["Physical exam reveals a confused man with a garlic odor on his breath and the finding in Figure A. Cardiopulmonary exam reveals a rapid heart rate with no murmurs and clear breath sounds."], "Others": ["He works in a large industrial compound that manufactures semiconductors."]}
{"Patient Personal Background": ["Pregnancy and delivery were uncomplicated but the mother had limited prenatal care during the third trimester."], "Patient Symptoms": ["The mother reports that the patient has developed a cough and nasal discharge.", "Upon visual examination of the eyes, mucoid ocular discharge and eyelid swelling are noted."], "Examination and Results": ["Immediately after delivery, the baby was given silver nitrate drops and vitamin K. His temperature is 99\u00b0F (37.2\u00b0C), blood pressure is 81/52 mmHg, pulse is 135/min, and respirations are 36/min with an oxygen saturation of 98% O2 on room air.", "A fluorescein test is negative.", "On lung exam, scattered crackles are appreciated.", "A chest radiograph is performed that shows hyperinflation with bilateral infiltrates."], "Treatment": ["Immediately after delivery, the baby was given silver nitrate drops and vitamin K. His temperature is 99\u00b0F (37.2\u00b0C), blood pressure is 81/52 mmHg, pulse is 135/min, and respirations are 36/min with an oxygen saturation of 98% O2 on room air."]}
{"Patient Personal Background": ["She has no other past medical history and takes no medications.", "She uses a copper intrauterine device and is in a monogamous relationship."], "Patient Symptoms": ["The pain is most pronounced in the lower abdomen and has gotten worse over the past day.", "Her last menstrual period was 7 weeks ago."], "Examination and Results": ["Her temperature is 99\u00b0F (37.2\u00b0C), blood pressure is 79/50 mmHg, pulse is 135/min, and respirations are 20/min.", "Physical examination is notable for diffuse abdominal tenderness upon palpation.", "Pelvic examination demonstrates uterine and adnexal tenderness and uterine bleeding.", "Laboratory studies are shown below:\n\nHemoglobin: 9.5 g/dL\nLeukocyte count: 6,000/mm^3\nSerum beta-human chorionic gonadotropin (hCG): 2,700 IU/L\n\nThe patient is started on intravenous fluids."], "Treatment": [], "Others": ["She denies any recent abdominal or vaginal trauma."]}
{"Patient Personal Background": ["She denies pain, but reports her right eye \u201cfeels funny.\u201d The patient\u2019s medical history is significant for a previous myocardial infarction, hypertension, and osteoporosis.", "Her current medications include aspirin, metoprolol, rosuvastatin, lisinopril, and alendronate."], "Patient Symptoms": ["She was in her usual state of health until waking up this morning unable to see out of her right eye.", "She denies pain, but reports her right eye \u201cfeels funny.\u201d The patient\u2019s medical history is significant for a previous myocardial infarction, hypertension, and osteoporosis."], "Examination and Results": ["Her temperature is 98\u00b0F (36.7\u00b0C), blood pressure is 145/86 mmHg, pulse is 62/min, and respirations are 12/min with an oxygen saturation of 98% on room air.", "The patient's pupils are symmetric in size and equally reactive to light with accommodation.", "The left optic fundus is unremarkable."], "Others": ["A fundoscopic exam of the right eye is shown in Figure A."]}
{"Patient Personal Background": ["Of note, the patient has presented to the emergency department before for a similar reason when she was struggling with online dating.", "The patient states that she struggles with her romantic relationships though she deeply desires them."], "Patient Symptoms": ["The patient states she knew her boyfriend was having sexual thoughts about the woman from the grocery store, prompting her decision to cut her own wrist.", "When interviewing the patient, she is teary and apologizes for her behavior."], "Examination and Results": ["Her temperature is 98.6\u00b0F (37\u00b0C), blood pressure is 112/71 mmHg, pulse is 73/min, and respirations are 14/min.", "On physical exam, you note a frightened young woman who is wearing a revealing dress that prominently displays her breasts."], "Treatment": ["In the emergency department, the bleeding has stopped and the patient is currently medically stable.", "You tell the patient that she will have to stay in the psychiatric emergency department for the night which makes her furious."], "Others": ["She is grateful to you for her care and regrets her actions."]}
{"Patient Personal Background": ["The patient has a medical history of obesity, anxiety, and constipation.", "He is currently not taking any medications and has not filled his prescriptions for over 1 year."], "Patient Symptoms": ["He has been taking his medications and resting.", "The patient states he feels better since the incident."], "Examination and Results": ["At this visit, his temperature is 99.5\u00b0F (37.5\u00b0C), blood pressure is 130/87 mmHg, pulse is 80/min, respirations are 11/min, and oxygen saturation is 96% on room air."], "Treatment": ["The patient is managed appropriately and is discharged on atorvastatin, metoprolol, aspirin, clopidogrel, and sodium docusate."], "Others": ["An ECG is obtained and is seen in Figure A.", "The patient visits his primary care physician 4 weeks later and claims to be doing better."]}
{"Patient Personal Background": ["Pregnancy and delivery were uncomplicated.", "The mother denies that anyone in the house smokes.", "The family has a cat at home."], "Patient Symptoms": ["Then 1 day ago, the patient developed eyelid edema and eye redness.", "This morning, the newborn developed a thick yellow-white eye discharge."], "Examination and Results": ["The patient\u2019s rectal temperature is 99\u00b0F (37.2\u00b0C), blood pressure is 80/50 mmHg, pulse is 134/min, and respirations are 34/min with an oxygen saturation of 98% O2 on room air.", "The patient's physical exam is otherwise unrevealing."], "Others": ["The newborn had been sleeping regularly and feeding well.", "Figure A shows a photograph of one of the patient's eyes."]}
{"Patient Personal Background": ["His family history is unknown as he was adopted.", "He drinks a few glasses of wine per week and has never smoked."], "Patient Symptoms": ["His wife reports that her husband has not been himself for the last 2 months.", "Whereas he was previously outgoing and \u201cthe life of the party,\u201d the patient is now irritable and withdrawn.", "The patient cannot explain the recent changes to his mood and tearfully admits he fears there is something seriously wrong with him.", "His wife says that he is getting worse."], "Examination and Results": ["His temperature is 98.6\u00b0F (37\u00b0C), blood pressure is 141/87 mmHg, pulse is 81/min, and respirations are 12/min.", "On physical exam, the patient has a flat affect with a facial grimace and sudden jerky movements of his upper extremities."], "Treatment": ["The patient\u2019s medical history is significant for hypertension, for which he takes lisinopril."], "Others": ["He is a partner at an accounting firm, but his colleagues are threatening to fire him if he continues to perform poorly at work.", "The patient met his mother once and never knew his father but was told he died in his 50s."]}
{"Patient Personal Background": ["She has a medical history of hypertension for which she takes hydrochlorothiazide."], "Patient Symptoms": ["She states that she feels well and has no complaints."], "Examination and Results": ["Her temperature is 98.6\u00b0F (37.0\u00b0C), blood pressure is 138/74 mmHg, pulse is 80/min, and respirations are 13/min.", "Her BMI is 32.4 kg/m^2.", "A pelvic exam reveals a non-tender, 12-week-size uterus with an irregular contour.", "A transvaginal ultrasound is performed and demonstrates two intramural leiomyomas."], "Others": ["The patient\u2019s mother had breast cancer at age 68, and her sister has endometriosis."]}
{"Patient Personal Background": ["He has a history of migraine headaches, but he feels that this headache is significantly more painful than his typical migraines.", "His medical history is significant for migraines and hypertension.", "He has a 20-pack-year smoking history and a history of cocaine use.", "He drinks 5-6 beers per week."], "Patient Symptoms": ["He suddenly developed a throbbing, bitemporal headache about 5 hours ago \"out of nowhere.\"", "The patient took his prescribed sumatriptan with no relief of his symptoms.", "He also endorses nausea and he reports that he vomited once before arrival in the emergency department.", "On physical exam, he appears to be in moderate distress and has pain with neck flexion."], "Examination and Results": ["His temperature is 98.6\u00b0F (37\u00b0C), blood pressure is 147/91 mmHg, pulse is 62/min, and respirations are 12/min.", "He has no focal neurologic deficits.", "A head CT is performed and can be seen in Figure A."], "Treatment": ["The patient took his prescribed sumatriptan with no relief of his symptoms."]}
{"Patient Personal Background": ["He admits to occasional cocaine and marijuana use.", "Otherwise, the patient has no significant medical history and is not taking any medications."], "Patient Symptoms": ["During this past week, he has been unable to properly study and prepare for final exams because he is exhausted.", "He has been going to bed early but is unable to get a good night\u2019s sleep.", "On physical exam, the patient is a tired and anxious appearing young man.", "The patient states that he fears he will fail his courses if he does not come up with a solution."], "Examination and Results": ["His temperature is 98.6\u00b0F (37\u00b0C), blood pressure is 115/71 mmHg, pulse is 72/min, and respirations are 12/min.", "His neurological exam is within normal limits."]}
{"Patient Symptoms": ["The patient states that when he left for work this morning he was certain that he had closed the door to his pantry.", "The patient is certain that his neighbors have been tampering with his food and potentially poisoned him.", "He further states that he knows they have been trying to break into his house and steal his things.", "It is for this reason that he is certain that they are trying to get their revenge upon him.", "The patient is outraged at this news and requests a competent doctor who is not colluding with his enemies."], "Examination and Results": ["His temperature is 98.6\u00b0F (37\u00b0C), blood pressure is 115/71 mmHg, pulse is 72/min, and respirations are 12/min."], "Others": ["Upon returning home, he saw that the door to his pantry was wide open.", "He has tried multiple times to get them evicted from the building to no avail.", "The physician performs a physical exam and tells the patient that he thinks there is nothing to be concerned about, but that he should call him or come into the office if he experiences any symptoms.", "He storms out of the office angrily, stating that he deserves the best in medical care."]}
{"Patient Personal Background": ["His medical history includes type 1 diabetes mellitus and an episode of herpes zoster on his right flank 1 year ago.", "His only home medication is insulin."], "Patient Symptoms": ["He reports that he has headaches at night several times a week.", "He first developed these headaches over 1 year ago, but they started up again 3 weeks ago.", "The episodes start suddenly and feel like a stabbing, electrical pain over his left eye.", "He also reports tearing of the left eye during these episodes.", "The headaches self-resolve over the course of 2-3 hours, but the patient complains that he is avoiding going to sleep for fear of waking up in pain."], "Examination and Results": ["His temperature is 98.6\u00b0F (37\u00b0C), blood pressure is 112/69 mmHg, pulse is 61/min, and respirations are 14/min.", "On physical exam, his extraocular muscles are intact and his eyes are not injected.", "A CT of the head and sinuses shows no acute abnormalities."]}
{"Patient Personal Background": ["Her home medications include levothyroxine, oral contraceptive pills, and topical trans-retinoin.", "She has 2 glasses of wine with dinner several nights a week and has never smoked.", "She works as a receptionist at a marketing company."], "Patient Symptoms": ["Every few weeks she has an episode of a right-sided, throbbing headache.", "The episodes began several years ago and are accompanied by nausea and bright spots in her vision.", "The headache usually subsides if she lies still in a dark, quiet room for several hours.", "The patient denies any weakness, numbness, or tingling during these episodes."], "Examination and Results": ["Her temperature is 98.6\u00b0F (37\u00b0C), blood pressure is 125/81 mmHg, pulse is 64/min, and respirations are 11/min.", "On physical exam, the patient has no focal neurologic deficits.", "A CT of the head is performed and shows no acute abnormalities."], "Others": ["Her medical history is significant for acne, hypothyroidism, obesity, and endometriosis."]}
{"Patient Personal Background": ["His medical history is significant for hypertension, hyperlipidemia, coronary artery disease, and a prior transient ischemic attack.", "His medications include atorvastatin and lisinopril."], "Patient Symptoms": ["He lost consciousness for about 30 seconds.", "When he woke up, he was mildly confused but able to ski down the rest of the mountain.", "During the ride, he became gradually more somnolent.", "He is difficult to arouse with a GCS of 7."], "Examination and Results": ["In the emergency department, his temperature is 97.8\u00b0F (36.6\u00b0C), blood pressure is 141/84 mmHg, pulse is 71/min, and respirations are 16/min.", "A head CT is performed and can be seen in Figure A."], "Treatment": ["The paramedics report that at the scene the patient had a Glasgow Coma Score (GCS) of 15."], "Others": ["The patient lost control of his skis and collided with a tree.", "The patient initially denied medical treatment but his wife convinced him to be taken by ambulance to the emergency department for evaluation."]}
{"Patient Personal Background": ["Her medical history is significant for hyperlipidemia, mild intermittent asthma, and type 2 diabetes mellitus.", "She has never smoked and has 10-15 alcoholic drinks per week.", "She works as an aide at a nursing home."], "Patient Symptoms": ["Over the past week, she has had increasing difficulty chewing her food and progressive pain in the left side of her jaw.", "This morning, she was unable to close her mouth for several minutes after taking a bite of her breakfast."], "Examination and Results": ["Her temperature is 100.8\u00b0F (38.2\u00b0C), blood pressure is 133/74 mmHg, pulse is 105/min, and respirations are 14/min.", "On physical exam, there is a bluish hue to the skin on the lower left side of the patient\u2019s face.", "A 3x4 cm non-tender mass can be palpated inferior to the angle of the left mandible.", "Thick exudate is draining from an opening in the skin."], "Others": ["Two months ago, the patient had a root canal on a left molar.", "The gram stain of the exudate can be seen in Figure A."]}
{"Patient Symptoms": ["The patient has had headaches in the past but this is the worst headache of her life.", "Her symptoms started yesterday and have been getting progressively worse.", "The patient states that the pain is mostly on the left side of her head.", "On exam, the patient is an obese girl who is clutching her head with the light in the room turned off."], "Examination and Results": ["Her temperature is 98.6\u00b0F (37\u00b0C), blood pressure is 123/74 mmHg, pulse is 85/min, and respirations are 13/min.", "Her neurological exam is within normal limits.", "Fundoscopic exam reveals mild bilateral papilledema.", "An MRI of the head is obtained and reveals cerebral edema.", "A lumbar puncture reveals an increased opening pressure with a normal glucose level."], "Treatment": ["There has been a recent outbreak of measles at the patient\u2019s school and the patient\u2019s mother has been trying to give her daughter medicine to prevent her from getting sick."], "Others": ["Her mother fears that her daughter may have caught measles."]}
{"Patient Personal Background": ["He reports that he traveled to Africa last year and returned from a vacation to Thailand 10 days ago.", "His immunizations are up to date, although he missed the pre-departure travel medicine consult before his trip to Thailand."], "Patient Symptoms": ["He also endorses sweats, headache behind the eyes, sore throat, muscle and joint pain, and a new rash seen in Figure A."], "Examination and Results": ["His temperature is 101.5\u00b0F (38.6\u00b0C), blood pressure is 125/80 mmHg, pulse is 105/min, and respirations are 14/min."]}
{"Patient Personal Background": ["He endorses a history of unprotected sex with multiple partners and intravenous drug use during a recent vacation to Mexico but has no other significant medical history.", "He drinks socially and has never smoked."], "Patient Symptoms": ["He also endorses loss of appetite and subjective fever.", "He has had vague, mild discomfort in the right upper quadrant since the start of this wrestling season."], "Examination and Results": ["His temperature is 98.6\u00b0F (37\u00b0C), blood pressure is 119/72 mmHg, pulse is 102/min, and respirations are 12/min.", "Physical exam demonstrates pain on palpation of the right lower quadrant and mild pain in the right upper quadrant.", "He has significant acne on his face, chest, and back.", "A CT of the abdomen confirms appendicitis.", "The scan also shows a large liver mass measuring 6 cm as seen in Figure A."], "Diagnosis": ["A CT of the abdomen confirms appendicitis."]}
{"Patient Personal Background": ["He has a history of hypertension, hyperlipidemia, and depression.", "He currently takes amlodipine and atorvastatin and is compliant with his medications.", "He has a 45-pack-year smoking history, but he does not drink alcohol or use any illicit drugs."], "Patient Symptoms": ["He was eating dinner when he started feeling severe pain in his abdomen that made him lose his appetite.", "He denies any diarrhea or hematochezia and says the pain is not affected by movement.", "During evaluation, the patient becomes diaphoretic and pale and reports that he feels fatigued."], "Examination and Results": ["His temperature is 98.6\u00b0F (37\u00b0C), his blood pressure is 110/64 mmHg, pulse is 97/min, and respirations are 15/min.", "Physical exam is notable for diffuse abdominal tenderness without rigidity or guarding.", "Repeat blood pressure is 87/50 and pulse is 127."], "Treatment": ["Intravenous fluid boluses are administered."]}
{"Patient Personal Background": ["She has had regular menses since menarche, and her last menstrual period ended 8 days ago.", "She has no significant medical history."], "Examination and Results": ["Her temperature is 98.6\u00b0F (37\u00b0C), blood pressure is 114/71 mmHg, pulse is 81/min, and respirations are 12/min.", "A physical exam is unremarkable.", "A urine pregnancy test is negative."], "Treatment": ["She had unprotected sexual intercourse earlier that morning and requests emergency contraception.", "The patient asks for an emergency contraceptive pill and would prefer that her parents not be notified about her visit."]}
{"Patient Personal Background": ["He states this weekend he had a barbecue.", "The patient has a medical history of obesity, diabetes, depression, anxiety, diverticulosis, constipation, and a surgical repair of his anterior cruciate ligament.", "His current medications include metformin, insulin, lisinopril, fluoxetine, and sodium docusate."], "Patient Symptoms": ["When he was lifting a heavy object, he suddenly felt pain in his lower back.", "He describes the pain as in his buttocks but states that at times it travels down his leg.", "He states that it feels electrical and burning in nature."], "Examination and Results": ["His temperature is 98.6\u00b0F (37\u00b0C), blood pressure is 131/82 mmHg, pulse is 82/min, and respirations are 14/min.", "On physical exam, he is found to have an intact motor and sensory function in his lower extremities bilaterally.", "No clonus or Babinski sign is appreciated.", "An exam of the cranial nerves is intact bilaterally."]}
{"Patient Personal Background": ["He states that he lives at home with his parents his entire life and recently was able to get a job at a local factory."], "Patient Symptoms": ["Ever since the patient started working, he has had trouble focusing on his job.", "He is unable to stay focused on any task.", "His boss often observes him \"daydreaming\" with a blank stare off into space.", "His boss will have to yell at him to startle him back to work.", "The patient states that he feels fatigued all the time and sometimes will suddenly fall asleep while operating equipment.", "He has tried going to bed early for the past month but is unable to fall asleep until 2 hours prior to his alarm."], "Examination and Results": ["His temperature is 98.6\u00b0F (37\u00b0C), blood pressure is 112/68 mmHg, pulse is 81/min, and respirations are 12/min.", "A physical exam is within normal limits."], "Others": ["The patient fears that if this continues he will lose his job."]}
{"Patient Personal Background": ["The patient has a medical history of type 2 diabetes mellitus, depression, anxiety, and irritable bowel syndrome.", "Her current medications include metformin, glyburide, escitalopram, and psyllium husks."], "Patient Symptoms": ["The pain was initially a 4/10 in severity but has increased recently to a 6/10 prompting her to come in.", "On exam, the patient is an obese woman with pain upon palpation of the right upper quadrant."], "Examination and Results": ["Her temperature is 99.2\u00b0F (37.3\u00b0C), pulse of 95/min, blood pressure of 135/90 mmHg, respirations of 15/min with 98% oxygen saturation on room air.", "Initial labs are are below:\n\nNa+: 140 mEq/L\nK+: 4.0 mEq/L\nCl-: 100 mEq/L\nHCO3-: 24 mEq/L\nAST: 100 U/L\nALT: 110 U/L\nAmylase: 30 U/L\nAlkaline phosphatase: 125 U/L\n\nBilirubin\nTotal: 2.5 mg/dL\nDirect: 1.8 mg/dL\n\nThe patient is sent for a right upper quadrant ultrasound demonstrating an absence of stones, no pericholecystic fluid, a normal gallbladder contour and no abnormalities noted in the common bile duct.", "MRCP with secretin infusion is performed demonstrating patent biliary and pancreatic ductal systems."], "Others": ["Her lab values and clinical presentation remain unchanged 24 hours later."]}
{"Patient Personal Background": ["The patient has a medical history of marijuana and IV drug use as well as multiple suicide attempts.", "He is currently homeless."], "Patient Symptoms": ["He was brought in by police for shouting on a subway.", "The patient claims that little people were trying to kill him and he was acting within his rights to defend himself.", "While in the ED, the patient is combative and refuses a physical exam.", "Though he is no longer aggressive, he is seen making \"armor\" out of paper plates and plastic silverware to defend himself."], "Examination and Results": ["His temperature is 98.6\u00b0F (37\u00b0C), blood pressure is 115/71 mmHg, pulse is 72/min, and respirations are 12/min."], "Treatment": ["He is given IM haloperidol and diphenhydramine.", "The patient is transferred to the inpatient psychiatric unit and is continued on haloperidol throughout the next week."]}
{"Patient Personal Background": ["The patient has an unknown medical history and is currently not on any medications.", "She is not sexually active and does not intend to become pregnant in the near future."], "Patient Symptoms": ["The patient's teacher describes her as occasionally \"daydreaming\" for periods of time during where the patient does not respond or participate in school activities.", "The only other concern that the patient's mother has is that, upon awakening, she notices that sometimes the patient's arm will jerk back and forth.", "The patient states she is not doing this intentionally."], "Examination and Results": ["Her temperature is 98.6\u00b0F (37\u00b0C), blood pressure is 112/74 mmHg, pulse is 63/min, and respirations are 11/min.", "On physical exam, you note a young, healthy girl whose neurological exam is within normal limits."], "Others": ["Nothing has helped the patient change her behavior, including parent-teacher conferences or punishment.", "The patient has no other concerns."]}
{"Patient Personal Background": ["The patient has a medical history of obesity, diabetes, bipolar disorder, and tonic-clonic seizures.", "The patient has IV drug and alcohol use disorder and has presented to the ED many times for intoxication."], "Patient Symptoms": ["She was at a rehabilitation hospital when her symptoms started.", "Physical exam reveals anasarca and asymmetric lower extremity swelling."], "Examination and Results": ["Her temperature is 98.6\u00b0F (37\u00b0C), blood pressure is 115/71 mmHg, pulse is 72/min, and respirations are 12/min.", "Physical exam reveals anasarca and asymmetric lower extremity swelling.", "Laboratory studies are shown below."], "Treatment": ["Based on the results of a doppler ultrasound of her swollen lower extremity, heparin is started."], "Others": ["The patient is then transferred to the general medicine floor for continued management."]}
{"Patient Personal Background": ["The patient is a non-smoker and has a history of GERD for which she takes antacids."], "Patient Symptoms": ["She states she has had a cough for the past week.", "She also has abdominal pain and trouble focusing that has been worsening and has lost 5 pounds recently.", "Her gastroesophageal reflux disease (GERD) has been poorly controlled recently."], "Examination and Results": ["Her temperature is 98.6\u00b0F (37\u00b0C), blood pressure is 115/71 mmHg, pulse is 72/min, and respirations are 12/min.", "A physical exam is within normal limits."]}
{"Patient Personal Background": ["His activity level has been normal and he has been attending school until this morning.", "He has no medical history or known allergies, but he has not received any of the recommended vaccines due to parental refusal."], "Patient Symptoms": ["On examination, the child is fussy."], "Examination and Results": ["His temperature is 100.3\u00b0F (37.9\u00b0C), blood pressure is 98/62 mmHg, pulse is 85/min, respirations are 22/min, and oxygen saturation is 98% on room air.", "Bilateral conjunctivae are injected, and there is redness on and around the tonsils.", "Faint rhonchi are heard at the lung bases bilaterally."], "Others": ["There is no lymphadenopathy."]}
{"Patient Personal Background": ["Her medical history is notable for depression, anxiety, and gonococcal urethritis that was appropriately treated.", "She is sexually active and does not use condoms.", "She admits to drinking at least 5 standard alcoholic drinks a day.", "The patient also recently lost a large amount of weight for a fitness show she planned on entering.", "The patient's current medications include oral contraceptive pills, fluoxetine, alprazolam, ibuprofen, acetaminophen, and folate."], "Patient Symptoms": ["The pain has been dull and progressive, but became suddenly worse while she was exercising."], "Examination and Results": ["Her temperature is 99.5\u00b0F (37.5\u00b0C), blood pressure is 80/40 mmHg, pulse is 110/minute, and respirations are 15/minute with an oxygen saturation of 96% on room air.", "On physical exam, you note an athletic young woman with burly shoulders, a thick neck, and acne on her forehead and back.", "On abdominal exam you note diffuse tenderness with 10/10 pain upon palpation of the right upper quadrant."], "Treatment": ["Intravenous fluids are started and labs are sent."], "Others": ["A urinary \u00df-hCG has been ordered."]}
{"Patient Personal Background": ["His past medical history is significant for human immunodeficiency virus (HIV) infection, diagnosed 15 years ago.", "The patient is intermittently compliant with his antiretroviral therapy (ART)."], "Patient Symptoms": ["He has no concerns."], "Examination and Results": ["His temperature is 99.0\u00b0F (37.2\u00b0C), blood pressure is 130/84 mmHg, pulse is 92/min, and respirations are 11/min.", "His most recent lab work showed a cluster of differentiation CD4 count of 150 cells/\u00b5L."], "Treatment": ["He received a dose of the 13-valent pneumococcal vaccine and a dose of the 23-valent pneumococcal vaccine 15 years ago, as well as a second dose of the 23-valent pneumococcal vaccine 10 years ago."]}
{"Patient Personal Background": ["The patient\u2019s medications include aspirin and carvedilol.", "He reports that he is a smoker with a 50-pack-year history."], "Patient Symptoms": ["When it started, he felt like a \u201ccurtain was pulled down\u201d over his right eye but wasn't able to seek care immediately because it was snowing outside and he didn't want to travel in inclement weather.", "A review of systems is significant for occasional palpitations and presyncope."], "Examination and Results": ["The patient\u2019s temperature is 99\u00b0F (37.2\u00b0C), blood pressure is 112/72 mmHg, pulse is 84/min, and respirations are 14/min with an oxygen saturation of 97% on room air.", "Physical exam reveals 20/800 vision in the right eye.", "A fundoscopic exam of the right eye is shown in Figure A.", "Physical and fundoscopic examinations of the left eye are unremarkable."]}
{"Patient Personal Background": ["His medications include hydrochlorothiazide.", "His temperature is 98.6\u00b0F (37\u00b0C), blood pressure is 135/91 mmHg, pulse is 72/min, and respirations are 12/min."], "Patient Symptoms": ["He reports that he was rocking his grandson to sleep when the symptoms began.", "He states the pain is constant and is primarily located on his right side.", "When asked to indicate the area of pain, he says that it surrounds his eye and upper forehead.", "He had one episode of vomiting.", "The patient also reports difficulty seeing out of his right eye, which he attributes to excessive tearing."], "Examination and Results": ["The patient\u2019s right eye is shown in Figure A.", "Upon physical examination, the right pupil is minimally responsive to light and the globe feels firm.", "A right-sided carotid bruit is appreciated."]}
{"Patient Personal Background": ["She has a history of chlamydial infection in her 20's and has had 3 urinary tract infections over the past year.", "She has no other significant medical history and does not take any medications."], "Patient Symptoms": ["She states that she has had involuntary loss of urine about 4 times each day over the past 3 months.", "It is not associated with coughing or sneezing.", "The patient has not been sexually active with her husband due to pain with intercourse."], "Examination and Results": ["Her temperature is 98.6\u00b0F (37.0\u00b0C), blood pressure is 115/70 mmHg, pulse is 70/min, and respirations are 12/min.", "On physical examination, the vulvar skin is pale and atrophic with reduced elasticity and multiple areas of petechiae.", "The vaginal mucosa also has a loss of rugae and several areas of friable irritation.", "There is minimal clear vaginal discharge.", "Urinalysis is normal and fecal occult blood test is negative.", "Pelvic ultrasound reveals a small, retroverted uterus."], "Others": ["Menopause occurred at age 52."]}
{"Patient Personal Background": ["He has no significant medical history and takes no medications.", "He exercises twice a day, often with heavy weightlifting, and eats a high-protein diet.", "He reports occasional alcohol use and remote marijuana use.", "He is sexually active with his wife and has no history of sexually transmitted infections."], "Examination and Results": ["His temperature is 99.5\u00b0F (37.5\u00b0C), blood pressure is 148/90 mmHg, pulse is 84/min, and respirations are 15/min.", "Physical exam reveals small testes and a receding hairline.", "He also has palpable tissue underneath his nipples bilaterally.", "His muscle tone is normal in his upper and lower extremities bilaterally."]}
{"Patient Personal Background": ["He drinks a glass of wine with dinner every night and took up scuba diving 2 months ago but otherwise does not exercise.", "His temperature is 97.5\u00b0F (36.4\u00b0C), blood pressure is 124/68 mmHg, pulse is 82/min, and respirations are 16/min.", "His body mass index (BMI) is 18.1 kg/m^2."], "Patient Symptoms": ["The pain started a year ago and has progressed.", "He now has 8/10 pain when climbing stairs or rising from a seated position.", "He localizes the pain to the front of his groin."], "Examination and Results": ["He denies any erythema or swelling.", "Physical exam reveals left groin pain at the terminal ranges of hip abduction and internal rotation.", "There is no point tenderness."], "Others": ["A radiograph is obtained as in Figure A."]}
{"Patient Personal Background": ["He has no significant medical history and takes no medications."], "Patient Symptoms": ["He first felt the pain while lifting boxes at work but thought that he had just strained a muscle.", "The pain appears to be worse in the mornings and after rest.", "Exercise and physical activity appear to temporarily make the pain better."], "Examination and Results": ["His temperature is 98.6\u00b0F (37.0\u00b0C), blood pressure is 115/70 mmHg, pulse is 70/min, and respirations are 12/min.", "On physical exam, he is found to have limited flexion and extension of his spine as well as tenderness to palpation over the insertion of his patellar tendons bilaterally."], "Treatment": ["He has taken acetaminophen and ibuprofen for the pain."]}
{"Patient Personal Background": ["The patient was born at 39 weeks of gestation via spontaneous vaginal delivery.", "He is up to date with routine vaccinations."], "Patient Symptoms": ["His mother is concerned about his vision, as she noticed him squinting while watching television.", "When focusing on the pediatrician's penlight, the patient's left eye wanders."], "Examination and Results": ["His temperature is 98.6\u00b0F (37.0\u00b0C), blood pressure is 80/55 mmHg, pulse is 105/min, and respirations are 25/min.", "On exam, his pupils are round and reactive to light.", "However, when the right eye is covered, the left eye refocuses on the light.", "The rest of his neurological exam, including extraocular movements, is within normal limits."], "Others": ["He is able to walk alone, speak 3 words, and scribble with a crayon.", "A photograph of his eyes is shown in Figure A."]}
{"Patient Personal Background": ["He has a history of obesity, hypertension, type 2 diabetes mellitus, and depression.", "His current medications include metformin, aspirin, rosuvastatin, lisinopril, and fluoxetine.", "He has a 25-pack-year smoking history and drinks 1 glass of wine a day."], "Examination and Results": ["His temperature is 98.6\u00b0F (37.0\u00b0C), blood pressure is 115/70 mmHg, pulse is 70/min, and respirations are 12/min.", "On physical exam, he has a 1.2 x 1.7 cm ulcer on the plantar surface of his left metatarsal head."]}
{"Patient Personal Background": ["He enjoys spending time with his spouse, playing cards with his friends, and taking daily walks around his neighborhood."], "Patient Symptoms": ["His wife has noticed that he has a worsening ability to organize, plan, and exhibit impulse control over the last month.", "The patient states that he is able to complete his activities of daily living without assistance, but has some weakness of his left upper and lower extremities that began 3 months prior.", "He needs reminders from his wife about daily tasks to complete."], "Examination and Results": ["His temperature is 98.2\u00b0F (36.8\u00b0C), blood pressure is 149/87 mmHg, pulse is 87/min, and respirations are 12/min.", "Physical exam reveals an elderly man who is oriented to person, place, and time.", "He has 4/5 left-sided weakness of the upper and lower extremities and associated pronator drift of the left upper extremity.", "A mini-mental status exam reveals he is able to remember 2 out of 3 words after 4 minutes.", "He is able to appropriately draw a clock.", "A magnetic resonance imaging study of the brain is shown in Figure A."]}
{"Patient Personal Background": ["He has a medical history of hypertension, glaucoma, and osteoarthritis in his left knee that requires him to walk with a cane.", "He takes hydrochlorothiazide, timolol eyedrops, and occasional acetaminophen."], "Patient Symptoms": ["The patient initially became less talkative than usual before starting to confuse her with her sister.", "The patient also could not remember what day of the week it was and he was out of groceries and likely had been for several days when visited.", "While she was talking to him, he fell asleep and was difficult to rouse.", "The patient is unable to provide a clear history."], "Examination and Results": ["His temperature is 98.5\u00b0 F (36.9\u00b0 C), blood pressure is 122/74 mmHg, pulse is 75/min, and respirations are 14/min.", "The patient is lethargic but arousable, oriented only to person, and disheveled.", "Neurologic exam reveals intact cranial nerves, 1+ deep tendon reflexes throughout, and 4/5 strength in all extremities.", "There is a 3 x 5 cm green-blue area of ecchymosis on the lateral aspect of his left knee."], "Others": ["A CT of the head without contrast is performed and shown in Figure A."]}
{"Patient Personal Background": ["Her medical history is notable for hypertension and hyperlipidemia for which she takes amlodipine and atorvastatin."], "Patient Symptoms": ["On exam, her abdomen is soft, non-distended, and non-tender to palpation; however she has diffuse discomfort upon palpation of the abdomen with no rebound, rigidity, or guarding."], "Examination and Results": ["Her temperature is 37.0\u00b0C (98.6\u00b0F), blood pressure is 118/82 mmHg, pulse is 98/min, respirations are 14/min, and oxygen saturation is 98% on room air.", "On exam, her abdomen is soft, non-distended, and non-tender to palpation; however she has diffuse discomfort upon palpation of the abdomen with no rebound, rigidity, or guarding."], "Treatment": ["She recently completed a course of clindamycin 2 weeks ago for a tooth infection."], "Others": ["She traveled recently and has no sick contacts."]}
{"Patient Personal Background": ["Her husband tells the physician that he is concerned that the patient has been increasingly obsessed about her weight recently.", "She has a history of major depressive disorder for which she takes escitalopram."], "Patient Symptoms": ["She has been experiencing nausea, vomiting, and diarrhea after eating leftovers 2 days ago."], "Examination and Results": ["Her temperature is 98.6\u00b0F (37.0\u00b0C), blood pressure is 110/72 mmHg, pulse is 110/min, and respirations are 11/min.", "Physical examination is notable for dry mucous membranes and tachycardia with regular rhythm.", "Laboratory testing shows the following results:\n\nSerum:\nNa+: 135 mEq/L\nCl-: 96 mEq/L\nK+: 2.9 mEq/L\nHCO3-: 36 mEq/L\n\nVenous blood gas shows a pH of 7.52."]}
{"Patient Personal Background": ["He has a history of hypertension, major depressive disorder, Raynaud disease, and chronic obstructive pulmonary disease (COPD) on 2 liters of oxygen at home.", "Current medications include lisinopril, inhaled umeclidinium-vilanterol, and as-needed albuterol.", "He drinks 4 beers a day and has smoked 1 pack of cigarettes a day for 40 years."], "Patient Symptoms": ["He began feeling the palpitations 3 days ago while eating dinner.", "He denies chest pain, shortness of breath, or loss of consciousness."], "Examination and Results": ["His temperature is 98.9\u00b0 F (37.2\u00b0 C), blood pressure is 130/85 mmHg, pulse is 125/min, and respirations are 16/min.", "Physical exam is notable for an irregular pulse and scattered end-expiratory wheezes.", "An echocardiogram performed 1 month ago showed a left ventricular ejection fraction of 60-65%.", "The patient requires 3 liters of oxygen today.", "An ECG is performed as seen in Figure A."]}
{"Patient Personal Background": ["She has no significant medical history, is up to date on all vaccinations, and her last tetanus shot was 3 years ago."], "Examination and Results": ["On arrival, her temperature is 36.7\u00b0C (98\u00b0F), blood pressure is 82/63 mmHg, pulse is 120/min, respirations are 20/min, and oxygen saturation is 97% on 2L oxygen nasal cannula.", "On physical exam, there are extensive ecchymoses and abrasions along her left posterior ribs and left flank.", "A CT scan of the abdomen is obtained, which is shown in Figure A."]}
{"Patient Personal Background": ["He has no known medical allergies.", "He smokes 1 pack of cigarettes per day and denies alcohol or illicit drug use."], "Patient Symptoms": ["He was seen 4 days ago for a new lesion on his arm that had been present for 1 week prior to that visit.", "Today, he reports that he became sunburned this morning within an hour of beginning his workday, despite wearing appropriate sunscreen."], "Examination and Results": ["His temperature is 98.6\u00b0F (37.0\u00b0C), blood pressure is 125/70 mmHg, pulse is 65/min, and respirations are 12/min.", "On exam, there is a blistering erythematous rash on the arms and shoulders.", "The previous skin lesion appears unchanged."], "Treatment": ["At that time, he was prescribed treatment for the lesion and instructed to follow up as necessary."], "Others": ["A photograph of the lesion is shown in Figure A.", "He has a medical history significant for type 2 diabetes mellitus that is controlled with metformin."]}
{"Patient Personal Background": ["She has a history of obesity, hypertension, and depression for which she takes losartan and sertraline.", "She has smoked 1 pack of cigarettes per day for 30 years."], "Examination and Results": ["Her temperature is 99.5\u00b0F (37.5\u00b0C), blood pressure is 148/90 mmHg, pulse is 84/min, and respirations are 15/min.", "Physical exam is unremarkable, including no costovertebral or suprapubic tenderness to palpation."]}
{"Patient Personal Background": ["His parents report that he is doing well in school and has many friends.", "The parents have so far managed the condition using herbal teas and essential oils but have not sought formal medical care."], "Patient Symptoms": ["Their only concern is that he has a \u201cdifficult stomach.\u201d Every few months, he complains of intermittent abdominal pain that takes several days to pass.", "He occasionally misses school due to the pain.", "There is blood in his stool during these episodes.", "These symptoms have persisted for many years."], "Examination and Results": ["His temperature is 98.2\u00b0F (36.8\u00b0C), blood pressure is 106/61 mmHg, pulse is 88/min, and respirations are 12/min.", "He has lost 10 pounds since his annual visit the year before and is the same height.", "On physical exam, the patient is thin with conjunctival pallor.", "His sclerae are anicteric and his abdomen is soft and non-tender without hepatosplenomegaly.", "He undergoes an abdominal CT that shows disease affecting the terminal ileum."], "Others": ["He also has the findings seen in Figure A."]}
{"Patient Personal Background": ["Her last menstrual period was 8 weeks ago.", "The patient has a medical history of type 1 diabetes mellitus since childhood and her home medications include insulin.", "The patient\u2019s brother is autistic but her family history is otherwise unremarkable."], "Examination and Results": ["Her hemoglobin A1c 2 weeks ago was 13.7%.", "At that time, she was also found to have microalbuminuria on routine urinalysis.", "Her temperature is 98.6\u00b0F (37.0\u00b0C), blood pressure is 124/81 mmHg, pulse is 75/min, and respirations are 14/min.", "A physical exam is unremarkable."], "Treatment": ["Her primary care provider prescribed lisinopril but the patient has not yet started taking it."]}
{"Patient Symptoms": ["There were no passengers and he was awake but disoriented at the scene.", "He is speaking but is confused, opens his eyes to voice commands, and follows simple commands.", "His cardiac exam is normal and his lungs are clear to auscultation bilaterally."], "Examination and Results": ["Paramedics report that the patient was driving the car and crashed into a tree at roughly 25 miles per hour.", "His temperature is 97.9\u00b0F (36.6\u00b0C), blood pressure is 131/88 mmHg, pulse is 89/min, and respirations are 14/min.", "He has multiple lacerations on his face and arms and smells of alcohol and marijuana.", "He has bruising over his abdomen without any tenderness to palpation, distension, or rigidity."]}
{"Patient Personal Background": ["The patient was born at 29 weeks gestation to a G1P1 mother.", "Her postnatal course was complicated by a prolonged neonatal intensive care unit stay for neonatal respiratory distress syndrome (NRDS).", "Since discharge from the hospital, her mother reports that the patient has been doing well without health problems.", "She has been gaining weight appropriately."], "Examination and Results": ["Her temperature is 98.6\u00b0F (37.0\u00b0C), blood pressure is 80/50 mmHg, pulse is 120/min, and respirations are 25/min."], "Diagnosis": ["Her postnatal course was complicated by a prolonged neonatal intensive care unit stay for neonatal respiratory distress syndrome (NRDS)."], "Others": ["The patient's mother asks the pediatrician about potentially delaying the 2-month vaccine doses due to the baby's medical history.", "Which of the following is the correct vaccination plan for this infant in terms of the vaccinations below?"]}
{"Patient Personal Background": ["Her medical history is significant for mild intermittent asthma for which she uses an albuterol inhaler as needed.", "She is sexually active with 1 male partner.", "She recently returned from South India following a mission trip for 6 weeks."], "Patient Symptoms": ["These symptoms have been going on for 2 months.", "She has lost 6 pounds (2.7 kg) over these 2 months."], "Examination and Results": ["Her temperature is 98.6\u00b0F (37.0\u00b0C), blood pressure is 105/70 mmHg, pulse is 95/min, and respirations are 14/min.", "On examination, the patient\u2019s skin is pale.", "Labs are obtained and show the following results:\n\nLeukocyte count: 4,500/mm^3\nHemoglobin: 10.5 g/dL\nPlatelets: 110,000/mm^3\nMean corpuscular volume (MCV): 116 \u00b5m^3\nReticulocyte count: 0.5%\n\nA biopsy of the small bowel reveals blunting of villi and a mixed infiltration of lymphocytes, plasma cells, and eosinophils."]}
{"Patient Symptoms": ["He was found lying down at a bus stop unresponsive.", "On arrival, the patient has slurred speech and is somnolent.", "Further is unable to be elicited."], "Examination and Results": ["His temperature is 98.0\u00b0F (36.7\u00b0C), blood pressure is 130/80 mmHg, pulse is 80/min, and respirations are 12/min with a saturation of 97% on room air.", "Physical exam reveals a sleeping man with miotic pupils.", "The patient is easily arousable to voice and sternal rub but falls asleep rapidly.", "He has decreased bowel sounds.", "He is able to state his name and knows that he is at the hospital and has an otherwise normal neurologic exam."]}
{"Patient Personal Background": ["She has a history of hypertension, hyperlipidemia, and diabetes.", "Her medications are lisinopril, amlodipine, atorvastatin, and metformin.", "There is no family history of malignancy.", "She is a non-smoker and drinks 3-4 standard drinks per week.", "Her temperature is 98.2\u00b0F (36.8\u00b0C), blood pressure is 142/84 mmHg, pulse is 82/min, and respirations are 16/min."], "Patient Symptoms": ["She has no complaints and is asymptomatic."], "Examination and Results": ["On physical exam, a solid, immobile neck mass is palpated inferior to the cricoid cartilage to the left of midline.", "An ultrasound is obtained and shows a 1.2 cm hypoechoic mass with microcalcifications.", "Serum thyroid-stimulating hormone (TSH) concentration is 7.2 \u00b5U/mL."]}
{"Patient Personal Background": ["He is asymptomatic and has no acute complaints, has no medical problems, and takes no medications.", "He was born in the United States but moved to El Salvador at age 11 and has only recently moved back to the United States in the past year.", "He was up to date on his vaccinations prior to his move to El Salvador."], "Examination and Results": ["The patient\u2019s temperature is 98.2\u00b0F (36.8\u00b0C), blood pressure is 120/76 mmHg, pulse is 82/min, and respirations are 16/min.", "There are no rashes noted on physical exam."], "Treatment": ["He last received a diphtheria, tetanus, and acellular pertussis (DTaP) vaccine 14 years ago at age 5, the second dose of a meningococcal vaccine 3 years ago, and an influenza vaccine 2 months ago."]}
{"Patient Personal Background": ["His medical history is significant for chronic renal failure for which he received a renal transplant 5 years prior, as well as multiple surgeries for skin cancer.", "His current medications include aspirin, atorvastatin, prednisone, tacrolimus, and mycophenolate mofetil."], "Patient Symptoms": ["The lesion has grown rapidly over the previous 2 weeks.", "He endorses trauma to the area when he accidentally scraped his hand against a window and notes that there was some bleeding."], "Examination and Results": ["His temperature is 98.6\u00b0F (37\u00b0C), blood pressure is 136/91 mmHg, pulse is 82/min, and respirations are 11/min.", "Physical exam is notable for a 2 x 2.5 cm nodular lesion of the dorsal hand as seen in Figure A."]}
{"Patient Personal Background": ["He has a medical history of diabetes and hypertension for which he is on metformin and losartan."], "Patient Symptoms": ["He states that the pain is dull in quality, started 30 minutes ago, has been gradually worsening, and is worse with exertion.", "He also endorses some shortness of breath.", "He also believes the pain is worse when leaning back and improved when leaning forward.", "His wife noticed he fainted after the pain started but regained consciousness shortly after."], "Examination and Results": ["His temperature is 99.2\u00b0F (37.3\u00b0C), blood pressure is 130/87 mmHg, pulse is 99/min, respirations are 22/min, and oxygen saturation is 100% on room air.", "Physical exam reveals an overweight man.", "A normal S1 and S2 are auscultated with clear breath sounds.", "An ECG is performed as seen in Figure A."]}
{"Patient Personal Background": ["He was the driver in a head-on collision and was not wearing a seatbelt.", "His medical history is unknown."], "Patient Symptoms": ["The patient is acutely intoxicated and is attempting to attack the nurses."], "Examination and Results": ["His temperature is 97.6\u00b0F (36.4\u00b0C), blood pressure is 74/34 mmHg, pulse is 180/min, respirations are 32/min, and oxygen saturation is 98% on room air.", "Physical exam is notable for jugular venous distension.", "An electrocardiogram (ECG) is performed as seen in Figure A."], "Treatment": ["Soon after presentation, he is sedated, paralyzed, and intubated."]}
{"Patient Personal Background": ["The patient has a medical history of alcoholism and has been admitted to the hospital multiple times for withdrawal, abdominal pain, and traumatic injuries from his drinking.", "The patient states that his last drink was more than 1 year ago."], "Examination and Results": ["His temperature is 99.3\u00b0F (37.4\u00b0C), blood pressure is 115/78 mmHg, pulse is 78/min, respirations are 15/min, and oxygen saturation is 99% on room air.", "Physical exam reveals a non-tender, non-distended abdomen.", "Laboratory studies are notable for a serum calcium of 7.0 mg/dL.", "A computed tomography (CT) scan of the abdomen is performed as seen in Figure A.", "A Sudan Black stain of the patient\u2019s stool is positive."]}
{"Patient Personal Background": ["The patient is otherwise healthy.", "He has no other significant medical history and does not take any medications."], "Patient Symptoms": ["He noticed this yesterday as well, but it was much scanter.", "He was celebrating his birthday last night and admits having \"too much to drink\" and vomited profusely overnight.", "He currently feels well and is not nauseous."], "Examination and Results": ["His temperature is 99.2\u00b0F (37.3\u00b0C), blood pressure is 110/75 mmHg, pulse is 82/min, respirations are 16/min, and oxygen saturation is 100% on room air.", "Physical exam reveals a nontender abdomen with normal bowel sounds.", "Rectal exam reveals grossly bloody stool."], "Others": ["Laboratory studies are ordered as shown below."]}
{"Patient Personal Background": ["The patient is otherwise healthy and does not take any medications."], "Patient Symptoms": ["He was punched in the eye and is having pain and blurry vision."], "Examination and Results": ["His temperature is 98.1\u00b0F (36.7\u00b0C), blood pressure is 132/84 mmHg, pulse is 103/min, respirations are 17/min, and oxygen saturation is 98% on room air.", "Physical exam is notable for conjunctival injection of the patient\u2019s left eye as shown in Figure A.", "Visual acuity reveals 20/20 vision in his right eye and 20/40 vision in his left.", "His left pupil is sluggish to constrict when compared to the right.", "A fluorescein stain is unremarkable and tonometry reveals a pressure of 45 mmHg in the left eye."]}
{"Patient Personal Background": ["He has never smoked cigarettes but does have a history of opiate use prior to incarceration.", "He does not take any medications."], "Patient Symptoms": ["He noticed a gradual weight loss over the past year despite no changes to his diet or physical activity."], "Examination and Results": ["His temperature is 100.8\u00b0F (38.2\u00b0C), blood pressure is 142/88 mmHg, pulse is 78/min, and respirations are 12/min.", "Physical exam reveals a thin, ill-appearing man.", "Pulmonary auscultation reveals faint, inspiratory crackles in the right upper lobe.", "His chest radiograph is shown in Figure A."]}
{"Patient Symptoms": ["The shaking improves when he reaches for objects but returns when he is not using his hand.", "His left hand exhibits a 4-6 Hz tremor when resting on his lap.", "The tremor extinguishes with voluntary movement.", "In addition, his left upper extremity has increased tone with passive range of motion."], "Examination and Results": ["His temperature is 98.6\u00b0F (37.0\u00b0C), blood pressure is 115/70 mmHg, pulse is 70/min, and respirations are 12/min."]}
{"Patient Personal Background": ["His medical history is significant for IV drug use, HIV (CD4: 47/mm^3), hypertension, hyperlipidemia, diabetes mellitus, and seasonal allergies.", "He denies recent IV drug use."], "Patient Symptoms": ["His nasal congestion started about 1 week ago and he noticed the blurry vision this morning when he struggled to read the words on his television screen.", "He has injected conjunctiva and rhinorrhea."], "Examination and Results": ["His temperature is 100.8\u00b0F (38.2\u00b0C), blood pressure is 127/85 mmHg, pulse is 78/min, and respirations are 12/min.", "His cranial nerves are intact, and his motor and sensory neurologic exam is normal.", "A MRI of the brain is performed and can be seen in Figure A."], "Treatment": ["His home medications include hydrochlorothiazide, atorvastatin, metformin, cetirizine, darunavir, tenofovir, and emtricitabine."]}
{"Patient Personal Background": ["She returned from a recent missionary trip to South America 12 months prior where she endorsed eating a local delicacy as well as a period of fevers and eyelid swelling during her stay."], "Patient Symptoms": ["She endorses decreased exercise tolerance as well as intermittent palpitations."], "Examination and Results": ["Her temperature is 99.1\u00b0F (37.3\u00b0C), pulse is 95/min, blood pressure is 130/85 mmHg, respirations are 15/min, and oxygen saturation is 97% on room air.", "Physical exam is notable for a laterally displaced point of maximal impulse as well as a 2/6 diastolic murmur radiating to the axilla.", "A blood smear is shown in Figure A."]}
{"Patient Personal Background": ["She was delivered preterm at 35 weeks, and her medical history is significant for several ear infections over the last year.", "Her older brother has been diagnosed with attention-deficit hyperactivity disorder (ADHD), but the rest of her family history is otherwise unremarkable.", "Otherwise, the patient is energetic and started preschool 3 months ago."], "Patient Symptoms": ["The patient has become more withdrawn lately and has sometimes been ignoring her parents when asked to perform tasks at home.", "This seems to have worsened over the last 8 weeks.", "She seems distracted during the interview and responds only intermittently to the physician\u2019s directions."], "Examination and Results": ["Her temperature is 98.6\u00b0F (37\u00b0C), blood pressure is 98/62 mmHg, pulse is 97/min, and respirations are 26/min.", "The patient successfully draws a square and can stand on 1 foot.", "Her neurological examination is normal, and she is at the 50th percentile for height and weight."], "Others": ["Her language skills are unchanged from her appointment 6 months ago."]}
{"Patient Personal Background": ["Her family history is notable for hypothyroidism in her mother.", "She does not smoke cigarettes, stopped drinking alcohol prior to pregnancy, and does not use drugs."], "Patient Symptoms": ["She first presented 4 weeks ago with bilateral hand tremors.", "She reports mild improvement in her symptoms but continues to experience sweating and palpitations."], "Examination and Results": ["At that time, she was found to have a thyroid-stimulating hormone (TSH) concentration <0.01 mU/L and an elevated free T4.", "Her temperature is 97.6\u00b0F (36.4\u00b0C), blood pressure is 113/70 mmHg, pulse is 126/min, and respirations are 18/min.", "On physical exam, she appears anxious, mildly diaphoretic and has a non-tender prominence on her neck which is shown in Figure A."], "Treatment": ["She was started on propranolol and propylthiouracil.", "The dosage of both medications has been titrated to the maximum dose."], "Others": ["She has a past medical history of polycystic ovary syndrome."]}
{"Patient Personal Background": ["His past medical history is notable for hypertension, type 2 diabetes mellitus, and hyperlipidemia.", "His medications include amlodipine, atorvastatin, and metformin."], "Patient Symptoms": ["For the past few months, he has pain in his chest with physical activity.", "The pain goes away after he takes a break.", "He reports no chest pain while he is resting, and the pain is not worsening."], "Examination and Results": ["His temperature is 36.5\u00b0C (97.7\u00b0F), blood pressure is 132/80 mmHg, pulse is 74/min, respirations are 14/min, and oxygen saturation is 98% on room air.", "He has a regular rate and rhythm, normal S1 and S2, and no murmurs, rubs, or gallops.", "His anterior, lateral, and posterior chest are non-tender to palpation.", "His electrocardiogram is shown in Figure A. Troponin I level is < 0.017 ng/mL."]}
{"Patient Personal Background": ["He has no medical problems and takes no medications.", "He gets along with his 2 brothers, plays turn-taking games with his friends, and completes his chores."], "Patient Symptoms": ["At school, he interrupts class by making barking noises.", "His mother notes that he has been making throat-clearing noises daily for the past 2 years.", "On exam, he grimaces several times and blinks his eyes rapidly."], "Examination and Results": ["His temperature is 98.4\u00b0F (36.9\u00b0C), blood pressure is 118/72 mmHg, pulse is 72/min, and respirations are 16/min.", "He does not appear to be reacting to internal stimuli.", "His mood and affect are normal."]}
{"Patient Personal Background": ["He just switched from being home-schooled to public school and joined the basketball team.", "He is otherwise healthy and has met all developmental milestones.", "He does not currently take any medications."], "Patient Symptoms": ["He has fainted several times during basketball practices.", "He did not sustain any injuries or have any prodromes prior to these episodes.", "He is usually unconscious for less than a minute."], "Examination and Results": ["His temperature is 97.6\u00b0F (36.4\u00b0C), blood pressure is 104/54 mmHg, pulse is 100/min, respirations are 19/min, and oxygen saturation is 98% on room air.", "Physical exam reveals a well-appearing and playful boy.", "An ECG is performed as seen in Figure A.", "An echocardiogram is ordered and pending."]}
{"Patient Symptoms": ["He had a similar episode about 1 month ago which resolved after a few hours.", "The pain feels like a stabbing sensation behind his right eye.", "He denies any symptoms on the left side.", "The last time he had an episode like this, his eye was tearing."], "Examination and Results": ["His temperature is 98.2\u00b0F (36.8\u00b0C), blood pressure is 120/90 mmHg, pulse is 110/min, and respirations are 12/min.", "Physical exam reveals a 2 mm pupil on the right and a 5 mm pupil on the left.", "Extraocular movements are intact bilaterally.", "The remainder of the neurologic exam is unremarkable."]}
{"Treatment": ["The resident suggests performing one on the deceased patient, as the student cannot harm him."], "Others": ["A medical student rotating in the intensive care unit asked if she can practice performing intubations during her rotation."]}
{"Patient Symptoms": ["For 2 months, she has experienced intermittent palpitations along with menstrual irregularity and hair loss.", "At home, the air conditioner is at its coldest setting, but the patient still feels overheated."], "Examination and Results": ["Her temperature is 99.5\u00b0F (37.5\u00b0C), blood pressure is 135/90 mmHg, pulse is 120/min, and respirations are 22/min.", "The patient is diaphoretic with tremulous hands, demonstrates thyromegaly, and protrusion of her eyes is noted."], "Treatment": ["She is given atenolol in the emergency department with improvement of her palpitations and is instructed to follow up with her primary doctor for further management."]}
{"Patient Personal Background": ["The patient works on a farm and does not see a doctor often.", "He has a history of hypertension but does not take medications routinely.", "He smokes cigarettes occasionally."], "Patient Symptoms": ["He has not had any chest pain, dyspnea, or weakness during this time frame and currently feels at his baseline."], "Examination and Results": ["His temperature is 98.1\u00b0F (36.7\u00b0C), blood pressure is 152/93 mmHg, pulse is 86/min, respirations are 15/min, and oxygen saturation is 98% on room air.", "Physical exam is unremarkable and the patient walks with a stable gait and no focal weakness.", "An ECG is performed as seen in Figure A.", "Laboratory studies are ordered as seen below."]}
{"Patient Personal Background": ["The patient has no medical conditions and takes no medications.", "She typically swims or uses an exercise bike for 45 minutes, 5 days a week, and plays in an office soccer league for 1 hour on 1 day per week."], "Examination and Results": ["The first day of her last menstrual period was 7 weeks prior to presentation.", "Her temperature is 98.6\u00b0F (37.0\u00b0C), blood pressure is 110/70 mmHg, pulse is 64/min, and respirations are 17/min.", "Physical exam is notable for a nontender abdomen.", "Pelvic exam reveals a closed cervix with no adnexal or uterine tenderness.", "A urine pregnancy test is positive, and an intrauterine singleton pregnancy measuring approximately 9 weeks gestational age is visualized on transvaginal ultrasound."], "Others": ["The patient asks if she should modify her current exercise regimen due to her pregnancy."]}
{"Patient Symptoms": ["He was in class when he suddenly fainted and became unresponsive."], "Examination and Results": ["An autopsy is performed and is notable for no clear abnormalities.", "The patient\u2019s laboratory studies were unremarkable from a visit to the pediatrician 3 weeks ago.", "A previous ECG is seen in Figure A."], "Treatment": ["His teacher began chest compressions and he has received epinephrine and defibrillation from paramedics while in transport."], "Others": ["On arrival, the patient remains pulseless and is pronounced dead."]}
{"Patient Personal Background": ["She is otherwise healthy.", "She lives with her mother who has diabetes whose medications include metformin, insulin, lisinopril, amlodipine, and glyburide."], "Patient Symptoms": ["This has happened several times this past month with increasing frequency.", "Each time her symptoms improved with eating."], "Examination and Results": ["Her temperature is 98.0\u00b0F (36.7\u00b0C), blood pressure is 132/81 mmHg, pulse is 85/min, respirations are 16/min, and oxygen saturation is 98% on room air.", "Physical exam reveals a confused woman.", "She is moving all her extremities but follows commands poorly."], "Others": ["Laboratory studies are ordered as seen below."]}
{"Treatment": ["At a teaching hospital with residents, the time to tissue plasminogen activator administration is roughly 2 hours."], "Others": ["This has led to many adverse outcomes and increased morbidity at the teaching hospital."]}
{"Patient Personal Background": ["The patient is not aware of any medical problems and just started seeing a primary care physician last week.", "He recently used a friend's prescription for ondansetron for nausea."], "Patient Symptoms": ["He was outside tending to his lawn for several hours in the heat, when he stood up suddenly from pulling weeds and fainted.", "He denies any preceding symptoms and returned to baseline within 1 minute."], "Examination and Results": ["His temperature is 99.3\u00b0F (37.4\u00b0C), blood pressure is 142/88 mmHg, pulse is 107/min, respirations are 14/min, and oxygen saturation is 99% on room air.", "Physical exam reveals intact cranial nerves, normal strength and sensation, and a stable gait.", "His abdomen is soft and nontender.", "An ECG is performed as seen in Figure A."]}
{"Patient Personal Background": ["His other medications include albuterol."], "Patient Symptoms": ["Since then, he notes that his symptoms are roughly unchanged.", "Physical exam reveals a depressed affect."], "Examination and Results": ["His temperature is 99.3\u00b0F (37.4\u00b0C), blood pressure is 132/88 mmHg, pulse is 77/min, respirations are 14/min, and oxygen saturation is 99% on room air.", "His neurologic exam is non-focal.", "A serum thyroid stimulating hormone (TSH) resulted from his last visit and is noted to be 4.8 \u00b5U/mL (normal: 0.5-5 \u00b5U/mL)."], "Treatment": ["He started taking fluoxetine 3 weeks ago when he was diagnosed with major depressive disorder after a divorce."], "Diagnosis": ["He started taking fluoxetine 3 weeks ago when he was diagnosed with major depressive disorder after a divorce."]}
{"Patient Personal Background": ["He has no past medical history and takes no medications."], "Patient Symptoms": ["He states he has a constant sensation that the room is spinning.", "He is now having trouble walking and has been vomiting intermittently.", "His gait is ataxic and he exhibits rightward nystagmus.", "His dizziness is constant and unchanged with performance of the Dix-Hallpike maneuver."], "Examination and Results": ["His temperature is 98.0\u00b0F (36.7\u00b0C), blood pressure is 122/84 mmHg, pulse is 80/min, respirations are 16/min, and oxygen saturation is 98% on room air.", "Physical exam reveals a young man who is vomiting.", "His dizziness is constant and unchanged with performance of the Dix-Hallpike maneuver.", "The head impulse test reveals a corrective saccade and there is no skew deviation."]}
{"Patient Personal Background": ["He has a history of heart failure with reduced ejection fraction, obesity, diabetes, hypertension, acute coronary syndrome, atrial fibrillation, and peripheral vascular disease."], "Patient Symptoms": ["He states that his wife made him come in when he fainted today while attempting to stand up.", "He otherwise states he has noticed some visual changes, including noting a yellow tint to objects."], "Examination and Results": ["His temperature is 98.5\u00b0F (36.9\u00b0C), blood pressure is 153/91 mmHg, pulse is 40/min, respirations are 15/min, and oxygen saturation is 97% on room air.", "Physical exam reveals a frail man who is unable to ambulate secondary to lightheadedness.", "His neurological exam is otherwise non-focal.", "An ECG is performed as seen in Figure A."]}
{"Patient Personal Background": ["The patient has a history of diabetes and is followed closely by an endocrinologist."], "Patient Symptoms": ["Today, he experienced a headache with blurry vision, thus prompting his presentation.", "Otherwise, he has lost 10 pounds over the past month.", "His gait is mildly ataxic as well, but his neurological exam is otherwise nonfocal."], "Examination and Results": ["His temperature is 100\u00b0F (37.8\u00b0C), blood pressure is 122/90 mmHg, pulse is 84/min, respirations are 16/min, and oxygen saturation is 99% on room air.", "Physical exam is notable for a thin man but is otherwise unremarkable.", "His visual acuity is 20/100 in both eyes, though he says that he normally has 20/20 vision."], "Others": ["Laboratory studies are ordered as seen below."]}
{"Patient Personal Background": ["They order the patient\u2019s home medications including clobazam; however, they accidentally order clonazepam."], "Patient Symptoms": ["Subsequently, the patient is over-sedated and has to be transferred to the ICU for airway monitoring."], "Treatment": ["They order the patient\u2019s home medications including clobazam; however, they accidentally order clonazepam."]}
{"Patient Personal Background": ["He has experienced similar symptoms before."], "Patient Symptoms": ["Today, he was hit in the face with a football, followed by significant swelling of his lips and tongue.", "The patient speaks with a muffled voice."], "Examination and Results": ["His temperature is 98.1\u00b0F (36.7\u00b0C), blood pressure is 120/83 mmHg, pulse is 80/min, respirations are 16/min, and oxygen saturation is 98% on room air.", "Physical exam reveals swollen lips and a protruding, enlarged tongue.", "His breath sounds are clear.", "He demonstrates no rash and his abdomen is soft and nontender."]}
{"Patient Personal Background": ["He is otherwise healthy and takes no medications."], "Patient Symptoms": ["He states he has had profuse, watery diarrhea for the past 24 hours.", "He notes that eating and drinking make him defecate more, thus he has been refraining from drinking."], "Examination and Results": ["His temperature is 97.7\u00b0F (36.5\u00b0C), blood pressure is 84/64 mmHg, pulse is 130/min, respirations are 17/min, and oxygen saturation is 99% on room air.", "Physical exam reveals dry mucous membranes with an otherwise benign exam."], "Treatment": ["The patient is given 1L of normal saline and drinks 1L of oral fluids."]}
{"Patient Personal Background": ["His past medical history is significant for previous myocardial infarction, a 30-pack-year smoking history, gastroesophageal reflux disease, and poorly controlled hypertension.", "The patient\u2019s only home medication is omeprazole."], "Examination and Results": ["His temperature is 98.6\u00b0F (37\u00b0C), blood pressure is 140/90 mmHg, pulse is 90/min, respirations are 30/min, and oxygen saturation is 88% on room air.", "Physical exam is significant for a jugular venous pressure of 15 cm, an S3 heart sound, bibasilar crackles, and 2+ pitting edema to the knees bilaterally.", "His abdomen is soft and non-tender.", "His neurological exam is nonfocal and he walks with a steady gait."]}
{"Patient Personal Background": ["He has a history of depression which is well managed with fluoxetine.", "He has a past medical history of diabetes and notes that his home blood glucose readings have been higher lately."], "Patient Symptoms": ["He states that since starting the medication, his sexual drive has increased, yet he is unable to achieve orgasm.", "As a result, he refuses to take the medication anymore."], "Examination and Results": ["His temperature is 98.3\u00b0F (36.8\u00b0C), blood pressure is 127/82 mmHg, pulse is 88/min, respirations are 14/min, and oxygen saturation is 99% on room air.", "Physical exam reveals an obese man in no acute distress with a normal affect and non-focal neurologic exam."], "Treatment": ["The physician agrees to change the patient\u2019s antidepressant."]}
{"Patient Personal Background": ["She is sexually active and uses condoms."], "Patient Symptoms": ["She states that it started 1 day ago and has not improved with hygiene products.", "She does not complain of any abdominal or pelvic pain but states she has some mild burning when urinating."], "Examination and Results": ["Her temperature is 97.6\u00b0F (36.4\u00b0C), blood pressure is 111/74 mmHg, pulse is 81/min, respirations are 12/min, and oxygen saturation is 98% on room air.", "Physical exam is notable for thick, white discharge from the cervix.", "There is no cervical motion or adnexal tenderness or masses.", "Some whitish discharge is noted from the urethra.", "A urine pregnancy test is negative."]}
{"Patient Personal Background": ["He has a history of anxiety managed with fluoxetine and lorazepam.", "He also has hypertension but does not take any medications."], "Patient Symptoms": ["Today, his symptoms have been persistent despite taking his medications.", "He says that he feels lightheaded and can\u2019t walk.", "During the exam, the patient states that he feels lightheaded and appears occasionally somnolent."], "Examination and Results": ["His temperature is 98.7\u00b0F (37.1\u00b0C), blood pressure is 120/72 mmHg, pulse is 183/min, respirations are 25/min, and oxygen saturation is 99% on room air.", "Physical exam reveals a somnolent and uncomfortable man.", "His pulse is rapid and regular.", "An ECG is performed as seen in Figure A."]}
{"Patient Personal Background": ["He has a medical history of obesity and smokes regularly."], "Patient Symptoms": ["The patient states that his symptoms have been worsening over the past week.", "He also has experienced abdominal pain and diarrhea.", "He states that the rash is painful."], "Examination and Results": ["His temperature is 97.5\u00b0F (36.4\u00b0C), blood pressure is 142/82 mmHg, pulse is 85/min, respirations are 15/min, and oxygen saturation is 98% on room air.", "Physical exam is notable for an erythematous rash with papules and plaques on the patient's face, torso, and extremities.", "A fingerstick blood glucose is unable to accurately read his blood glucose and gives a reading of > 500 mg/dL."]}
{"Patient Personal Background": ["He has a past medical history of diabetes, obesity, and hypertension.", "He had his Achilles tendon repaired 4 weeks ago and he has been less mobile."], "Patient Symptoms": ["He recently had a cold that kept him home from work for the past week.", "Physical exam is notable for dyspnea provoked by walking short distances."], "Examination and Results": ["His temperature is 99.2\u00b0F (37.3\u00b0C), blood pressure is 150/85 mmHg, pulse is 82/min, respirations are 16/min, and oxygen saturation is 100% on room air.", "Jugular venous distension is noted on exam.", "The patient\u2019s blood pressure is 130/70 mmHg during inspiration.", "A bedside echocardiogram demonstrates impaired diastolic filling with normal ventricular contractility.", "An ECG is performed as seen in Figure A."]}
{"Patient Personal Background": ["He has no past medical history and takes no medications."], "Patient Symptoms": ["The patient is unable to offer a history and repetitively asks the nurses what happened.", "He is complaining of a headache."], "Examination and Results": ["His temperature is 97.6\u00b0F (36.4\u00b0C), blood pressure is 122/74 mmHg, pulse is 90/min, respirations are 12/min, and oxygen saturation is 98% of room air.", "Physical exam reveals a confused young man.", "Cranial nerves 2-12 are intact and the patient has normal strength and sensation.", "He demonstrates a stable gait."], "Others": ["He drove his car into a pole while speeding at night.", "He knows his name and address and is able to remember other information about himself.", "Throughout the exam, he continuously asks what happened to him.", "A head CT scan is ordered."]}
{"Examination and Results": ["Analyzing only those subjects who responded throughout the entire period, it is determined that opioid use disorder only minimally impairs individuals in their daily functioning."], "Others": ["Individuals are surveyed using a validated method and followed up in 6-month intervals for 5 years.", "At the end of the study period, 40% of individuals have replied to the survey throughout the entire period."]}
{"Patient Symptoms": ["While holding her newborn, the mother endorses a headache, blurry vision, and abdominal pain."], "Examination and Results": ["Her temperature is 98.0\u00b0F (36.7\u00b0C), blood pressure is 194/104 mmHg, pulse is 100/min, respirations are 18/min, and oxygen saturation is 98% on room air.", "There is blood in her vagina and her uterus is contracted.", "Her cranial nerve exam is unremarkable and she has normal strength and sensation."], "Treatment": ["She subsequently undergoes an uncomplicated vaginal delivery.", "The child is healthy and is heated, suctioned, and stimulated."], "Others": ["Physical exam reveals an uncomfortable woman.", "Laboratory studies and a urinalysis are pending."]}
{"Patient Personal Background": ["This has happened in the past, but his mother thought he was fabricating his symptoms.", "He has had an MRI of the brain with no acute findings in the past.", "The child has a history of migraine headaches with aura that resolve with ibuprofen.", "He is otherwise healthy and has no medical problems or recent illness and is up to date on his vaccinations."], "Patient Symptoms": ["The mother states this episode lasted about 3 minutes and involved full-body jerking.", "After the episode, the child was non-responsive but was breathing on his own.", "He initially is unable to move his left upper and lower extremity and has a left facial droop; however, after a few minutes, he has 4/5 strength in the affected side with resolution of his facial weakness.", "The mother notes that this is similar to his past episodes."], "Examination and Results": ["His temperature is 97.6\u00b0F (36.4\u00b0C), blood pressure is 100/64 mmHg, pulse is 90/min, respirations are 12/min, and oxygen saturation is 99% on room air.", "The patient is protecting his airway but is unable to answer questions.", "He is able to move the right upper and lower extremity.", "He initially is unable to move his left upper and lower extremity and has a left facial droop; however, after a few minutes, he has 4/5 strength in the affected side with resolution of his facial weakness."], "Treatment": ["She has taken him to a free health clinic to have him seen by a doctor who prescribed medication; however, she has been unable to fill the prescription."]}
{"Patient Personal Background": ["He uses intravenous drugs and is unable to offer a history."], "Patient Symptoms": ["He was found unconscious in a park.", "Physical exam reveals an obtunded man covered in vomit, with track marks on his arm and several skin abscesses."], "Examination and Results": ["His temperature is 99.0\u00b0F (37.2\u00b0C), blood pressure is 80/40 mmHg, pulse is 156/min, and respirations are 26/min.", "As the fourth liter of fluids is finishing, the patient is noted to have jugular venous distension and an oxygen saturation of 92% on nonrebreather.", "An ECG is obtained as seen in Figure A."], "Treatment": ["The patient is given 4 liters of Ringer lactate and intravenous antibiotics.", "He is subsequently intubated.", "The patient is started on norepinephrine, and his blood pressure is subsequently found to be 85/44 mmHg."]}
{"Patient Personal Background": ["The patient is a software engineer and enjoys hiking, going to nightclubs, and dancing."], "Patient Symptoms": ["His symptoms started a few weeks ago but have been worsening.", "Sometimes he notes blood on the toilet paper.", "He has to strain to have bowel movements and has trouble defecating secondary to pain."], "Examination and Results": ["His temperature is 98.1\u00b0F (36.7\u00b0C), blood pressure is 112/83 mmHg, pulse is 83/min, respirations are 13/min, and oxygen saturation is 98% on room air.", "Physical exam reveals a small, superficial fissure that is lateral to the anus and lateral to the midline."], "Others": ["He is generally healthy and does not smoke."]}
{"Patient Personal Background": ["His primary care provider was concerned and had advised him to go to the hospital, as the patient is on warfarin for atrial fibrillation."], "Patient Symptoms": ["He was seen in the emergency department 2 days ago for profuse epistaxis.", "Physical exam reveals an obtunded man who cannot answer questions.", "A dark, purpuric rash is noted on his torso and extremities."], "Examination and Results": ["Upon presentation to the ED today, his temperature is 97.6\u00b0F (36.4\u00b0C), blood pressure is 64/33 mmHg, pulse is 160/min, respirations are 32/min, and oxygen saturation is 100% on room air.", "A dark, purpuric rash is noted on his torso and extremities."], "Treatment": ["The patient is given IV fluids and blood cultures are drawn."], "Others": ["However, his bleeding resolved with pressure and nasal packing.", "The patient\u2019s nasal packing is removed with no further bleeding."]}
{"Patient Personal Background": ["The patient is obese, and her only medication is an oral contraceptive pill.", "She otherwise is known to smoke cigarettes on occasion."], "Patient Symptoms": ["She was found to have altered mental status at home, and during transport to the hospital, she became pulseless."], "Examination and Results": ["Physical exam is notable for a critically ill patient with chest compressions ongoing.", "The monitor shows pulseless electrical activity.", "A bedside echocardiograph is notable for a dilated and hypokinetic right ventricle with septal bowing into a hyperkinetic left ventricle."], "Treatment": ["Cardiopulmonary resuscitation is ongoing and 2 intravenous lines are placed.", "The patient regains her pulse after several rounds of CPR and epinephrine."], "Others": ["She recently underwent Achilles tendon repair.", "Her right lower extremity is in a post-operative splint."]}
{"Patient Personal Background": ["He has a medical history significant for high blood pressure, hyperlipidemia, and seasonal allergies with no prior surgical history.", "He has no history of tobacco use.", "He moved from India 7 years prior to presentation.", "He currently lives in Oregon and has not left the west coast since moving.", "His temperature is 99\u00b0F (37.2\u00b0C), blood pressure is 100/70 mmHg, pulse is 76/min, and respirations are 16/min."], "Patient Symptoms": ["He has had a chronic cough and a 20 pound unintentional weight loss over the past 6 months."], "Examination and Results": ["His physical exam is significant for hyperpigmentation of the oral mucosa and temporal muscle wasting.", "Radiography of the abdomen demonstrates bilateral adrenal calcifications."]}
{"Patient Personal Background": ["He is up to date on his vaccinations."], "Patient Symptoms": ["Over the past several weeks, the child has been more fatigued and his parents state that \u201che always seems to be sick.\u201d They state that sometimes he complains about his bones hurting and they note that he is less playful."], "Examination and Results": ["His temperature is 102\u00b0F (38.9\u00b0C), blood pressure is 92/60 mmHg, pulse is 115/min, respirations are 23/min, and oxygen saturation is 99% on room air.", "Physical exam is notable for diffuse non-tender lymphadenopathy.", "Abdominal exam reveals hepatosplenomegaly."]}
{"Patient Personal Background": ["He states that ever since his wife died 4 months ago, he has been eating and sleeping more and no longer engages in any activities he once enjoyed such as hiking or fishing.", "The patient has a past medical history of obesity, poorly controlled diabetes, hypertension, and peripheral vascular disease."], "Patient Symptoms": ["He feels guilty for not spending more time with his wife before she died.", "He was recently fired for making several major bookkeeping mistakes at work as an accountant as he had trouble focusing.", "The patient is requesting oxycodone at this appointment as he states he has burning pain in his legs that feels worse now than it has in years past.", "His affect seems depressed."], "Examination and Results": ["His temperature is 98.7\u00b0F (37.1\u00b0C), blood pressure is 129/82 mmHg, pulse is 83/min, respirations are 15/min, and oxygen saturation is 99% on room air.", "Physical exam reveals a stable gait and reduced sensation symmetrically over the lower extremities.", "He complains of electric pain when touching his lower extremities."]}
{"Patient Personal Background": ["His past medical history is notable for a myocardial infarction 7 years ago, COPD, heart failure with a left ventricular ejection fraction of 22%, obesity, diabetes, and peripheral vascular disease."], "Patient Symptoms": ["He typically has poor exercise tolerance and is only able to walk from his house to his mailbox before becoming dyspneic.", "He now has shortness of breath even at rest.", "He had a cold recently but has no new medical problems."], "Examination and Results": ["His temperature is 97.7\u00b0F (36.5\u00b0C), blood pressure is 124/82 mmHg, pulse is 140/min, respirations are 32/min, and oxygen saturation is 78% on room air.", "Physical exam reveals an uncomfortable man with increased work of breathing.", "He demonstrates bilateral crackles and wheezing on pulmonary exam."], "Treatment": ["The patient is started on BiPAP, and his oxygen saturation improves to 94%."], "Others": ["An ECG is performed, as seen in Figure A, and a chest radiograph is performed, as seen in Figure B."]}
{"Patient Symptoms": ["The patient was found on a mountain trail non-responsive.", "Dark bullae are noted on the patient's extremities."], "Examination and Results": ["His temperature is 91\u00b0F (32.8\u00b0C), blood pressure is 103/61 mmHg, pulse is 60/min, respirations are 11/min, and oxygen saturation is 97% on room air.", "An ECG is performed as seen in Figure A."], "Treatment": ["The patient is placed under a warm air circulator, and his extremities are bathed in warm water."], "Others": ["His mental status rapidly improves with warming.", "Laboratory studies are ordered and are pending."]}
{"Patient Personal Background": ["He has a history of diabetes, obesity, and hypertension but does not see a physician for his underlying conditions."], "Patient Symptoms": ["His symptoms lasted 20 minutes but by the time he arrived at the emergency department he was symptom-free.", "The patient denies any preceding symptoms."], "Examination and Results": ["His temperature is 99.2\u00b0F (37.3\u00b0C), blood pressure is 140/85 mmHg, pulse is 82/min, respirations are 16/min, and oxygen saturation is 100% on room air.", "Physical exam reveals normal vision, strength, and sensation with a stable gait.", "Finger-nose testing and tandem gait are unremarkable.", "A CT scan of the head is performed and is unremarkable."]}
{"Patient Personal Background": ["The patient has dementia at baseline and is minimally interactive."], "Patient Symptoms": ["She was last known to be normal the night before.", "This morning, she was found to be obtunded."], "Examination and Results": ["Her temperature is 95.0\u00b0F (35.0\u00b0C), blood pressure is 84/54 mmHg, pulse is 50/min, respirations are 9/min, and oxygen saturation is 98% on room air.", "Physical exam reveals an obtunded woman who only withdraws her extremities to pain.", "Her skin is cool and pale, and her hair is thin.", "Laboratory values are notable for a whole blood sodium of 120 mEq/L."], "Treatment": ["The patient is given several intravenous boluses of fluids and her blood pressure improves to 100/60 mmHg."], "Others": ["No further history was provided from the nursing home, and the patient is unable to provide any history.", "There are no signs of trauma noted on exam."]}
{"Patient Personal Background": ["The patient has a past medical history of atrial fibrillation and is currently taking metoprolol and warfarin."], "Patient Symptoms": ["He has never had epistaxis before and has been unable to control it with pressure, head elevation, and ice."], "Examination and Results": ["His temperature is 98.5\u00b0F (36.9\u00b0C), blood pressure is 123/81 mmHg, pulse is 90/min, respirations are 13/min, and oxygen saturation is 97% on room air.", "Physical exam reveals a comfortable man in no distress.", "Inspection reveals active bleeding in the anterior nares.", "There is not a clear, single bleeding vessel."]}
{"Patient Personal Background": ["His temperature is 98.5\u00b0F (36.9\u00b0C), blood pressure is 153/89 mmHg, pulse is 90/min, respirations are 11/min, and oxygen saturation is 97% on room air."], "Patient Symptoms": ["He states that this has happened to him multiple times, particularly when he changes body position from sitting to standing, exerts himself, or turns his head quickly.", "He says that he notes numbness, vertigo, and sometimes even trouble with speaking immediately prior to fainting.", "When he wakes up, he is mildly confused but typically returns to baseline within a minute.", "However, when he is asked to stand up and start walking, he experiences the same numbness and tingling and feels like he may faint."], "Examination and Results": ["The episodes usually last 1-5 minutes.", "The patient has a past medical history of diabetes, dyslipidemia, and hypertension.", "The patient's neurological exam is unremarkable."]}
{"Patient Personal Background": ["He has a past medical history of diabetes and atrial fibrillation and is currently taking warfarin.", "His other medications are not known."], "Patient Symptoms": ["He was last seen normal 1 hour ago.", "His wife noticed that he was confused, slurring his speech, and had notable weakness that caused him to drop his cup of coffee.", "The patient is confused and not able to answer any questions.", "Facial drooping of the left lower face is noted, and the patient cannot follow any commands.", "The patient is not able to follow any commands for further neurologic evaluation but does not appear to be moving his right upper extremity."], "Examination and Results": ["His temperature is 98.0\u00b0F (36.7\u00b0C), blood pressure is 150/90 mmHg, pulse is 115/min, and respirations are 17/min."]}
{"Patient Personal Background": ["He has a medical history significant for hypertension that is well-controlled with lisinopril.", "He had an uncomplicated appendectomy when he was 23 years old.", "He has no family history of gastrointestinal malignancy."], "Patient Symptoms": ["He describes the blood as bright red wisps that float on the surface of the stool.", "He has no pain with bowel movements but notes on occasion he may strain.", "He does not endorse fatigue, fever, constipation, diarrhea, nausea, vomiting, abdominal pain, weight loss, or dyspnea."], "Examination and Results": ["His last colonoscopy was 3 years prior to presentation and was benign.", "His temperature is 98.6\u00b0F (37.0\u00b0C), blood pressure is 140/90 mmHg, pulse is 76/min, and respirations are 16/min.", "On physical exam, the patient's abdomen is soft, non-distended, and non-tender with normal bowel sounds and without organomegaly or masses.", "The anus is patent without fissures, hemorrhoids, or skin tags."]}
{"Patient Personal Background": ["His past medical history is notable for diabetes and obesity.", "He has smoked 1 pack of cigarettes per day for the past 30 years."], "Patient Symptoms": ["His symptoms started at work when he was lifting boxes.", "He states that he currently feels crushing pressure over his chest.", "He is given nitroglycerin, with minimal improvement in his symptoms."], "Examination and Results": ["His temperature is 97.9\u00b0F (36.6\u00b0C), blood pressure is 155/99 mmHg, pulse is 110/min, respirations are 22/min, and oxygen saturation is 98% on room air.", "Physical exam reveals an uncomfortable, diaphoretic man.", "His heart and breath sounds are unremarkable.", "The patient\u2019s chest pain is worse when the ECG in the emergency department is taken, compared to the one taken in triage."], "Treatment": ["He is given aspirin and an ECG is performed in triage, as seen in Figure A.", "He is given nitroglycerin, with minimal improvement in his symptoms.", "A troponin level is drawn."], "Others": ["A repeat ECG in the emergency department is performed, also seen in Figure A."]}
{"Patient Personal Background": ["The patient is otherwise healthy and takes no medications."], "Patient Symptoms": ["He states that he has been a bit more fatigued lately but believes it is secondary to poor sleep at his new house."], "Examination and Results": ["His temperature is 98.0\u00b0F (36.7\u00b0C), blood pressure is 141/90 mmHg, pulse is 82/min, respirations are 16/min, and oxygen saturation is 98% on room air.", "Physical exam is notable only for minor pallor but is otherwise unremarkable.", "Basic laboratory studies are ordered as seen below."]}
{"Patient Personal Background": ["The patient has a history of coronary artery disease with a drug-eluting stent placed 1 year ago, obesity, hypertension, and dyslipidemia."], "Patient Symptoms": ["He has had severe nausea, vomiting, and diarrhea for the past 3 days.", "Today, his wife noticed that he was confused.", "He denies chest pain or dyspnea, but complains of diffuse abdominal pain."], "Examination and Results": ["His temperature is 99.0\u00b0F (37.2\u00b0C), blood pressure is 100/60 mmHg, pulse is 105/min, and respirations are 22/min.", "Physical exam reveals a confused man with dry mucous membranes.", "His abdomen is diffusely tender to palpation.", "Laboratory studies are ordered and notable for the following:\n\nSerum:\nNa+: 147 mEq/L\nCl-: 112 mEq/L\nK+: 3.5 mEq/L\nHCO3-: 14 mEq/L\nBUN: 80 mg/dL\nGlucose: 100 mg/dL\nCreatinine: 2.1 mg/dL\nTroponin: 0.10 mcg/L (normal < 0.01 mcg/L)\n\nAn ECG is ordered and is pending."]}
{"Patient Personal Background": ["Her past medical history is unremarkable and she is not currently taking any medications.", "She denies drinking alcohol, smoking cigarettes, or using recreational drugs."], "Patient Symptoms": ["She has generally been feeling well, but notes feeling intermittent palpitations over the past few months.", "She attributes her palpitations to recently drinking more caffeine, but would like to obtain an electrocardiogram since her symptoms are worrisome and affecting her ability to concentrate on her career as a fitness instructor."], "Examination and Results": ["Her temperature is 36.9\u00b0C (98.4\u00b0F), blood pressure is 116/76 mmHg, pulse is 55/min, respirations are 12/min, and oxygen saturation is 98% on room air.", "Her electrocardiogram is shown in Figure A."]}
{"Patient Personal Background": ["He has a history of alcohol use disorder and has vomited small streaks of blood in the past, but has never undergone formal medical workup for it."], "Patient Symptoms": ["His wife states that he began vomiting bright red blood this evening while eating dinner, and has produced about 5 cups total.", "On exam, he has bright red blood in his mouth and pharynx, and also displays a distended abdomen with a fluid wave, jaundice, scattered spider angiomas, and multiple ecchymoses."], "Examination and Results": ["His temperature is 98.4\u00b0F (36.9\u00b0C), blood pressure is 98/68 mmHg, pulse is 125/min, and respirations are 22/min.", "A rapid point-of-care hemoglobin and platelet count is 8.8 g/dL and 80,000/mm^3, respectively."], "Treatment": ["The patient is given 1L of normal saline."]}
{"Patient Personal Background": ["His past medical history is notable for hypertension and atrial fibrillation treated with metoprolol, apixaban, and lisinopril."], "Patient Symptoms": ["At home, the patient thought he was simply dehydrated, but he rapidly began to have trouble speaking.", "When his wife noted this she brought him into the hospital.", "On arrival to the emergency department, the patient is not responding to verbal stimuli and only withdraws his left upper extremity and lower extremity to pain.", "The patient has a seizure and subsequently demonstrates agonal breathing.", "He no longer responds to painful stimuli."], "Examination and Results": ["His temperature is 99.0\u00b0F (37.2\u00b0C), blood pressure is 170/100 mmHg, pulse is 95/min, and respirations are 16/min.", "A fingerstick blood glucose is 122 mg/dL."]}
{"Patient Personal Background": ["One month prior to his ED visit, he had been treated with oral antibiotics when he presented to an urgent care center with left-sided otorrhea, otalgia, and hearing loss."], "Patient Symptoms": ["In the ED, he denied headaches, fever, otalgia, otorrhea, or hearing loss."], "Examination and Results": ["Magnetic resonance imaging of the brain with contrast showed diffuse enhancement and possible coalescence in the left mastoid process with adjacent dural enhancement and sigmoid sinus occlusion.", "There was no periauricular swelling or erythema.", "Otoscopic examination showed no inflammation of the external auditory canals, and the tympanic membranes were translucent without evidence of retraction or effusion.", "Computed tomographic venogram confirmed occlusion of the left transverse and sigmoid sinuses, and computed tomography of the temporal bone showed coalescence of mastoid air cells with erosion into the sigmoid sinus.", "Histologic findings from the specimens demonstrated cells with oval nuclei and abundant cytoplasm arranged in syncytial clusters with occasional whorls, pseudoinclusions, and psammomatous calcifications (Figure, A).", "Immunohistochemical stains were positive for epithelial membrane antigen (EMA) and vimentin (Figure, B).Hematoxylin-eosin stain (A) and immunohistochemical stain (B) after mastoidectomy for biopsy and culture specimens."], "Treatment": ["He received intravenous vancomycin and cefepime and was started on a heparin drip before being transferred to our facility.", "Mastoidectomy was performed for biopsy and culture specimens."], "Others": ["On presentation at our facility, the patient appeared well with normal vital signs."]}
{"Patient Personal Background": ["Additional treatment with fluconazole, augmentin, doxycycline, omeprazole, prednisone, and bactrim failed to improve symptoms.Further exploration of the patient\u2019s history revealed that 5 years earlier, he had traveled to Guyana in South America.", "After that trip, he sought medical care for multiple neck subcutaneous nodules as well as for a 4-cm focus of neck cellulitis."], "Patient Symptoms": ["B, Physical examination showed recurrent skin lesions at incision site and in the surrounding skin.Empirical treatment with augmentin and nystatin oral suspension for possible bacterial or fungal pharyngitis was unsuccessful, with symptoms worsening during the subsequent 2 weeks."], "Examination and Results": ["A physical examination, including flexible laryngoscopy, revealed cobbling, adherent, thick yellow mucus and ulceration of the uvula (Figure 1A).A, Nasopharyngoscopic imaging revealed infected nasal surface of uvula.", "Results of laboratory testing for group A Streptococcus, COVID-19, and mononucleosis were negative.", "A tissue biopsy was performed, and results of pathology revealed epithelial hyperplasia with suppurative granulomatous inflammation without evidence of dysplasia or malignancy.", "There was no evidence of fungal or acid-fast organisms.", "Tissue culture revealed only normal respiratory flora.", "Findings of pathologic testing revealed dense granulomatous inflammation."], "Treatment": ["B, Physical examination showed recurrent skin lesions at incision site and in the surrounding skin.Empirical treatment with augmentin and nystatin oral suspension for possible bacterial or fungal pharyngitis was unsuccessful, with symptoms worsening during the subsequent 2 weeks.", "Additional treatment with fluconazole, augmentin, doxycycline, omeprazole, prednisone, and bactrim failed to improve symptoms.Further exploration of the patient\u2019s history revealed that 5 years earlier, he had traveled to Guyana in South America."], "Others": ["After failed treatment with empirical antibiotics, the largest lesion was excised.", "However, results of stains for bacteria, fungus, and acid-fast bacillus were negative (Figure 1B)."]}
{"Patient Symptoms": ["Review of systems was notable for fatigue."], "Examination and Results": ["Examination of the mouth revealed multiple coalescing painless nonpruritic black macules and patches on the tongue, roof of the mouth, and buccal mucosa.", "Examination of the skin was notable for erythematous and hyperpigmented patches covering 90% of the body surface area, consistent with her known mycosis fungoides.", "Other notable findings on examination were 1- to 2-cm lymphadenopathy in the bilateral inguinal folds and axillae."], "Treatment": ["The patient had previously received 5 cycles of romidepsin with progression of disease, followed by 4 doses of pegylated liposomal doxorubicin hydrochloride, which was followed by partial response.Black macules and patches on the tongue, roof of the mouth, and buccal mucosa."]}
{"Patient Personal Background": ["He had immigrated from Nigeria 10 years prior, had not returned since, and was working as a traveling nurse."], "Patient Symptoms": ["Ophthalmology was consulted to evaluate for a conjunctival foreign body of the left eye.", "At the time of the examination, his symptoms had resolved; however, he had a photograph from a cellular phone taken during the episode (Figure 1).", "He reported a similar sensation of movement in his left eye that occurred for 1 night about 5 years ago for which he visited an urgent care center where he was diagnosed with allergic conjunctivitis.", "He also reported recent swelling of the left side of his face with associated numbness and occasional swelling of his left hand, all of which resolved after a few days."], "Examination and Results": ["The photograph shows an irregular, serpiginous extension from beneath the plica semilunaris toward the corneal limbus with localized conjunctival hyperemia.", "A slitlamp examination did not reveal any conjunctival hyperemia, foreign bodies, or other abnormalities like those shown in the photograph.", "His uncorrected visual acuity was 20/20, extraocular movements were full and without pain or abnormal sensation, and intraocular pressure was normal.", "His dilated fundus examination was unremarkable."]}
{"Examination and Results": ["On examination, his best-corrected visual acuity was 20/20 OU, and intraocular pressures were normal in both eyes.", "Results of slitlamp examination of the right eye were unremarkable.", "Slitlamp examination of the left eye revealed a round, pigmented lesion measuring 3\u2009\u00d7\u20093 mm in basal dimension and with gravitational shifting within the anterior chamber fluid with patient head tilt (Video).", "There was no corneal guttatae or edema.", "Anterior segment optical coherence tomography depicted the lesion in the anterior chamber angle abutting the corneal endothelium and resting on the iris stroma with no internal fluid level and no solid component.", "Ultrasound biomicroscopy confirmed the lesion to be cystic with a thickness of 1.6 mm.", "Dilated fundus examination revealed normal findings in both eyes."]}
{"Patient Personal Background": ["Her medical history was notable for morbid obesity, hypertension, diabetes, and stroke."], "Patient Symptoms": ["She reported no fever, fatigue, weight changes, gastrointestinal symptoms, difficulty concentrating, anxiety, or hyperhidrosis."], "Examination and Results": ["Physical examination results revealed multiple firm skin-colored papules and nodules coalescing to form a large plaque on the anterior aspect of the left lower leg, whereas the right lower leg had diffuse induration and hyperpigmentation (Figure 1).", "There was no palpable lymphadenopathy.", "Laboratory analysis revealed normal complete blood cell count, thyroid function, serum protein electrophoresis, and serum immunofixation.", "A biopsy of a left leg nodule was performed.Multiple firm skin-colored papules and nodules coalesce to form a large plaque on the anterior aspect of the left lower leg."], "Treatment": ["The patient had previously been diagnosed with elephantiasis nostras verrucosa, and she was advised to elevate and compress the leg but was unavailable for follow-up."], "Diagnosis": ["The patient had previously been diagnosed with elephantiasis nostras verrucosa, and she was advised to elevate and compress the leg but was unavailable for follow-up."]}
{"Patient Personal Background": ["The patient used a wheelchair due to a right-sided hemiparesis and hemianopsia caused by an intracranial hemorrhage.", "Clinical examination also demonstrated a lipolymphedema of the lower legs that had been attributed to a functional venous insufficiency with insufficient venous pump activity.", "The patient had been wearing compression stockings for years.", "The family history was positive for cerebral venous malformations involving the patient\u2019s father and aunt, the father having died of an intracranial hemorrhage in his early 70s.A, Clinical picture."], "Patient Symptoms": ["Since the age of 24 years, the lesions had been growing very slowly in number and size and had been bleeding occasionally after a trauma."], "Examination and Results": ["B and C, Hematoxylin-eosin stain.Sonography of the skin lesions demonstrated intradermal slow-flow vascular malformations with a maximum diameter of 1.2 cm.", "A biopsy of a lower-extremity papule was performed (Figure, B and C)."], "Diagnosis": ["At the age of 4 years, recurrent seizures had led to the diagnosis of cerebral venous malformations.", "Mutational analysis resulted in the detection of a heterozygous pathogenic KRIT1 variant."]}
{"Patient Personal Background": ["She disclosed a history of macular degeneration in both eyes and retinal detachment in the left eye that was treated 35 years previously.", "Medical history revealed cutaneous basal cell carcinoma and squamous cell carcinoma, both treated surgically.On examination, visual acuity was 20/50 OD and 20/400 OS."], "Examination and Results": ["External examination showed posterior-chamber intraocular lenses in both eyes and conjunctival scarring in the left eye from circumferential scleral buckle surgery with no visible extraocular tumor.", "Fundus evaluation showed macular drusen in the right eye and a pale optic disc with geographic macular atrophy in the left eye, explaining her visual acuity of 20/400 OS.", "In addition, a shallow circumferential buckle effect and an inferotemporal mass measuring 15.0\u2009\u00d7\u200910.0 mm in basal dimension and 9.1 mm in thickness (Figure, A) were seen in the left eye.", "The mass appeared elevated, amelanotic with overlying retinal vasculature, and with chorioretinal atrophy.", "No retinal detachment or breaks were seen.", "By ultrasonography the mass was echolucent (Figure, A inset).", "Magnetic resonance imaging (MRI) revealed a T1, T2-hypointense shallow circumferential band in the left eye.", "In addition, there was an inferotemporal nodular mass in the left eye showing T1 (gadolinium) hypointense, T2-hyperintense features, underlying the encircling buckle, and with adjacent subtle delineation.", "There was no enhancement with gadolinium (Figure, B).Fundus photograph and magnetic resonance imaging of the left eye.", "A, Fundus photograph of left eye showed a pale optic disc, geographic macular atrophy, and an inferotemporal amelanotic mass (white arrowhead); inset shows ultrasonography revealing an echolucent mass (white arrowhead).", "B, Magnetic resonance imaging (MRI) (T2-weighted axial orientation) revealed a shallow hypointense circumferential band in the left eye (pink arrowheads), inferotemporal hyperintense nodular mass (asterisk), and inward compressed sclera (white arrowhead); inset (T1-weighted coronal orientation with gadolinium) shows hypointense encircling band (pink arrowhead), subtle scleral indentation (white arrowhead), and no gadolinium enhancement of mass (asterisk)."], "Diagnosis": ["She was referred to the Ocular Oncology Service, Wills Eye Hospital, Philadelphia, Pennsylvania, for suspected choroidal melanoma."]}
{"Patient Symptoms": ["On close inspection, milia and a few erosions with partially detached epidermis were identified.", "No extracutaneous involvement was observed.A, Multiple pruritic erythematous to violaceous lichenified papules and plaques on the left shin."], "Examination and Results": ["There were no abnormalities of the mucous membranes, nails, hair, or teeth.", "B, Close-up of the skin lesions showing an erosion with partially detached epidermis and multiple milia.", "C, Histopathologic examination revealed dermoepidermal separation (hematoxylin-eosin stain).", "D, Histopathologic examination revealed several milia (hematoxylin-eosin stain)."]}
{"Patient Personal Background": ["Her medical history was positive for relapsing urinary tract infections since early infancy without adequate follow-up."], "Patient Symptoms": ["Three weeks prior, she had presented with mild fever and flulike symptoms, associated with a severe frontal headache that was mildly relieved by analgesics."], "Examination and Results": ["Findings of an ophthalmological examination 1 year prior were reported as normal.At initial examination, she was conscious but somewhat lethargic.", "Her best-corrected visual acuity was 20/20 OD and 20/80 OS.", "Pupillary light responses, extrinsic ocular motility, anterior segment biomicroscopy, and intraocular pressure were normal in both eyes.", "Dilated fundus examination revealed a bilateral sectorial macular star that was more extended in the left eye, with retinal veins slightly dilated and tortuous, attenuated arterioles, some juxta and peripapillary nerve fiber layer infarcts, and optic disc edema with marked papillary telangiectasia; in addition, some faint, small, tan-yellow dots were observed at the level of the retinal pigment epithelium in the posterior pole, some of them already grayish and with a hypopigmented halo (Figure 1).", "Optical coherence tomography displayed elevated optic discs and hyperreflective material in the outer plexiform layer temporal to the optic disc in both eyes and a macular neurosensory detachment in the left eye.", "Results of visual field testing were normal in the right eye and showed a central scotoma in the left eye.Fundus image of the right eye (A) and left eye (B) showing slight dilation of retinal veins (magenta arrowheads), intraretinal lipid deposits in the papillomacular bundle and the inferonasal macular quadrant forming an incomplete macular star (yellow arrowheads), optic disc edema and epipapillary telangiectasia (blue arrowheads), nerve fiber layer infarcts or cotton-wool nodules (green arrowheads) over the inferior margin of the optic disc in the right eye and juxta and parapapillary in the left eye, and paramacular temporal light-pigmented subretinal dots at the level of the retinal pigment epithelium (white arrowheads) in both eyes, with some already scarred (pigmented dot surrounded by a pale halo; gold arrowhead)."]}
{"Patient Symptoms": ["This firm-to-palpation mass was noted at birth and remained proportional in size with the child\u2019s somatic growth, measuring approximately 1 cm in diameter on presentation."], "Examination and Results": ["Preoperative magnetic resonance imaging (MRI) documented the mass to be uniformly solid and well circumscribed without cystic components or flow voids, hypointense on T2, and hyperintense with homogeneous contrast enhancement on T1.", "His head, neck, and general examination findings were otherwise normal with no cervical lymphadenopathy or additional masses."]}
{"Patient Symptoms": ["Five days after surgery, the patient noted erythema, edema, pain, pruritus, and serous fluid drainage at the mastectomy incision sites (Figure 1).", "Two days later, she developed an erythematous papulovesicular rash on her trunk and upper and lower extremities."], "Examination and Results": ["The skin swab bacterial culture result was negative, and her skin findings did not improve with antibiotics."], "Treatment": ["A skin swab was sent for bacterial culture, and she was prescribed cefadroxil (500 mg twice daily for 1 week)."]}
{"Patient Symptoms": ["Her course was complicated by severe mucositis, acute kidney injury, and neutropenic fever.", "During her admission, the patient also developed painful necrotic skin lesions, a nonproductive cough, and altered mental status.Physical examination findings demonstrated dusky, purpuric, and pink papulonodules, some with overlying eschar, scattered on the scalp, neck, trunk, and extremities (Figure, A)."], "Examination and Results": ["Laboratory study results revealed a white blood cell count of 150/\u03bcL (reference range, 3500/\u03bcL to 10\u202f500/\u03bcL), an absolute neutrophil count of 130/\u03bcL (reference range, 1500/\u03bcL to 7400/\u03bcL), and a platelet count of 19\u2009\u00d7103/\u03bcL (reference range, 150\u2009\u00d7103/\u03bcL to 400\u2009\u00d7103/\u03bcL).", "Blood culture results were negative.", "The results of a computed tomography (CT) scan of the brain showed no acute intracranial hemorrhage, territorial infarction, or mass effect.", "The results of a CT scan of the chest demonstrated multifocal bilateral ground-glass patchy opacities, scattered solid bilateral pulmonary nodules, and a moderately sized pericardial effusion.", "A biopsy specimen from a skin nodule on the left lateral thigh was obtained for histopathologic examination and tissue culture, and wet mount preparation of a tissue culture colony was performed (Figure, B).A, Physical examination findings demonstrate dusky and pink papulonodules, some with overlying eschar, scattered on the scalp, neck, and extremities.", "B, Lactophenol cotton blue staining of a tissue culture colony reveals septated hyphae and oval microconidia."], "Others": ["(To convert the white blood cell and neutrophil counts to cells \u00d7109/L, multiply by 0.001; conversion of the platelet count to cells \u00d7109/L is 1:1.)"]}
{"Patient Personal Background": ["He received a diagnosis of primary salivary duct carcinoma of the hard palate 1 year prior and had been receiving treatment with oral bicalutamide and radiotherapy."], "Patient Symptoms": ["He reported that the lesion had been asymptomatic but was increasing in size, with progression from his face to anterior chest."], "Examination and Results": ["On clinical examination, a hemorrhagic and erythematous plaque with multiple purpuric-to-blackish infiltrative papules and nodules extending from cheek, lateral neck, to the interclavicular area was found (Figure 1).", "An incisional biopsy from the infiltrative nodule on cheek was performed and submitted for histopathologic analysis.Hemorrhagic and erythematous plaque with multiple infiltrative purpuric-to-blackish papules and nodules with varying sizes extending from left cheek, neck, to chest."], "Others": ["A partially regressive change of the palatal tumor was noted radiographically during regular follow-up 3 months previously."]}
{"Patient Personal Background": ["Her personal, past, and family histories were unremarkable.On physical examination, there was a 6\u2009\u00d7\u20096-cm protuberant, thick-walled, and well-defined red bullalike tumor on the right upper arm, which extended 1 to 3 cm from the epidermal surface (Figure, A)."], "Patient Symptoms": ["The lesion initially started as a small cutaneous nodule without obvious triggers that gradually developed and enlarged to form a red-colored tumor with a hard nodule inside."], "Examination and Results": ["Inside the tumor, a nontender, firm-to-hard nodule was palpated.", "There was no regional lymphadenopathy, and results of the rest of the physical and systemic examinations were normal.", "Laboratory examinations of hematologic, biochemical, and urinalysis tests were normal."], "Treatment": ["The tumor was excised completely under local anesthesia, and part of the tissue was sent for pathological examination.A, A tumor on the patient\u2019s right shoulder."], "Others": ["There was no history of local trauma or insect bite.", "B, The excisional tumor showed multilocular spaces below the epidermis and a solid tumor present in the deep dermis with a chalky-white cut surface and lobulated appearance.", "C and D, Histological examination revealed basophilic cells and shadow cells as well as dilated lymphatic vessels (hematoxylin-eosin; original magnification \u00d7100)."]}
{"Patient Personal Background": ["She had a history of optometric examinations with no known ocular disease.", "On review of systems, the patient noted a long-standing growth on her cheek, which on examination was a 4\u2009\u00d7\u20093-mm exophytic, brownish-red vascular papule (Figure, B), as well as a history of lightly pigmented patches of skin and multiple subungual fibromas on her toes."], "Examination and Results": ["Visual acuity with correction was 20/40 in the right eye and 20/20 in the left eye.", "Anterior segment examination of both eyes was unremarkable, and the retina in the left eye appeared normal.", "In the right eye, there was an area of superior macular whitening with associated intraretinal hemorrhages and exudates.", "Fluorescein angiography showed abnormally dilated and tortuous retinal vessels, irregular capillary branching patterns, and bulblike telangiectasis with late leakage in the superior macula.", "Optical coherence tomography showed disorganized and hyperreflective inner retinal thickening (Figure, A) and intraretinal and subretinal fluid in the central macula.", "Systemic blood pressure was normal.Features of tuberous sclerosis complex.", "Two optical coherence tomography line scans inset through the main lesion (orange) and through the fovea (blue) with relative location marked with dotted lines, demonstrating disorganized and hyperreflective inner retinal thickening consistent with type 1 astrocytic hamartoma of the retina and associated macular edema.", "Arrowhead indicates bulblike telangiectasis on fluorescein angiography and blocking from intraretinal hemorrhage."], "Diagnosis": ["A, An area of superior macular whitening following the superior arterial arcade with associated intraretinal hemorrhages and exudate."], "Others": ["B, Elevated papule."]}
{"Patient Personal Background": ["He reported no known ill contacts or recent travel outside the US."], "Patient Symptoms": ["He had no nausea, vomiting, abdominal pain, melena, or hematochezia but reported a cough productive of yellow sputum, dyspnea on exertion, and fatigue."], "Examination and Results": ["At presentation, his heart rate and blood pressure were normal, and oxygen saturation was 95% on room air.", "Physical examination revealed a maculopapular rash over his neck and chest (Figure, left panel) and bibasilar crackles on lung auscultation.", "Laboratory testing showed a white blood cell count of 14.3\u2009\u00d7\u2009103/\u03bcL (reference, 4.2-9.1\u2009\u00d7\u2009103/\u03bcL); creatine kinase level, 2060 U/L (34.40 \u03bckat/L) (reference, 44-196 U/L [0.73-3.27 \u03bckat/L]), aldolase level, 18 U/L (0.30 \u03bckat/L) (reference, <8 U/L [<0.13 \u03bckat/L]), C-reactive protein level, 30 mg/L (reference, <8 mg/L), and erythrocyte sedimentation rate, 35 mm/h (reference, <20 mm/h).", "Antinuclear antibody immunofluorescent assay findings were positive.", "Results from testing for HIV, hepatitis B, and hepatitis C were negative.", "A barium swallow study showed no visualized aspiration.", "Endoscopy revealed clean-based esophageal and duodenal ulcers and nonspecific gastritis.", "Chest computed tomography (CT) showed bibasilar pulmonary consolidations and ground glass opacities (Figure, right panel).Left, Shawl-like rash on patient\u2019s chest."], "Treatment": ["The patient had been treated for presumed pneumonia with 3 courses of azithromycin over the prior 3 months due to infiltrates on a chest radiograph."]}
{"Patient Symptoms": ["He denied pain, aspiration, noisy breathing, obstructive episodes, dysphonia, and weight loss.A physical examination revealed fullness in the left oropharynx and left level 3 of the neck."], "Examination and Results": ["Findings of flexible laryngoscopy showed a submucosal mass in the left oropharynx extending inferiorly into the hypopharynx, obliterating the left pyriform sinus, abutting the base of tongue with hooding over the epiglottis.", "The supraglottis and glottis were unremarkable.", "Computed tomography imaging with contrast of the neck revealed a 4.6\u2009\u00d7\u20094.0\u2009\u00d7\u20098.0-cm heterogeneously enhancing mass in the left oropharynx and hypopharynx with cystic components and clear planes separating the mass from the spinal musculature and carotid sheath (Figure 1).Computed tomography imaging with contrast of the neck with the coronal cut demonstrating the well-circumscribed heterogeneous mass involving the retropharyngeal space, abutting the great vessels, and extending from superiorly in the oropharynx to inferiorly in the hypopharynx."]}
{"Patient Symptoms": ["She had brisk reflexes, poor coordination, and a wide-based unsteady gait.", "She demonstrated sluggish but reactive pupils and new-onset ophthalmoplegia.", "She was readmitted to the hospital and demonstrated diminished reflexes bilaterally and unsteady gait."], "Examination and Results": ["On examination, pupils were fixed and dilated to 8 mm, extraocular movements were intact, and fundus examination was normal.", "Bloodwork revealed leukocytosis and an elevated erythrocyte sedimentation rate; cultures remained without growth.", "Lumbar puncture with cerebrospinal fluid studies, computed tomography scan, and magnetic resonance imaging of brain and orbits were normal.", "The patient was discharged 3 days later following improvement in lethargy and gait with a diagnosis of acute cerebellar ataxia.When she presented to ophthalmology for 1-week follow-up, her visual acuity was central, steady, and maintained in both eyes.", "She was unable to move either eye in any direction, including with doll\u2019s head maneuver."], "Treatment": ["Two weeks prior, she had upper respiratory symptoms and bacterial conjunctivitis treated with topical ofloxacin."], "Diagnosis": ["The patient was discharged 3 days later following improvement in lethargy and gait with a diagnosis of acute cerebellar ataxia.When she presented to ophthalmology for 1-week follow-up, her visual acuity was central, steady, and maintained in both eyes."]}
{"Patient Personal Background": ["The patient was a construction worker and used tobacco daily."], "Patient Symptoms": ["He reported limited shoulder movements and denied other symptoms."], "Examination and Results": ["It began with a quarter-size maculopapular lesion and continued to progress during the next 3 years.", "On physical examination, there was a 24\u2009\u00d7\u200915-cm fungating, necrotic, and ulcerated left shoulder mass (Figure 1A).", "A punch biopsy showed sheets of highly pleomorphic atypical spindle and epithelial cells within the superficial and deep dermis, extending into the subcutaneous tissue, and with 18 mitoses/mm2.", "Immunohistochemistry demonstrated SOX10-positive and pankeratin-negative tumor cells.", "A whole-body positron emission tomographic and computed tomographic scan revealed an intensely hypermetabolic left shoulder mass and multiple hypermetabolic enlarged left axillary lymph nodes, with no distant metastases (Figure 1B).", "Brain magnetic resonance imaging was negative for intracranial metastasis.A, Left shoulder giant fungating mass in a 46-year-old man."], "Others": ["There was no medical or surgical history, and he had a negative personal or familial oncologic history.", "B, Positron emission tomographic and computed tomographic (PET-CT) scan shows the hypermetabolic left shoulder mass and no distant metastases."]}
{"Patient Personal Background": ["The referring retina specialist noted vitritis and vasculitis intraoperatively, but the result of vitreous biopsy cytology was negative for malignant cells.At presentation to our institution, the patient was taking oral prednisone, 40 mg/d."], "Patient Symptoms": ["The patient noted blurry vision started around the time of cabozantinib therapy initiation."], "Examination and Results": ["His visual acuity was 20/500 OD and hand motions OS, with an intraocular pressure of 18 mm Hg in both eyes.", "Right eye slitlamp examination results showed pigmented cells in the anterior chamber and lens capsule; the left eye showed prolapsed pigmented vitreous at the pupillary margin.", "Right eye fundus examination results revealed sheets of pigmented cell and vascular sheathing with optic nerve pallor.", "The left eye had a poor view, with 90% gas fill.", "Fluorescein angiography illustrated disc and vessel leakage (predominantly arteriole), capillary dropout, and peripheral nonperfusion in the right eye (Figure 1A) with no view in the left eye.", "Optical coherence tomography revealed debris at the vitreoretinal interface (Figure 1B).Fluorescein angiography and optical coherence tomography on presentation demonstrate retinal vasculitis and vitritis (right eye results shown).", "A, Fluorescein angiography shows dense vitritis, predominantly arteriole leakage (arrowheads), and nonperfusion."], "Treatment": ["Cabozantinib therapy was discontinued for surgery and resumed 3 days later."]}
{"Patient Personal Background": ["Ten years prior to presentation, he underwent surgical decompression for syringomyelia.", "A magnetic resonance imaging (MRI) scan of his cervical and thoracic spine performed 2 years prior to presentation revealed a recurrent syrinx extending from C1 to T11, which was not resected because it did not cause symptoms at that time."], "Patient Symptoms": ["On physical examination, he had mild tenderness to palpation and reduced range of motion of the left shoulder with abduction and flexion limited to 120\u00b0 (normal range of motion, 180\u00b0).", "The left scapular muscles were atrophic, and pain and temperature sensation were reduced in his proximal left arm, and dorsal aspect of his left shoulder."], "Examination and Results": ["His complete blood cell count, serum glucose levels, C-reactive protein levels, and erythrocyte sedimentation rate were normal.", "Results of tests for rheumatoid factor and antinuclear antibody were negative.", "Left shoulder radiograph showed complete absence of the left humeral head and a well-demarcated smooth osseous margin of the proximal humerus with associated soft tissue swelling and periarticular calcification (Figure 1).", "A chest radiograph taken 2 years prior revealed a normal left shoulder joint.", "The patient was hospitalized for further evaluation and treatment.Anteroposterior radiograph of the patient\u2019s left shoulder demonstrating complete destruction of the proximal humeral head."]}
{"Patient Personal Background": ["Before presentation, the patient reported good health with satisfactory employment-mandated routine physical examinations.", "She denied a history of smoking, alcohol, or illicit drug use.", "She was not taking hormonal birth control or hormone therapy.", "Laboratory values demonstrated a normal complete blood cell count and metabolic panel."], "Patient Symptoms": ["She was noted to have tachycardia (110 beats/min) and hypoxemia (90% receiving room air) with a blood pressure of 106/81 mm Hg.", "She denied any clear physical or emotional triggers preceding presentation."], "Examination and Results": ["Cardiac, respiratory, and pulse examination results were unremarkable.", "Chest radiograph results were unremarkable.", "A computed tomographic chest scan excluded pulmonary embolism but suggested pulmonary and interstitial edema.", "Results of an electrocardiogram revealed sinus tachycardia with premature ventricular contractions, subcentimeter ST-segment elevation in leads I and aVL and 1-mm ST-segment depression in leads II, III, aVF, and V5 through V6.", "Initial high-sensitivity troponin was 110\u202f000 ng/mL (to convert to micrograms per liter, multiply by 1).", "Results of cardiac point-of-care ultrasonography demonstrated a severely reduced left ventricular ejection fraction of 40%, with hypokinesis of the anterolateral and posterior walls.", "Emergent cardiac catheterization revealed spontaneous coronary artery dissection (SCAD) of the left main coronary artery (Figure 1 and Video).Angiographic image of left main spontaneous coronary artery dissection (A) and intravascular ultrasonography image of left main spontaneous coronary artery dissection (B)."], "Diagnosis": []}
{"Patient Personal Background": ["Medical history included hypertension, for which he took losartan, and seasonal allergies, for which he used fexofenadine and fluticasone."], "Patient Symptoms": ["Review of symptoms was negative for fatigue, weight loss, cough, shortness of breath, joint pain, ocular symptoms, mucosal ulcerations, history of blood clots, photosensitivity, pleurisy, urine changes, and diarrhea."], "Examination and Results": ["Laboratory evaluation revealed mild neutropenia and lymphopenia with normal hemoglobin and platelet counts.", "Antinuclear antibody screening results were negative.", "The results of a comprehensive metabolic panel, C3, C4, serum protein electrophoresis, serum free light chains, methylmalonic acid, homocysteine, ferritin, copper, zinc, haptoglobin, HIV, hepatitis B and C serologic tests, and rapid plasma reagin were negative.", "Lactate dehydrogenase was mildly elevated.", "Erythrocyte sedimentation rate was elevated at 41 mm/h.", "Routine cancer screening was up to date."], "Treatment": ["Treatments included hydroxychloroquine, 400 mg/d, for 4 years; mycophenolate mofetil, 1000 mg/d, for 6 months; and oral prednisone tapers, starting at 40 mg/d.", "Of these, only prednisone appeared to elicit a response.", "Therapeutic trials of dapsone and dapsone in combination with colchicine were not effective."], "Diagnosis": ["The result of a skin biopsy performed 4 years prior was interpreted as subacute cutaneous lupus erythematosus (SCLE)."]}
{"Patient Personal Background": ["However, her younger sister had developed the same skin symptoms."], "Patient Symptoms": ["In early childhood, she had developed asymptomatic yellowish coalesced papules confined to flexural areas.", "Subsequently, severe skin sagging occurred on her abdomen with loss of elasticity, then spread extensively with developmental growth."], "Examination and Results": ["The results of a physical examination showed thick and leathery skinfolds on the neck, axillae, inguinal regions, abdomen, and limbs (Figure, A), with yellowish papules scattered on the dorsal neck.", "Coagulation-related tests indicated a low clotting activity of factor X (52.2%; reference range, 77%-131%) and a prolonged prothrombin time (12.8 seconds; reference range, 10.4-12.6 seconds).", "The results of other laboratory investigations were unremarkable.", "Echocardiographic and fundoscopic examination results were normal.", "A skin biopsy specimen was obtained from her neck for histopathologic examination (Figure, B).A, Clinical image of the neck, axillae, and abdomen.", "B, Skin biopsy specimen taken from the neck shows excessive calcification of elastic fiber fragments scattered in the reticular dermis (von Kossa)."], "Others": ["The patient had no extracutaneous involvement and was born to healthy nonconsanguineous parents.", "Severe skin laxity with deep cutaneous folds on the cervical, axillary, and abdominal regions."]}
{"Patient Personal Background": ["He lived in rural China and had close contact with dogs, cattle, and sheep."], "Patient Symptoms": ["Lung auscultation revealed absent breath sounds on the right hemithorax."], "Examination and Results": ["His blood pressure was 93/60 mm Hg; heart rate, 100/min; respiratory rate, 26/min; and oxygen saturation, 94% on room air.", "His abdomen was soft and nontender, without hepatosplenomegaly.", "His white blood cell count was 8000/\u03bcL, with 25.8% eosinophils (reference range, 0%-9%).", "C-reactive protein level and results from tuberculin skin test, interferon-\u03b3 release assay, nucleic acid amplification testing for tuberculosis, acid-fast bacilli smear microscopy, and HIV antibody testing were normal.", "A thoracoabdominal computed tomography (CT) scan showed a ruptured 10\u2009\u00d7\u20099\u2009\u00d7\u20095\u2013cm right upper lobe pulmonary cyst compressing the right main bronchus and 3 liver cysts (Figure 1).Left, Chest computed tomography (CT) scan (transverse view) showing a giant cystic mass in the right upper lobe of the lung with rupture and compression of the right main bronchus.", "Right, Abdominal CT scan (coronal view) showing 3 round water-density cysts in the right anterior lobe, right posterior lobe, and left lateral lobe of the liver."]}
{"Patient Personal Background": ["The patient did not take any prescription medications or herbal supplements and had immigrated to the US from Samoa 4 years prior."], "Patient Symptoms": ["He reported numbness and paresthesia in the areas of affected skin and an inability to fully extend his fingers."], "Examination and Results": ["Physical examination revealed multiple tattoos and annular erythematous plaques on his face, chest (Figure, left panel), back, arms, and legs.", "The patient had bilateral palpable thickened auricular and ulnar nerves, claw-hand deformity (Figure, right panel), foot drop bilaterally, and decreased sensation to temperature over the areas of skin plaque.", "Results of testing for rapid plasma reagin, antinuclear antibodies, and rheumatoid factor were negative.", "Examination of punch biopsy samples from 2 plaques on his back revealed granulomatous periadnexal and perivascular dermatitis with diffuse granulomatous infiltrate and foamy histiocytes.", "Findings on acid-fast bacilli stains and mycobacterial polymerase chain reaction (PCR) testing were negative."]}
{"Patient Personal Background": ["The patient also had a history of lumbar spinal stenosis."], "Examination and Results": ["On presentation, blood pressure was 104/73 mm Hg; heart rate, 91/min; respiratory rate, 16/min; and oxygen saturation, 96% on room air.", "Physical examination revealed edema to the mid-calf bilaterally, hypoesthesia below the knees, and ankle plantar flexion strength of 3 of 5 based on the Medical Research Council Scale for muscle strength.", "Laboratory testing revealed a high-sensitivity troponin level of 52 ng/L (reference, <34 ng/L); brain-type natriuretic peptide, 112 pmol/L (reference, <30 pmol/L); aspartate aminotransferase, 51 U/L (0.85 \u03bckat/L) (reference, 0-35 U/L [0-0.58 \u03bckat/L]); and alanine aminotransferase, 76 U/L (1.27 \u03bckat/L) (reference, 0-45 U/L [0-0.75 \u03bckat/L]).", "A chest radiograph showed cardiomegaly without pulmonary vascular redistribution or pulmonary edema.An electrocardiogram revealed normal sinus rhythm, left anterior fascicular block, and down-sloping anterolateral ST segments.", "The patient was admitted to the hospital, where electromyography results included reduced amplitude of peroneal nerve action potentials, consistent with axonal sensorimotor polyneuropathy of the bilateral lower extremities.", "Coronary angiography showed no coronary atherosclerosis, and cardiac magnetic resonance imaging demonstrated asymmetric left ventricular hypertrophy.", "Results of serum protein electrophoresis (SPEP) and serum free light chain testing were normal.", "A bone scintigraphy scan using technetium Tc 99m\u2013labeled hydroxymethylene diphosphonate demonstrated increased cardiac uptake (Figure).Anterior (left) and posterior (right) bone scintigraphy scan of the patient."]}
{"Patient Personal Background": ["There was no history of trauma."], "Examination and Results": ["Her medical history was unremarkable.On examination, her best-corrected visual acuity measured 20/60 OD and  20/25 OS.", "The anterior segment showed dilated corkscrew conjunctival vessels (Figure 1), a shallow anterior chamber in the right eye, and nuclear cataract in both eyes.", "Pupillary reaction and color vision were normal in both eyes.", "Intraocular pressure was 16 mm Hg by Goldman applanation tonometry in both eyes.", "Gonioscopy revealed an occludable angle in the right eye without evidence of blood in the Schlemm canal.", "Both eyes\u2019 extraocular movements were full and free in all directions of gaze."]}
{"Patient Symptoms": ["A few days before surgery, she noticed a sudden decrease in her left visual acuity measured at 20/80."], "Examination and Results": ["Her eye specialist then observed a reverse pupillary block in her left eye and referred the patient to our department.", "Slitlamp examination showed a unilateral deepening of the anterior chamber associated with signs of anterior uveitis (ie, keratic precipitates and severe aqueous flare, 3+) and posterior synechiae between the iris and the lens.", "In addition, fundus examination revealed an inferior retinal detachment without any associated visible tear.", "Intraocular pressure was 15 mm Hg in the right eye and 9 mm Hg in the left eye.", "Anterior segment optical coherence tomography images and fundus photographs of both eyes are shown in Figure 1.While anterior segment optical coherence tomography (AS-OCT) and fundus imaging were unremarkable for the right eye, the left anterior chamber was substantially deepened with a backbowing of the iris and an apposition to the lens, leading to a disappearance of the posterior chamber on AS-OCT scan.", "An inferior retinal detachment without any associated visible tear was present in the left eye (white arrowheads)."], "Others": ["At presentation, no other remarkable medical history was recorded and no precipitating factors identified."]}
{"Patient Personal Background": ["He received nivolumab (anti\u2013programmed cell death 1 checkpoint inhibitor) 9 months prior, obinutuzumab (B-cell lymphoma 2 inhibitor) 3 months later, and 5-mg oral prednisone daily."], "Patient Symptoms": ["On presentation, nivolumab and obinutuzumab treatment was complete.His visual acuity was 20/125 OD and 20/50 OS.", "At this time, the active anterior and vitreous cells had resolved.However, 2 weeks later, visual acuity decreased to count fingers in his right eye and hand motions in the left eye."], "Examination and Results": ["Ophthalmoscopy revealed bilateral panuveitis with diffuse pigmentary abnormalities.", "Fluorescein angiography showed diffuse retinal pigment epithelium loss and late staining of the retinal lesions.", "The anterior and vitreous chambers had grade +0.5 pigmented cells.", "The ophthalmoscopic examination showed a leopard-spot pattern (Figure 1), and optical coherence tomography showed substantial retinal pigment epithelium and outer retinal layer loss.", "Repeat testing for Treponema pallidum, Lyme disease, and HIV was negative.", "Results of magnetic resonance imaging of the brain and orbit were negative for leukemic infiltration.A, Ultra-widefield fundus photograph of the right eye showing pigmentary abnormalities (arrowhead) within and peripheral to the macula."], "Treatment": ["He received 60 mg of oral prednisone daily for 2 weeks with a planned 10-week taper.", "However, prednisone was discontinued due to positive Lyme disease exposure 6 weeks later."], "Others": ["This finding was similar in both eyes.", "A red-free image is depicted in the bottom left corner of the panel.", "B, Ultra-widefield fundus autofluorescence image of the right eye showing hypoautofluorescent (pink arrowhead) and hyperautofluorescent patches (blue arrowhead) within and peripheral to the macula."]}
{"Patient Symptoms": ["The patient experienced left jaw tightness, aural fullness, and facial discomfort."], "Examination and Results": ["The MRI results demonstrated a well-circumscribed, ovoid mass in the left prestyloid PPS that measured 12\u2009\u00d7\u200915\u2009\u00d7\u200922 mm.", "The lesion was isointense on T1-weighted imaging, was hyperintense on T2-weighted imaging, and demonstrated heterogeneous enhancement following gadolinium administration (Figure 1).", "A computed tomography\u2013guided fine-needle aspiration was performed, which demonstrated blood, fibrin, and rare mesenchymal cells.", "Histopathologic evaluation demonstrated a well-circumscribed, 12-mm mass.Magnetic resonance imaging of the face.", "A, Coronal section from a T2-weighted image demonstrates a hyperintense mass in the left parapharyngeal space (PPS).", "B, Axial section from a postcontrast T1-weighted image shows a heterogeneously enhancing mass in the prestyloid PPS."], "Treatment": ["Given her ongoing symptoms, the patient requested surgical resection.", "The patient underwent transoral robotic surgery for resection of her PPS mass to achieve definitive diagnosis and treatment."]}
{"Patient Personal Background": ["She was receiving oral antidiabetic agents, and her blood glucose level was 110 mg/dL (to convert to millimoles per liter, multiply by 0.0555).", "There was no history of prior COVID-19 infection."], "Patient Symptoms": ["Physical examination findings were consistent with left lower-motor-neuron type of facial nerve palsy."], "Examination and Results": ["She was conscious and well oriented, with no other relevant clinical signs or focal neurological deficits.", "Magnetic resonance imaging (MRI) of the brain was requested, with clinical suspicion of metastasis in view of mildly elevated CA125 levels.The results of MRI of the brain did not reveal any neuroparenchymal or meningeal lesions.", "However, both maxillary sinuses showed mucosal thickening, which was intermediate to hypointense on T2-weighted imaging and hypointense on T1-weighted imaging with postcontrast enhancement.", "Computed tomography sections confirmed bony destruction with foci of remodeling involving the walls of the maxillary sinuses (Figure 1).A, Axial T2-weighted magnetic resonance imaging (MRI) shows T2 heterogeneous soft tissue in the maxillary sinus with perimaxillary inflammatory changes (yellow arrowhead).", "B, In this axial contrast-enhanced, T1-weighted (T1\u2009+\u2009C) image, linear enhancement corresponds to expected course of buccal branch of facial nerve (VII) (white arrow).", "The enhancement extends medially and involves the mandibular branch of the trigeminal nerve (V3).", "P indicates parotid gland, and the yellow dashed line outlines the edge of the parotid gland.", "B and C, The white arrow shows the intercommunication between the auriculotemporal branch of V3 and the intraparotid facial nerve (green marker).", "C, Additionally, involvement of enhanced thickening is seen up to the left foramen ovale, without involvement of the trigeminal ganglion.", "D, In oblique sagittal images, the thick enhancing branches of the facial nerves within the left parotid gland are seen (orange arrows).", "The enhancement of facial nerve extends up to the stylomastoid foramen (SMF) (blue arrow), and there is subtle enhancement along its mastoid segments (MSs).", "Iodinated contrast medium was used.Fat stranding and enhancing soft tissue was seen in the retroantral spaces bilaterally as well as the pterygopalatine fossae.", "Anteriorly, enhancing soft tissue was present in premaxillary space, from which contiguous linear enhancement was seen extending to left parotid gland\u2014along the expected course of buccal branch of left facial nerve.", "The entire extracranial left facial nerve proximal to this showed diffuse enhancement and thickening.", "Associated stylomastoid foramen widening was present with subtle enhancement along its mastoid and tympanic segments.", "These features were compatible with perineural extension of disease (Figure 1A and B).Additionally, there was involvement of the mandibular branch of the trigeminal nerve via intercommunication between the auriculotemporal branch of trigeminal nerve and the intraparotid facial nerve.", "Diffuse enhancement and thickening was seen up to the left foramen ovale, without involvement of the trigeminal ganglion (Figure 1C and D)."], "Diagnosis": ["She was diagnosed as having recurrent high-grade serous cystadenocarcinoma of the ovary and developed these symptoms after cycle 4 of chemotherapy."]}
{"Patient Personal Background": ["Overall, he was in good health with no underlying systemic diseases."], "Patient Symptoms": ["The intraoral examination revealed an erythematous denuded area of the midline posterior dorsal tongue, with a central nodular component (Figure 1A).", "The nodule was firm to palpation and nontender."], "Examination and Results": ["The patient was asymptomatic and unaware of the lesion prior to it being discovered by his dentist.", "Results of the most recent serologic analysis and urinalysis were also reportedly within normal limits.The extraoral examination was unremarkable, with no skin lesions, asymmetry, redness, swelling, or lymphadenopathy observed.", "The remaining oral soft tissue was unremarkable.", "Because a biopsy specimen was already obtained, blank slides were requested from the aforementioned institution, and staining was performed in house.A, Clinical examination revealed a pink nodule in the midline dorsal tongue with surrounding atrophic papillae.", "B, Hematoxylin-eosin stain of the biopsy specimen showed acellular, amorphous, and eosinophilic material arranged in lobules.Histologic evaluation revealed a piece of soft tissue with normal overlying epithelium.", "In the connective tissue, acellular, amorphous, and eosinophilic material arranged in lobules was noted (Figure 1B)."], "Others": ["He underwent incisional biopsy at another institution and presented for a second opinion on the diagnosis."]}
{"Patient Personal Background": ["He denied any history of trauma, falls, or occlusive headgear use.", "His medical history was significant for atrial fibrillation, receiving anticoagulation medication, and heart failure.On physical examination, numerous nontender violaceous plaques were seen on the forehead and scalp of the patient (Figure, A)."], "Examination and Results": ["On full skin examination, nonspecific skin-colored plaques were noted on the chest, and a 1.8\u2009\u00d7\u20092.5-cm erythematous plaque was noted on the left lower back.", "There was no appreciable lymphadenopathy or hepatosplenomegaly.", "Peripheral blood test results revealed a hemoglobin level of 9.1 g/dL, a platelet count of 68\u2009\u00d7\u2009103/\u03bcL, a white blood cell count of 2800/\u03bcL, and an absolute neutrophil count of 1.0/\u03bcL.", "Lactate dehydrogenase level was 202 U/L.", "A 4-mm punch biopsy was performed on the erythematous plaque on the left lower back (Figure, B and C).A, Violaceous plaques on the scalp.", "B, Punch biopsy showing a grenz zone and infiltrate extending into deeper dermis (hematoxylin-eosin).", "C, Punch biopsy showing cellular infiltrate of basophilic blastoid cells (hematoxylin-eosin).", "D, Punch biopsy showing cellular infiltrate with CD123 staining."], "Others": ["(To convert hemoglobin to g/L, multiply by 10.0; platelets to \u00d7109/L, by 1; white blood cell and neutrophil counts to \u00d7109/L, by 0.001; and lactate dehydrogenase to \u03bckat/L, by 0.0167.)"]}
{"Patient Personal Background": ["In the previous month, he had received the first cycle of a chemotherapeutic regimen of ixazomib, lenalidomide, and dexamethasone to treat a recurrence of IgG-\u03ba multiple myeloma with a 10-year history."], "Patient Symptoms": ["Physical examination showed annular erythematous plaques of up to 2 cm in diameter, with violaceous and crusted centers on the neck and trunk.", "On the right chest, an annular erythematous lesion with 2 zones of color\u2014a central area of purpura and an outer erythematous and edematous ring\u2014was present (Figure, A)."], "Examination and Results": ["Laboratory investigations found pancytopenia: a white blood cell count of 2.3\u2009\u00d7\u2009103/\u03bcL (reference range, 3.5-9.8\u2009\u00d7\u2009103/\u03bcL), hemoglobin levels of 12.1 g/dL (reference range, 13.5-17.6 g/dL), platelet count of 29\u2009\u00d7\u2009103/\u03bcL (reference range, 130-400\u2009\u00d7\u2009103\u03bcL), and elevated serum C-reactive protein levels of 3.31 mg/dL (reference range, <0.30 mg/dL).", "Blood culture results were negative."], "Others": ["Granulocyte colony-stimulating factor analogs had not been prescribed to the patient.", "Skin biopsy from a lesion on the left chest was performed for histopathological and immunohistochemical analyses (Figure, B-D).A, Clinical image of annular erythematous plaques on the chest.", "B, A histopathologic image revealing inflammatory infiltrate of predominantly mononuclear cells in the superficial and mid dermis (hematoxylin-eosin stain).", "C, The predominantly infiltrated cells showing large, elongated, vesicular nuclei, single inconspicuous nucleoli, and scant, slightly eosinophilic cytoplasm (hematoxylin-eosin stain).", "D, An immunohistochemical image showing myeloperoxidase-positive cells."]}
{"Patient Symptoms": ["He had new-onset daily occipital headache for 1 month of mild to moderate severity and pulsating character.", "Occasionally, the headache became severe accompanied by vomiting, photophobia, and phonophobia.", "The child had 4 to 5 episodes of generalized tonic-clonic seizures 1 day prior to admission.", "He remained unconscious for several hours and spontaneously regained consciousness over 24 hours.", "There was no history of fever, weight loss, limb weakness, vision impairment, or any strokelike illness."], "Examination and Results": ["His birth and developmental history were unremarkable.On examination, his pulse rate was 80 beats per minute (regular) with all peripheral pulses palpable without any radio-femoral delay.", "His blood pressure was 170/110 mm Hg with less than 10 mm Hg difference of systolic and diastolic blood pressure in other limbs.", "Abdominal examination revealed abdominal bruit.", "Fundus examination revealed papilledema with changes of hypertensive retinopathy.", "He was not oriented to place and time.", "The cranial nerves, motor, sensory, and autonomic system examination were unremarkable.", "There was no evidence of neurocutaneous markers.", "His cranial magnetic resonance imaging revealed bilateral white matter hyperintensity that was more marked in the bilateral parieto-occipital region.", "Ultrasound of the abdomen revealed a small right kidney and renal Doppler was suggestive of right renal-artery stenosis.", "His computed tomography angiography revealed short segment (3 cm) and short circumferential thickening of the descending aorta with right renal artery narrowing (Figure 1).", "His repeat cranial magnetic resonance imaging showed significant reduction in the white matter hyperintensities.Maximum-intensity projection computed tomography (CT) angiography abdomen axial section (thickness 7 mm) (A) showing narrowing of whole length of right renal artery and thickened abdominal aortal wall (black arrowhead) and coronal section (B) showing small asymmetrical right kidney and compensatory enlarged left kidney."], "Others": ["Meningeal signs were absent."]}
{"Patient Personal Background": ["He reported no new prescription medications, over-the-counter drugs, or herbal supplements prior to the onset of the exanthem.", "He had no history of psoriasis, atopic dermatitis, or other skin disorder, and no recent viral or bacterial infection."], "Examination and Results": ["The patient had no fever, night sweats, fatigue, recent unintentional weight loss, shortness of breath, chest pain, nausea, vomiting, or diarrhea.", "On presentation, his temperature was 37.1 \u00b0C (98.7 \u00b0F); blood pressure, 128/86 mm Hg; heart rate, 110/min; and respiratory rate, 30/min.", "Physical examination revealed confluent salmon-colored plaques composed of folliculocentric scaly papules across his body with several patches of unaffected skin on his trunk.", "The patient had waxy, exfoliative scale on the volar aspect of his hands and feet and thickened, onycholytic nails.", "Severe ectropion prevented complete eyelid closure (Figure).", "He was referred to the emergency department, where laboratory testing revealed a normal complete blood cell count and normal lactate dehydrogenase level."], "Treatment": ["The patient was admitted to the hospital and was treated with intravenous fluids and daily wet-wrap therapy with topical triamcinolone ointment (0.1%) applied to his trunk, arms, and legs, followed by a layer of warm, damp gauze and dry, cotton pajamas.Clinical examination at the time of presentation revealed generalized and coalescing salmon-colored plaques with \u201cislands of sparing\u201d on the abdomen (far left); waxy, exfoliative scale on the palms (center left) and soles (center right); and ectropion (far right)."]}
{"Patient Personal Background": ["He reported no prior lingual discoloration and did not smoke cigarettes, use chewing tobacco or illicit drugs, or drink alcohol.Elongated filiform papillae and black discoloration of patient\u2019s tongue."], "Patient Symptoms": ["He had tenderness to palpation and decreased range of motion of his right shoulder.", "One week after hospitalization, the patient developed asymptomatic black discoloration of the dorsal surface of his tongue (Figure)."], "Examination and Results": ["His temperature was 37.9 \u00b0C (100.2 \u00b0F); heart rate, 74/min; and blood pressure, 90/49 mm Hg.", "Laboratory testing showed a white blood cell count of 9.6\u2009\u00d7\u2009\u2009109/L (reference, 4.0-9.0\u2009\u00d7\u2009109/L); C-reactive protein level, 35.6 mg/dL (reference, <0.3 mg/dL), and creatine kinase level, 1036 U/L (17.30 \u03bckat/L) (reference, 60-270 U/L [1.00-4.51 \u03bckat/L]).", "Magnetic resonance imaging revealed an effusion and synovial thickening with enhancement in the right shoulder joint and inflammation in the right subscapularis muscle.", "Gram stain of the synovial fluid revealed gram-positive cocci in clusters."], "Treatment": ["Intravenous cefazolin therapy was initiated, and he underwent right shoulder joint arthroscopic irrigation, synovectomy, and surgical drainage for subscapularis pyomyositis.", "Blood and synovial fluid cultures grew methicillin-susceptible Staphylococcus aureus, and intravenous cefazolin was continued."]}
{"Patient Personal Background": ["She was otherwise healthy with no history of recurrent pharyngitis.On examination, her vital signs were within normal limits."], "Patient Symptoms": ["Her parents noted the lesion 18 months prior.", "It remained stable in size and was asymptomatic.", "She denied sore throat, dysphagia, and dyspnea."], "Examination and Results": ["She was comfortable with no noted stridor and tolerated her oral secretions.", "Her oropharyngeal examination was notable for size 2+ palatine tonsils without exudate and a white mass on the posterior tonsillar pillar.", "She did not tolerate palpation of the lesion.", "There was no palpable cervical adenopathy, and her lungs were clear to auscultation.", "B and C, A keratinizing squamous epithelium with Actinomyces colonization was found overlying pilosebaceous units including hair follicles, arrector pili muscles, and sebaceous glands (hematoxylin-eosin stains).Gross examination revealed a 2.2\u2009\u00d7\u20091.1\u2009\u00d7\u20090.7-cm, pink-tan to purple, rubbery lesion.", "Histologic examination demonstrated both ectodermal and mesodermal components.", "A keratinizing squamous epithelium with Actinomyces colonization was found overlying pilosebaceous units including hair follicles, arrector pili muscles, and sebaceous glands (Figure, B and C).", "The core of the lesion comprised adipose and fibrous tissue.", "The stalk was covered with acanthotic squamous epithelium, and the base contained embedded salivary glands."], "Treatment": ["No laboratory work or imaging were performed.The patient was taken to the operating room for an excisional biopsy."], "Others": ["There, a more thorough gross examination of the lesion was notable for a pedunculated, white rubbery mass arising from the left posterior tonsillar pillar with a narrow mucosal stalk (Figure, A).A, Pedunculated, white rubbery mass arising from the left posterior tonsillar pillar with a narrow mucosal stalk."]}
{"Patient Personal Background": ["Her medical history included Leber congenital amaurosis treated with voretigene neparvovec (Luxturna; Spark Therapeutics) 8 years ago, and acute myeloid leukemia (AML) diagnosed 6 months prior to presentation treated with cytarabine and idarubicin."], "Patient Symptoms": ["She also reported rhinorrhea and lethargy."], "Examination and Results": ["A complete blood cell count was ordered, revealing anemia, neutropenia, lymphocytopenia, and monocytopenia in the setting of recent chemotherapy.", "Blood cultures were drawn, and results were pending at the time of presentation.Her ophthalmic examination showed visual acuity of 20/800 OD and 20/400 OS, decreased from her baseline of 20/200 OU.", "Intraocular pressures were 37 mm Hg OD and 31 mm Hg OS.", "Slitlamp examination revealed chemosis, conjunctival hyperemia, and microcystic corneal edema bilaterally.", "There were more than 20 cells per high-power field of 1 mm\u2009\u00d7\u20091 mm beam, with fibrin bilaterally and 2.5-mm hypopyon in the right eye and 2.7-mm hypopyon in the left eye (Figure 1)."], "Others": ["Her latest chemotherapy was 3 weeks before presentation, and a peripherally inserted central catheter (PICC) was removed 2 weeks ago."]}
{"Patient Personal Background": ["Her medical history included esophageal atresia, small bowel obstruction, mild cognitive impairment, low tone, and increased reflexes.", "Prenatal history was complicated by insulin-controlled gestational diabetes and polyhydramnios."], "Patient Symptoms": ["Her ocular history was notable for eye movement abnormalities since birth."], "Examination and Results": ["She had no family history of ocular disease.On examination, her visual acuity was 20/150 OU and did not improve with correction (right eye, \u22121.50 [2.00]\u2009\u00d7\u2009180; left eye, \u22121.00 [1.50]\u2009\u00d7\u2009180).", "Pupillary responses were normal.", "Alternating vertical and torsional nystagmus was noted (Figure 1).", "Specifically, 1 eye was noted to rise and intort while the other would fall and extort, followed by reversal of the vertical and torsional components in the opposite eye (Video).", "The optic nerve and foveal reflexes were normal in both eyes.", "Flash visual evoked potential (VEP) demonstrated strong ipsilateral activity of the occipital lobe.", "Results of a previously obtained brain magnetic resonance imaging (MRI) scan were reported as normal."]}
{"Patient Personal Background": ["Four years earlier, he started taking lenalidomide, 10 mg/d (28-day cycle), to treat worsening anemia; after 2 cycles of treatment, he became transfusion independent.", "Since then, he has remained stable with the same dose and schedule of lenalidomide without significant adverse effects.", "Additionally, the patient also had hypertension and hypercholesterolemia for which he was taking lisinopril and simvastatin, respectively."], "Patient Symptoms": ["The presenting skin lesions developed 1 month before presentation and began as small pustules that rapidly transformed into painful ulcers."], "Examination and Results": ["Thus, he was transferred to our facility.Physical examination showed multiple cutaneous ulcers with gray undermined borders and red papules of varying depths involving the chest, back, and upper extremity; lesions were as large as 9\u2009\u00d7\u200915 cm.", "A complete blood cell count showed a white blood cell count of 16.2\u2009\u00d7\u2009103/\u03bcL (to convert to 109/L, multiply by 1.0) with an absolute neutrophil count of 12.7\u2009\u00d7\u2009103/\u03bcL, hemoglobin level of 9.4 g/dL (to convert to g/L, multiply by 10.0), and platelet count of 262\u2009\u00d7\u2009103/\u03bcL with no circulating blasts.", "Results of additional laboratory studies, including blood culture and tests for herpes zoster virus (via polymerase chain reaction), antinuclear antibody, rheumatoid factor, and antineutrophil cytoplasmic antibody were all negative.", "Pathologic sampling from skin lesions demonstrated a dense dermal infiltrate with predominantly neutrophils along with reactive histiocytes, fibroblasts, and angioplasia (Figure, A).", "Immunohistochemical staining showed myeloperoxidase-positive neutrophils (Figure, B), histiocytic markers (CD43, CD63, CD168), and CD117-positive mast cells, but no immature myeloid precursors.", "Results of Grocott-Gomori methenamine silver staining were unremarkable.A, Hematoxylin-eosin staining shows polymorphonuclear neutrophils admixed with scattered histiocytes and vasculatures with a prominent endothelial lining."], "Treatment": ["He was treated with valacyclovir for a presumed diagnosis of shingles, but the lesions did not improve.", "Cultures from the surgical specimen grew methicillin-resistant Staphylococcus hemolyticus.", "However, the lesions continued to worsen despite vancomycin and additional debridement."], "Others": ["Because of suspected necrotizing fasciitis, he underwent incision and drainage of the lesions."]}
{"Patient Personal Background": ["Her medical history was notable for end-stage kidney disease requiring a kidney transplant at age 50 years and a second transplant at age 65 years.", "She had received her medical care at outside facilities, the records of which were not available.", "She could not recall being given any precise diagnosis but reported having proteinuria since age 7 years.", "Her other medical conditions included hyperlipidemia, arterial hypertension, and pulmonary Mycobacterium avium complex infection.", "Her family history was unremarkable.", "She had 2 healthy adult children.One year after the first kidney transplant, she noted an inferior visual field defect in the left eye and was diagnosed with nonarteritic anterior ischemic optic neuropathy."], "Patient Symptoms": ["She could not recall being given any precise diagnosis but reported having proteinuria since age 7 years.", "She had 2 healthy adult children.One year after the first kidney transplant, she noted an inferior visual field defect in the left eye and was diagnosed with nonarteritic anterior ischemic optic neuropathy."], "Examination and Results": ["Color vision was 14/14 plates for each eye.", "There was a left relative afferent pupillary defect.", "Confrontation visual field was full for the right eye and demonstrated an inferior defect for the left eye.", "External and slitlamp examinations were notable only for bilateral pseudophakia.", "Both optic discs were anomalous in appearance, with central excavation in the left eye greater than the right eye (Figure).", "The remainder of the posterior pole examination, including the retinal vessels, appeared normal in both eyes.The right optic disc is dysplastic, with a subtle appearance of the peripheral location of blood vessels emanating from the central disc.", "There is a central excavation of the left optic disc, with peripherally located blood vessels and the absence of central vessels."], "Treatment": ["She was taking tacrolimus, amlodipine, atorvastatin, ethambutol, rifampin, and clarithromycin."], "Diagnosis": ["She had 2 healthy adult children.One year after the first kidney transplant, she noted an inferior visual field defect in the left eye and was diagnosed with nonarteritic anterior ischemic optic neuropathy."], "Others": ["Several years later, she underwent uncomplicated bilateral cataract procedures.Visual acuity with distance correction was 20/25 OD and 20/30 OS."]}
{"Examination and Results": ["Skin examination revealed a 5-mm bright pink, dome-shaped papule with overlying vessels located at the crown of the scalp (Figure, A).", "There was no purulent discharge or overlying skin changes.", "B, Hematoxylin-eosin staining of the lesion from biopsy.", "Scanning magnification demonstrates dermal-based tumor cells arranged in a vague nodular configuration.", "C, Proliferation of tumor cells is present around small vessels with scattered mitoses (black arrowhead) and necrosis (yellow arrowheads) (hematoxylin-eosin).", "D, Smooth muscle actin stain."], "Treatment": ["A shave skin biopsy was performed and submitted for histopathologic analysis (Figure, B-D).A, Bright pink, dome-shaped papule of the scalp crown with overlying vessels measuring 5 mm."]}
{"Patient Symptoms": ["No triggers, such as local infection, insect bite, or trauma, occurred before the appearance of the lesions.", "She denied fever, weight loss, or fatigue."], "Examination and Results": ["Physical examination showed multiple firm, nonscaly, purple erythematous patches and plaques with irregular borders on her left axilla, medial upper arm, and lateral thoracic region (Figure, A).", "No extracutaneous involvement was observed.", "A skin biopsy specimen was obtained from the left side of her chest for histopathological examination (Figure, B and C).A, Multiple nonscaly, erythematous-violaceous patches and plaques with irregular borders on the patient\u2019s left axilla, medial upper arm, and lateral thoracic region.", "B, Irregularly branched, thin-walled blood vessels dissecting through collagen bundles within the superficial to mid dermis (hematoxylin-eosin).", "C, Irregularly branched, thin-walled blood vessels with plump endothelial cells dispersed between thickened collagen bundles without signs of atypia (hematoxylin-eosin).", "D, Endothelial cells positive for cluster of differentiation (CD) 31 (CD31)."]}
{"Examination and Results": ["On admission, vital signs showed blood pressure as 98/66 mm Hg while receiving dobutamine and norepinephrine from the referral hospital, a regular heart rate of 90 beats per minute, a respiratory rate of 22 breaths per minute, peripheral oxygen saturation 96% nasal oxygen at 3 L per minute, and a temperature of 36.7\u00b0 C. Echocardiography showed reduced left ventricle systolic function (estimated ejection fraction, 34%) and hypokinesia of the anteroseptal, anterior, anterolateral, and septal walls.", "Lung ultrasound demonstrated multiple B-lines in both lung fields.", "Diagnostic coronary angiography revealed a total occlusion in the left main coronary artery.", "Chest radiography during the loading dose of amiodarone showed infiltrates in both lung fields (Figure 1A).", "Chest computed tomography showed a reticular pattern predominantly in the perihilar area with consolidation and diffuse ground-glass opacity in both lung fields (Figure 1B).", "In addition, hemodynamic evaluation and lung ultrasound showed no congestion and laboratory markers, including a procalcitonin level of 0.01 ng/mL, and ruled out an infectious etiology."], "Treatment": ["Percutaneous coronary intervention (PCI) was successful in opening the osteal left main and drug-eluting stents were placed in the left main and left anterior descending arteries.Following PCI, the patient had episodes of supraventricular tachycardia and atrial fibrillation with a rapid ventricular response.", "Electrical cardioversion was performed and a loading dose of amiodarone was administered.", "While in the intensive cardiovascular care unit, maintenance doses of amiodarone were continued because of episodes of paroxysmal supraventricular tachycardia, ventricular tachycardia, and torsaded de pointes."], "Others": ["On the third day of hospitalization, despite adequate diuresis, the chest radiography showed persistent pulmonary edema."]}
{"Patient Personal Background": ["She was otherwise in excellent health and not taking any medications.", "She had no family history of syncope or sudden death."], "Patient Symptoms": ["She described several other episodes occurring at rest over the past several weeks.", "She denied palpitations, chest pain, and shortness of breath."], "Examination and Results": ["Her vital signs and physical examination were unremarkable.", "The initial electrocardiogram (ECG) results were normal, but premature ventricular contractions (PVCs) were noted on telemetry.", "Shortly thereafter, 2 episodes of fast polymorphic ventricular tachycardia (PVT), 30 minutes apart, were recorded, both lasting less than 4 seconds (Figure 1A).", "A repeat ECG showed PVCs (Figure 1B).", "Laboratory test results including serum potassium and magnesium as well as 3 serial troponin levels were normal.", "Echocardiography showed normal left ventricular systolic function without wall motion abnormalities or valvular abnormalities.", "Coronary angiography showed a 50% stenosis of the left circumflex artery."], "Others": ["Instant wave-free ratio across the stenosis was 1.0.A, A continuous rhythm strip showing a short episode of polymorphic ventricular tachycardia (PVT), which is initiated by a short-coupled premature ventricular contraction (PVC) identical in morphology and coupling interval to the PVC occurring a few beats earlier.", "B, A subsequent electrocardiogram (ECG) showed frequent short-coupled premature ventricular contractions."]}
{"Patient Personal Background": ["She reported no hematemesis, hematochezia, or melena and had no history of abdominal surgery."], "Patient Symptoms": ["On physical examination, her abdomen was distended, tympanic, and slightly tender to palpation diffusely."], "Examination and Results": ["On admission to the emergency department, she was afebrile, her blood pressure was 80/60 mm Hg, and heart rate was 122/min.", "Blood testing showed a white blood cell count of 10\u202f450/\u03bcL (84.1% neutrophils); C-reactive protein level, 9.5 mg/dL; potassium level, 3.0 mEq/L (reference, 3.6-5.2 mEq/L); and creatinine level, 5.57 mg/dL (429.39 \u03bcmol/L, up from a baseline level of 0.80 mg/dL [70.72 \u03bcmol/L])."], "Treatment": ["Sodium and liver function values were normal.In the emergency department, she received a 500-mL bolus of intravenous crystalloid fluid and 1 g of intravenous ceftriaxone.", "A nasogastric tube was placed and initially drained 300 mL of biliary fluid.A non\u2013contrast-enhanced abdominal computed tomography (CT) scan was performed (Figure 1).Left, Abdominal computed tomography scan showing a thickened gallbladder with air and gallstones adherent to the duodenum, with a suspected fistula tract."]}
{"Patient Personal Background": ["She was a farmer in rural Japan who did not drink alcohol and had been diagnosed with bullous pemphigoid 8 months prior, initially treated with prednisolone (15 mg daily).", "Her medications at presentation were prednisolone (8 mg daily) and lansoprazole."], "Patient Symptoms": ["She had experienced 1 episode of dyspnea on exertion 2 weeks before presentation but reported no fevers, cough, wheeze, nausea or vomiting, hematochezia, or melena."], "Examination and Results": ["In the emergency department, her temperature was 37.7 \u00b0C (99.9 \u00b0F); blood pressure, 110/56 mm Hg; heart rate, 125/min; and oxygen saturation, 95% on room air.", "On physical examination her lungs were clear to auscultation, and her abdomen was diffusely tender to palpation without rebound.", "Skin examination revealed purpuric macules and small thumbprint-like patches on the upper abdomen and central chest (Figure 1).Purpuric macules and thumbprint-like patches (arrowheads) on patient\u2019s upper abdomen and central chest.Laboratory testing showed white blood cell count, 13\u202f600/\u03bcL (89.9% neutrophils, 0.2% eosinophils); hemoglobin, 10.9 g/dL; serum sodium, 130 mEq/L (reference, 138-145 mEq/L); creatinine, 0.82 mg/dL (72.49 \u03bcmol/L); aspartate aminotransferase, 55 U/L (0.92 \u03bckat/L) (reference, 13-30 U/L [0.22-0.50 \u03bckat/L]); alanine aminotransferase, 54 U/L (0.90 \u03bckat/L) (reference, 7-23 U/L [0.12-0.38 \u03bckat/L]); and erythrocyte sedimentation rate, 31 mm/h (reference, 3-15 mm/h).", "Platelet count and prothrombin time were normal."]}
{"Patient Personal Background": ["The patient was taking systemic immunosuppression but recently stopped taking maribavir because of concerns about resistance and was transitioned to cidofovir and CMV immune globulin."], "Examination and Results": ["On clinical examination, the visual acuity measured 20/25 OD and 20/20 OS.", "Motility, visual fields, and anterior segment examination were normal.", "Dilated fundus examination revealed tortuous vasculature, multiple cotton wool spots along the arcades and periphery, and granular, hypopigmented retinal lesions without hemorrhage in the macula and temporal periphery in both eyes (Figure 1A).", "Optical coherence tomography showed localized areas of full-thickness retinitis (Figure 1B).", "CMV titers indicated viremia at 2.24 million IU/mL."], "Treatment": ["Despite the patient\u2019s documented UL97 and UL54 mutations, a series of 5 biweekly intravitreal injections of foscarnet and ganciclovir were performed given their vision-threatening lesions."]}
{"Patient Personal Background": ["When she was 36 years old, she underwent a hysterectomy due to abnormal uterine bleeding and was taking estradiol to control postmenopausal vasomotor symptoms for the past 20 years."], "Examination and Results": ["Bilateral diagnostic mammography revealed a high-density irregular mass in the left axilla with no nodules, architectural distortions, or microcalcifications in the breasts.", "Ultrasonography of the left breast showed a 4.6-cm lobulated mixed cystic and solid left axillary mass.", "Contrast-enhanced magnetic resonance imaging showed an enhancing 5.2-cm left axillary mass with no breast lesions (Figure 1A).", "The biopsy examination indicated high-grade adenocarcinoma with papillary features (estrogen receptor\u2013 and progesterone receptor\u2013positive, ERBB2 [formerly HER2]\u2013negative, and a high Ki67 index).", "Positron emission tomography/computed tomography revealed only high uptake in the left axilla region."], "Treatment": ["The patient was treated at an outside hospital with neoadjuvant dose-dense doxorubicin and cyclophosphamide, followed by weekly paclitaxel for 10 weeks."], "Diagnosis": ["The biopsy examination indicated high-grade adenocarcinoma with papillary features (estrogen receptor\u2013 and progesterone receptor\u2013positive, ERBB2 [formerly HER2]\u2013negative, and a high Ki67 index)."], "Others": ["She then transferred her care to our center for surgical management.", "We requested the pathology slides for review at our laboratory and additional immunostaining was performed, which revealed high-grade adenocarcinoma with tumor cells positive for PAX8 (Figure 1B), p53, and WT1 and negative for GATA3.A, Magnetic resonance image of the breasts shows an enhancing 5.2-cm left axillary mass (arrowhead) but no breast lesions."]}
{"Patient Personal Background": ["His parents denied any medical history of trauma, infection, or surgery."], "Examination and Results": ["Physical examination showed a 1.3\u2009\u00d7\u20090.7\u2009\u00d7\u20090.6 cm, yellowish, hump-like mass with hairy surface and cartilage-like consistency on the anterior border of the lower third of the left sternocleidomastoid muscle (SCM) (Figure, A).", "No other anomalies were observed.", "Ultrasonography revealed a 1.2\u2009\u00d7\u20091.0\u2009\u00d7\u20090.9 cm, hypoechoic, avascular, bulging nodule with an anechoic tubular structure extending to the subcutaneous fat and reaching the surface of the muscular layer.", "Magnetic resonance imaging (MRI) demonstrated a protuberant nodule with diffuse, slight hyperintensity on T1WI; and 2 mild hyperintense foci surrounded by hypointense tissue on fat-suppressed T2WI (Figure, B).", "The neck mass was completely excised under general anesthesia in the department of pediatric surgery."], "Treatment": ["Intraoperatively, the mass extended into the anteromedial fascia of the left SCM and did not involve the deeper neck structures."], "Others": ["Postoperative histopathologic analysis showed normal-appearing epidermis, multiple pilosebaceous follicles, abundant adipose tissue, and 2 centrally circumscribed segments of cartilage in the subcutis (Figure, C).", "Van Gieson stain highlighted elastic fibers surrounding individual chondrocytes.A, A yellowish hump-like mass with hairy surface on the anterior-inferior third border of the left sternocleidomastoid muscle (SCM).", "B, Transverse T2-weighted, fat-suppressed magnetic resonance image (MRI) revealed a nodular bulge with 2 mild hyperintense foci (arrowheads) surrounded by hypointense tissue.", "C, Whole-slide hematoxylin-eosin stain showed normal-appearing epidermis, multiple pilosebaceous follicles, abundant adipose tissue, and 2 centrally circumscribed segments of cartilage (arrowheads) in the subcutis (original magnification \u00d710)."]}
{"Examination and Results": ["On examination, there was an easily palpable 3-cm firm, fixed, well-circumscribed left supraclavicular mass without overlying skin changes or cutaneous involvement.", "She had no other masses, cervical lymphadenopathy, or systemic symptoms.", "In workup for this mass, she initially underwent ultrasound imaging, which demonstrated a hypoechoic mass.", "Findings from fine-needle aspiration and core-needle biopsy were inconclusive, demonstrating histiocytes.", "Magnetic resonance imaging demonstrated a well-circumscribed mass of mainly soft tissue density with contrast enhancement (Figure 1).Magnetic resonance imaging of the left-sided supraclavicular mass.", "T2 sequencing with contrast demonstrates strong enhancement of the mass.Given persistence of the lesion, and inconclusive biopsies, the decision was made to pursue surgical excision.", "Pathology confirmed complete excision of a well-circumscribed lesion with peripheral casing of bone, cyst-like spaces filled with serous fluid, walls of spindle-shaped fibroblasts, osteoclast-type giant cells, thin trabeculae of woven bone surfaced with osteoblasts, and scattered macrophages.", "There was local infiltration into surrounding skeletal muscle, but no atypical mitoses or pleomorphic cells were identified.", "The lesion was positive for USP6 locus rearrangement (17p13.2) on florescence in situ hybridization."], "Treatment": ["In the operating room, a well-defined 5.5-cm left level V mass was excised.", "The mass was found to attach deep to the middle scalene and was fed by several unnamed vessels; however, there was no involvement of the clavicle."]}
{"Patient Symptoms": ["He had undergone multiple evaluations by dermatologists and urologists and had not responded to systemic antibiotics and topical corticosteroids."], "Examination and Results": ["Physical examination revealed an erythematous, pinpoint orifice on his glans penis, with peripheral telangiectasias and a linear bluish structure on dermoscopy (Figure, A and B).", "Ultrasonography revealed a hypoechoic focal zone on the right side of the glans, with multiple hyperechoic bilaminar structures (Figure, C).", "A biopsy was performed (Figure, D).A, Clinical image of glans penis with a pinpoint orifice.", "B, Dermoscopy reveals an orifice surrounded by peripheral telangiectasias and an extending bluish linear structure.", "C, Ultrasonography of the glans penis demonstrates a hypoechoic focal zone in the parenchyma on the right containing multiple hyperechoic bilaminar tracts (arrowheads) (18 MHz; longitudinal view).", "D, Hematoxlyin-eosin stain with original magnification \u00d7100."]}
{"Patient Personal Background": ["Medications included insulin lispro (sliding scale 3 times daily) and insulin glargine (20 units nightly)."], "Patient Symptoms": ["He reported a tingling sensation in the affected area but no pruritus or pain."], "Examination and Results": ["On physical examination, he was afebrile and had normal vital signs.", "His extremities were warm with palpable distal pulses.", "Hyperpigmented macules were present on the anterior lower legs below the knees, and tense bullae were present on the anterior aspect of the right lower extremity, dorsal foot surface, and toes (Figure).", "There was no surrounding erythema or edema, and findings on the remainder of the skin and mucocutaneous examination were unremarkable.", "Laboratory testing revealed a blood glucose level of 375 mg/dL (20.81 mmol/L) and hemoglobin A1c level of 9.8%.", "Results of a basic metabolic panel and complete blood cell count were within reference range except for mild anemia (hemoglobin level, 10.9 g/dL).Patient's right lower extremity with bullae and hyperpigmented macules and patches, characteristic of diabetic dermopathy (left)."], "Diagnosis": [], "Others": ["He had no history of leg trauma and no chemical or extreme temperature exposure."]}
{"Patient Personal Background": ["She took no regular medication and did not smoke.At presentation, her visual acuities were perception of light OD and 20/20 OS."], "Patient Symptoms": ["She also reported a 4-week history of right ear pain and fullness, discomfort over her frontal and maxillary sinuses, and nasal congestion without discharge.", "Over the past 2 weeks, she had experienced drenching night sweats, cramps in her quadriceps, and weight loss of 3 kg.", "She denied respiratory symptoms, headaches, scalp tenderness, or jaw claudication."], "Examination and Results": ["There was a right relative afferent pupillary defect.", "Dilated fundus examination showed a cherry red spot in the right macula with hyperreflectivity and thickening of the inner retinal layers on optical coherence tomography (Figure 1A and B).", "External eye examination results and ocular motility were normal.", "Examination by an otolaryngologist revealed normal tympanic membranes and a dry but otherwise normal nasal mucosa on flexible endoscopy.", "Blood tests showed leukocytosis (white blood cell count, 15\u202f000 /\u00b5L; to convert to 109 per liter, multiply by 0.001) with neutrophilia (white blood cell count, 12\u202f500 /\u00b5L), elevated C-reactive protein (19.4 mg/dL; to convert to milligrams per liter, multiply by 10), elevated plasma viscosity (2.06 mPas), and thrombocytosis (467\u2009\u00d7103/\u00b5L; to convert to \u00d7109 per liter, multiply by 1).", "Kidney function was within normal limits.", "Chest radiograph results were unremarkable.False-color and red-free (inset) fundus photograph of the right eye shows retinal pallor (white arrowheads) with a cherry red spot (yellow arrowhead) in the macula (A)."]}
{"Patient Personal Background": ["His medical history included hypothyroidism, psoriasis, and recent diagnosis of multiple myeloma, and he was taking daratumumab and zoledronic acid."], "Patient Symptoms": ["Examination of the right eye was notable for visual acuity of 20/50, reduced ocular motility in all gazes, proptosis, and chemosis."], "Examination and Results": ["There was no afferent pupillary defect.", "Examination of the left eye was unremarkable.", "Computed tomography of the orbits with contrast demonstrated right preseptal edema and intraorbital fat stranding of the extraconal and intraconal fat without sinus disease.", "Nasal endoscopy performed by the otolaryngology service showed no evidence of invasive fungal sinusitis.", "After 48 hours, motility, proptosis, and chemosis worsened (Figure 1A).A, External photograph of the right eye demonstrating periocular edema, conjunctival injection, and chemosis.", "B, Axial T1 fat-suppressed postcontrast magnetic resonance imaging (MRI) demonstrating proptosis of the right eye with optic nerve straightening, diffuse enhancement of the right intraconal and extraconal fat, and periorbital tissues.Magnetic resonance imaging of the orbits with and without contrast (Figure 1B) was remarkable for proptosis with optic nerve straightening, enhancement of the intraconal and extraconal fat, edema and enhancement of the right extraocular muscles, new thickening of the left sphenoid sinus with internal air-fluid level, and new inflammation of the left masticator space."], "Treatment": ["The patient received a single dose of intravenous vancomycin and ceftriaxone, then was transitioned to ampicillin-sulbactam for presumed orbital cellulitis.", "Under guidance from the infectious disease service, antibiotics were broadened back to vancomycin and ceftriaxone with continued worsening."], "Others": ["He denied eye trauma, dental surgery, or sinus disease.", "A follow-up computed tomography of the sinus with contrast showed no evidence of osseous structure destruction to suggest invasive fungal sinusitis."]}
{"Patient Personal Background": ["He had undergone laser retinopexy for retinal tears in his right eye and a scleral buckle and vitrectomy for a retinal detachment in his left eye 1 year earlier.", "The patient was discharged taking timolol, dorzolamide, brimonidine, and prednisolone."], "Patient Symptoms": ["The patient started treatment with 500 mg of acetazolamide daily and referred to the glaucoma service for surgical evaluation.Ultrasound biomicroscopy of the left eye demonstrating angle closure (arrowheads).When the patient returned for his glaucoma evaluation 3 days later, he was noted to have loss of appetite, drowsiness, nausea, and malaise.", "During this visit, the patient developed acute chest pain and respiratory insufficiency requiring immediate transfer to the emergency department."], "Examination and Results": ["Best-corrected visual acuity (BCVA) was 20/40 OD and counting fingers OS.", "Intraocular pressure (IOP) was 14 mm Hg in the right eye and 44 mm Hg in the left eye.", "Anterior segment examination of the right eye was unremarkable, while ophthalmoscopic examination showed vascular attenuation and treated retinal breaks.", "In the left eye, microcystic corneal edema and Descemet membrane folds limited examination, but no residual lenticular fragments or neovascularization of the iris or angle were seen.", "Twelve days later, the cornea had cleared and IOP in the left eye improved to 32 mm Hg.", "Gonioscopy revealed 360\u00b0 of anterior synechiae and complete angle closure, which was documented on ultrasound biomicroscopy (Figure 1).", "The patient\u2019s intraocular examination was stable bilaterally."], "Treatment": ["The patient was discharged taking timolol, dorzolamide, brimonidine, and prednisolone.", "The patient started treatment with 500 mg of acetazolamide daily and referred to the glaucoma service for surgical evaluation.Ultrasound biomicroscopy of the left eye demonstrating angle closure (arrowheads).When the patient returned for his glaucoma evaluation 3 days later, he was noted to have loss of appetite, drowsiness, nausea, and malaise."]}
{"Patient Personal Background": ["She had a history of substantial sun exposure but no history of skin cancer."], "Patient Symptoms": ["The rash had been present for 3 weeks and had recently worsened.", "Her palms and soles were spared."], "Treatment": ["Her disease had progressed after receiving first-line therapy with palbociclib and anastrozole.", "Subsequent treatments with fulvestrant and paclitaxel were also followed by progressive disease.", "She received treatment with capecitabine; after 6 weeks of treatment, she developed some redness on her hands and feet that resolved on its own.She then presented to the clinic with pruritic, erythematous, scaly macules and papules on her forearms, faces, chest, and upper back (Figure).", "The rash did not respond to treatment with topical clindamycin, oral solumedrol, or doxycycline."], "Others": ["She had locally advanced disease that was invading the skin overlying her right breast and metastatic disease to the thoracic and lumbar spine, liver, and mediastinal, axillary, and retroperitoneal lymph nodes."]}
{"Patient Symptoms": ["Her symptoms were initially most prominent while playing sports and were suspected to be due to asthma or seasonal allergies.", "More recently, the patient\u2019s parents noted that she developed stridor while sleeping and while at rest, prompting the family to present for medical attention.Previous workup, including pulmonary function testing, was concerning for an upper airway obstructive process, for which she was referred to otolaryngology."], "Examination and Results": ["In-office flexible videostroboscopy revealed a mass in the distal cervical trachea that appeared nearly obstructive.", "Chest radiography confirmed the presence of an approximately 1.5-cm, well-circumscribed soft tissue mass within the cervical trachea.Direct laryngoscopy and bronchoscopy were performed in the operating room under general anesthesia.", "This demonstrated an exophytic, pedunculated mass that emanated from the anterior wall of the cervical trachea (Figure 1A and B)."], "Treatment": ["The patient was intubated via Seldinger technique to bypass the mass, with a 4.0-mm cuffed endotracheal tube loaded over a 0-degree Hopkins endoscope (Figure 1C).", "With the airway secured, attention was turned to excision of the mass.", "Lidocaine, 1%, with epinephrine 1:100\u202f000 was injected in a submucosal plane, and laryngeal scissors were used to excise the attachment of the mass from the tracheal wall.", "The mass was then resected en bloc and removed with laryngeal cupped forceps.", "The attachment site was then ablated with the Coblator (Figure 1D).Intraoperative photographs demonstrating supraglottic view of intratracheal mass (A); exophytic, pedunculated mass emanating from the anterior wall of the cervical trachea (B); endotracheal intubation via Seldinger technique bypassing the mass (C); and cervical trachea following ablation of attachment site (D)."]}
{"Patient Symptoms": ["Clinical findings suggested unilateral right middle ear effusion associated with ipsilateral conductive hearing loss."], "Examination and Results": ["A high-resolution computed tomography scan of the temporal bone showed a lytic aspect of the right temporal bone extending to the petrous apex and the petrous bone, sparing the otic capsule (Figure 1A).", "There was soft tissue opacification of the right mastoid air cells.", "It showed a hyperintense T2 signal in the petrous apex and mastoid air cells.", "Magnetic resonance imaging also showed signs of Chiari malformation type 1.", "There was associated soft tissue partial opacification of the right mastoid air cells.", "B, Coronal magnetic resonance imaging of the brain and skull base, T2-weighted images showed a hypersignal in the right mastoid and middle ear with suspected communication through the tegmen."], "Treatment": ["After an initial observation period, a right tympanostomy tube was inserted."], "Diagnosis": ["This confirmed the presence of a cerebrospinal fluid (CSF) leak.The patient was referred to our tertiary referral center hospital.", "Magnetic resonance imaging also showed signs of Chiari malformation type 1."], "Others": ["During the procedure, a clear liquid pulsating from the middle ear was noted, and samples were sent for \u03b2-2-transferrine analysis.", "The leak settled with conservative management, and imaging of the brain and skull base was performed.", "Magnetic resonance imaging of the skull base with contrast was performed (Figure 1B).", "There was a suspected communication into the soft tissues of the right neck in the posterior triangle.", "After a skull base multidisciplinary discussion, the patient underwent a bone biopsy through a transmastoid approach.A, Axial high-resolution computed tomography scan of the temporal bones at the level of the basal turn of the cochlea showed osteolysis involving the petrous part of the right temporal bone.", "The destructive process did not involve the otic capsule.", "There was also a hypersignal in the soft tissues of the right neck in keeping with extravasation of cerebrospinal fluid in cervical lymphatics."]}
{"Patient Personal Background": ["She had a medical history of essential thrombocytosis (ET), which was treated with hydroxyurea for 14 years, with a total cumulative dose of approximately 2500 g. She was otherwise reasonably well and denied any other constitutional symptoms.", "She did have a medical history of nonmelanoma skin cancer (NMSCa), which had previously been treated surgically."], "Patient Symptoms": ["The ulcerations had slowly increased in number and size over several years and were quite painful (Figure, A-C)."], "Examination and Results": ["Several tangential shave biopsies were performed to help clarify the patient\u2019s diagnosis.A-C, Clinical findings including widespread photodistributed ulcerated pink papules and plaques on the extremities.", "D, Histopathologic findings (hematoxylin-eosin stain)."]}
{"Patient Personal Background": ["The patient had consanguineous parents, but no other family member, including her children, had the disease.A, Multiple subcutaneous masses in the occipital and bilateral temporal regions."], "Patient Symptoms": ["At 5 years of age, the patient had developed multiple subcutaneous masses in the occipital and bilateral temporal regions.", "Tumors recurred 5 years after surgery, with their size and number gradually increasing with age."], "Examination and Results": ["Physical examination revealed scalp masses from 4 to 6 cm in diameter, with hard textures and smooth surfaces (Figure, A), and subcutaneous nodules of 1\u2009\u00d7\u20091 cm to 2\u2009\u00d7\u20092 cm with hard textures on the hands (Figure, B), feet, trunk, and lower extremities.", "The patient had no tenderness, swelling, or other skin manifestations.", "The diameter of the scalp masses varied from 4 to 6 cm, with hard textures and smooth surfaces.", "B, Subcutaneous hard nodules on the hands, ranging from 1\u2009\u00d7\u20091 cm to 2\u2009\u00d7\u20092 cm.", "C and D, Large amounts of homogeneous eosinophilic hyaline matrix with scattered fibroblasts."], "Treatment": ["At age 10, she was diagnosed with neurofibromatosis and underwent surgical resection of the tumors at a local hospital."], "Diagnosis": ["At age 10, she was diagnosed with neurofibromatosis and underwent surgical resection of the tumors at a local hospital."]}
{"Examination and Results": ["A head computed tomography showed a 0.9-cm left subdural hematoma with a mild left to right midline shift.", "Her ethanol level was 202 mg/dL (to convert to millimoles per liter, multiply by 0.2171); magnesium, 1.7 mg/dL (to convert to millimoles per liter, multiply by 0.4114); potassium, 4.4 mEq/L (to convert to millimoles per liter, multiply by 1); and ionized calcium, 4.6 mg/dL (to convert to millimoles per liter, multiply by 0.25).", "Echocardiography demonstrated a left ventricular ejection fraction of 50% and no regional wall motion abnormalities.", "Alternans in T-wave polarity is evident in most leads (especially V3-V6) while alternans in T-wave amplitude is seen in leads II and aVF."], "Treatment": ["She subsequently underwent embolization of the middle meningeal artery.", "As a result, on the 11th day of her hospitalization, she had a burr hole evacuation."], "Others": ["The patient developed cardiac arrest due to ventricular arrhythmias in the emergency department and was successfully resuscitated.", "After embolization, however, a worsening rightward midline shift was discovered.", "During day 15 of admission, the patient had 3 episodes of torsade de pointes (TdP) while receiving 50 mg of metoprolol succinate daily, and her 12-lead electrocardiogram (ECG) is shown in Figure 1.The 12-lead electrocardiogram obtained on day 15 of admission."]}
{"Patient Symptoms": ["However, suddenly, the patient developed acute onset of dyspnea along with retrosternal chest pain."], "Examination and Results": ["On physical examination, her pulse was 70 beats per minute, and blood pressure was 110/70 mm Hg.", "The cardiovascular examination showed a loud S1, normal S2, and an opening snap along with a mid-diastolic, soft, rumbling murmur at the apex of the heart.", "The electrocardiogram showed normal sinus rhythm with left atrial enlargement.", "The echocardiogram showed severe mitral stenosis with a mitral valve area of 0.9 cm2 with a mean (SD) gradient of 20 (4) mm Hg.", "There was no evidence of any subvalvular thickening, leaflet calcification, or mitral regurgitation."], "Treatment": ["The patient was taken for balloon mitral valvotomy (BMV).", "A 6F pigtail catheter was placed in the left ventricle via the right femoral artery.", "The interatrial septum was punctured using a Mullins sheath and Brockenbrough needle via the right femoral vein.", "Entry into the left atrium was made and confirmed with a dye injection."], "Others": ["Her blood pressure at the time of the event was 100/60 mm Hg, pulse was 70 beats per minute, and oxygen saturation was 96%.", "The catheter was pulled back into the right atrium, and chest fluoroscopy was performed (Figure; Video).The fluoroscopy image of the patient at the time of dyspnea."]}
{"Patient Personal Background": ["Two years ago, she underwent uncomplicated right cataract surgery at a different center.", "Her postoperative course had been complicated by persistent low-grade anterior uveitis for which she received maintenance loteprednol, 0.5%, eye drops on alternate days.", "Her medical history was only significant for hypertension, which was well controlled with ramipril.", "She denied any ocular trauma or recent travel outside of the country.", "Review of systems was unremarkable.Slitlamp photographs of the right eye showing 2 darkly pigmented corneal lesions (A) and the location of the lesion on the right corneal endothelium and stroma (B)."], "Examination and Results": ["The third lesion is covered by the upper eyelid.On examination, her visual acuity was 20/80 OD and 20/20 OS.", "Her intraocular pressures measured 17 mm Hg OD and 15 mm Hg OS.", "The right sclera and conjunctiva were white with 3 distinct hyperpigmented corneal lesions affecting the corneal endothelium and stroma (Figure 1B).", "There were 2+ cells in the anterior chamber and 1+ vitritis."], "Treatment": ["She also used latanoprost eye drops at night in both eyes for primary open-angle glaucoma."]}
{"Patient Personal Background": ["He previously received failed systemic and radiation therapy for tumor stage mycosis fungoides (MF).", "He had received 11 courses of extended beam radiation therapy, including 3 courses of total skin irradiation of 24 to 30 Gy, and focal irradiation to the left posterior thigh and hip/buttock with 2.5/3 Gy to 12.5/24 Gy, respectively, and the right posterior thigh and hip with 2 Gy to 20 and 26 Gy, respectively.", "His post-transplant course was complicated by severe chronic graft vs host disease of the skin, eyes, and gut, for which he received systemic corticosteroid therapy, tacrolimus, methotrexate, and long-term extracorporeal photopheresis."], "Patient Symptoms": ["Three years after the HSCT, he developed chronic ulcerations on the hips, back, and arms at the site of previously irradiated tumors, as well as multiple friable, hemorrhagic, and bleeding nodules on bilateral hips and his forearms while receiving treatment with corticosteroids and extracorporeal photopheresis.", "In this latest visit, physical examination revealed recurrent hemorrhagic and friable nodules on his left lateral hip and left lateral buttock (Figure 1).", "Similar nodules were noted on his right hip and forearm."], "Examination and Results": ["The patient underwent repeated debulking and biopsy.", "Positron emission tomography (PET) computed tomography (CT) results did not show evidence of visceral or extracutaneous disease.Recurrent hemorrhagic and friable nodules on the left lateral hip."], "Treatment": ["He underwent several debulking procedures and excision biopsies of the nodules, which revealed granulation tissue on histology.", "He was also treated with micafungin, amphotericin B, levofloxacin, dapsone, acyclovir, pentamidine, penicillin VK, and posaconazole."], "Others": ["Seven years before this visit, he underwent a reduced-intensity, matched, unrelated donor, allogeneic hematopoietic stem cell transplant (HSCT)."]}
{"Patient Personal Background": ["Active medical issues included hypertension, very poorly controlled type 2 diabetes, hyperlipidemia, tobacco use, and asthma.", "Her brother and father both had a history of chronic orbital swelling."], "Patient Symptoms": ["She also reported bilateral rhinorrhea, congestion, and right frontal and temporal headaches."], "Examination and Results": ["Vital signs were unremarkable, and examination of the right eye showed moderate chemosis, injected conjunctiva, and periorbital edema.", "Both eyes were proptotic, right worse than left.", "She had normal bilateral extraocular movements, pupillary light reflexes, and gross vision.", "Computed tomography with contrast revealed bilateral ethmoid and frontal sinus opacification and right worse than left orbital fat stranding (Figure 1A).", "Magnetic resonance imaging with contrast demonstrated both enlargement and enhancement of bilateral extraocular muscles, especially the right superior rectus (Figure 1B).", "Both orbital and nasal cultures grew methicillin-resistant Staphylococcus aureus.", "Orbital biopsy showed nodular lymphoplasmacytic infiltrates without evidence of fungal infection or necrosis (Figure 1C).", "Further workup revealed elevated erythrocyte sedimentation rate, C-reactive protein, total IgG, and IgG4 levels and normal white blood cell count, thyroid-stimulating hormone, angiotensin-converting enzyme, lysozyme, antinuclear antibody, and antineutrophil cytoplasmic antibody (ANCA) levels.A, Computed tomography with contrast revealed bilateral ethmoid and frontal sinus opacification and right worse than left orbital fat stranding."], "Treatment": ["Initially she was started on antibiotic therapy.", "Right nasal biopsy, right endoscopic sinus surgery, and right anterior superior orbital tissue biopsy were performed."], "Others": ["Intraoperatively, the sinus mucosa demonstrated only edema and mild secretions, but there was no necrosis or purulence."]}
{"Patient Symptoms": ["Four days after treatment, a white head formed overlying the tumor that erupted through the skin surface (Figure 1).", "Thin, cloudy discharge that was not foul-smelling drained from the tumor from posttreatment days 5 to 10, at which point the drainage stopped spontaneously."], "Examination and Results": ["Laboratory results on days 5, 9, and 14 demonstrated the absence of leukocytosis, and serial wound cultures failed to demonstrate pathogenic growth."], "Treatment": ["The patient completed the neoadjuvant immunotherapy and underwent a margin-negative tumor resection without intraoperative or postoperative complications.This photo documents clinical tumor behavior after neoadjuvant immunotherapy treatment."], "Others": ["Throughout, the patient reported no pain and remained afebrile.", "No antibiotics were administered."]}
{"Patient Symptoms": ["Since the initial onset, the bruise and pain had persisted despite icing and resting the area."], "Examination and Results": ["She denied any personal or family history of bleeding disorders.On examination, an ill-defined indurated blue-green plaque was noted on the dorsum of the left hand (Figure 1).", "Radiography results showed soft tissue swelling but were otherwise unremarkable.", "Subsequent magnetic resonance imaging showed a heterogeneously fluid hyperintense and T1 heterogeneously hyperintense lesion measuring approximately 1.6\u2009\u00d7\u20090.5\u2009\u00d7\u20092.9 cm that was centered within the dorsal subcutaneous soft tissue of the hand."], "Treatment": ["An excision was performed."]}
{"Patient Personal Background": ["She denied any new medications or exposure to chemotherapy, imaging with intravenous contrast, or recent travel."], "Patient Symptoms": ["The rash initially developed on the patient\u2019s legs 13 days before presentation and subsequently progressed to her feet, arms, hands, and trunk.", "Associated symptoms included a burning sensation and occasional pain."], "Examination and Results": ["On physical examination, there were numerous erythematous edematous coalescing papules and plaques on the upper and lower extremities and scattered erythematous papules and plaques on the back and buttocks (Figure, A).", "Some plaques were annular and polycyclic in configuration, with central hyperpigmentation (Figure, B).", "A complete blood cell count was notable for an eosinophilia of 11%, with an absolute cell count of 0.80 \u00d7103/uL.", "Results from a comprehensive metabolic panel were normal.", "A biopsy was performed on her right thigh for histopathological examination.A, Clinical photographs show numerous erythematous edematous coalescing papules and plaques on the bilateral upper and lower extremities."], "Treatment": ["Her medical history was notable for endometrial adenocarcinoma status post hysterectomy and recent postoperative radiotherapy (total of 50.4 Gy in 28 fractioned doses), which was completed 4 days after the onset of the rash."], "Others": ["The remainder of her review of systems was unremarkable.", "Her chest, abdomen, face, and oral mucosa were clear.", "B, Some plaques were annular and polycyclic in configuration with central hyperpigmentation."]}
{"Examination and Results": ["On arrival to the emergency department, his vital signs were stable.", "Serum electrolyte levels were within normal range and C-reactive protein was less than 6 mg/dL (to convert to milligrams per liter, multiply by 10).", "High-sensitivity troponin peaked at 1078 pg/mL.", "He continued in sinus rhythm with episodes of nonsustained ventricular tachycardia observed on telemetry, as shown in Figure 1B.", "Cardiac catheterization revealed patent coronary arteries.", "Cardiac magnetic resonance imaging was remarkable for a dilated right ventricle with moderately reduced systolic function and transmural late gadolinium enhancement with akinesis and dyskinesis involving the right ventricular (RV) free wall and outflow tract extending to the left ventricular (LV) anterior, septal, and apical segments.Electrocardiogram (ECG) and telemetry."], "Treatment": ["He was administered a 150-mg bolus of intravenous amiodarone, which failed to terminate his arrhythmia.", "He ultimately required synchronized cardioversion with a biphasic direct current shock of 100 J."], "Others": ["Emergency medical services found him to be in a wide complex tachycardia.", "His initial 12-lead ECG is shown in Figure 1A.", "A, Twelve-lead ECG on arrival to the emergency department."]}
{"Patient Personal Background": ["He had no history of tobacco, alcohol, or drug misuse."], "Patient Symptoms": ["In the past month, he felt neck stiffness, accompanied by swelling and persistent dull pain of the upper anterior chest wall, which could be transiently relieved by taking oral ibuprofen.", "Six days before admission, the patient\u2019s neck stiffness transited to an endurable dull ache.", "When turning his head, there was severe burning pain in the posterior neck and occiput, followed immediately by an electric shocklike numbness on ipsilateral side tongue, which led to a forced head position.", "In the past 3 days, with the intensification of neck pain, the patient found pustules on both hands, which gradually increased."], "Examination and Results": ["Magnetic resonance imaging of the cervical spine with gadolinium on admission revealed signal abnormality in C1/C2 vertebrae (Figure 1A).", "On examination, he was afebrile.", "There was tenderness in the right sternoclavicular articulation, upper neck, post aurem, and occiput.", "Multiple pustules were seen in the palm and back of both hands (Figure 1B).", "Complete blood cell count and liver and kidney function yielded normal results, except for elevated erythrocyte sedimentation rate (ESR) of 93 mm/h and C-reactive protein (CRP) level of 5.5 mg/dL (to convert to milligrams per liter, multiply by 10).", "Results of workup for rheumatic and infectious disease, including antinuclear, antineutrophil cytoplasmic and anticardiolipin antibodies, human leukocyte antigen B27, repeated blood cultures, rapid plasma reagin test, Aspergillus galactomannan antigen, brucella, Mycobacterium tuberculosis, and rickettsial antibodies, were all negative.", "Cell count, protein, and glucose in cerebrospinal fluid were normal.", "Cultures of cerebrospinal fluid revealed no organisms.", "Whole-body fluorodeoxyglucose\u2013positron emission tomography/computed tomography revealed no malignancy.Abnormal enhancement of C1/C2 vertebrae with prevertebral and retrodental tissue as well as of the anterior vertebrae at C4/C5 with hyperostotic anterior osteophytes on magnetic resonance imaging (MRI) (A) and multiple pustules on the palm (B)."]}
{"Patient Personal Background": ["He was taking no regular daily medications, did not smoke cigarettes, and had no history of oral trauma.", "Over the prior 6 months, he reported sexual contact with 1 male partner."], "Patient Symptoms": ["The patient reported no sore throat, dysphagia, hoarse voice, cough, dyspnea, nausea, vomiting, headache, fever, night sweats, weight loss, rash, or genital, rectal, or oral ulcers over the past 6 months."], "Examination and Results": ["Physical examination revealed irregular gray-white ulcers with a surrounding erythema on the soft palate, uvula, and tonsils (Figure 1) and nontender bilateral submandibular lymphadenopathy.", "His tongue was of normal appearance, and he had no skin lesions or mucosal erosions in the anal or genital areas.Patient presentation showing irregular gray-white pseudomembranous ulcerated plaques on an erythematous base on the soft palate, uvula, tonsils, and posterior pharynx."], "Treatment": ["These findings developed over the prior week and did not improve after treatment with 3 days of oral cefuroxime."], "Others": ["The white appearance on the tongue is a cotton swab."]}
{"Patient Personal Background": ["His family history was significant for non-Hodgkin lymphoma (mother) and leukemia (mother and maternal grandfather)."], "Patient Symptoms": ["He reported intermittent dull pain in his left eye for 1 month that improved with acetaminophen."], "Examination and Results": ["On examination, his best-corrected visual acuity was 20/25 OD and 20/200 OS, limited by keratoconus.", "Extraocular movements were full, there was no relative afferent pupillary defect, and intraocular pressures were 13 mm Hg OD and 11 mm Hg OS.", "There was no proptosis.", "Anterior segment examination demonstrated keratoconus with corneal scarring in both eyes and Descemet folds in the left eye.", "Both eyes had mixed cataract.", "There were no signs of anterior segment or vitreous inflammation.", "Ophthalmoscopic examination revealed an amelanotic area of choroidal thickening (confirmed by optical coherence tomography) overhanging the inferonasal margin of the optic disc with associated subretinal fluid and scattered areas of hyperpigmentation (Figure 1A).", "There was an additional, subtle amelanotic elevated lesion under the fovea.", "Fundus autofluorescence demonstrated hyperautofluorescence in a leopard-spotting pattern (Figure 1B).", "Indocyanine green angiography revealed hypocyanescent lesions inferonasal to the disc and at the fovea.A, Montage color fundus photograph of the left eye demonstrating a 14\u2009\u00d7\u200912\u2009\u00d7\u20092.0-mm nasal peripapillary lesion with mottled overlying areas of hyperpigmentation (arrowheads)."]}
{"Examination and Results": ["On examination, best-corrected visual acuity was 20/20 OU and intraocular pressures were normal in both eyes at 10 mm Hg.", "Slitlamp biomicroscopy of the anterior chamber was within normal limits in both eyes.", "Dilated fundus examination revealed normal findings in the right eye and clear vitreous with a subretinal mass in the left eye inferior to the optic disc and measuring 3\u2009\u00d7\u20092 mm in base.", "Color fundus photography of the left eye (Figure, A) showed an amelanotic lesion under the retina inferior to the optic disc and 3 mm from the foveola surrounded by a subtle orange halo.", "Fundus autofluorescence (Figure, B) showed the lesion to be hyperautofluorescent.", "Optical coherence tomography (OCT) imaging of the lesion showed the mass was primarily in the sclera and pushed and thinned the overlying choroid (Figure, C).A, Color fundus photography of the left eye showing a 3\u2009\u00d7\u20092-mm yellow lesion with orange halo 0.5 mm inferior to the optic disc.", "B, Fundus hyperautofluorescence of the lesion."]}
{"Patient Personal Background": ["He had a history of metabolic syndrome treated with antihypertensives and oral hypoglycemics."], "Patient Symptoms": ["He had noticed the rash a few days after receiving the second dose of an mRNA COVID-19 vaccine (Moderna).", "He denied itching, weeping, bleeding, or discharge from the rash or the nipple."], "Examination and Results": ["The physical examination showed a morbidly obese White man.The skin examination showed a 19\u2009\u00d7\u200910-cm pink, fallacious purple color deep-infiltrated papule in the left breast and a similar 15\u2009\u00d7\u20097-cm papule under the left clavicle (Figure, A).", "The breast examination was notable for bilateral gynecomastia and inverted left nipple without any palpable lumps.", "No lymphadenopathy was noted either.", "His laboratory results showed stage 2 chronic kidney disease.", "Results of a viral panel including hepatitis A, B, and C and HIV were negative.", "The punch biopsy of the skin showed a diffuse island of atypical cells in the dermis (Figure, B).", "On immunohistochemical staining, the atypical cells stained positive for CK-7, GATA-3, and PAX-8 (weak focal staining) and negative for estrogen receptor (ER)/progesterone receptor (<1%), TTF-1, SATB-2, CDX-2, and NKX-3.1.", "The positron emission tomography\u2013computed tomography scan showed a diffuse, infiltrating fluorodeoxyglucose (FDG)-avid cutaneous lesion on the left chest wall (standardized uptake value, 6.5) and multiple FDG-avid nodes in the axilla (bilaterally), left internal mammary, and left cervical chain."], "Others": ["The core biopsy from the lymph node is shown in the Figure, C.A, Rash on the left chest wall."]}
{"Patient Personal Background": ["On further questioning, he had a similar mass that was treated with liposuction 10 years prior.", "His family history was negative for any head and neck benign or malignant disease.", "His social history was negative for tobacco or alcohol use.", "This patient was not taking any steroid medications.Physical examination showed an enlarged right more than left-sided neck mass."], "Patient Symptoms": ["The growing neck mass was causing solid food dysphagia and difficulty breathing at night."], "Examination and Results": ["He did not have any neurological deficits.", "It was tense but compressible to palpation.", "Flexible fiber-optic laryngoscopy showed a crowded oropharynx with lingual tonsil hypertrophy and narrow oropharynx and hypopharynx.", "An outside computed tomography scan showed diffuse symmetric fatty infiltration of the pharynx, larynx, trachea, and esophagus.", "A magnetic resonance imaging scan with and without contrast (Figure, A) showed extensive areas of fat deposition within the neck that bilaterally extended from the level of C1 in the retropharyngeal space to the level of the sternal notch.", "Given that the patient was symptomatic, surgical intervention was recommended.Preoperative magnetic resonance imaging (A) and gross specimen (B).Surgery was approached like a neck dissection."], "Treatment": ["The entire specimen was removed, including its capsule, which measured 17.0\u2009\u00d7\u200914.0\u2009\u00d7\u20095.0 cm (Figure, B).", "Six months later, a postsurgical magnetic resonance imaging scan showed that the fat prominence had largely been resected."], "Diagnosis": ["The patient was seen and evaluated by a local surgical oncologist with a working diagnosis of possible lymphoma."]}
{"Patient Personal Background": ["There was nonconsanguineous marriage of his parents, and no family members had similar lesions.", "The patient was otherwise in good general health and without developmental delay."], "Examination and Results": ["Some of the eruptions on his trunk had spontaneously resolved with developmental growth.", "Physical examination showed generalized, linear hyperkeratotic papules with numerous central small filiform keratotic white spicules and brown plugs on the head, face, neck, trunk, and bilateral upper and lower extremities (Figure, A and B), including his palms and soles along Blaschko lines, accompanied with alopecia of the scalp and eyebrows.", "The examination of nails, mucosae, and teeth was unremarkable.", "No extracutaneous involvement was observed.", "Dermoscopic examination showed many central white spines on the face (Figure, C) and brown cores surrounded by yellow crater-like rings on the right palm.", "A skin biopsy specimen was taken from the hyperkeratotic papules with white spicules on his right thigh (Figure, D).A, Generalized, linear hyperkeratotic papules and plaques with numerous white spicules and plugs on the head, face, neck, and both arms are accompanied by alopecia of the scalp and eyebrows.", "B, Generalized hyperkeratotic papules with numerous central small filiform keratotic white spicules on the face (close-up view).", "C, Dermoscopic examination on the face showing many central whitish spines.", "D, Skin biopsy specimen taken from the right thigh showing hyperkeratosis, acanthosis, and parakeratotic columns overlying the dilated epidermal invaginations, as well as thinner granular layers and dilated eccrine ostia and acrosyringia under the parakeratotic columns (hematoxylin-eosin)."]}
{"Patient Symptoms": ["These lesions started as itchy, weepy, reddish papules and plaques, which gradually progressed to form ulcers and were associated with pain and pus discharge.", "They did not heal completely after multiple courses of topical as well as systemic antibiotics, antifungals, and steroids.", "She frequently experienced scaling and greasiness on her scalp, which was treated with shampoos and topical steroids.", "She also complained of polyuria and polydipsia for the past 4 years.General examination revealed multiple mobile, firm, nonmatted, and nontender lymph nodes in cervical and inguinal region."], "Examination and Results": ["On systemic examination, hepatomegaly (2 cm below the right costal margin) was seen.", "There was also bilateral enlargement of the parotid area, which was tender on palpation.", "Cutaneous examination revealed yellowish greasy scales on the scalp, suggestive of seborrheic dermatitis.", "Erythematous edematous papules were present over the retroauricular areas and the inframammary folds (Figure, A).", "On examination of external genitalia, deep ulcers were observed in the bilateral inguinal folds, resembling knife-cut ulcers (Figure, B).", "Similar lesions were present over the junction of labia majora and labia minora and were associated with yellowish pus discharge."], "Treatment": ["They did not heal completely after multiple courses of topical as well as systemic antibiotics, antifungals, and steroids.", "She frequently experienced scaling and greasiness on her scalp, which was treated with shampoos and topical steroids."]}
{"Patient Personal Background": ["Current medications included carvedilol, 25 mg, twice daily and apixaban, 5 mg, twice daily."], "Patient Symptoms": ["Review of prior physician encounters revealed reports of lightheadedness and electrocardiograms (ECGs) with atrial fibrillation with ventricular rates of 40 to 50 beats per minute."], "Examination and Results": ["An ECG (Figure, A) showed atrial fibrillation with an irregular ventricular rate of around 60 beats per minute, right bundle branch block (RBBB), and left posterior fascicular block (LPFB).Comparison of current (A) and past (B) electrocardiogram (ECG) findings.Telemetry revealed heart rates of 50 to 60 beats per minute, which did not change with activity.", "Findings of echocardiography were unremarkable."], "Others": ["We reviewed a prior ECG (Figure, B)."]}
{"Patient Personal Background": ["His medical history was significant for thyroid cancer treated with total thyroidectomy resulting in a chronic left accessory nerve injury, type 2 diabetes, hypertension, and gout.", "His medications were metformin, allopurinol, perindopril, thyroxine, and rabeprazole.", "He had no history of smoking and drank 3 glasses of wine per week.", "His family history was unremarkable.Examination revealed significant wasting of proximal and paraspinal muscles with a flexed spine posture in the upright position (Figure 1A)."], "Patient Symptoms": ["He reported a 20-kg weight loss and numbness to the ankles.", "He had symmetric Medical Research Council grade 4/5 weakness of neck flexion, shoulder abduction, elbow flexion and extension, and hip flexion and extension bilaterally.", "He had weakness of left shoulder elevation and winging of the left scapula secondary to the accessory nerve injury."], "Examination and Results": ["Pinprick sensation was reduced in both feet.Lateral profile of the patient (A) revealing a flexed spine posture (camptocormia) with marked generalized muscle atrophy.", "B, A G\u00f6m\u00f6ri trichrome stain of frozen left vastus muscle (original magnification \u00d7400) reveals 3 atrophic muscle fibers with a patchy granular appearance (red arrowheads).Metabolic, endocrine, autoimmune, and infectious screens had unremarkable findings.", "Creatine kinase levels were normal.", "A myositis panel demonstrated low-positive Mi2 antibodies.", "Serum electrophoresis and immunofixation identified a small immunoglobulin G (IgG) \u03ba paraprotein with normal findings on bone marrow biopsy.", "A whole-body positron emission tomography scan was normal.", "Nerve conduction studies revealed a mild axonal sensorimotor polyneuropathy.", "Concentric needle electromyography showed no spontaneous activity with widespread small, brief, polyphasic units, particularly in proximal and axial muscles, consistent with a myopathic process.", "Because the patient\u2019s symptoms were worsening, a second muscle biopsy of vastus lateralis was performed."], "Others": ["His deep tendon reflexes were normal and symmetric.", "An initial deltoid muscle biopsy did not show evidence of myopathy."]}
{"Patient Symptoms": ["She described infrequent abrupt awakenings with a sensation of breathlessness but reported no witnessed apnea.", "She had fatigue but no headaches or excessive daytime sleepiness."], "Examination and Results": ["Her blood pressure was 182/97 mm Hg, oxygen saturation was 98%, and body mass index was 51.3 (calculated as weight in kilograms divided by height in meters squared).", "The remainder of her physical examination findings were normal.", "Laboratory evaluation revealed a serum bicarbonate level of 24 mEq/L (reference range, 23-29 mEq/L).", "The patient underwent home sleep testing using a home sleep test device."], "Treatment": ["Results are presented in the Table.Advise use of a wedge pillow to avoid sleeping in the supine position."]}
{"Patient Personal Background": ["He also had mild chronic macular edema in both eyes after remote cataract surgery and vitrectomy with membrane peel in both eyes.", "Two years prior, he underwent Baerveldt tube shunt in his left eye, and his IOP since surgery had been 8 to 14 mm Hg.", "Ophthalmic medications on presentation were timolol eye drops twice daily, brinzolamide-brimonidine eye drops 3 times daily, bimatoprost eye drops every night at bedtime, bromfenac eye drops once daily, and fluorometholone eye drops twice daily in both eyes.During his visit, the patient complained of severe physical exhaustion, syncopal episodes, dysphagia, and sinus congestion."], "Patient Symptoms": ["On external examination, he had diffuse facial edema and erythema without proptosis."], "Examination and Results": ["Slitlamp examination showed mild chemosis and hyperemia in both eyes and a patent Baerveldt tube ostium in the midanterior chamber with normal bleb morphology without a tense capsule.", "A 24-2 Humphrey visual field showed new glaucoma progression in the left eye (Figure 1).A, A 24-2 Humphrey visual field (HVF) of the left eye after tube shunt showed superior and inferior arcuate defects.", "The mean deviation (MD) was \u22128.57 dB; pattern standard deviation (PSD), 6.53 dB; and visual field index (VFI), 81%.", "B, Two years later, 24-2 HVF showed worsening defects."]}
{"Patient Symptoms": ["The swelling worsened over the following 3 weeks despite use of warm compresses and a course of doxycycline prescribed by his outside eye care professionals.", "He had progressive binocular diplopia and right periorbital pain, swelling, and redness.", "Blurriness of the right eye that started the week before presentation eventually caused enough concern that the patient presented to his local emergency department where magnetic resonance imaging (MRI) of the brain and orbits revealed an intraconal mass (Figure, A)."], "Examination and Results": ["He then came to our institution\u2019s emergency department for urgent ophthalmology consultation.A, Magnetic resonance imaging (MRI) axial T1 orbit fat-suppressed postcontrast image shows a right retro-orbital intraconal lesion (asterisk) with intrinsic T1 hyperintensity but without fat saturation or enhancement.", "The lesion causes proptosis (difference between the dotted lines) and posterior globe flattening (white arrowheads).", "B, B-scan ultrasonography of the right eye shows a well-circumscribed and homogenous lesion with low internal reflectivity (asterisk) sitting directly behind the globe (left).", "There is a possible thin septation (white arrowheads).His examination revealed a visual acuity of 20/60 OD and 20/20 OS, intraocular pressures of 24 mm Hg and 17 mm Hg in the right and left eyes, respectively, and a normal pupil examination without a relative afferent pupillary defect.", "His right eye had 5-mm relative proptosis, hyperglobus, supraduction deficit, conjunctival injection, grade IV optic disc edema, and choroidal folds.", "An ultrasonography examination revealed a 2.0 \u00d7 2.5-cm echolucent avascular lesion (Figure, B)."], "Treatment": ["The swelling worsened over the following 3 weeks despite use of warm compresses and a course of doxycycline prescribed by his outside eye care professionals."]}
{"Examination and Results": ["Computed tomography (CT) of the neck with contrast at his initial hospital admission was concerning for suppurative lymphadenitis.", "Results of subsequent workup\u2014including Haemophilus, tetanus, and pneumococcal antibody titers; QuantiFERON-TB Gold test; serum IgG, IgM, IgA, and IgE levels; absolute lymphocyte count; neutrophil phenotype and function; angiotensin-converting enzyme level; HLA-B27 test; and antinuclear antibody level\u2014were within normal limits.", "Magnetic resonance imaging of the neck with gadolinium contrast demonstrated bilateral, bulky, enlarged cervical lymph nodes, as well as enhancing nodules in the left laryngeal ventricle (2.3\u2009\u00d7\u20091.6\u2009\u00d7\u20091.2 cm), right false vocal cord, and right tracheal wall (0.6\u2009\u00d7\u20090.4 cm).", "Findings from nasal endoscopy, awake flexible laryngoscopy, and operative microlaryngoscopy revealed yellow submucosal masses in the left nasal cavity, left laryngeal ventricle, and right trachea, as well as left vocal cord paresis (Figure, A).", "Histopathologic examination revealed a prominent infiltrate of benign-appearing histiocytes with numerous forms showing emperipolesis and some nuclei showing distinct central nucleoli.", "Immunohistochemical staining in these cells was positive for S100 and negative for CD1a.A, Awake flexible laryngoscopy showing a yellow mucosal mass in the left laryngeal ventricle."], "Treatment": ["Despite incision and drainage, and intravenous ampicillin and sulbactam, his cervical lymphadenopathy persisted.", "Biopsies were taken of the tracheal, laryngeal, and nasal cavity masses, and an excisional biopsy was taken of a left cervical lymph node (Figure, B)."]}
{"Patient Personal Background": ["Subsequently, the practitioner referred the patient to an otolaryngologist.The patient denied any enlarged lymph nodes, fevers, fatigue, rash, weight loss, or abnormal gastrointestinal symptoms and had no noteworthy medical history.", "He reported mild alcohol consumption, denied any cigarette or illicit substance use, and endorsed engaging in oral and anal intercourse.A physical examination was notable for bilateral raised leukoplakia on the tongue; it was larger on the right side than the left and had a slightly hairy appearance."], "Patient Symptoms": ["He stated that the pain was exacerbated by spicy foods.", "He had initially presented to a primary care practitioner, was prescribed clotrimazole lozenges, and reported mild initial improvement followed by symptom progression."], "Examination and Results": ["The lesion was tender to touch and could not be scraped off (Figure 1A).", "The lips and oral mucosa were without lesions, masses, or ulcers.", "The patient had no cervical lymphadenopathy.", "The findings of the physical examination were otherwise unremarkable.A, Clinical image of the right anterolateral tongue showing a 1\u2009\u00d7\u20093 cm plaque over tongue mucosa.", "Left lateral tongue (not shown) had multiple gray papular lesions with similar appearance.", "B, Hematoxylin-eosin stain of right tongue biopsy specimen revealing prominent lymphoplasmacytic infiltrate involving squamous mucosa; no cellular atypia is seen among lymphocytes.A biopsy procedure of the right oral tongue lesion was performed, and hematoxylin-eosin staining of the specimen revealed dense perivascular plasmacytic infiltration and neutrophilic inflammation (Figure 1A)."], "Treatment": ["He had initially presented to a primary care practitioner, was prescribed clotrimazole lozenges, and reported mild initial improvement followed by symptom progression."]}
{"Examination and Results": ["On clinical examination, visual acuity measured 20/70\u2009+\u20091 in the right eye and 20/100 in the left eye, while she previously had visual acuity of 20/25 in each eye on examination 8 years prior.", "Motility, visual fields, and anterior segment examination results were normal.", "Dilated fundus examination revealed subtle reddish geographic irregularities at the level of the retinal pigment epithelial at a nasal juxtafoveal location in both eyes.", "The optic discs, vessels, and periphery were normal.", "Near-infrared (IR) imaging highlighted the irregularities in both eyes (Figure 1).Near-infrared imaging of the right eye (A) and left eye (B) demonstrates juxtafoveal irregularity.", "The foveal regions have subtle juxtafoveal geographic areas (white arrowheads), mostly nasal to the foveal center in both eyes (A\u2009>\u2009B)."]}
{"Patient Personal Background": ["She denied experiencing a stressful event recently, and no habitual pulling of hair was observed by her family."], "Patient Symptoms": ["Since the age of 1 year, the girl had begun to have frequent hair loss without pulling.", "Her mother also found that her hair grew to approximately the same maximum length down to the upper neck without trimming."], "Examination and Results": ["Her scalp hair was relatively normal in terms of density and length at birth.", "On clinical examination, diffuse, short, sparse, lanugolike, black hair over the scalp was found (Figure, A and B).", "The surface of the scalp was smooth without inflammatory changes or focal alopecic patches.", "No involvement of eyebrows, eyelashes, nails, teeth, or body hair was found.", "Her intellectual performance was normal at presentation and no developmental delay had ever been noted.", "C, Punch biopsy showed a mild lymphocytic perifollicular infiltrate and increased telogen hair with decreased anagen-to-telogen ratio (hematoxylin-eosin staining, magnification 2x).The hair pull test was positive with predominately anagen hair extracted.", "Light microscopy of scalp hair shafts revealed no structural abnormalities, such as cuticular damage, twisting, bending, or miniaturization.", "Blood levels of ferritin, zinc, and hemoglobin were normal.", "A punch biopsy from the alopecic area of the scalp was performed (Figure, C)."], "Others": ["Family history regarding hair loss was unremarkable.A and B, Diffuse, sparse, and abnormally short hair over the entire scalp is shown."]}
{"Patient Personal Background": ["The patient had no remarkable medical or family history and was not concurrently being treated with any medications.", "She had been previously diagnosed with eczema and treated with topical steroid ointments and oral compound glycyrrhizin tablets, which had no obvious effect.Clinical images of keratotic papules diffusely distributed on an extremity, original (A) and magnified (B).Laboratory investigations, including routine blood, liver and kidney function, antistreptolysin O, C-reactive protein, antinuclear antibody, and rheumatoid factor tests, disclosed no abnormal findings."], "Patient Symptoms": ["The lesions consisted of scattered, erythematous, annular papules measuring up to 5 mm wide (Figure 1).", "Further examination revealed a few asymptomatic brown flat papules scattered on her face; the palms, soles, and oral mucosa were not involved."], "Examination and Results": ["Further examination revealed a few asymptomatic brown flat papules scattered on her face; the palms, soles, and oral mucosa were not involved.", "She had been previously diagnosed with eczema and treated with topical steroid ointments and oral compound glycyrrhizin tablets, which had no obvious effect.Clinical images of keratotic papules diffusely distributed on an extremity, original (A) and magnified (B).Laboratory investigations, including routine blood, liver and kidney function, antistreptolysin O, C-reactive protein, antinuclear antibody, and rheumatoid factor tests, disclosed no abnormal findings."], "Treatment": ["She had been previously diagnosed with eczema and treated with topical steroid ointments and oral compound glycyrrhizin tablets, which had no obvious effect.Clinical images of keratotic papules diffusely distributed on an extremity, original (A) and magnified (B).Laboratory investigations, including routine blood, liver and kidney function, antistreptolysin O, C-reactive protein, antinuclear antibody, and rheumatoid factor tests, disclosed no abnormal findings."], "Others": ["A biopsy specimen was obtained for histopathologic examination."]}
{"Patient Personal Background": ["He had never smoked, was physically active, and did not take any medications."], "Examination and Results": ["His Lp(a) level was elevated at 136 nmol/L and his coronary calcium score of 137 Agatston units was notable and placed him in the 94th percentile for his age (Figure 1)."], "Others": ["He had no traditional risk factors for ASCVD and no cardiac symptoms or limitations.", "His 10-year ASCVD risk was estimated at 1.6% (low risk) based on the pooled cohort equations (PCEs); however, he had 2 risk-enhancing factors: South Asian ancestry and a FHx of premature ASCVD.", "His father had a myocardial infarction at age 39 years, and, importantly, his older brother had angioplasty with multiple stents at age 43 years.", "Additionally, multiple male cousins on his father\u2019s side had coronary artery disease, the details of which were unspecified.Owing to his striking FHx of premature ASCVD, he underwent screening for elevated lipoprotein(a) [Lp(a)] and obtained a coronary calcium score."]}
{"Patient Personal Background": ["The patient had become progressively disabled and had been using a wheelchair for 4 years prior to presentation."], "Patient Symptoms": ["Ataxia was seen on finger-to-nose and heel-knee-shin tests.", "Chorea was present in both legs."], "Examination and Results": ["Neurological examination showed gaze-evoked horizontal nystagmus in both directions along with slow saccades and gaze restriction in both vertical and horizontal planes.", "There was ataxic dysarthria.", "Tone was normal in all 4 limbs but stretch reflexes were absent and plantar fascia were mute.", "Limb power was normal.", "Ankle inversion with bilateral hammertoes was noted.", "Electromyography revealed sensory neuronopathy.", "On brain magnetic resonance imaging (MRI), diffuse cerebellar atrophy was noted along with T2 hyperintensities in bilateral middle cerebellar peduncles, cerebellar white matter, pons, and bilateral thalamus (Figure).", "Psychiatric treatment was commenced for her severe anxiety but did not relieve the fear of falling.Magnetic resonance brain images showing T2 fluid-attenuated inversion recovery hyperintensities."], "Treatment": []}
{"Patient Personal Background": ["She reported no precipitating factors for the pain and had no history of pregnancy, abdominal surgery, or abdominal trauma.", "Over the previous 2 years, the patient had experienced similar intermittent episodes of abdominal pain lasting approximately 1 week."], "Patient Symptoms": ["She had no associated nausea, vomiting, diarrhea, hematochezia, bloating, or anorexia.", "Over the previous 2 years, the patient had experienced similar intermittent episodes of abdominal pain lasting approximately 1 week.", "During palpation of this 1-cm area, the pain increased when she lifted her head and tensed her abdominal muscles."], "Examination and Results": ["Results from laboratory tests, upper endoscopy, colonoscopy, and an abdominal computed tomography scan performed 1 year prior to presentation were normal.In the emergency department, her vital signs were normal and her body mass index was 20.4 (calculated as weight in kilograms divided by the square of height in meters).", "Abdominal examination revealed no rigidity or guarding; however, a 1-cm point of maximal tenderness was identified in the left lower abdominal quadrant (Figure).", "During palpation of this 1-cm area, the pain increased when she lifted her head and tensed her abdominal muscles."]}
{"Patient Symptoms": ["Six days prior to presentation, multiple vesiculobullous lesions appeared on his palms and soles.", "Three days later, he developed erythema; vesicles and erosions on his face, trunk, and limbs; erosions on his lips and oral mucosa; eyelid swelling; and blisters on his anal mucosa.On presentation, his temperature was 38.7 \u00b0C (101.7 \u00b0F); heart rate, 125/min; blood pressure, 98/50 mm Hg; and oxygen saturation, 98% on room air."], "Examination and Results": ["Physical examination revealed bilateral exudative conjunctivitis and white exudates on his tongue, posterior pharynx, and buccal mucosa.", "Erosions with overlying dried blood were noted around his eyes, lips, and anal mucosa.", "He had targetoid erythematous papules on his face and vesiculobullous lesions on his torso and extremities (Figure).", "Auscultation of his lungs revealed bilateral crackles.", "Laboratory testing showed a white blood cell count of 15\u202f000/\u03bcL (82% neutrophils); erythrocyte sedimentation rate, 39 mm/h; and C-reactive protein level, 57.1 mg/L.", "A computed tomography scan of the chest revealed bilateral lower lobe infiltrates."], "Treatment": ["Azithromycin (10 mg/kg daily, intravenously) was started.Patient presentation."], "Others": ["A, Erosions with overlying dried blood around the lips and targetoid erythematous papules on the face.", "B, Vesiculobullous lesions on the trunk and arms.", "C, Vesiculobullous lesions on the palms."]}
{"Patient Personal Background": ["Seven days prior, she inadvertently broke aseptic technique when tightening a leaking connection of her PD catheter tubing."], "Patient Symptoms": ["Physical examination revealed diffuse abdominal tenderness."], "Examination and Results": ["On presentation, she was afebrile and had normal vital signs.", "Physical examination revealed diffuse abdominal tenderness."]}
{"Patient Symptoms": ["Five months after surgery, he presented to the otolaryngology clinic with 3 weeks of mild odynophagia and dysphagia.", "It was noted that the patient had a prominent posterior pharyngeal wall, subtle asymmetry of vocal fold motion, and pooling of secretions in the left pyriform (Video 1).", "During the next 6 months, he gradually developed shortness of breath and stridor, and eventually presented to the emergency department in respiratory distress requiring intubation for 2 days."], "Examination and Results": ["It was noted that the patient had a prominent posterior pharyngeal wall, subtle asymmetry of vocal fold motion, and pooling of secretions in the left pyriform (Video 1).", "Shortly after extubation, laryngeal examination showed fullness of the posterior pharyngeal wall and severely limited vocal fold abduction bilaterally (Figure 1A; Video 1).", "A modified barium swallow study showed intermittent laryngeal penetration without aspiration (Video 2).", "Although the patient was unable to tolerate magnetic resonance imaging, a soft tissue computed tomography scan of the neck with contrast revealed a well-positioned plate with no evidence of fluid collection in the setting of a normal leukocyte count."], "Treatment": ["During the next 6 months, he gradually developed shortness of breath and stridor, and eventually presented to the emergency department in respiratory distress requiring intubation for 2 days."]}
{"Patient Personal Background": ["The mass had been present for decades and multiple prior office visits with referring ophthalmologists, most recently 4 years prior, showed the mass remained stable in size.The patient\u2019s ocular history included cataract extraction with intraocular lens placement and retinal tear of the right eye and cataract of the left eye."], "Examination and Results": ["Visual acuity without correction was 20/20 OD and 20/25+ OS.", "Intraocular pressures were normal.Slitlamp examination of the right eye was unremarkable, and the left eye had a raised pigmented iris lesion without prominent internal vasculature and with mammillations on the surface (multiple small smooth dome-shaped protuberances on the surface of the tumor).", "There were large pigment granules on the surface of the tumor and on the adjacent iris surrounding the mass (Figure 1A).", "There was no ectropion uvea or iris neovascularization.", "There were mild nuclear sclerotic changes across the lens in the left eye.", "Ultrasound biomicroscopy showed a homogeneous intrinsic iris solid tumor with a height of 1.4 mm and basal diameter of 4.1 mm, without angle or ciliary body involvement (Figure 1B).Color slitlamp photograph shows a pigmented iris mass (note both the mammillations [black arrowheads] as well as the pigment granules stuck on the tumor surface [white arrowheads]) (A); ultrasound biomicroscopy shows solid, echogenically homogeneous iris stromal tumor with high internal reflectivity (B)."], "Others": ["Review of systems was negative for any recent changes in health, weight loss, fever, or night sweats."]}
{"Patient Personal Background": ["His medical history was remarkable for mild anemia because of untreated hemorrhoids."], "Patient Symptoms": ["He denied systemic complaints such as weakness, fever, night sweats, or weight loss."], "Examination and Results": ["Physical examination revealed numerous symmetrically distributed, well-defined, erythematous skin nodules on his back, buttocks, and limb extensors (Figure, A).", "Prominent lymphadenopathies on bilateral cervical, axillary, and inguinal lymph nodes were noted, with the largest lymph node measuring approximately 5\u2009\u00d7\u20092 cm.", "Laboratory tests were significant for atypical lymphocytes in the peripheral blood (count up to 6%), an elevated CD4+/CD8+ lymphocyte ratio (9.21; normal range, 0.7-3.1), moderate anemia (hemoglobin level, 8.7 g/dL; normal range, 11.5-15.0 g/dL [to convert to g/L, multiply by 10.0]), a high erythrocyte sedimentation rate (35 mm/h; normal range, 0-25 mm/h), and cryoglobulins composed of mixed polyclonal immunoglobulins.", "The platelet count (161\u2009\u00d7\u2009103/\u03bcL; normal range, 125-350\u2009\u00d7\u2009103/\u03bcL [to convert to \u00d7109/L, multiply by 1.0]) and lactate dehydrogenase (217 U/L; normal range, 100-240 U/L [to convert to \u03bckat/L, multiply by 0.0167]) were normal.", "Quantification of Epstein-Barr virus (EBV) DNA showed high loads of virus in the peripheral blood (846 copies/mL in serum, 27\u202f700 copies/mL in lymphocytes; normal range, <500 copies/mL).", "B, Skin biopsy sample showed infiltration of atypical lymphocytes and histiocytes with proliferation of high endothelial venules (hematoxylin-eosin).", "C, In situ hybridization was positive for Epstein-Barr virus in the skin."], "Treatment": ["Oral glucocorticoids did not show any therapeutic effect."], "Others": ["A biopsy specimen from a skin nodule was sent for histopathologic examination (Figure, B).A, Physical examination showed widespread, symmetrically distributed, well-defined nodules on the trunk and extremities."]}
{"Patient Personal Background": ["He reported occasional alcohol intake, and there was no history of tobacco-related habits or oral trauma."], "Patient Symptoms": ["Intraoral examination revealed multiple yellowish to erythematous papules and verrucous cobblestone-like plaques on the mucosal surface on both sides of his tongue (Figure, A and B)."], "Examination and Results": ["The skin of the face, neck, arms, and other sun-exposed areas did not reveal any associated lesions.", "The results of laboratory investigations, including a complete blood cell count, serum chemistry panel, liver and kidney function test, C-reactive protein levels, lipid profile, and serum and urine electrophoresis disclosed no abnormalities.", "C and D, Circumscribed eosinophilic, amorphous fissured masses in the subepithelial connective tissue (hematoxylin-eosin)."], "Treatment": ["With the clinical suspicion of squamous cell carcinoma, an incisional biopsy was performed (Figure, C and D).Yellowish plaques in a cobblestone pattern on the right (A) and left (B) side of the tongue."]}
{"Patient Symptoms": ["The patient developed a rash on the dorsal aspect of his hand half a year ago without any pain or itching discomfort and denied any history of injury or exposure to suspected pathogens prior to onset.", "After self-medication with topical herbal medicine, the lesions gradually spread to the forearm and fused into plaques, and ulcers often recurred on the surface."], "Examination and Results": ["Physical examination revealed large, firm, mildly swollen erythematous plaques on the back of the left forearm with purulent discharge and crusting (Figure, A).", "Results of routine laboratory investigations, including complete blood cell count, biochemical profile, and chest radiography, were normal.", "B, Hyperkeratosis, pseudoepitheliomatous hyperplasia, and lymphohistiocytic infiltrate with neutrophils, plasma cells, and a small amount of multinucleated giant cells in the dermis (hematoxylin-eosin)."], "Treatment": ["After self-medication with topical herbal medicine, the lesions gradually spread to the forearm and fused into plaques, and ulcers often recurred on the surface."], "Others": ["He denied any systemic symptoms and concerns.", "A biopsy specimen was taken for pathological examination (Figure, B-D).A, A large, firm, mildly swollen erythematous plaque with purulent discharge and crusting on the back of the left forearm.", "C, Periodic acid\u2013Schiff staining.", "D, Transmission electron microscopy."]}
{"Patient Personal Background": ["The patient currently smoked 30 cigarettes per day and had a 20 pack-year history of smoking.", "He was taking no daily medications and had no family history of cardiovascular disease."], "Patient Symptoms": ["Two days earlier, he reported a similar 20-minute episode of chest pain and diaphoresis.", "On admission to the ED, the patient was asymptomatic."], "Examination and Results": ["Blood pressure was 102/74 mm Hg, heart rate was 84/min, and oxygen saturation was 100% on room air.", "His physical examination results were unremarkable.", "Laboratory testing produced the following results: troponin T, 16 ng/mL (reference, <14 ng/mL); creatine kinase (CK), 82 U/L (1.37 \u00b5kat/L) (reference, <190 U/L [<3.17 \u00b5kat/L]); CK-MB, 16 U/L (reference, <24 U/L); low-density lipoprotein (LDL) cholesterol, 106 mg/dL (2.75 mmol/L) (reference, <130 mg/dL [<3.37 mmol/L]); and high-density lipoprotein (HDL) cholesterol, 38 mg/dL (0.98 mmol/L) (reference, >35 mg/dL [>0.91 mmol/L]).", "His initial electrocardiogram (ECG) is shown in Figure 1.Biphasic T waves in leads V2 and V3 on patient\u2019s initial electrocardiogram."]}
{"Patient Symptoms": ["Two weeks later, the patient presented to the ED for another episode of acute, painless, right proptosis, and the VA had decreased to 20/40 OD.", "The VA was 20/20 OU, with a persistent, mild, nonreducible, nonpulsatile proptosis unrelated to Valsalva maneuver but associated with extraocular movement limitation in upgaze."], "Examination and Results": ["Visual acuity (VA) was 20/32 OD and 20/20 OS.", "Anterior-segment and fundus examination results were normal.", "Magnetic resonance imaging (MRI) of the orbits revealed a right retro-orbital hemorrhage.", "No etiology could be identified on the image.", "MRI showed a right retrobulbar hemorrhage.", "Systemic corticosteroid therapy was again prescribed for 48 hours with rapid resolution of the visual impairment but incomplete resolution of the proptosis.One month later, the patient presented to our ophthalmology department."], "Treatment": ["The proptosis decreased, and the patient was discharged.After 6 months, complete ophthalmologic examination was performed again; VA was 20/20 OU, and there was no remaining proptosis.", "Systemic corticosteroid therapy was again prescribed for 48 hours with rapid resolution of the visual impairment but incomplete resolution of the proptosis.One month later, the patient presented to our ophthalmology department."], "Others": ["There was no contributory medical history, recent trauma, or surgery.", "Systemic corticosteroid therapy (methylprednisolone, 1 mg/kg per day) was prescribed for 48 hours."]}
{"Patient Personal Background": ["She had been taking 60 mg of oral prednisone; topical prednisolone acetate, 1%; and oral ibuprofen for 10 days without relief.", "Three years prior, sinus pressure symptoms led to magnetic resonance imaging that revealed a nasal sinus mass."], "Patient Symptoms": ["Ultrasound biomicroscopy revealed an elevated and tender uveal-episcleral lesion."], "Examination and Results": ["Visual acuity was 20/30 in the left eye and 20/25 in the right eye.", "She was suspected of being a steroid responder due to elevated intraocular pressure bilaterally.", "Biopsy demonstrated a histiocytic infiltrate with emperipolesis, consistent with Rosai-Dorfman-Destombes (RDD) disease."], "Treatment": ["She had been taking 60 mg of oral prednisone; topical prednisolone acetate, 1%; and oral ibuprofen for 10 days without relief.", "Timolol-dorzolamide topical drops were initiated."], "Diagnosis": ["Biopsy demonstrated a histiocytic infiltrate with emperipolesis, consistent with Rosai-Dorfman-Destombes (RDD) disease."], "Others": ["Staging evaluations showed no other sites of RDD disease.Pretreatment."]}
{"Patient Symptoms": ["The patient was lost to follow-up and re-presented 5 months later with an enlarged crusting and ulcerating lesion of the right temple/brow (Figure 1A).", "He had mild proptosis in the right eye and right lower eyelid retraction."], "Examination and Results": ["On review of history, maxillofacial magnetic resonance imaging (MRI) with and without contrast done 5 months prior to presentation showed a 5.9\u2009\u00d7\u20095.3\u2009\u00d7\u20093.7-cm mass centered at the right temple that tracked along the right lateral orbital wall as well as an enhancing right intraparotid lymph node.", "On ocular examination, best-corrected visual acuity was 20/100 OD and 20/125 OS due to cataracts, pupils reacted normally without afferent pupillary defect, and ocular motility was full.", "Orbicularis strength was intact and symmetric in both eyes.", "MRI of the orbits, face, and neck with and without contrast showed a 6.1\u2009\u00d7\u20095.7\u2009\u00d7\u20094.0-cm mass with erosion through the right sphenoid wing, involvement of the lacrimal gland, and abutment of the lateral rectus (Figure 1B)."], "Treatment": ["In discussing treatment strategies for the orbital component of the disease, the patient was strongly against an orbital exenteration.A, External photograph showing a large right brow mass with overlying crust after the patient was lost to follow-up and re-presented 5 months later."]}
{"Patient Personal Background": ["She had a history of cutaneous nodular melanoma in the right arm.", "Ocular history was positive for cataract surgery bilaterally."], "Patient Symptoms": ["After cataract surgery in the right eye, an asymptomatic vision loss was noted and the cause was attributed to the presence of choroidal neovascularization (CNV), for which the patient underwent intravitreal anti\u2013vascular endothelial growth factor (anti-VEGF) injections.Examination showed a best-corrected visual acuity of 20/60 OD and 20/20 OS, unremarkable anterior segment findings, and intraocular pressures of 12 mm Hg OU."], "Examination and Results": ["A fundus examination in the right eye revealed scarce pigmented cells in the anterior vitreous, a dark-pigmented epiretinal membrane, and an area of retinal hyperpigmentation in the inferior temporal arcade corresponding to the CNV (Figure 1).", "Optical coherence tomography imaging revealed a hyperreflective structure on the surface of the inner retina with increased macular thickness, compatible with the described epiretinal membrane (Figure 1).Fundus examination in the right eye revealed scarce pigmented cells in the anterior vitreous, a dark-pigmented epiretinal membrane (white arrowheads), and an area of retinal hyperpigmentation in the inferior temporal arcade corresponding to the choroidal neovascularization (black arrowhead)."], "Treatment": ["In April 2018, axillary lymphadenectomy was performed for local recurrence and the patient started treatment with an immune checkpoint inhibitor (ICI) pembrolizumab, without further local or metastatic evidence of the tumor.", "After cataract surgery in the right eye, an asymptomatic vision loss was noted and the cause was attributed to the presence of choroidal neovascularization (CNV), for which the patient underwent intravitreal anti\u2013vascular endothelial growth factor (anti-VEGF) injections.Examination showed a best-corrected visual acuity of 20/60 OD and 20/20 OS, unremarkable anterior segment findings, and intraocular pressures of 12 mm Hg OU."], "Diagnosis": ["She had a history of cutaneous nodular melanoma in the right arm."], "Others": ["Tumor staging was classified as T3N0M0 in August 2017, at the time of diagnosis and excision."]}
{"Patient Personal Background": ["Three years prior, she was diagnosed with a solitary HCC and underwent surgical resection with curative intent.", "Pathology revealed poorly differentiated HCC, 16 cm in largest dimension, with large vein involvement (T3bNXM0, R0 resection).", "The patient underwent expectant observation.", "One and a half years prior to the current presentation, laboratory results revealed an elevated \u03b1-fetoprotein (AFP), and cross-sectional imaging revealed multiple lung nodules consistent with metastases."], "Patient Symptoms": ["She was treated with nivolumab every other week and attained a biochemical (baseline, 212.2 ng/dL; best response, 3.3 ng/dL) and radiographic complete response.In the current presentation, the patient reported nonradiating epigastric pain of moderate intensity for 1 month.", "Associated symptoms included nausea, anorexia, and water brash without emesis.", "Review of systems was positive for unchanged chronic abdominal bloating and negative for other constitutional or gastrointestinal symptoms."], "Examination and Results": ["Laboratory results, including liver function tests, amylase, lipase, and AFP, were within normal limits, and hepatitis B virus polymerase chain reaction was undetectable.", "Computed tomography with multiphasic liver protocol showed new enlarged mesenteric nodes and diffuse thickening of the gastric body (Figure, A).", "Esophagogastroduodenoscopy (EGD) identified diffuse inflammation and ulcerations in the gastric body and antrum (Figure, B).", "Biopsy specimens showed chronic and active mixed inflammatory infiltrate, including intraepithelial lymphocytosis (Figure, C).", "No overt viral cytopathic effects were observed, and immunostaining results for Helicobacter pylori, cytomegalovirus, and adenovirus were negative.A, Coronal view of restaging computed tomography of chest, abdomen, and pelvis with contrast."], "Treatment": ["One and a half years prior to the current presentation, laboratory results revealed an elevated \u03b1-fetoprotein (AFP), and cross-sectional imaging revealed multiple lung nodules consistent with metastases.", "She was treated with nivolumab every other week and attained a biochemical (baseline, 212.2 ng/dL; best response, 3.3 ng/dL) and radiographic complete response.In the current presentation, the patient reported nonradiating epigastric pain of moderate intensity for 1 month."], "Others": ["The yellow circle notes borderline enlarged mesenteric nodes inferior to the stomach, and the yellow arrowheads show thickened gastric body wall.", "B, Gross appearance of the gastric mucosa visualized via upper endoscopy, which showed diffuse inflammation and ulceration in the gastric body and antrum.", "C, Biopsy of the gastric mucosa showed marked chronic and active intraepithelial infiltration of lymphocytes (blue arrowheads) and neutrophils (yellow arrowhead) and associated glandular epithelial injury with withered glands and gland dropout (red circle) (original magnification \u00d7100)."]}
{"Patient Personal Background": ["He had a medical history of myocardial infarction, sleep apnea, M\u00e9ni\u00e8re disease, and congenital cataract.", "The patient used atorvastatin and acetylsalicylic acid, did not smoke, and reported drinking 2 glasses of wine daily."], "Patient Symptoms": ["Furthermore, he did not report otalgia, otorrhea, a recent episode of M\u00e9ni\u00e8re disease, or other ear, nose, and throat or systemic symptoms.", "The lesion was hard and painful during palpation (Figure 1A)."], "Examination and Results": ["Otoscopy of the left ear revealed a yellow-whitish calcareous lobular mass located in the mesotympanum anterior to the malleus with an intact tympanic membrane.", "Otoscopy results for the right side were normal.Conductive hearing loss of the left ear because of a middle ear mass, seen on otoscopy (A) and on computed tomography (CT) (B).Pure-tone audiometry results showed a left-sided mixed hearing loss with a pure tone average of 110 dB HL and bone conduction levels at approximately 60 dB HL.", "The tympanogram showed a normal A-type curve with a normal to low middle ear compliance of 0.5 mm on the left side.", "Computed tomography (CT) imaging of the middle ear showed a heterogeneous hyperdense round mass of 5.5 mm in the left middle ear with a close relation to the malleus, eardrum, and tegmen (Figure 1B)."], "Diagnosis": ["Otoscopy results for the right side were normal.Conductive hearing loss of the left ear because of a middle ear mass, seen on otoscopy (A) and on computed tomography (CT) (B).Pure-tone audiometry results showed a left-sided mixed hearing loss with a pure tone average of 110 dB HL and bone conduction levels at approximately 60 dB HL."], "Others": ["There were no other abnormalities in the mastoid, ossicular chain, facial nerve canal, or surrounding blood vessels."]}
{"Patient Symptoms": ["Her parents stated that her stridor began acutely at 4 months of age without any inciting illness or event.", "The stridor was worse with agitation but was without positional exacerbation.", "The family reported that the stridor had remained stable since onset.", "Her parents noted mild dysphagia but denied shortness of breath, cyanosis, or apnea."], "Examination and Results": ["Laboratory test results revealed acute COVID-19 infection.", "Physical examination was unremarkable other than mild inspiratory stridor.", "Findings from bedside flexible laryngoscopy revealed intact vocal fold motion bilaterally with glottic competence.", "No supraglottic or glottic masses were identified.", "Anterior-posterior neck and chest radiography demonstrated narrowing and tortuosity of the trachea with displacement to the right proximal to the thoracic inlet and diffuse patchy heterogenous airspace opacities (Figure, A).", "Subsequent neck ultrasonography and computed tomography scan demonstrated a 3.2\u2009\u00d7\u20092.0-cm low-density lesion abutting the trachea and hypopharynx at the level of thoracic inlet, with rightward displacement of the trachea and larynx (Figure, B-D).", "Operative laryngoscopy, bronchoscopy, and esophagoscopy revealed extrinsic compression of the trachea, right mainstem bronchus, and esophagus with rightward deviation of the trachea and esophagus."], "Others": ["No mucosal tract was identified.A, Narrowing and tortuosity of the trachea with rightward deviation on anterior-posterior neck radiograph (arrowhead delineates tracheal deviation).", "B, Echogenic cystic lesion on ultrasonogram.", "C and D, Low-density lesion abutting the trachea and pharynx with rightward deviation of the trachea and larynx on coronal and axial neck computed tomography (black arrowheads delineate tracheal deviation; yellow arrowheads depict the lesion)."]}
{"Patient Symptoms": ["The mass had been present since birth but had slowly grown larger in the previous 2 years."], "Examination and Results": ["On physical examination, a 2.5\u2009\u00d7\u20091.5-cm, nontender, blue, soft, cystic mass was observed in the right postauricular area.", "There were no fistular openings around the auricle or in the external auditory canal (EAC), and there were no additional cysts, sinuses, or fistulas at the right neck from the hyoid bone and chin to the EAC.", "On temporal bone computed tomography, a 2.5\u2009\u00d7\u20091.5-cm, hypodense, oval-shaped cystic mass was revealed at the subcutaneous fat layer superoposterior to the right auricle.", "On temporal magnetic resonance imaging (MRI), an oval cystic mass was revealed at the same location, with high signal intensity on both T1-weighted and T2-weighted images and low signal intensity on enhanced T1-weighted fat suppression and T2-weighted short T1 inversion recovery images (Figure, A-D).", "The cyst contained keratinous debris (Figure, E).", "E, Hematoxylin-eosin staining showed a cyst composed of keratinizing stratified squamous epithelium, hair follicles, and sebaceous glands."], "Treatment": ["In surgery, the well-demarcated cystic mass was completely excised.", "Yellowish fluid leaked out of the cyst during excision."], "Others": ["On histopathologic examination, the cyst was lined by keratinizing stratified squamous epithelium with hair follicles and sebaceous glands.", "There was no recurrence 6 months after surgery.A-D, Magnetic resonance imaging showed a 2.5\u2009\u00d7\u20091.5-cm, oval cystic mass at the subcutaneous fat layer superoposterior to the right auricle with high signal intensity on both T1-weighted and T2-weighted images and low signal intensity on enhanced T1-weighted fat suppression and T2-weighted short T1 inversion recovery images (in order from the left)."]}
{"Patient Personal Background": ["The patient had been treated previously with steroids and amoxicillin for the presumptive diagnosis of chronic laryngitis but reported no improvement in symptoms."], "Patient Symptoms": ["She also reported odynophonia, globus sensation, and mild dysphagia to solids.", "Laboratory workup was positive for elevated antinuclear antibodies and erythrocyte sedimentation rate and was consequently referred to our institution.On presentation, the patient had only minimal dysphonia.", "Interestingly, the patient denied any shortness of breath."], "Examination and Results": ["She underwent a transnasal flexible laryngoscopy that demonstrated a severely edematous epiglottis, posterior pharyngeal wall, aryepiglottic folds, and arytenoids (Figure, A).", "The vocal folds were difficult to visualize but seemed normal in appearance and mobility.", "Stroboscopy could not be performed because of obstruction from the prolapsing arytenoids.", "Results of laboratory testing revealed normal levels of all components of a comprehensive metabolic panel, thyroid-stimulating hormone, and angiotensin-converting enzyme.", "The patient\u2019s erythrocyte sedimentation rate was elevated to 75 mm/h (reference range, 0-15 mm/h).", "Findings of chest radiography were normal.", "An esophagram showed no evidence of reflux esophagitis and a computed tomography of the neck showed edema of the supraglottis with some edema in the posterior hypopharyngeal wall.A, Awake flexible laryngoscopy image of the edematous epiglottis, arytenoids, and posterior pharyngeal wall.", "B, High-magnification of hematoxylin-eosin staining reveals well-formed noncaseating granulomas (arrowheads) with lymphoid reaction visible around the granulomas.Subsequently, the patient underwent a direct laryngoscopy with laryngeal biopsy."], "Treatment": ["Pathology results demonstrated hyperplastic squamous mucosa with submucosal chronic inflammation and fibrosis and were negative for high-grade dysplasia and carcinoma; scattered nonnecrotizing granulomas in the subepithelium were also observed (Figure, B)."]}
{"Patient Personal Background": ["Other physical examinations as well as his medical and family histories were unremarkable."], "Patient Symptoms": ["The skin lesions continued to progress and worsened after scratching.", "Physical examinations revealed disseminated erythematous papules, hypertrophic plaques approximately 1 to 2 cm in diameter, and dome-shaped nodules with excoriated whitish or pink centers on the scalp, chest, abdomen, back, waist, and extremities (Figure, A and B)."], "Examination and Results": ["Subsequent examinations of the mucosal membranes appeared normal.", "Peripheral eosinophils, serum total immunoglobulin E level, enzyme-linked immunosorbent assay (ELISA) test for HIV, and results of other routine laboratory tests were within normal ranges or negative.", "A biopsy specimen was taken from one of the skin lesions on his right forearm for histopathological examination and direct immunofluorescence (DIF) testing (Figure, C and D).A and B, Clinical images showed disseminated erythematous papules, hypertrophic plaques approximately 1 to 2 cm in diameter, and dome-shaped nodules with excoriated whitish or pink centers on the back, waist, and extremities.", "C, A biopsy specimen taken from the right forearm showed marked hyperkeratosis, acanthosis with irregular elongation of the rete ridges, fibrotic dermis, and perivascular lymphocytic infiltrate (hematoxylin-eosin).", "D, Direct immunofluorescence revealed linear deposition of immunoglobulin G along the basement membrane zone."], "Treatment": ["The patient had been initially diagnosed with nodular prurigo at a local hospital and treated with various topical steroids and oral antihistamines for 2 months, without significant improvement."], "Diagnosis": ["The patient had been initially diagnosed with nodular prurigo at a local hospital and treated with various topical steroids and oral antihistamines for 2 months, without significant improvement."]}
{"Patient Personal Background": ["The patient was born at full term via spontaneous vaginal delivery; the birth mother had not received prenatal care.", "Neither the birth mother nor the infant had any known history of environmental or occupational exposure to hazardous substances.", "The paternal family medical history was unremarkable; maternal family medical history was unknown.Physical examination revealed numerous bright red macules, papules, and plaques ranging in size from 1.0\u2009\u00d7\u20091.0 mm to 2.2\u2009\u00d7\u20092.3 cm, many of which had hemorrhagic crust and dark scale (Figure, A and B)."], "Patient Symptoms": ["The guardian reported first noticing the papules at birth.", "During the following months, the papules grew in number and size, involving the head and neck, trunk, extremities, right palm, mons pubis, and buttocks.", "At the height of severity, the patient had 39 lesions, some of which were associated with ulceration and bleeding."], "Examination and Results": ["Additional examination findings included retrognathia, thickened maxillary frenulum, and anterior ankyloglossia.A, Irregularly shaped red vascular plaque (2.2\u2009\u00d7\u20092.3 mm) with overlying scale, dark crusting, and a dark blue component with surrounding (1.0-3.0 mm) red papules.", "B, Numerous bright-red macules and papules (1\u2009\u00d7\u20091 mm-3\u2009\u00d7\u20093 mm) and 1 vascular red nodule (1.6\u2009\u00d7\u20091.1 cm) on the left lateral neck with dark overlying crusting.", "C, Low-power view of histopathology findings demonstrating epidermal hyperplasia and an upper dermal vascular proliferation (hematoxylin-eosin section)."]}
{"Patient Symptoms": ["He did not complain of headaches, facial numbness, dysarthria, facial droop, dysphagia, or limb weakness or numbness."], "Examination and Results": ["There was no history of joint pain or constitutional symptoms.Neurological examination revealed a nonfatigable partial left-eyelid ptosis, left-eye hypotropia at primary position, and impaired left eye supraduction (Figure 1) with a nonreactive left pupil on direct and consensual light reflexes.", "There were no other cranial nerve deficits.", "Limb reflexes, motor testing, and sensory testing results were normal, and the plantar responses were flexor.Top left (looking right and up), middle left (looking right), bottom left (looking right and down), center (primary position), top right (looking left and up), middle right (looking left), and bottom right (looking left and down).", "The images demonstrate left-eye hypotropia and left-eyelid ptosis at the primary position and impaired left-eye supraduction worse at lateral gaze on extraocular movements.Laboratory evaluation showed a normal fasting serum glucose level, thyroid function test result, and erythrocyte sedimentation rate.", "Anti\u2013double-stranded DNA, antinuclear antibodies, and HIV test results were negative.", "Repetitive nerve stimulation did not show any decremental response and anti-acetylcholine receptor antibodies were negative.", "A computed tomography (CT) angiography of the circle of Willis did not show any aneurysms and a routine magnetic resonance imaging (MRI) of the brain did not show any infarcts or masses."]}
{"Patient Personal Background": ["His medical history was noncontributory, except for allergic rhinitis, for which he was prescribed fexofenadrine pro re nata."], "Patient Symptoms": ["He also reported redness of his right eye with watery discharge.", "He developed a skin rash affecting his trunk, limbs, and genitalia within the previous week."], "Examination and Results": ["His visual acuity was 6/6 in both eyes.", "Examination of his right eye revealed erythematous swollen eyelids.", "A slightly raised dome-shaped umbilicated nodule, of approximately 3 mm, was present on his medial one-third lower eyelid margin, with a similar lesion developing on the corresponding upper eyelid margin (Figure).", "A vesicular lesion was also present on the caruncle and there was global conjunctival hyperemia, mostly pronounced nasally and around the lesions (Figure, B).", "There were no signs of corneal involvement, and the anterior chamber was quiet.", "The left eye was normal.", "Results of fundus examination in both eyes were normal.", "No preauricular or submandibular lymph node involvement was noted, but cervical lymph nodes were enlarged.", "The pharynx was erythematous and swollen with white pus patches.", "The skin lesions were dome-shaped papules, round, pinkish-white in color, surrounded by an erythematous area."], "Others": ["Full blood cell count and tests for HIV, AIDS, and syphilis were ordered.", "Conjunctival swabs and eyelid vesicle fluid were taken for polymerase chain reaction testing."]}
{"Patient Personal Background": ["His history included full-term birth by cesarean delivery from an uncomplicated pregnancy.", "He had healthy, nonconsanguineous parents.The ocular examination showed a visual acuity of 20/20 OU with no anterior segment abnormalities."], "Examination and Results": ["He reported no present or past ocular symptoms and had negative findings on a review of systems.", "Findings of dilated fundus examination of the right eye were within normal limits.", "In the left eye, a white, translucent solid lesion with calcification was noticeable in the inferonasal quadrant (Figure, A).", "The lesion measured approximately 1.6 mm in height, exhibited mild underlying chorioretinal changes, and had associated 3 vitreous seeds (Figure, A).", "There were no signs of internal vascularization or vitritis.", "Optical coherence tomography confirmed an intraretinal location and calcified deposits within the lesion (Figure, B).A, Left eye fundus photograph showing the white retinal lesion and vitreous seeds (arrowheads).", "B, Optical coherence tomography confirming an intraretinal tumor with calcification (asterisks).", "Scan noise due to the lesion\u2019s peripheral location."]}
{"Patient Personal Background": ["Ocular history included high hyperopia and amblyopia, and abnormal foveal contour was discovered when he was aged 3 years.", "Family history was noncontributory."], "Examination and Results": ["Best-corrected visual acuity was 20/50 in the right eye and 20/30 in the left.", "Pupils were round and reactive to light, and intraocular pressure and anterior segment examination were within normal limits.", "Dilated fundus examination revealed blunted foveal reflexes and abnormal vasculature in the inferonasal quadrant of the right eye.", "Fluorescein angiography displayed symmetric bilateral circular areas of hypofluorescence around the macula and irregular fovea with no leakage (Figure 1A).", "Color fundus photography showed symmetric bilateral mottling of the retinal pigment epithelium in the periphery (Figure 1B).", "Spectral-domain optical coherence tomography on initial examination showed an abnormal foveal contour with loss of the foveal pit and intraretinal cystoid cavities within the inner nuclear layer."]}
{"Patient Symptoms": ["At the time of initial presentation to her local retina specialist 1 week following her cataract surgery, the patient had severe pain and redness.", "Her visual acuity was light perception."], "Examination and Results": ["Her ocular history was notable for recent cataract surgery 5 weeks prior to presentation that was complicated by endophthalmitis.", "A normal funduscopic examination was documented prior to cataract surgery.", "An examination revealed a 2-mm hypopyon and dense vitreous haze with no view of the retina.", "Examination showed a deep and quiet anterior chamber with a well-positioned intraocular lens without any plaques or deposits on the lens capsule.", "Dilated ophthalmoscopic examination demonstrated improvement in the vitreous debris with 1+ vitritis and numerous superficial, round, white lesions spread throughout the fundus in all 4 quadrants and in the macula (Figure 1A).", "Optical coherence tomography verified the preretinal location of the lesions (Figure 1B).A, Fundus photograph of the left eye at presentation shows vitreous debris with numerous white lesions throughout the retina."], "Treatment": ["She was treated for presumed endophthalmitis with a vitreous tap and intravitreal injections of vancomycin (1 mg/0.1 mL), ceftazidime (2.2 mg/0.1 mL), and dexamethasone (0.4 mg/0.1 mL).", "The vitreous sample obtained at the time of treatment grew Staphylococcus caprae susceptible to vancomycin.At time of examination in our clinic 4 weeks following treatment, the patient was receiving topical steroid and cycloplegic drops."], "Diagnosis": ["Her ocular history was notable for recent cataract surgery 5 weeks prior to presentation that was complicated by endophthalmitis.", "She was treated for presumed endophthalmitis with a vitreous tap and intravitreal injections of vancomycin (1 mg/0.1 mL), ceftazidime (2.2 mg/0.1 mL), and dexamethasone (0.4 mg/0.1 mL)."]}
{"Patient Personal Background": ["The patient had recently immigrated from rural Moldova 1 month prior to presentation, where she had exposure to farm animals, including dogs and cats.", "She had not traveled to any other countries.Painful and pruritic lower eyelid lesion with a vermiform appearance (arrow) (A)."], "Patient Symptoms": ["The lesion resolved after 1 month, but she developed redness and swelling of the inner part of her right conjunctiva the next day (Figure 1B).", "She denied any vision changes, eye pain, eye discharge, or systemic symptoms, such as fevers, chills, night sweats, weight loss, or diarrhea.", "She had not traveled to any other countries.Painful and pruritic lower eyelid lesion with a vermiform appearance (arrow) (A)."], "Examination and Results": ["This was followed by an elevation in the bulbar conjunctiva with whitish linear opacities within the lesion (B).Ophthalmological examination showed a best-corrected visual acuity of 20/40 OU and intraocular pressures of 17 OD and 18 OS.", "Pupils were equal and reactive to light.", "On slit-lamp examination of the right eye, there was diffuse conjunctival vasodilation and hyperemia that was worse nasally.", "There was a cystic elevation of the bulbar conjunctiva nasally with whitish linear opacities within the lesion (Figure 1B).", "The cornea was clear.", "There was no anterior chamber or vitreous inflammation."]}
{"Patient Symptoms": ["She denied having any symptoms, tenderness, numbness, or facial nerve weakness."], "Examination and Results": ["Physical examination revealed a mass in the buccinator space that was smooth, was nontender to palpation, and had no overlying cutaneous changes.", "A contrast-enhanced maxillofacial computed tomography scan demonstrated a 1.8\u2009\u00d7\u20091.8\u2009\u00d7\u20091.9-cm rounded, well-circumscribed lesion at the anterior aspect of the left masticator space (Figure 1).", "The mass was abutting the parotid duct, which did not appear dilated, and appeared to have a peripheral rim of hyperenhancing soft tissue with a central cystic/necrotic component.", "Results of ultrasound-guided fine-needle aspiration revealed rare epithelial cells with degenerative changes and inflammatory cells present.", "Findings from a core biopsy demonstrated a spindle cell neoplasm of uncertain origin.", "On immunostaining, spindle cells were CK8/18, S100, and SOX10 negative; myosin and smooth muscle actin (SMA) negative; and CD31 negative.", "However, STAT6 staining was diffusely positive.Axial view of the contrast-enhanced maxillofacial computed tomography scan demonstrating the left cheek mass (arrowhead)."]}
{"Patient Symptoms": ["On physical examination, the patient presented a grade VI peripheral left facial paralysis."], "Examination and Results": ["On audiometry, normal hearing sensitivity in the right ear and a severe to profound sensorineural hearing loss with poor word recognition score in the left ear were noted.", "Findings from the rest of the clinical examination were within normal limits.Results of cerebral magnetic resonance imaging (MRI) and temporal bone computed tomography (CT) revealed a left internal auditory canal mass, measuring 13\u00d712 mm, developed at the expense of nerve VII, with a dilation of the various portions of the facial nerve with extension to its distal branches.", "It presented a hypointensity on T2, isointensity on T1, and was strongly enhanced after the injection of gadolinium.", "This mass was responsible for the enlargement of the internal auditory canal and was in close contact with the left middle cerebral fossa, without intraparenchymal extension (Figure 1A and B).A, Cerebral MRI T1-weighted contrast-enhanced image showing the mass.", "B, Temporal bone CT scan showing the mass.", "Arrowheads indicate the abnormal facial nerve."]}
{"Patient Personal Background": ["The patient lived in Southern California but had visited Kenya for an extended trip a few years prior."], "Patient Symptoms": ["Review of systems was negative for fevers, night sweats, weight loss, headache, vision changes, respiratory distress, or arthralgias.", "On the left nasal dorsum and medial cheek, there was a 3\u2009\u00d7\u20094 cm violaceous plaque with focal purulent drainage.", "Within several weeks, the lesion rapidly expanded into a vegetative, freely draining plaque covering the cheeks and glabella and approaching the medial canthi (Figure, B)."], "Examination and Results": ["Computed tomography revealed findings consistent with abscess that did not involve the orbits, sinuses, or bone.", "Chest radiography results were unremarkable.", "Punch biopsy specimens were obtained for histopathological analysis and tissue cultures (Figure, C).", "Tissue culture results at 2 weeks remained negative, and a QuantiFERON-TB Gold test result was negative.A, Violaceous plaque on the nose and left cheek.", "B, Rapid progression of the lesion involved the cheeks and glabella, with substantially worsening drainage at 6-week follow-up.", "C, Punch biopsy of lesion showing suppurative and granulomatous dermatitis (hematoxylin-eosin)."], "Others": ["D, Posttreatment, there was improvement of the lesion from initial presentation, but substantial residual facial scarring remained."]}
{"Examination and Results": ["On physical examination, the patient showed a rhythmic tachycardia with a rate of 178 beats/min and blood pressure of 130/80 mm Hg.", "The 12-lead electrocardiogram (ECG) revealed a regular tachycardia with a rate of 178 beats/min; no obvious P waves were recognizable (Figure 1A).", "The QRS complexes displayed 2 different morphologies occurring with a definite allorhythmic distribution: pairs of beats exhibiting complete right bundle branch block (RBBB) and QRS duration of 140 milliseconds followed by a third beat with normal configuration and QRS duration of 70 milliseconds.", "This trigeminal variation in intraventricular conduction occurred without any change in cycle length and was maintained.", "Numbers within the tracing indicate the R-R intervals (in milliseconds).", "The variability in ventricular cycle lengths results from small changes in both the P-P and P-R intervals."], "Treatment": ["Adenosine administration quickly slowed the ventricular rate allowing recognition of an atrial tachycardia with a rate of 178/min and a 2:1 atrioventricular (AV) ratio (Figure 1B).A, Regular supraventricular tachycardia with right bundle branch block aberration disappearing every third beat."], "Others": ["B, Lead II."]}
{"Patient Personal Background": ["His medical and family histories were unremarkable."], "Patient Symptoms": ["Six months prior, he found his palms could not make full contact with each other (the \u201cprayer sign\u201d).", "He had not been able to fully clench his fists for 2 months or squat for the past 10 days."], "Examination and Results": ["No erythema, edema, or sclerotic skin plaque had been found on his limbs or trunk.", "No Raynaud phenomenon had occurred.", "On examination, he showed bilateral limited mobility of interphalangeal (hands), metacarpophalangeal, wrist, interphalangeal (feet), metatarsophalangeal, and ankle joints (Video).", "No muscular atrophy or sclerodactyly was found.", "The prayer sign (Figure 1A) and the \u201cgroove sign\u201d (Figure 1B) were observed.", "Blood test results indicated eosinophilia (absolute eosinophil count, 1300 \u03bcL; reference, <500\u03bcL [to convert to \u00d7109/L, multiply by 0.001]), elevated erythrocyte sedimentation rate (ESR, 31 mm/h; reference, <15 mm/h) and C-reactive protein (CRP, 3.01 mg/dL; reference, <0.8 mg/dL [to convert to mg/L, multiply by 10]).", "Liver and kidney function tests, creatine kinase level, electrolyte level, thyroid function, globulin concentration, and antinuclear antibody (ANA) level were unremarkable.", "Electrocardiogram, cervical spine magnetic resonance imaging, and plain radiographs of hands, wrists, feet, and ankles were normal.", "Nerve conduction studies performed in all 4 limbs were normal.", "Electromyography (EMG) showed spontaneous activities in muscles of limbs, including fibrillation potentials and positive sharp waves (1+ or 2+).", "Myotonic discharges were seen in bilateral extensor digitorum.A, The patient\u2019s bilateral palms and fingers could not make full contact due to the limited mobility of interphalangeal and metacarpophalangeal joints.", "B, Linear depression (arrowheads) was seen along the course of superficial vein when limb was elevated."]}
{"Patient Personal Background": ["At age 4 years, she developed white oral plaques that resolved with oral nystatin.", "Approximately 6 months later, the oral plaques recurred, her toenails became thickened and yellowed, and red plaques appeared on both feet and lower legs.", "Over the following years, she received intermittent 3- to 6-month courses of daily itraconazole for recurrent skin, nail, and oral mucosal abnormalities, which typically recurred within 6 to 12 months of discontinuing itraconazole.", "Her last dose of itraconazole was approximately 2 years prior to presentation."], "Patient Symptoms": ["On physical examination, the patient had white, moist, nonadherent plaques in the oral mucosa and moist red fissures at bilateral oral commissures (Figure, left panel).", "She also had thickened, yellowed toenails and scaly erythematous plaques on her lower legs and feet bilaterally (Figure, right panel)."], "Examination and Results": ["Results of complete blood cell count with differential were normal, as were results of measurement of serum IgG, IgA, IgM, and IgE levels and analysis of CD3, CD4, and CD8 T-cell subsets.", "Potassium hydroxide wet mount preparation of skin scrapings from the lower extremities demonstrated fungal elements.", "Fungal culture of the skin scrapings grew Candida albicans.Patient presentation."], "Treatment": ["After 3 months of daily oral itraconazole, her skin, nail, and oral mucosal abnormalities resolved for approximately 1 year."], "Others": ["Left, White plaques in the oral mucosa and angular cheilitis.", "Right, Thickened, yellowed toenails and scaly erythematous plaques on both lower legs and feet."]}
{"Patient Symptoms": ["She reported 2 months of increasing right-sided blurry vision and a sensation of eye dryness."], "Examination and Results": ["She was found to have incomplete eyelid closure by her primary care physician, who initiated artificial tear lubrication and bedtime eyelid taping with partial symptom improvement.Clinical examination revealed 20/25 visual acuity OD with full extraocular motility and normal intraocular pressure.", "She was noted to have right upper eyelid retraction (Figure 1A) with substantial static upper eyelid lag on downgaze (Figure 1B).", "She had 1-mm right lagophthalmos with incomplete blink.", "Frontalis and orbicularis oculi strength were intact.", "She was measured to have a 2-mm relative right enophthalmos and no resistance to retropulsion."], "Treatment": ["She was found to have incomplete eyelid closure by her primary care physician, who initiated artificial tear lubrication and bedtime eyelid taping with partial symptom improvement.Clinical examination revealed 20/25 visual acuity OD with full extraocular motility and normal intraocular pressure."], "Others": ["A review of patient photographs from 2 years prior showed symmetric bilateral eyelid appearance without retraction.Right upper eyelid retraction (A) with substantial static eyelid lag on downgaze (B)."]}
{"Patient Personal Background": ["He had a history of stage 3B melanoma treated with ipilimumab complicated by grade 3 colitis refractory to high-dose corticosteroids and infliximab requiring colectomy and stomal hernia after hernia repair.", "His medical history was notable for hypertension controlled with metoprolol."], "Patient Symptoms": ["He denied any changes in vision, flashes, floaters, eye pain, or eye redness."], "Examination and Results": ["His mother had a history of breast cancer but otherwise family history was unremarkable.Visual acuity was 20/20 OD and 20/25 OS.", "Intraocular pressure was 16 mm Hg OD and 15 mm Hg OS.", "Anterior segment examination showed inferior corneal endothelial pigmentation in the right eye (Figure, A) and trace nuclear sclerotic cataracts in both eyes.", "Dilated ophthalmoscopy was unremarkable.", "Four-mirror gonioscopy in the right eye showed an open angle, normally pigmented trabecular meshwork, and a well-demarcated pigmented brown lesion without extension into the angle (Figure, B)."], "Others": ["He denied a history of trauma, intraocular surgery, or inflammation in the eyes.", "Serial positron emission tomography/computed tomography scans showed no evidence of metabolically active disease.", "He did not have ectropion uvea, corectopia, or feeder vessels."]}
{"Patient Symptoms": ["At age 3 years, he presented to the clinic with a persistent cheek and orbit lesion, dense amblyopia, large-angle monocular esotropia and hypertropia, and proptosis of the left eye.", "A repeated magnetic resonance image showed persistent orbital involvement causing medial displacement of the lateral rectus muscle and mass effect on the globe (Figure 1B).Infantile hemangioma prior to treatment."], "Examination and Results": ["An ophthalmic evaluation at an outside hospital was concerning for amblyopia because of anisohypermetropia, greater on the left, and a left esotropia and hypertropia.", "A magnetic resonance image revealed an orbital mass surrounding the left lateral rectus muscle with mass effect on the globe and extension into the eyelid, pterygopalatine fossa, and cheek.Given the risk of amblyopia, the patient underwent 2 embolization and debulking procedures of the orbital and cheek components of the lesion, which were positive for glucose transporter 1 on pathology.", "The left extraocular muscle showed inability to abduct past midline (Figure 1A).", "A repeated magnetic resonance image showed persistent orbital involvement causing medial displacement of the lateral rectus muscle and mass effect on the globe (Figure 1B).Infantile hemangioma prior to treatment.", "A, Left abduction deficit (asterisk) from complex infantile hemangioma involving the orbit, pterygopalatine fossa, and cheek.", "Arrowhead indicates cheek component of hemangioma.", "B, Magnetic resonance imaging orbits axial image (postgadolinium, T1) showing enhancing orbital component (arrowhead)."], "Treatment": ["He was diagnosed with a capillary hemangioma, and propranolol was started at age 1 month with progression despite dosage increases.", "Topical timolol was tried without improvement; oral prednisolone decreased the size of the lesion, but was poorly tolerated and discontinued.", "However, the esotropia abruptly worsened after the second debulking."], "Diagnosis": ["He had a pink macule on his left cheek at birth, which became raised and discolored around age 3 to 4 weeks.", "He was diagnosed with a capillary hemangioma, and propranolol was started at age 1 month with progression despite dosage increases."]}
{"Patient Symptoms": ["The lesions gradually enlarged and coalesced into large plaques and nodules.", "Mild erosions occurred occasionally on the surface of the lesions.", "She denied having fever, fatigue, chills, night sweats, or weight loss.Physical examination demonstrated ill-defined, indurated erythematous-violaceous patches, nodules, and plaques involving the surface of her head and face with sporadic erosion and brownish crusts (Figure, A)."], "Examination and Results": ["The findings of systemic reviews were unremarkable, and there was no lymphadenopathy.", "The complete blood cell count revealed normal white blood cell count.", "The biopsy from an erythematous nodule displayed sheets of medium to large mononuclear cells infiltrated in the dermis, some of which filled and expanded apparent dermal blood vessels and had large, irregular, pleomorphic nuclei (Figure, B).", "The initial immunohistochemical stain revealed the tumor cells were positive for CD3 and negative for CD20, AE1/AE3, CK20, chromogranin A, and melan-A.", "The Ki-67 labeling index was 70%.A, Ill-defined, indurated erythematous-violaceous patches, nodules, and plaques on the head and face with sporadic erosion and brownish crusts.", "B, The biopsy showed dilated vessels expanded by cohesive clusters of large atypical lymphoid cells (hematoxylin-eosin staining).", "C, Immunohistochemical staining of D2-40 highlighted the exclusively lymphovascular location of the lymphoma."], "Others": ["In addition, some neoplastic cells formed a balloon appearance.", "No epidermotrophism was found."]}
{"Patient Personal Background": ["Five years before this otolaryngology evaluation, the patient developed diffuse skin plaques with erythema and was subsequently diagnosed with hypopigmented cutaneous T-cell lymphoma (CTCL, mycosis fungoides type)."], "Patient Symptoms": ["Owing to significant worsening of his symptoms 4 months before his evaluation, a biopsy of his cutaneous lesions was performed to rule out progression of CTCL (Figure 1)."], "Examination and Results": ["Physical examination demonstrated large annular plaques with peripheral hyperpigmentation of the body.", "There were also confluent, indurated pink plaques with slightly raised edges along the forehead, malar eminence, and scalp.", "The nasal septum demonstrated an inverted V deformity with compromise of the keystone junction.", "Nasal passages were obstructed with thick mucus and synechiae formation, nearly obstructing the entire nasal passage bilaterally.A, Fite acid-fast stain of cutaneous lesion identifying pink bacilli (original magnification \u00d7100)."], "Treatment": ["The patient was treated with a regimen of narrowband UV-B phototherapy and triamcinolone cream, which he has continued for 4 years."], "Others": ["B, Hematoxylin-eosin stain of the same cutaneous lesion showing poorly formed granulomas (original magnification \u00d740)."]}
{"Patient Personal Background": ["She was breastfeeding her 10-month-old, had no history of alcohol use, and had a remote history of hookah use.", "She was a Southern California native with travel history to Pakistan, Turkey, Jordan, Israel, Qatar, and Dubai 5 years prior to symptom onset.", "One month prior to onset, she drove from Los Angeles, California, to Houston, Texas."], "Patient Symptoms": ["She denied recent unintentional weight loss, cough, fever, night sweats, chills, stridor, dyspnea, dysphonia, or rash.On examination, her vital signs were within normal limits, and physical examination revealed a small right tonsillolith, mild tonsillar erythema that was worse on the right side, and a mobile 2-cm, right level 2 lymph node that was slightly tender to palpation."], "Examination and Results": ["She denied recent unintentional weight loss, cough, fever, night sweats, chills, stridor, dyspnea, dysphonia, or rash.On examination, her vital signs were within normal limits, and physical examination revealed a small right tonsillolith, mild tonsillar erythema that was worse on the right side, and a mobile 2-cm, right level 2 lymph node that was slightly tender to palpation.", "Laboratory evaluation was notable for an elevated eosinophil count and positive Epstein-Barr immunoglobulin G. Her white blood cell count and mononucleosis spot test result were within normal parameters.Her symptoms persisted despite treatment with penicillin, azithromycin, and steroids from her primary physician and amoxicillin-clavulanate, sinus rinses, fluticasone propionate, and azelastine spray from an otolaryngologist to treat any contributing postnasal drainage and tonsillitis.Flexible transnasal videolaryngoscopy revealed a lesion on the laryngeal surface of the right epiglottis passing midline extending to the right aryepiglottic fold, but not involving the true vocal cords (Figure 1A).", "Given inconclusive office biopsy results, direct laryngoscopy with biopsy was performed, showing extensively inflamed squamous mucosa with ulceration, granulation tissue, pseudoepitheliomatous hyperplasia, and atypia (Figure 1B).A, In-office laryngoscopy showing an ulcerative, papillomatous lesion on the laryngeal surface of the right epiglottis that passed midline and extended to the right aryepiglottic fold but did not involve the true vocal cords.", "B, Laryngeal biopsy specimen demonstrating extensively inflamed squamous mucosa with ulceration, granulation tissue, pseudoepitheliomatous hyperplasia, and atypia, with background chronic granulomatous inflammation."], "Treatment": ["Laboratory evaluation was notable for an elevated eosinophil count and positive Epstein-Barr immunoglobulin G. Her white blood cell count and mononucleosis spot test result were within normal parameters.Her symptoms persisted despite treatment with penicillin, azithromycin, and steroids from her primary physician and amoxicillin-clavulanate, sinus rinses, fluticasone propionate, and azelastine spray from an otolaryngologist to treat any contributing postnasal drainage and tonsillitis.Flexible transnasal videolaryngoscopy revealed a lesion on the laryngeal surface of the right epiglottis passing midline extending to the right aryepiglottic fold, but not involving the true vocal cords (Figure 1A)."]}
{"Patient Personal Background": ["He denied any history of dysphagia, odynophagia, fevers, unintentional weight loss, cough, or reflux symptoms.", "There was no prior history of smoking, head and neck surgeries, or radiation exposure.", "He was treated for asthma with inhaled steroids by his primary care physician without improvement in symptoms."], "Patient Symptoms": ["On physical examination, the patient was stridulous and considerably hoarse."], "Examination and Results": ["His neck examination was unremarkable.", "Subsequent videostroboscopy revealed severe laryngeal mucosal edema, most significant in the false vocal folds, interarytenoid, and postcricoid regions (Figure 1A).", "There was right true vocal fold immobility with compensatory squeeze of the false vocal folds and an absent mucosal wave.", "Computed tomographic (CT) scan of the neck with contrast showed irregularity along the free edges of the true vocal folds but no evidence of a neoplasm or cervical lymphadenopathy.", "The patient underwent urgent direct laryngoscopy with biopsy, which showed edematous, irregular, friable laryngeal mucosa with significant airway narrowing.", "Laryngeal biopsy findings are shown in Figure 1, B and C.A, Laryngeal videostroboscopic image."], "Others": ["B, Hematoxylin-eosin stain.", "C, Grocott methenamine silver stain."]}
{"Patient Personal Background": ["The child had an older sibling with no skin ailments, and no other family members were affected."], "Patient Symptoms": ["The lesions started on the left foot and subsequently progressed to involve the face, trunk, and extremities, with distal interphalangeal joint deformity of both hands (Figure, A).", "Parents reported decreased oral intake, decreased activity, and delayed motor development.A, Nodules on the right hand and joint deformity.", "The child weighed 8 kg (normal, 13-15 kg) and was 87 cm (normal, 91-95 cm) in length."], "Examination and Results": ["B and C, Histopathological images show a granulomatous pattern, numerous foamy cells, marked collagen degeneration, and mucin deposition (hematoxylin-eosin stain).", "D, Comma-shaped curvilinear tubular structures (yellow arrowhead).On examination, dozens of tough to hard subcutaneous skin-colored nodules ranging from 0.5 to 5 cm in diameter were observed on both sides of the nose and parts of both wrists, the knees, elbows, ankles and hips, and the trunk.", "Symmetrical beaded subcutaneous nodules were observed in the bilateral auricles, while the mucous membrane was not involved.", "In addition, a physical examination revealed horizontal nystagmus and voice hoarseness.", "The distal interphalangeal joints of both hands were stiff with limited extension.", "The interphalangeal joints of the third through fifth distal segments of both feet were slightly bent.", "A complete hematological and biochemical survey, including liver and renal function, C-reactive protein levels, thyroid function, rheumatoid factor, and antinuclear antibodies, identified no abnormalities.", "A magnetic resonance imaging study of the brain showed volume loss in the parietooccipital region.", "Ultrasonographic evaluation of metacarpophalangeal joints showed multiple hypoechoic nodules on the skin of the hands.", "Radiography showed deformities of the interphalangeal joints with soft tissue swelling."]}
{"Patient Personal Background": ["The patient\u2019s medical history was otherwise unremarkable."], "Patient Symptoms": ["The patient denied any known preceding triggers or trauma to the area of the rash.", "Review of systems was negative for any new or worsening constitutional, respiratory, or gastrointestinal symptoms."], "Examination and Results": ["Examination findings were notable for firm, red-brown plaques without overlying scale on the proximal upper extremities and anterior trunk (Figure, A and B).", "There was no appreciable skin tightening in the affected areas.", "Complete blood cell count with differential was unremarkable.", "Lesional punch biopsy specimens were obtained (Figure, C and D).A, Clinical image of firm, red-brown plaques without overlying scale on the proximal upper extremities and anterior trunk.", "B, Clinical image of nodular plaques on the right shoulder and chest."], "Treatment": ["He had tried treating with topical aloe, without improvement."], "Others": ["C and D, Lesional punch biopsy specimens (hematoxylin-eosin)."]}
{"Patient Personal Background": ["Past medical history included schizophrenia, hypothyroidism, and supraventricular tachycardia.Her examination demonstrated normal visual acuity in both eyes."], "Patient Symptoms": ["She reported difficulty opening her jaw, pain when chewing, and a 2.3-kg weight loss.", "The week prior, she experienced left-sided ptosis that persisted for 2 days and subsequently resolved."], "Examination and Results": ["Pupils were equal, round, and reactive.", "There was right upper-eyelid ptosis.", "Extraocular motility demonstrated limitation of elevation and abduction bilaterally (Figure 1).", "Results of dilated fundus examination were normal, and the remainder of her neurologic examination results were normal.", "Her eye movements and ptosis did not change with fatiguability, rest, or an ice-pack test.", "Investigations revealed a C-reactive protein level of 292 mg/L (normal, <10 mg/L; to convert to milligrams per deciliter, divide by 10) and erythrocyte sedimentation rate of 93 mm/h (normal, <30 mm/h).", "A lumbar puncture demonstrated normal opening pressure, cell count, and glucose and protein levels.", "Magnetic resonance imaging with contrast of the brain demonstrated diffuse edema and enhancement of the scalp, skull base, neck, and paraspinal soft tissues, as well as T2 hyperintensity and enhancement of the extraocular muscles bilaterally."], "Diagnosis": ["An additional test was obtained, and a diagnosis was made.Extraocular movements on presentation."], "Others": ["She denied vision changes, eye pain, scalp tenderness, and myalgias.", "Examination reveals deficits in elevation and abduction of both eyes not conforming to a cranial nerve distribution."]}
{"Examination and Results": ["She had pseudophakia with an otherwise normal anterior segment examination in each eye.", "Fundus examination was remarkable for macular PEDs and SRF in each eye.", "There was an epiretinal membrane in the left eye.Optical coherence tomography (OCT) in the right eye disclosed a central PED with SRF that extended beyond the inferior border of the PED (Figure, A).", "Hyperreflective foci, suggestive of vitelliform material, were visible on the photoreceptors.", "OCT in the left eye demonstrated 2 PEDs in the parafovea (Figure, B).", "SRF was present with overlying thickening of the photoreceptors.", "The choroid was thin in each eye.", "Fluorescein angiography revealed punctate hyperfluorescent staining within the body of the PEDs in each eye.", "There was no evidence of leakage in either eye.", "Fundus autofluorescence displayed dispersed, speckled hyperautofluorescence corresponding to the potential vitelliform material and SRF in the right eye.", "A, A 3000-\u03bcm-diameter pigment epithelial detachment with a 30-\u03bcm layer of subretinal fluid overlying the pigment epithelial detachment and a 140-\u03bcm layer of subretinal fluid inferior to the pigment epithelial detachment.", "There are hyporeflective pockets within the pigment epithelial detachment possibly representing fluid.", "B, Two 500-\u03bcm pigment epithelial detachments with subretinal fluid and thickening of the photoreceptors in the left eye."], "Diagnosis": ["Ocular history included presumed exudative age-related macular degeneration.", "Central serous chorioretinopathy was also suspected secondary to the presence of yellow subretinal deposits located within an inferior macular detachment in the right eye.Visual acuity was 20/40 OD and 20/25 OS."], "Others": ["Review of the autofluorescence 3 years prior revealed boat-shaped hyperautofluorescence located in the most inferior aspect of the SRF in the right eye.Optical coherence tomography with corresponding autofluorescence image is shown in each eye.", "Hyperreflective deposits on the photoreceptors are suggestive of vitelliform deposits (arrowheads)."]}
{"Patient Personal Background": ["Her medical history included neonatal seizures.", "Both parents were healthy and denied consanguinity.", "The patient has 3 half sisters, all of whom are healthy.A, Fundus autofluorescence discloses attenuated, narrow vasculature and diffuse peripheral patchy hypoautofluorescence."], "Patient Symptoms": ["She was initially evaluated at an outside institution and was found to have bilateral symmetric vision loss with nyctalopia.", "The patient did not receive any ophthalmological care until 2 years later, when she was seen for marked vision loss and was noted to have a BCVA of light perception in both eyes.When she presented to the pediatric retina service, she demonstrated poor mentation and was unable to recall simple things such as the name of her siblings."], "Examination and Results": ["At that time, her best-corrected visual acuity (BCVA) was 20/70 OU.", "Her BCVA was light perception.", "Her pupils were round and reactive.", "The anterior segment examination and intraocular pressures were within normal limits.", "Fundus autofluorescence disclosed attenuated, narrow vasculature and diffuse peripheral patchy hypoautofluorescence (Figure 1A).", "Color fundus photography showed optic disc pallor, attenuated retinal vasculature, prominent choroidal markings, and central retinal atrophy with diffusely mottled pigmentation (Figure 1B).", "Optical coherence tomography displayed decreased retinal thickness, more prominent in the inner layers, and hyper-reflective dots in the outer retinal layers."], "Others": ["The onset of the symptoms was unknown.", "Family history included unilateral vision loss in her paternal grandmother in her late 20s.", "B, Color fundus photograph displays optic disc pallor, attenuated retinal vasculature, prominent choroidal markings, and central retinal atrophy with diffusely mottled pigmentation."]}
{"Patient Personal Background": ["Her symptoms began after relocation to California and occurred more frequently at her home.", "However, she could not discern any environmental or dietary triggers."], "Patient Symptoms": ["She reported pruritus and swelling, which were usually moderate but occasionally severe, prompting several emergency department visits."], "Examination and Results": ["During an emergency department visit, she was diagnosed with acute parotitis based on clinical and radiographic findings of diffuse gland edema, without salivary stones or masses.", "A differential blood cell count revealed 10% eosinophils (normal, <6%) and an absolute eosinophil count 500/\u00b5L (to convert to \u00d7109/L, multiply by 0.001).", "Titers for antinuclear antibodies, rheumatoid factor, anti-Ro (SS-A), and anti-La (SS-B) were negative.Sialendoscopy of her right parotid and left submandibular glands found no obstructing stones or strictures.", "An open biopsy of the right parotid tail revealed nonspecific inflammatory changes and otherwise normal parenchyma.", "Further histologic examination of the surgical specimen revealed substantial periductal inflammatory infiltrate with eosinophils, as seen in the Figure.Medium-powered (A) and high-powered (B) field from the superficial parotid gland (hematoxylin-eosin)."], "Treatment": ["Her symptoms responded to oral prednisone bursts and diphenhydramine, but not to second-generation antihistamines or montelukast.Her workup included immune serology and total immunoglobulin (Ig) E measurements, all of which were within normal limits.", "Concurrent steroid irrigation did not provide any substantial benefit.", "Given the frequency and severity of her symptoms along with multiple treatment failures, she opted to undergo a right superficial parotidectomy, which proceeded without complications."], "Diagnosis": ["During an emergency department visit, she was diagnosed with acute parotitis based on clinical and radiographic findings of diffuse gland edema, without salivary stones or masses."]}
{"Examination and Results": ["On physical examination, there was a nontender 4-cm mass in the left submandibular region with no overlying skin changes.", "Ultrasonography results showed an avascular cystic structure with internal debris and a single thin septation.", "Contrast-enhanced computed tomography (CT) of the neck soft tissue revealed a 3-cm low attenuation, nonenhancing, cystic-appearing mass that elevated the submandibular gland to the level of the parapharyngeal fat space with medial extension of the lesion into the tongue musculature.", "The walls were thin except for mildly thickened capsule along the posterior aspect of the lesion (Figure, A and B).", "Fluid that aspirated from the cyst was serous, and cytology showed mature and anucleate squamous cells with acute inflammation.", "The mass returned after 3 weeks.", "At age 12 months, the mass was excised via neck dissection.", "A, Axial: the blue arrowhead indicates extension into the tongue musculature, the yellow arrowhead indicates focally thickened capsule posteriorly, and the white arrowhead indicates a displaced sternocleidomastoid muscle.", "B, Coronal: the black arrowhead indicates an elevated left submandibular gland, and the white arrowhead indicates a normal right submandibular gland.", "C, Axial T2-weighted magnetic resonance image showing marked interval enlargement of the multiseptated cystic mass."], "Treatment": ["A lateral component at the level of the sternocleidomastoid muscle was completely excised.", "An intraoperative rupture of the thin capsule caused some spillage of cystic contents that were milky white in some areas and mucinous in others.Contrast-enhanced computed tomography images."], "Others": ["Her parents reported no fevers, constitutional symptoms, or enlargement of the mass.", "Further analysis 8 months after the initial CT via contrast-enhanced magnetic resonance imaging (MRI) showed a large, multiseptated cystic structure (Figure, C); the capsule of the wall was mildly thickened and was contrast enhancing."]}
{"Patient Symptoms": ["The lesion had appeared without an identifiable cause, and for the previous 2 months, the patient had applied topical corticosteroids and antifungals with no improvement."], "Examination and Results": ["Physical examination revealed an ill-defined, nonindurated, erythematous-violaceous plaque that was slightly raised but with an atrophic appearance (Figure, A).", "A skin biopsy was obtained for histopathology examination (Figure, B-D).A, Clinical image of the left calf showing an ill-defined, erythematous-violaceous plaque with an atrophic appearance.", "B, Band-like vascular proliferation in the upper dermis with no grenz zone (hematoxylin-eosin).", "C, Round vascular channels lined by a single layer of endothelial cells without atypia (hematoxylin-eosin).", "D, CD34 immunostaining labels endothelial cells."], "Treatment": ["The lesion had appeared without an identifiable cause, and for the previous 2 months, the patient had applied topical corticosteroids and antifungals with no improvement."]}
{"Patient Symptoms": ["The patient fell asleep and his girlfriend tried to wake him, but he started shaking and slumped over on the ground.", "He denied confusion afterward but did not feel well with nausea, flushing, chest tightness, and a rapid heart rate.", "About 10 minutes later, he had a second syncopal episode for 2 to 3 minutes with more than 20 muscle jerks."], "Examination and Results": ["On presentation at the emergency department, he was afebrile, blood pressure was 120/59 mm Hg, heart rate was 85 beats per min, respiratory rate was 16 breaths per min, and oxygen saturation was 96% on room air.", "His cardiac examination revealed normal heart sounds with no murmurs.The electrocardiogram (ECG) was performed early on arrival in the emergency department (Figure).", "Transthoracic echocardiography revealed an ejection fraction of 54%, mild right ventricular (RV) dilation (RV diameter, 4.1 cm), and no significant valvular abnormalities.", "Cardiac magnetic resonance imaging showed no RV abnormalities and qualitatively normal RV function.", "Brain magnetic resonance imaging and electroencephalogram  were obtained, both of which results were normal."], "Others": ["Neurology consultation was obtained with concern for an epileptic seizure event surrounding the recurrent syncopal episodes.", "On further questioning, patient reported having a second cousin with sudden cardiac death of uncertain etiology in his early 20s.Initial electrocardiogram on presentation in the emergency department."]}
{"Patient Symptoms": ["On physical examination, the patient had normal vital signs, mild diffuse abdominal tenderness without rebound or guarding, and bluish pigmentation along his gingival margin (Figure, panel A)."], "Examination and Results": ["Blood testing showed alanine aminotransferase level 51 U/L (0.85 \u03bckat/L; reference range, 7-23 U/L [0.12-0.38 \u03bckat/L]), aspartate aminotransaminase 68 U/L (1.14 \u03bckat/L; reference range, 13-30 U/L [0.22-0.50 \u03bckat/L]), total bilirubin 3.2 mg/dL (54.73 \u03bcmol/L; reference range, 0.4-1.5 mg/dL [6.84-25.66 \u03bcmol/L]) and direct bilirubin 0.9 mg/dL (15.39 \u03bcmol/L; reference range, 0.0-0.4 mg/dL [0.0-6.84 \u03bcmol/L]).", "Hemoglobin level was 8.7 g/dL with a normal mean corpuscular volume, and ferritin level was 637.9 ng/mL (reference range, 39.9-465 ng/mL).", "Blood testing revealed normal lactate dehydrogenase, haptoglobin, iron, vitamin B12, folate, zinc, and copper levels, and results of urinalysis were normal.", "A peripheral blood smear demonstrated small, bluish-purple punctate inclusions in erythrocytes (Figure, panel B).", "Results of upper and lower endoscopy and abdominal-pelvic computed tomography performed within the past 3 months were unremarkable.A, Dark blue lines along patient\u2019s upper gingival margins."]}
{"Patient Personal Background": ["Medical history was notable for mild obesity (body mass index of 30 [calculated as weight in kilograms divided by height in meters squared]).Visual acuity was 20/20 OU, with briskly reactive pupils OU and no relative afferent pupillary defect."], "Patient Symptoms": ["Automated visual fields demonstrated subtle enlargement of the blind spots.Fundus photography demonstrating bilateral grade 1 optic disc edema.On neurologic examination, she had moderate weakness of dorsiflexors at the ankles bilaterally as well as toe extensors and everters.", "There was large and small fiber sensory loss distally in the legs.Findings of magnetic resonance (MR) imaging and MR venography of the head were unremarkable."], "Examination and Results": ["Intraocular pressure was 17 mm Hg OU.", "Ishihara color plates were 13/13 OU.", "Extraocular movements were full.", "Ophthalmoscopic examination revealed blurring and elevation of the nasal margins of the optic disc consistent with grade 1 optic disc edema in both eyes (Figure).", "Optical coherence tomography showed an elevated mean peripapillary retinal nerve fiber layer thickness of 170 \u03bcm OD and 150 \u03bcm OS.", "Automated visual fields demonstrated subtle enlargement of the blind spots.Fundus photography demonstrating bilateral grade 1 optic disc edema.On neurologic examination, she had moderate weakness of dorsiflexors at the ankles bilaterally as well as toe extensors and everters.", "There was large and small fiber sensory loss distally in the legs.Findings of magnetic resonance (MR) imaging and MR venography of the head were unremarkable.", "Electromyography suggested a brachial plexopathy.", "Lumbar puncture showed a normal opening pressure of 170 mm Hg with a cerebrospinal fluid protein of 113 mg/dL and 2 nucleated white blood cells.", "Serum studies were notable for a thrombocytosis of 479\u2009\u00d7\u2009103/\u03bcL (to convert to \u00d7\u2009109/L, multiply by 1) and an elevated quantitative monoclonal IgA \u03bb-protein level of 492 mg/dL (to convert to grams per liter, multiply by 0.01)."]}
{"Patient Symptoms": ["Several days into her hospital course, she developed acute-onset severe bilateral periorbital swelling, chemosis, and ophthalmoplegia as well as occasional flushing and palpitations.", "Her best-corrected visual acuity was 20/70 in both eyes."], "Examination and Results": ["Pupils, intraocular pressure, and color vision were normal.", "She had bilateral proptosis to 20/21 mm by Hertel exophthalmometer, \u22123 restriction of extraocular movements in all directions of gaze, diffuse punctate epithelial erosions, and mechanical lower lid entropion secondary to severe chemosis in both eyes (Figure 1A).", "Anterior segment examination and dilated ophthalmoscopy results were otherwise unremarkable.A, External photograph on initial presentation demonstrating bilateral periorbital swelling, chemosis (yellow arrowhead), and lower lid entropion (white arrowheads).", "B, Coronal T1 fat-suppressed postcontrast orbital magnetic resonance imaging (MRI) with nodular heterogenous enhancement of bilateral extraocular muscles.", "IR indicates inferior rectus; LR, lateral rectus; MR, medial rectus; SO, superior oblique; SR, superior rectus.Magnetic resonance imaging of the brain and orbit with contrast revealed bilateral and symmetric tendon-sparing extraocular muscle enlargement of all extraocular muscles (EOMs) with nodular heterogenous enhancement (Figure 1B)."]}
{"Patient Personal Background": ["He was otherwise well."], "Examination and Results": ["His best-corrected visual acuity was 20/20 OD and 20/30 OS with intraocular pressures of 20 mm Hg OD and 26 mm Hg OS.", "The anterior segments showed well-positioned posterior chamber intraocular lens implants with open posterior capsules.", "Dilated fundus examination revealed a small peripheral hypoautofluorescent chorioretinal scar in the right eye.", "In the left eye, there was trace vitreous haze and 2+ anterior vitreous cell.", "Multifocal chorioretinal scars extended from the left optic nerve into the macula in each quadrant (Figure 1).", "These lesions showed variable hypoautofluorescence and hyperautofluorescence.", "On indocyanine green angiography (ICGA), the confluent hypoautofluorescent lesions showed loss of the choriocapillaris and prominent large choroidal vessels, whereas the mottled hypoautofluorescence and hyperautofluorescent lesions appeared to block the underlying fluorescence.", "Routine laboratory testing was unremarkable except for a positive interferon-gamma release assay for Mycobacterium tuberculosis.", "A chest radiograph was normal.Fundus photograph of the left eye demonstrating multifocal outer retinal lesions with variable pigmentation extending from the optic nerve to the equator with sparing of the foveal center."], "Treatment": ["The referring physician was treating him with prednisolone eye drops for cystoid macular edema after recent left Nd:YAG capsulotomy."]}
{"Patient Personal Background": ["Local antiglaucoma therapy with a fixed-combination prostaglandin and \u03b2-blocker was used regularly in both eyes owing to long-standing primary open-angle glaucoma.", "Uneventful cataract surgery with phacoemulsification and in-the-bag insertion of an intraocular lens was performed 10 years earlier in both eyes."], "Examination and Results": ["Best corrected visual acuity (BCVA) was 1.0 and 0.5 (Snellen equivalent, 20/20 and 20/40) OD and OS, respectively.", "His manifest refraction revealed a difference of \u22120.75 D sphere compared with his own preexisting glasses in the right eye.", "IOP was 24 mm Hg in the right eye and 18 mm Hg in the left eye.Slitlamp examination revealed a milky substance in the retrolental space, more pronounced in the right eye (Figure) but evident in both.", "The rest of the slitlamp examination was unremarkable with moderate superficial punctate keratitis owing to ocular surface disease, an anterior chamber depth of Van Herick grade 4 (peripheral anterior chamber depth >1 corneal thickness), an absence of anterior chamber inflammation, and a moderate amount of Elschnig pearls in both eyes.Right eye with milky-opaque substance (between white arrowheads) in the retrolental space and distension of the capsular bag."], "Treatment": ["Local antiglaucoma therapy with a fixed-combination prostaglandin and \u03b2-blocker was used regularly in both eyes owing to long-standing primary open-angle glaucoma."]}
{"Patient Personal Background": ["Her history was notable for phthisis in her left eye due to a left orbit clear cell sarcoma with metastatic disease, after surgical excision and radiation, with recent enrollment in a palliative immunotherapy research protocol."], "Patient Symptoms": ["One day later, her mental status improved, and she reported central blurry vision in her right eye."], "Examination and Results": ["On examination, her visual acuity was 20/40 in this eye, she had normal intraocular pressure, and there was no evidence of anterior chamber or vitreous cells.", "Dilated fundus examination revealed segmental areas of venous sheathing (Figure 1A) in the right eye and was not possible in the left eye owing to phthisis.", "An optical coherence tomography scan of the right eye revealed hyperreflective changes along the outer plexiform and outer nuclear layers, small intraretinal cysts, and disruption of the ellipsoid and especially the interdigitation zone (Figure 1B).A, Color fundus photograph of the right eye at the time of presentation demonstrating segmental areas of venous sheathing (white arrowheads)."], "Treatment": ["After completing 2 days of broad-spectrum intravenous antibiotics and antivirals for presumed septic meningitis, her laboratory and imaging results returned negative and she was transitioned to intravenous methylprednisolone (1 mg/kg)."]}
{"Patient Symptoms": ["One month later, he presented to a local emergency department with diffuse abdominal pain.", "Symptoms began 6 weeks earlier and had been intermittent in nature.", "He had also experienced fatigue, night sweats, decreased appetite, and weight loss for 6 weeks.", "He otherwise denied having fevers, myalgias, nausea, vomiting, diarrhea, or easy bruising."], "Examination and Results": ["A fine-needle biopsy of an enlarged left-sided cervical lymph node yielded benign results.", "Physical examination revealed bilateral cervical, axillary, and inguinal lymphadenopathy in addition to mild diffuse abdominal pain.", "Laboratory results revealed a hemoglobin level of 13.1 g/dL (to convert to g/L, multiply by 10), a white blood cell count of 6.4\u2009\u00d7\u2009103/\u03bcL, and a platelet count of 404\u2009\u00d7\u2009103/\u03bcL  (to convert to \u00d7\u2009109/L, multiply by 1) in addition to negative results for HIV, hepatitis B virus, and hepatitis C assays.", "Additional workup results were notable for elevated levels of interleukin (IL) 10 (1091 pg/mL), IL-6 (3.1 pg/mL), C-reactive protein (4.9 mg/dL [to convert to mg/L, multiply by 10]), and erythrocyte sedimentation rate (79 mm/h).", "A computed tomography scan of the neck, chest, abdomen, and pelvis further revealed extensive cervical, supraclavicular, retroperitoneal, pelvic, and inguinal lymphadenopathy, with extensive inflammation and fat stranding adjacent to these enlarged nodes.", "Positron emission tomography\u2013computed tomography further demonstrated fluorodeoxyglucose-avid lymph nodes above and below the diaphragm.", "The patient then underwent excisional biopsy of an enlarged right cervical lymph node (Figure).A, Proliferation of slitlike blood vessels (hematoxylin-eosin).", "B, The lymphoid follicle shows regression, with onion-skinning of mantle zone lymphocytes and hypervascularity (hematoxylin-eosin).", "Scattered atypical plasma cells are present."]}
{"Patient Symptoms": ["The skin lesion was nail sized when first noticed 1\u00bd years earlier, then gradually developed over the 8 months prior to presentation.", "The patient denied any associated fevers, weight loss, or night sweats."], "Examination and Results": ["Physical examination revealed a slightly reddish verrucous mass with translucent papules and plaques on the right temple, about 5 cm in diameter, with surface hemorrhagic crust in the side adjacent to right eyebrow arch (Figure, A).", "The lesion was nontender with no purulent discharge and no severe necrotic changes.", "There was no hepatosplenomegaly or superficial lymphadenopathy.", "Laboratory tests, including blood cell counts, urinalysis, and kidney and hepatic panels, revealed no abnormalities.", "A skin biopsy was performed and submitted for histopathologic analysis (Figure, B-D).A, A slightly reddish verrucous mass with translucent papules and plaques on the right temple.", "B, The histological examination showed papillomatous epidermal hyperplasia, edema of dermal papillae, and neoplastic infiltration consisting of small round blue cells with alternating areas of dense and loose cellularity (hematoxylin-eosin).", "C, Small, round blue cells were observed in the dermis with round, fusiform, or oval hyperchromatic nuclei, conspicuous nucleoli, and scant cytoplasm (hematoxylin-eosin).", "D, Tumor cells were positive for MyoD1 (original magnification \u00d7400)."]}
{"Patient Symptoms": ["Dermatology was consulted for input on the cause of the ulcers, which had been ongoing for approximately 6 months prior; individual lesions lasted 1 to 3 weeks before self-resolving.", "Examination revealed exquisitely tender, ovoid, punched-out ulcerations of the inferior lip and scrapeable white plaques on the tongue (Figure, A), right buccal mucosa, and external anal mucosa (Figure, B)."], "Examination and Results": ["A punch biopsy from 1 of the perianal ulcers was performed (Figure, C and D).A, Healing oval punched-out ulceration of inferior lip and white plaques on tongue consistent with thrush.", "B, Two ovoid, punched-out ulcerations of the external anal mucosa.", "C, Hematoxylin-eosin staining of perianal lesion showed mixed infiltrate of histiocytes, neutrophils, lymphocytes, and eosinophils, with prominent admixed large and atypical cells at high power.", "D, Epstein-Barr virus\u2013encoded RNA staining showed scattered positivity in some cells."], "Treatment": ["During admission in the intensive care unit, treatment with broad-spectrum oral antibiotics for presumed infection and oral fluconazole for thrush led to improvement in the patient\u2019s medical condition, but the ulcers persisted."]}
{"Patient Symptoms": ["After recovering from anesthesia in the postanesthesia care unit, he experienced headache, facial numbness, inability to open both his eyes, and inability to move both eyes in any direction.He had a known enhancing central skull base lesion in sella turcica with compression of the optic chiasm and mild mass effect on the pons that was felt to be a pituitary macroadenoma (Figure).", "After symptom onset, the mass was hyperintense on T2-weighted images (not shown).During the bedside examination in the postanesthesia care unit, he was noted to have complete bilateral ptosis.", "He had decreased sensation to light touch and pinprick in the V1/V2 distribution of the trigeminal nerve bilaterally.", "Vestibulo-ocular reflex did not overcome the ophthalmoplegia."], "Examination and Results": ["His baseline examination before the cystectomy showed visual acuity of 20/20 OU with intact extraocular movements and unremarkable confrontational fields, although a mild bitemporal hemianopia was seen on automated visual fields.T1-weighted coronal magnetic resonance imaging (MRI) with contrast shows a 4.9\u2009\u00d7\u20094.6\u2009\u00d7\u20095.2-cm sellar/parasellar lobulated mass with homogenous enhancement before symptom onset (A), which became 5.3\u2009\u00d7\u20095.1\u2009\u00d7\u20095.3 cm and had loss of enhancement after symptom onset (B).", "The mass caused superior displacement of the optic chiasm and had extension into the cavernous sinus bilaterally.", "The mass also extended posteriorly and deformed the anterior aspect of the pons (not shown).", "His visual acuity was 20/20 OU with full visual fields on confrontational visual field testing.", "The right and left pupils were 5 mm and 6 mm in size, respectively, in both light and dark.", "There was no pupillary response to light or accommodation.", "Intraocular pressure was normal in both eyes.", "The patient was unable to move either eye in any direction on extraocular motility testing.", "Magnetic resonance imaging (MRI) was obtained 12 hours after symptom onset redemonstrating the large sellar mass, which no longer had central enhancement (Figure)."], "Diagnosis": ["After recovering from anesthesia in the postanesthesia care unit, he experienced headache, facial numbness, inability to open both his eyes, and inability to move both eyes in any direction.He had a known enhancing central skull base lesion in sella turcica with compression of the optic chiasm and mild mass effect on the pons that was felt to be a pituitary macroadenoma (Figure)."], "Others": ["No exophthalmos was noted."]}
{"Patient Personal Background": ["Her last intravenous heroin use occurred 9 days prior to presentation.", "She was not taking any prescription or herbal medications and had not been prescribed suppressive antiviral medication for chronic HBV infection.", "She reported no history of travel outside the US and no raw meat ingestion."], "Patient Symptoms": ["Her vital signs, mentation, and physical examination were normal except for scleral icterus (Figure)."], "Examination and Results": ["Results of blood testing were negative for hepatitis C virus RNA, anti\u2013hepatitis A IgM, and HIV antibody.", "Other selected laboratory values are shown in the Table."]}
{"Patient Symptoms": ["Twelve months prior, he experienced a self-limited episode of right eye pain and redness, and 2 months later, a similar episode occurred in his left eye.", "He reported no fevers, chills, headaches, visual changes, hearing loss, hoarseness, shortness of breath, wheezing, chest pain, arthralgias, or rash."], "Examination and Results": ["Physical examination revealed normal vital signs, and no abnormalities on nasal, cardiopulmonary, joint, and skin examination.", "His left eye had scleral erythema, and the cartilaginous portion of his left ear was swollen and erythematous (Figure).Left, erythematous and edematous patch on the patient\u2019s left sclera.", "Right, auricular erythema of the left external ear, with sparing of the earlobe.Laboratory testing revealed a white blood cell count of 4200/\u03bcL, hemoglobin level of 12.9 mg/dL, and platelet count of 142\u202f000/\u03bcL.", "Erythrocyte sedimentation rate (ESR) was 53 mm/h (reference range, 0-15 mm/h), and C-reactive protein was 135 mg/L (reference range, 0-8 mg/L)."]}
{"Patient Symptoms": ["She denied experiencing pain, diplopia, muscle weakness, dysarthria, dysphagia, difficulty breathing, or other neurologic deficits.On examination, corrected visual acuity was 20/20 bilaterally, with normal color vision, visual fields, intraocular pressure, extraocular movements, alignment, and pupils."], "Examination and Results": ["External examination was notable for left upper eyelid ptosis (Figure 1), with a margin-to-reflex distance 1 of 3.5 mm on the right and 0.5 mm on the left, intact levator function, and no fatiguability on sustained upgaze.", "There was no evidence of eyelid edema, erythema, or tenderness to palpation.", "There were no palpable adnexal masses or orbital rim deformities, but there was mild fullness in the left superior sulcus and mildly increased left-sided resistance to retropulsion.", "However, Hertel exophthalmometry did not reveal any relative proptosis.", "No lacrimal gland abnormalities or conjunctival masses were seen with upper eyelid eversion.", "There was no palpable preauricular or cervical lymphadenopathy.", "Slitlamp and fundus examination findings were normal.", "Serological testing results for antiacetylcholine receptor antibody were negative.Clinical photograph of both eyes showing left upper eyelid ptosis.", "Margin-to-reflex distance 1 was 3.5 mm on the right and 0.5 mm on the left."]}
{"Patient Personal Background": ["Her medical history included untreated hyperprolactinemia manifested by galactorrhea and oligomenorrhea.", "She did not take any medications, smoke, or drink alcohol.On examination, visual acuity was 20/20 in each eye."], "Patient Symptoms": ["She denied any other neurologic symptoms."], "Examination and Results": ["There was no relative afferent pupillary defect.", "There was minimal limitation in infraduction in the left eye with corresponding left hypertropia (Video), which was worse in left gaze and right head tilt.", "Ophthalmoscopy findings were normal in each eye."]}
{"Patient Symptoms": ["The patient was referred to a cornea specialist for further evaluation and treatment.Because of the COVID-19 pandemic, specialty evaluation occurred 10 weeks later at which time the patient complained of progressive vision loss in the right eye."], "Examination and Results": ["There was no recent ocular trauma or intraocular surgery.", "At the time of the initial examination, visual acuity was 20/50 in the right eye and 20/20 in the left eye, with a refraction of \u22121.50 diopters (D) sphere in both eyes.", "Examination was notable for a superonasal area of pigmentation with elevation of the conjunctiva and an inferotemporally subluxed PCIOL in the right eye.", "Results of the fundus examination were reported to be normal in both eyes and the anterior examination of the left eye was notable for only a well-positioned PCIOL.", "Visual acuity measured hand motion in the right eye with normal intraocular pressure.", "The PCIOL was subluxed inferotemporally with vitreous prolapse into the anterior chamber (Figure 1A).", "A 4 mm\u2009\u00d7\u20093.1-mm superonasal pigmented scleral lesion was also noted (Figure 1B).", "The examination of the left eye was remarkable only for a well-centered PCIOL and iris transillumination defects.A, Slitlamp photography of the right eye showing the inferotemporal intraocular lens implant subluxation (arrowhead)."]}
{"Patient Personal Background": ["The patient was nonverbal at baseline and exhibited restrictive and repetitive behaviors.", "His diet consisted exclusively of cookies, apples, potato chips, and Gatorade."], "Patient Symptoms": ["His mother noticed him frequently rubbing his eyes for several weeks, which she initially attributed to new-onset allergies."], "Examination and Results": ["She did not describe any reduction in visual function or ability to perform low-luminance tasks.The patient was admitted and ophthalmology was consulted.", "He required an examination under sedation.", "His visual acuity could not be determined.", "There was no relative afferent pupillary defect in either eye.", "The eyelids were mildly erythematous with bilateral eyelash hypertrichosis.", "The conjunctiva and cornea appeared dry and leathery bilaterally.", "The right cornea was diffusely hazy with a 3-mm paracentral epithelial defect with 60% stromal thinning and a 1-mm infiltrate.", "There was a small crescentic fibrin deposit nasally in the right anterior chamber.", "The left cornea was diffusely hazy with a 1-mm epithelial defect without stromal thinning (Figure).", "Dilated examination showed bilateral grade 3 optic nerve head edema and otherwise normal retinal findings.", "Results of magnetic resonance imaging of the brain were normal.Photographs of the right (A) and left (B) eyes reveal a dry and lusterless appearance of the conjunctivae and corneas of both eyes."], "Treatment": ["Fortified vancomycin eye drops, 25 mg/mL, and tobramycin eye drops, 15 mg/mL, were initiated."]}
{"Patient Personal Background": ["She denied any medical history of vertigo, recent upper respiratory infection, head trauma, or prior otologic surgery.A physical examination revealed no abnormalities on otoscopic evaluation; however, a strongly positive right-sided Dix\u2212Hallpike test was elicited with rotary nystagmus; a subsequent Epley maneuver was performed."], "Patient Symptoms": ["The patient\u2019s symptoms subjectively worsened during the following several days."], "Examination and Results": ["She denied any medical history of vertigo, recent upper respiratory infection, head trauma, or prior otologic surgery.A physical examination revealed no abnormalities on otoscopic evaluation; however, a strongly positive right-sided Dix\u2212Hallpike test was elicited with rotary nystagmus; a subsequent Epley maneuver was performed.", "Therefore, an audiogram test (Figure 1) and computed tomography (CT) of the temporal bone were performed.Preoperative audiogram reveals a right-sided low- to mid-frequency moderate conductive hearing loss and a bilateral high-frequency sensorineural hearing loss."], "Treatment": ["She denied any medical history of vertigo, recent upper respiratory infection, head trauma, or prior otologic surgery.A physical examination revealed no abnormalities on otoscopic evaluation; however, a strongly positive right-sided Dix\u2212Hallpike test was elicited with rotary nystagmus; a subsequent Epley maneuver was performed."], "Others": ["dB denotes decibels; HTL, hearing threshold level; SL, sensation level; SRT, speech reception threshold; and TDH, telephonic dynamic headphones."]}
{"Patient Personal Background": ["The patient denied any history of dysphagia, dysphonia, drainage, previous neck surgery, trauma, or recent fever.", "There was no significant medical or family history of thyroid disease."], "Examination and Results": ["On examination, the mass moved with swallowing.", "The patient had normal thyroid stimulating hormone and calcium levels and a parathyroid hormone (PTH) level of 63 pg/mL.", "Neck ultrasonography revealed a well-circumscribed anechoic lesion with a diameter of 5.9 cm in the right thyroid lobe without any internal solid nodularity or septation.", "A neck computed tomography (CT) scan revealed an intrathyroidal lesion extending inferiorly to 3 cm above the angle of Louis causing tracheal compression and displacement (Figure, A).", "Pathologic examination confirmed a normal right thyroid lobe, a normal right parathyroid gland, and a cystic lesion at the inferior pole with no evidence of malignant disease in the specimen.", "The tissue inside the lesion stained positive for PTH.A, A neck CT scan showing an intrathyroidal mass causing tracheal compression and is in close proximity to the right common carotid artery and right internal jugular vein."], "Treatment": ["The patient underwent right hemithyroidectomy to relieve tracheal compression."], "Others": ["A near-infrared autofluorescence (NIRAF) camera yielded a homogenously dim lesion (Figure, B).", "B, A NIRAF image of the surgical field showing right thyroid lobe, a right parathyroid gland, and a homogenously dim capsulated lesion of interest."]}
{"Patient Personal Background": ["She had a history of coronary artery disease and prior myocardial infarction that was treated with warfarin.", "She denied any personal or family history of cancer.", "She was previously briefly a smoker."], "Examination and Results": ["A physical examination revealed no erythema or tenderness of the parotid.", "Her cranial nerves were intact, specifically the right facial nerve and its branches.", "The oral mucosa was intact with no epithelial lesions.", "Urinalysis results revealed slight hematuria.", "Her international normalized ratio (INR) was 4.4.", "Contrast-enhanced computed tomography (CT) revealed an ill-defined infiltrative mass centered in the deep lobe of the right parotid with extension into surrounding soft tissue spaces (Figure, A).", "A follow-up CT was performed 6 weeks later (Figure, B).A, Axial contrast-enhanced computed tomography (CT) reveals an ill-defined, infiltrative lesion centered in the deep lobe of the right parotid gland."], "Treatment": ["She had a history of coronary artery disease and prior myocardial infarction that was treated with warfarin."]}
{"Patient Personal Background": ["Her medical and family histories were unremarkable.", "Her parents denied drug injection or trauma history."], "Patient Symptoms": ["The lesion initially occurred as an erythema in the neck and progressed centrifugally to the nape and submandibular areas.", "Atrophy was observed in the center of the lesion, surrounded by an erythematous border, with underlying blood vessels being visible deep to the atrophy (Figure, A).A, Atrophy in the center of the lesion, surrounded by an erythematous border, with underlying blood vessels deep to the atrophy."], "Examination and Results": ["B, A biopsy specimen taken from the edge of the depressed lesion showing normal epidermis and dermis, no inflammatory cell infiltration within the dermis, and somewhat diminished subcutaneous fatty tissue (hematoxylin-eosin).", "C, The same specimen at a greater magnification (hematoxylin-eosin).", "D, Ultrasonographic findings showing markedly thinner subcutaneous fat of the skin (thickness of thinner region, 0.08 cm).Cervical lymph nodes were palpable bilaterally.", "Tactile responses within the depressed as well as surrounding areas were normal.", "Other physical examinations were without abnormalities.", "Results of routine laboratory tests, HIV test, serological test of antibodies for Borrelia, and antinuclear antibody test were within normal limits or negative."], "Others": ["After obtaining informed consent from her parents, a biopsy specimen was taken from the edge of the depressed lesion for histological examination."]}
{"Patient Symptoms": ["Skin lesions developed 2 months earlier and progressively spread.", "She reported abdominal discomfort, weight loss, and vaginal bleeding.", "A solid mass on her lower abdomen that had been palpable about 10 years prior had rapidly increased in size within the past few months."], "Examination and Results": ["Physical examination revealed erythematous plaques on the right chest and flank without warmth.", "Punch biopsy of a lesion from the chest was sent for histopathological examination (Figure, B and C).A, Erythematous plaques involving the right chest and flank at the initial presentation.", "B and C, Large atypical cells with clear or eosinophilic cytoplasm forming papillary and glandular architectures are present in the deep dermis; lymphovascular invasion was observed in the superficial and deep dermis (hematoxylin-eosin).", "D, Contrast-enhanced computed tomographic scan of the abdomen and pelvis showing a large heterogeneous mass in the right rectus abdominis muscle (blue arrowhead) and cystic lesion in the left ovary (pink arrowhead)."]}
{"Patient Personal Background": ["His medical history comprised unexplained sensory hearing loss, hyperlipidemia, and osteoarthritis.", "Family history was negative for movement or developmental disorders."], "Patient Symptoms": ["At age 23 years, he had bilateral cataract surgery, and over the last 2 years, he developed worsening stiffness and walking difficulties with frequent falls.", "He reported features of rapid eye movement (REM) sleep behavior disorder, restless legs syndrome (RLS), visual daytime hallucinations, and rapid cognitive decline."], "Examination and Results": ["His neurologic examination showed hypomimia, symmetrical bradykinesia, and rigidity of the extremities without tremors (Video).", "There was full range of eye movements with large-amplitude saccadic intrusions on smooth pursuit in all directions.", "Neuropsychological assessment revealed significant abnormalities in cognitive functioning, affecting verbal and nonverbal cognitive skills (ie, speed of information processing, visuospatial skills, verbal and visual memory loss, executive skills).", "Mini-Mental Status Examination score was 26 of 30 points.", "Systemic examination was unremarkable.", "Laboratory and cerebral spinal fluid testing (ie, paraneoplastic antibodies Hu, Yo, Ri, CV2, Ma2, amphiphysin, glutamic acid decarboxylase, N-methyl-d-aspartic acid, LGI1, and Caspr2, 14-3-3 protein) were normal.", "Cranial magnetic resonance imaging (MRI) showed mild frontal and parietal atrophy.", "An electroencephalogram demonstrated slowing in keeping with moderate generalized encephalopathy.", "Total-body positron emission tomography (PET) using fluorine 18 (18F) fluorodeoxyglucose (FDG) as a tracer showed no FDG-avid lesions; however, a subsequent brain-specific FDG-PET/MRI revealed hypometabolism throughout the left cerebral hemisphere and crossed cerebellar diaschisis (Figure 1)."], "Treatment": ["He was given levodopa/benserazide (up to 200 mg/50 mg 4 times daily) without improvement on his Unified Parkinson Disease Rating Scale scores.", "Therefore, his dopaminergic medication was ceased."], "Diagnosis": ["As the patient\u2019s cognitive function and parkinsonism had deteriorated rapidly, a brain biopsy of the left frontal cortex was done."]}
{"Patient Personal Background": ["He reported no new medications or recent infection."], "Examination and Results": ["His temperature was 37.5 \u00b0C (99.5 \u00b0F); heart rate, 102/min; blood pressure, 98/72 mm Hg; respiratory rate, 12/min; and oxygen saturation, 94% on room air.", "His skin examination revealed 3 tender, nonfluctuant 10-cm scalp plaques with overlying hemorrhagic crust and necrosis on an erythematous indurated base (Figure, left panel).", "Similar-appearing papules and plaques were present on the dorsal surfaces of his hands.", "The remainder of his physical examination was normal.Left, 10-cm tender plaque on the patient\u2019s scalp, with overlying hemorrhagic crust and necrosis on an erythematous indurated base.", "Right, Tissue sample from punch biopsy of patient\u2019s hand shows papillary dermal edema, a dense dermal neutrophilic infiltrate, blister formation, and red cell extravasation (hematoxylin-eosin, original magnification \u00d7400).Blood testing revealed a hemoglobin level of 7.1 g/dL; white blood cell count, 2000/\u03bcL; and platelet count, 105\u202f000/\u03bcL.", "Results of vitamin B12, folate, and iron studies were within normal limits.", "Erythrocyte sedimentation rate was 85 mm/h and C-reactive protein level was 147 mg/L.", "A peripheral blood smear demonstrated no blast forms.", "Computed tomography scan of the chest, abdomen, and pelvis with intravenous contrast performed on the day of presentation showed no infiltrates, mass, lymphadenopathy, or pulmonary embolus but revealed an acute deep vein thrombosis (DVT) involving the left common and external iliac veins and distal inferior vena cava.", "The patient declined hospital admission, and treatment with apixaban was started.Punch biopsies of the scalp and left hand revealed a dense dermal neutrophilic infiltrate with marked edema without vasculitis (Figure, right panel)."], "Treatment": []}
{"Patient Personal Background": ["She took no prescription medications and reported no recent use of over-the-counter medications, including nonsteroidal anti-inflammatory drugs."], "Patient Symptoms": ["Twelve days after the booster vaccination, she developed pruritic wheals on her face and bilateral, transient eyelid swelling.", "Over the next week, a pruritic rash spread over her neck, chest, trunk, and arms; each lesion faded without scarring within 24 hours.", "She did not experience lip, tongue, or neck swelling; shortness of breath; wheezing; chest pain; or palpitations.", "Application of pressure to her forearm in a circular motion using a pen cap elicited wheal and flare lesions (Figure, left panel).", "On physical examination, performed 17 days after the onset of rash, her vital signs were normal.", "Wheal and flare lesions developed on her upper eyelids during the examination and resolved after approximately 30 minutes (Figure, right panel).", "Light pressure applied to her skin with a tongue depressor elicited wheal and flare lesions within 3 to 5 minutes.Wheal and flare lesions on patient\u2019s forearm (left) and eyelids (right).The patient had no history of atopy, urticaria, angioedema, or food or drug allergy and no recent infections."], "Examination and Results": ["She had no tongue, lip, or throat swelling, and her lungs were clear to auscultation bilaterally."], "Others": ["She had not experienced adverse effects after the first 2 vaccine doses on January 17 and February 5, 2021."]}
{"Patient Symptoms": ["His histology results showed a 5-cm Warthin tumor, with a focus of nodular oncocytic hyperplasia in the adjacent parenchyma and reactive intraparotid lymph nodes.He presented to the ear, nose, and throat clinic and complained of pain in the operative site of 6 months duration.", "This occurred intermittently once a week and lasted for a few minutes each time.", "It was associated with a small lump over the left neck, and the pain was worse on touch and head turning."], "Examination and Results": ["On examination, there was a 3-mm nodularity palpated deep to the neck wound along the mid sternocleidomastoid muscle.", "It was associated with focal tenderness.", "A magnetic resonance imaging (MRI) scan was performed, and the results showed no focal lesion in either parotid glands or at the area of interest over the left sternocleidomastoid muscle."], "Treatment": ["The patient was counseled for an excisional biopsy of the left neck nodule."], "Others": ["His facial nerve function was otherwise normal, and sensation in the ear lobe was intact.", "The intraoperative photograph of the neck and the excised specimen is shown in Figure 1.Intraoperative photograph of the left lateral neck and the excised specimen.", "The black arrowhead indicates left neck lesion, the white arrowhead the external jugular vein."]}
{"Patient Personal Background": ["Her history was notable for bilateral colobomas involving the iris, optic nerve, and retina; congenital cataracts after lensectomy of the left eye; retinal detachment with proliferative vitreoretinopathy of the left eye requiring a scleral buckle and silicone oil; and intractable glaucoma in the left eye requiring a superior trabeculectomy, an inferotemporal Ahmed tube implant, and multiple diode cyclophotocoagulation treatments.", "The patient presented 9 months after the last cyclophotocoagulation procedure.At presentation, she was taking dorzolamide-timolol, brimonidine, netarsudil, and latanoprost for her left eye."], "Patient Symptoms": ["There was a left hypertropia of more than 45\u00b0 by Hirschberg test."], "Examination and Results": ["Best-corrected visual acuity was 20/80 OD and light perception OS.", "Intraocular pressures (IOPs) were 11 mm Hg OD and 20 mm Hg OS.", "Examination of the left eye revealed a large, firm, pink subconjunctival mass inferotemporally near the Ahmed valve (Figure 1).", "The anterior chamber was deep with fine silicone oil bubbles superiorly.", "The aphakic left eye revealed a well-positioned tube.", "Cup-disc ratios were 0.7 OD and 0.8 OS."], "Others": ["Because of the high risk of retinal redetachment, the silicone oil was retained throughout the glaucoma procedures."]}
{"Patient Symptoms": ["The patient noted floaters in her right eye, which prompted an ophthalmology consultation."], "Examination and Results": ["Inflammatory markers were elevated with an erythrocyte sedimentation rate greater than 130 mm/h and a C-reactive protein level of 1.48 mg/dL (to convert to milligrams per liter, multiply by 10).", "On bedside examination, her near visual acuity was J1+ (Snellen equivalent, 20/20 OU), and color vision was full in both eyes; the patient\u2019s intraocular pressure, pupils, extraocular movements, and confrontational visual fields were all unremarkable.", "Dilated examination revealed grade I and II optic disc edema in the right and left eyes, respectively, and peripapillary hemorrhage in the right eye.", "Optical coherence tomography was obtained 3 days after initial consultation, which confirmed bilateral disc edema, more pronounced in the left eye than the right eye (Figure 1), and 24-2 Humphrey visual field examination in both eyes was normal.", "Magnetic resonance imaging (MRI) of the brain and orbits with and without contrast and lumbar puncture were obtained, and results showed diffuse signal abnormality in the bone marrow compartment and findings suggestive of papilledema.", "Magnetic resonance venography did not reveal thrombosis.", "Opening pressure during lumbar puncture was 37 cm H2O (upper limit of normal, 28 cm H2O); all cerebrospinal fluid (CSF) viral serology test results were negative, and glucose level and red and white blood cell counts were all within normal limits.", "CSF protein was slightly decreased at 10.4 mg/dL, and CSF cytospin findings were unremarkable.Optical coherence tomography of the right (A) and left (B) optic discs showing edema (mean retinal nerve fiber layer thickness, 158 \u03bcm and 187 \u03bcm in the right and left eye, respectively)."]}
{"Patient Personal Background": ["The patient underwent right-sided ptosis repair at another hospital less than 1 year earlier without improvement."], "Examination and Results": ["Best-corrected visual acuity was 20/30 OU, and pupil examination revealed no anisocoria or afferent pupillary defect.", "Color vision was full in both eyes.", "External examination revealed a margin reflex distance 1 (MRD1) of 0 mm OD, 4 mm OS without fatigability in extended upgaze (Figure 1A).", "The patient had a small exotropia in primary gaze with a \u22122 supraduction deficit.", "No proptosis was observed.", "An ice pack was applied in the clinic to the ptotic eyelid for 2 minutes, which led to a 1.5-mm improvement (Figure 1B) in ptosis and no appreciable change in strabismus."], "Treatment": []}
{"Patient Personal Background": ["Her ocular history included bilateral cataract surgery 5 years prior.", "She had no history of tobacco use.On examination of the left eye, visual acuity was hand motion, and intraocular pressure was 8 mm Hg."], "Patient Symptoms": ["Suspicious retinal detachment and intraocular mass were identified, which raised concerns for choroidal melanoma."], "Examination and Results": ["No symptoms or signs were reported in the right eye.", "The anterior segment showed diffuse conjunctival chemosis of yellow hue, low-grade aqueous reaction, and pseudophakia (Figure 1A).", "On the fundus evaluation, large pockets of subretinal fluid suggested choroidal effusion based on marked fluid shifting with head position.", "B-scan ultrasonography confirmed 4-quadrant choroidal hemorrhage and partially mobile serous retinal detachment.", "B-scans also exhibited a solid lesion from the 6- to 10-o\u2019clock meridians with irregular shape and variable internal reflectivity, measuring 5.8 mm in height.", "In the interim, she received oral steroids aiming to contain the abundant exudation and topical atropine for pain, evolving with minimal clinical improvement on these features.Coloration changes in the left eye associated with choroidal hemorrhage and an intraocular solid lesion."], "Treatment": ["Magnetic resonance imaging was requested to delineate the mass from the surrounding clot (Figure 1B).", "B, The arrowhead indicates the lesion and the asterisk, the adjacent clot."], "Diagnosis": ["Suspicious retinal detachment and intraocular mass were identified, which raised concerns for choroidal melanoma."], "Others": ["Review of systems yielded negative results, including for ocular trauma, jaundice, and cutaneous melanoma."]}
{"Patient Symptoms": ["Two weeks later, she developed progressive bilateral lower extremity numbness, pain, weakness, and imbalance, prompting emergent evaluation."], "Examination and Results": ["Magnetic resonance imaging (MRI) findings demonstrated extensive spinal cord edema extending from T2 to the conus and a posterior ring-enhancing intramedullary lesion at T9 to T10 without any mass effect (Figure 1).", "Lumbar puncture showed no malignant cells.", "Positron emission tomographic-computed tomographic (PET/CT) scan demonstrated multifocal intensely F-fluorodeoxyglucose (FDG)-avid disease, but only mild uptake from T9 to T12 and no definitive FDG-avidity at the intramedullary lesion.", "Of note, there was enhancement of the previously irradiated T11 vertebral body metastasis, and adjacent vertebrae demonstrated marrow hyperintensity on T1-weighed noncontrast imaging."], "Treatment": ["In November 2020, she underwent posterior lateral stabilization of C7-T4 for a T2 vertebral body metastasis causing cord compression, followed by postoperative stereotactic body radiation therapy to T2 to T3 (35 Gy/5 fractions) in January 2021.", "In February 2021, she received palliative radiation therapy (20 Gy/5 fractions) to T9 to T12 for a T11 vertebral body metastasis with epidural extension.", "From January to August 2021, she was treated with gemcitabine, and in September 2021, she received her first dose of liposomal doxorubicin.", "Because the intramedullary lesion appeared atypical for malignant disease given the lack of mass effect, she was prescribed high-dose steroids while further workup was pursued."], "Others": ["In 2020, she relapsed in the liver and spine.", "Her symptoms remained stable with steroid treatment and a plan was made to repeat an MRI of the spine in 6 to 8 weeks.A, T1-weighted postgadolinium sagittal image demonstrating an enhancing spinal intramedullary lesion (blue arrowhead)."]}
{"Patient Personal Background": ["The patient\u2019s medical history included anxiety, depression, emphysema, hyperlipidemia, migraines, and pseudoseizures.", "She denied prior head trauma and had no pertinent surgical history."], "Patient Symptoms": ["The patient reported that the facial and jaw symptoms had evolved gradually over the past 5 years and that multiple medical therapies had provided only minimal relief of pain.", "On physical examination, the patient had normal body habitus and reported bilateral tenderness of the temporomandibular joints and paresthesia of the right trigeminal nerve in the V2 and V3 distribution with intact masseteric nerve and symmetric facial nerve."], "Examination and Results": ["On physical examination, the patient had normal body habitus and reported bilateral tenderness of the temporomandibular joints and paresthesia of the right trigeminal nerve in the V2 and V3 distribution with intact masseteric nerve and symmetric facial nerve.", "Audiometric evaluation showed normal hearing bilaterally.", "Magnetic resonance imaging (MRI) revealed a cystic mass in the right side of infratemporal fossa (ITF) that was nonenhancing on T1 sequencing with contrast and hyperintense on T2 (Figure 1A)."]}
{"Patient Personal Background": ["He attributed these changes to the need for washing hands frequently in the period of the COVID-19 epidemic.", "He had no family history of similar skin problems and did not have a history of hyperhidrosis, cystic fibrosis, atopy, or trauma to the hands.Physical examination showed some changes emerged on both hands after water immersion contrasting with any other condition (Figure, A and B)."], "Patient Symptoms": ["The lesions occurred as symmetrical white and transparent papules, white keratosis, excessive wrinkling on the dorsum of hands after water immersion and worsened in summer, and remitted in winter.", "The lesions gradually aggravated, and the affected area dispersed to wrists and elbows during past the 1.5 years."], "Examination and Results": ["We took a skin biopsy specimen from white papules on the right hand, and representative histopathologic features are shown in the Figure, C and D.A and B, After immersing both hands in water for 10 mins, there were symmetrical white papules, white hyperkeratosis spots, and excessive wrinkling on the thenar eminence, wrist flexure of both hands, and dorsum of fingers and hands.", "C and D, A skin biopsy taken from white papules after water immersion for 10 mins showed hyperkeratosis, dilated eccrine ducts in the epidermis and dermis, and hyperplasia of the eccrine sweat glanda (hematoxylin-eosin)."], "Treatment": ["He was treated with topical tretinoin ointment intermittently per a diagnosis of chronic eczema at the local clinic with little improvement."], "Diagnosis": ["He was treated with topical tretinoin ointment intermittently per a diagnosis of chronic eczema at the local clinic with little improvement."]}
{"Patient Symptoms": ["Three days after admission, the patient developed erythema and edematous necrotic plaques of the bilateral ears (Figure, A and B).", "The necrosis progressed during the following days, primarily involving the earlobe of the right ear and a large portion of the helix of the left ear."], "Examination and Results": ["A punch biopsy specimen was performed (Figure, C and D)."], "Treatment": ["Following admission, he was intubated with prone positioning, and treatment with tocilizumab and dexamethasone was started.", "He was also found to have Staphylococcus hemolyticus bacteremia, and treatment with cefepime was initiated."], "Others": ["No devices had been used on the ears."]}
{"Patient Symptoms": ["She also reported dyspnea on exertion, which developed 6 months prior to presentation."], "Examination and Results": ["On physical examination, her peripheral oxygen saturation was 95% on room air.", "Auscultation of her lungs revealed crackles at the bases bilaterally.", "She had normal strength throughout all muscle groups and full range of motion in the joints of her hands.", "The palmar surfaces of her hands revealed livedo racemosa, erythema, and retiform purpura; ulcers overlying her phalangeal joint creases and fingertips; and scale and fissures on several digits (Figure).", "On the dorsal surfaces there was a large ulcer on the right second metacarpophalangeal joint and erythematous papules over several metacarpophalangeal joints.", "Ulcers were also noted on her elbows.", "Laboratory testing showed a hemoglobin level of 10.5 g/dL and normal creatine kinase level."]}
{"Patient Symptoms": ["Despite 3 days of treatment with an oral antibiotic (cefalexin), her thigh pain and swelling did not improve, and she was readmitted to the hospital and intravenous clindamycin was started.", "The following day, her temperature was 39.4 \u00b0C (102.9 \u00b0F), blood pressure was 86/42 mm Hg, and heart rate was 131/min.", "Surgical debridement of the right thigh was performed on hospital day 3.On hospital day 4, a new purple dusky border developed along the wound edge, and the patent underwent a second surgical debridement.", "Her right thigh had a deep 9\u2009\u00d7\u20098\u2013cm ulcer with a dusky violaceous border extending 2 to 5 cm from the wound edge (Figure, left), with many 1- to 2-mm pustules (not visible in Figure)."], "Examination and Results": ["Wound cultures and blood cultures obtained during incision and drainage performed on hospital day 1 were negative for bacterial, mycobacterial, and fungal organisms.", "Laboratory testing showed a white blood cell count of 30\u202f000/\u03bcL (88% neutrophils); lactate level, 77.5 mg/dL (8.6 mmol/L); and procalcitonin level, 16.1 ng/mL (reference, <0.1 ng/mL).", "Histologic examination of the tissue obtained during the second surgical debridement revealed ulceration with extensive neutrophilic inflammation (Figure, right).", "Right, Histopathologic examination of excised tissue showing dense dermal neutrophilic infiltration (hematoxylin-eosin, original magnification \u00d7400)."], "Treatment": ["Despite 3 days of treatment with an oral antibiotic (cefalexin), her thigh pain and swelling did not improve, and she was readmitted to the hospital and intravenous clindamycin was started.", "She was transferred to the intensive care unit for presumed septic shock, and her antibiotics were changed to vancomycin and meropenem.", "Surgical debridement of the right thigh was performed on hospital day 3.On hospital day 4, a new purple dusky border developed along the wound edge, and the patent underwent a second surgical debridement.", "After debridement on hospital day 5, her temperature was 39.8 \u00b0C (103.6 \u00b0F), and she required vasopressor infusion with norepinephrine for shock."], "Diagnosis": ["She was transferred to the intensive care unit for presumed septic shock, and her antibiotics were changed to vancomycin and meropenem."], "Others": ["Stains for microorganisms, and tissue and blood cultures, remained negative.Left, Patient\u2019s right thigh showing characteristic violaceous border surrounding the surgical wound edge after multiple debridements."]}
{"Patient Personal Background": ["She reported no history of facial trauma, recent travel, illicit drug use, or high-risk sexual behavior.", "The nasal deformity, which she attributed to use of her CPAP mask, had developed gradually over the past several years.Patient with deformity of the nasal bridge revealed upon removal of face mask.Laboratory testing showed a white blood cell count (WBC) of 7700/uL, hemoglobin level of 13.2 mg/dL, and platelet count of 404\u2009\u00d7\u2009103/\u03bcL."], "Patient Symptoms": ["However, a deformity of the nasal bridge was noted after she was asked to remove her face mask, which she was wearing as required during the COVID-19 pandemic (Figure)."], "Examination and Results": ["Radiographs of the hands and wrists performed 1 month prior showed degenerative changes but no bone erosions.", "Her vital signs and physical examination findings were normal.", "She had no redness, warmth, or swelling of any joints, and her skin examination was unremarkable.", "Creatinine was 1.2 mg/dL (baseline, 0.83 mg/dL); erythrocyte sedimentation rate was 43 mm/h (reference range, 0-40 mm/h) and C-reactive protein was 23 mg/L (reference range, 0-10 mg/L).", "Her urinalysis had more than 30 white blood cells/high-power field (HPF), more than 30 red blood cells/HPF, and 2+ protein.", "Urine sediment microscopy showed red blood cell casts."]}
{"Patient Personal Background": ["The patient endorsed a history of Crohn disease, and his medication had been changed from infliximab to ustekinumab 6 weeks prior owing to persistent intestinal inflammation.Clinical examination revealed bilateral periorbital edema, diplopia with decreased abduction in the right eye and decreased adduction in the left eye, chemosis, proptosis, and conjunctival hyperemia (Figure 1A)."], "Patient Symptoms": ["He reported diplopia and pain with extraocular movement.", "The patient endorsed a history of Crohn disease, and his medication had been changed from infliximab to ustekinumab 6 weeks prior owing to persistent intestinal inflammation.Clinical examination revealed bilateral periorbital edema, diplopia with decreased abduction in the right eye and decreased adduction in the left eye, chemosis, proptosis, and conjunctival hyperemia (Figure 1A)."], "Examination and Results": ["Visual acuity and neurologic and fundus examination findings were otherwise normal with no sign of optic neuropathy.Patient characteristics at initial presentation.", "The yellow arrowhead indicates right lateral rectus muscle enlargement, and the blue arrowhead indicates left medial rectus muscle enlargement.Laboratory investigation showed a mildly elevated erythrocyte sedimentation rate but was otherwise unremarkable.", "Levels of antinuclear antibody, antineutrophil cytoplasmic antibodies, IgG4 levels, serum angiotensin-converting enzyme, thyrotropin, and thyroglobulin receptor antibody were all normal.", "Orbital computed tomography showed moderate bilateral lateral rectus muscle enlargement and mild enlargement of the left medial rectus muscle (Figure 1B) with mild, homogenous enhancement.Prednisone was started at a dose of 60 mg daily, and the patient\u2019s symptoms resolved; however, eye pain immediately recurred when weaning the prednisone."], "Treatment": ["Orbital computed tomography showed moderate bilateral lateral rectus muscle enlargement and mild enlargement of the left medial rectus muscle (Figure 1B) with mild, homogenous enhancement.Prednisone was started at a dose of 60 mg daily, and the patient\u2019s symptoms resolved; however, eye pain immediately recurred when weaning the prednisone.", "An orbitotomy with lateral rectus biopsy was performed, which showed a prominent chronic inflammatory process with infiltrates composed of a mixture of epithelioid histiocytes and small-sized lymphocytes associated with severe muscle atrophy."], "Others": ["There were no constitutional, dermatologic, or neurologic symptoms.", "A, External photograph reveals greater chemosis and more pronounced conjunctival hyperemia and eyelid edema of the right eye than of the left eye.", "B, Coronal computed tomography (CT) of the orbits."]}
{"Patient Personal Background": ["She was told about these same findings 10 years ago but did not have a repeated eye examination until recently by another retina specialist.", "She reported no family history of retinal diseases."], "Examination and Results": ["Her best-corrected visual acuity (BCVA) was 20/60 OD and 20/50 OS.", "An anterior segment examination was normal.", "Dilated fundus examination revealed multiple vitelliform lesions involving the macula and superior macula bilaterally (Figure 1).", "Fluorescein angiography revealed staining of these lesions with a pseudohypopyon appearance of the central vitelliform lesion in the left eye.", "Optical coherence tomography (OCT) showed hyperreflectance corresponding to the yellow pigment in the vitelliform lesions in the subretinal space."], "Treatment": ["She initially received anti\u2013vascular endothelial growth factor (VEGF) treatment, but was later referred because of a concern about either the idiopathic or paraneoplastic variant of acute exudative polymorphous vitelliform maculopathy (AEPVM)."], "Others": ["Initial workup by her primary care physician was unremarkable for malignancy."]}
{"Patient Symptoms": ["Two weeks later she developed flickering photopsias and a temporal scotoma progressing to a \u201cbrown tint\u201d of her vision in her left eye.", "Her vision had decreased in her left eye and macular and optic nerve edema were noted and she was subsequently referred to us."], "Examination and Results": ["In our clinic, her visual acuity was 20/20 OD and 20/50 OS, and she had normal intraocular pressure, a shallow anterior chamber but open angle in both eyes, a patent LPI in the left eye, and clear crystalline lenses in both eyes.", "The rest of her anterior segment was unremarkable.", "The posterior examination was notable for shifting subretinal fluid with choroidal detachments without retinal breaks, inflammation, or optic nerve edema and leopard spotting, while her right eye was unremarkable (Figure, A).", "Fluorescein angiography was unrevealing, while optical coherence tomography showed shallow subretinal fluid and an irregular and thickened choroid (Figure, B).", "Ultrasonography showed an axial length of 20.0 mm, thickened sclera, anteriorly rotated ciliary body, and 360\u00b0 of ciliochoroidal detachments in both eyes but worse in the left eye.", "Results of a systemic laboratory evaluation for infectious and noninfectious disorders were unremarkable."], "Treatment": ["She was found to have narrow angles in both eyes and a laser peripheral iridotomy (LPI) was performed in her left eye.", "Systemic corticosteroids failed to resolve the subretinal fluid and her vision declined.Subretinal fluid and choroidal effusions following a laser peripheral iridotomy."], "Others": ["A, Fundus photography showed substantial choroidal effusions with overlying serous retinal detachments (asterisk)."]}
{"Patient Symptoms": ["A focused laboratory evaluation identified a significantly elevated angiotensin-converting enzyme (ACE) level and antinuclear antibody titer, but serum lysozyme, syphilis, and tuberculosis testing had negative results."], "Examination and Results": ["Vision was 20/250 OD and 20/60 OS.", "The anterior segment was unremarkable in either eye, while the posterior segment examination noted 1+ vitreous cell, asteroid hyalosis, and a multilobulated, serous retinal detachment (RD) in the right eye and trace vitreous cell and a multilobulated, serous RD in the left eye.", "Imaging included B-scan, optical coherence tomography, and fundus autofluorescence, which revealed diffuse choroidal and ciliary body thickening, multifocal pockets of subretinal fluid, and speckled hyperautofluorescence and hypoautofluorescence in both eyes (Figure 1).", "A review of systems was unremarkable, most notably a lack of any pulmonary symptoms.", "To better differentiate between Vogt-Koyanagi-Harada (VKH) syndrome, a lymphoproliferative disorder, or sarcoidosis as the underlying cause of the vitreous inflammation and multilobulated, serous RD in both eyes, a computed tomographic scan was performed.", "It showed marked lymphadenopathy throughout the mediastinum and diffuse scleral thickening in both eyes."], "Diagnosis": ["The institute\u2019s radiologists believed these computed tomography findings were nonspecific and could be indicative of either sarcoidosis or intraocular lymphoma.Vogt-Koyanagi-Harada syndrome\u2013like presentation of multilobulated pockets of subretinal fluid and choroidal thickening and undulations."], "Others": ["No poliosis or skin changes were noted.", "A, Serous retinal detachment (asterisk)."]}
{"Patient Personal Background": ["The patient\u2019s medical history was noteworthy for depression, for which she was taking bupropion and fluoxetine, and prior alcohol use disorder, for which she was 3 years sober.", "She denied any smokeless tobacco use but endorsed daily electronic cigarette use.The extraoral examination detected bilateral buccal facial swelling of the lower facial third without associated trismus or lymphadenopathy (Figure, A)."], "Patient Symptoms": ["Two months prior to presentation, the patient had awoken with bilateral linear \u201cgashes\u201d in her mandibular vestibule that were accompanied by bilateral buccal facial swellings.", "Since that day, the facial swelling remained unchanged, and although the mucosal lesions healed, the oral pain persisted.", "Small aphthous ulcerations were also present on the right buccal mucosa (Figure, B)."], "Examination and Results": ["Intraorally, bilateral scarring of the mandibular buccal vestibule was noted with focal areas of ulceration.", "An incisional biopsy of the right vestibular lesion was performed, and the specimen showed diffuse plasmalymphocytic infiltrates within the lamina propria.", "On higher magnification, noncaseating granulomatous inflammation was observed (Figure, C).", "Staining for acid-fast bacilli was negative.Clinical and histologic features of a patient with oral ulceration and facial swelling.", "A, Clinical examination shows bilateral buccal swelling.", "B, Intraoral examination shows linear vestibular ulcerations with buccolabial aphthous ulcers.", "C, Hematoxylin-eosin stain of biopsy specimen of the vestibular ulcerated tissue shows noncaseating granulomatous inflammation (original magnification, \u00d7100).", "Acid-fast bacilli staining was negative."]}
{"Patient Personal Background": ["He had no medical history or family history of cancer and was not a smoker."], "Patient Symptoms": ["The patient only returned 3 months later when his hoarseness became worse."], "Examination and Results": ["In the absence of other suggestive symptoms, as well as a normal physical examination that did not reveal any enlarged cervical lymph nodes or oropharyngeal or neck mass and an unremarkable nasoendoscopic examination, a diagnosis of laryngopharyngeal reflux was made.", "Repeat nasoendoscopy now showed left vocal cord palsy in the paramedian position.", "Results of a computed tomographic (CT) scan showed an ill-defined soft tissue mass, which was likely nodal disease, at the left supraclavicular (Figure 1), as well as the prevertebral and paravertebral region, which partially encased the left common carotid, left subclavian, and left vertebral arteries.", "A fused positron emission tomography with CT (PET/CT) scan with fluorodeoxyglucose (FDG) tracer was then performed.Coronal view of the computed tomographic scan of the patient\u2019s neck, including the left supraclavicular node (yellow arrowhead) and the left common carotid artery (black arrowhead)."], "Treatment": ["The patient was advised to try conservative management with dietary advice and proton pump inhibitors, and a clinical review was scheduled in 6 weeks."], "Diagnosis": ["In the absence of other suggestive symptoms, as well as a normal physical examination that did not reveal any enlarged cervical lymph nodes or oropharyngeal or neck mass and an unremarkable nasoendoscopic examination, a diagnosis of laryngopharyngeal reflux was made."], "Others": ["In the absence of a history of trauma and associated neurological or systemic symptoms, the main concern was an underlying tumor that impinged on the vagus nerve at various points or its recurrent branch.", "This was along the expected course of the left recurrent laryngeal nerve and likely accounted for the left vocal cord palsy.", "However, the primary site of disease remained unclear."]}
{"Patient Personal Background": ["The patient has a history of rosacea being treated with topical metronidazole gel for flares but was otherwise asymptomatic.", "There was no history of any exposure to radiation or arsenic, nutritional deficiency, inflammatory skin disease, or malignant neoplasm.", "There was no family history of a similar condition.Examination revealed multiple, submillimeter, skin-colored to yellowish keratotic spiny projections over the aforementioned areas, only on the left side of the body (Figure, A and B)."], "Patient Symptoms": ["The papules progressed proximally over the subsequent decade to involve the forearm, arm, scapular area, ankle, shin, and thigh, but only affected the left side of the body.", "The patient\u2019s face, palms, soles, and entire right side of the body were spared.", "The patient did not have any alopecia, night blindness, or dry eyes or skin."], "Examination and Results": ["Punch biopsy from a lesion showed orthokeratosis with parakeratotic columns emerging from an epidermal invagination.", "The epidermis was mildly acanthotic and with a normal granular layer.", "There was a sparse superficial perivascular lymphocytic infiltrate.", "Adjacent hair follicles were unaffected (Figure, C).A, Numerous, submillimeter, skin-colored spiny projections over left foot web spaces were present.", "B, Close-up photograph over the left scapular area showed lesions of similar morphologic characteristics.", "C, Histologic results showed a parakeratotic column overlying a mildly acanthotic epidermis with a normal granular layer and keratinocyte maturation.", "A sparse superficial perivascular lymphocytic infiltrate was present (hematoxylin-eosin)."]}
{"Patient Symptoms": ["He also had asthenia and mild intermittent arthralgias."], "Examination and Results": ["Physical examination revealed multiple millimetric erythematous to hyperpigmented monomorphic keratotic papules involving the head, trunk, and extremities.", "Symmetric annular brown erythematous plaques on the cheeks and temples were also seen.", "Laboratory investigations revealed a normal white blood cell count, mild anemia (hemoglobin level, 11.3 g/dL; normal level 12.50-15.50 g/dL; to convert to g/L, multiply by 10.0), hypocomplementemia, and moderate proteinuria.", "Autoimmune serology results showed raised levels of antinuclear antibodies (>1:160), anti-Smith antibodies, SSA/Ro antibodies, SSB/La antibodies, and anti-U1RNP antibodies.", "Anti-dsDNA antibodies, lupus anticoagulant, rheumatoid factor, IgG and IgM anticardiolipin antibody, and anti-\u03b22 glycoprotein 1 antibody results were negative."], "Others": ["There were no vesicles or pustules (Figure, A and B).", "A biopsy specimen obtained from an erythematous papule on the trunk and stained with hematoxylin-eosin is shown in the Figure, C and D.A, Millimetric erythematous to hyperpigmented monomorphic papules involving the trunk.", "B, Erythematous papules and symmetric annular brown erythematous plaques on the cheeks and temples.", "C and D, Punch biopsy results (hematoxylin-eosin)."]}
{"Examination and Results": ["On presentation, she was afebrile with cool extremities; her blood pressure was 75/51 mm Hg, heart rate was 147 beats per minute, respiratory rate was 20 breaths per minute, and oxygen saturation was 99% on mechanical ventilation.", "Her chest examination revealed bilateral coarse breath sounds and distant heart sounds.", "Transthoracic echocardiogram revealed an ejection fraction of 10% with elevated filling pressures and no significant valvular abnormalities.", "There was significant hemodynamic improvement within 48 hours; transthoracic echocardiogram was obtained and showed impressive recovery of the left ventricular function to an ejection fraction of 45%.", "In the interim, her vitals remained unchanged, but the patient developed hematuria and laboratory parameters suggestive of hemolysis.", "Chest radiography showed pulmonary edema, and low-flow alarms sounded on the device console.", "Transthoracic echocardiogram showed severe mitral regurgitation (MR), and a transesophageal echocardiogram was performed to evaluate pVAD positioning (Figure and Video).Transesophageal echocardiogram after low-flow alarm on peripheral ventricular assist device console."], "Treatment": ["Owing to hemodynamic instability, the patient was given venoarterial extracorporeal membrane oxygenation (ECMO) with the peripheral ventricular assist device (pVAD) Impella CP (Abiomed) and was administered high-dose intravenous corticosteroids.", "As a result, ECMO was decannulated after 72 hours.", "Left pVAD support was maintained alone for another 24 hours."], "Diagnosis": ["Endomyocardial biopsy showed lymphocytic viral myocarditis."], "Others": ["A, 2-Dimensional echocardiogram with color Doppler.", "B, 3-Dimensional echocardiogram of mitral valve."]}
{"Patient Personal Background": ["The white line indicates the position of the optical coherence tomography scan.Five years prior to presentation, the patient started treatment with latanoprost nightly in both eyes for an enlarged cup-disc ratio presumed due to normal-tension glaucoma.", "The patient denied a family history of eye disease."], "Examination and Results": ["Examination showed best-corrected visual acuity of 20/50 OD, 20/30 OS, and intraocular pressure of 13 mm Hg OU.", "In the right eye, dilated fundus examination and optical coherence tomography (OCT) of the macula revealed subretinal fluid and cystoid spaces within the outer nuclear layer and inner nuclear layer in the nasal macula (Figure 1).", "Results of the left eye fundus examination and macular OCT were normal.", "In both eyes, the optic cup appeared very deep with a large cup-disc ratio.Color fundus photograph (A) and optical coherence tomography of the macula (B) illustrating intraretinal and subretinal fluid at the nasal macula.", "At that time, intraocular pressure was 12 mm Hg OD and 14 mm Hg OS and central corneal thickness was normal.", "Visual field and OCT of the retinal nerve fiber layer were without reproducible defects over 5 years of follow-up."]}
{"Examination and Results": ["His visual acuity was count fingers OD and 20/70 OS.", "Intraocular pressure was 20 mm Hg OD and 16 mm Hg OS.", "There were 1+ (10-12 cells/high-power field) anterior chamber cells in both eyes with very hazy posterior pole details in the right eye and minimal vitreous haze in the left eye.", "There was a hazy view to the posterior pole in the right eye with disc edema and multiple flame hemorrhages surrounding the nerve.", "Examination of the posterior pole in the left eye revealed partial obstruction of all vessels and a complete halo on the disc with numerous flame hemorrhages emanating from and surrounding the optic nerve, along with a few dot blot hemorrhages within the macula (Figure).", "His blood pressure was 173/137 mm Hg, but the rest of his vital signs were normal.Widefield color image of the left eye of a 49-year-old man with acute loss of vision."], "Others": ["There is marked hemorrhagic disc edema with flame hemorrhages emanating from and surrounding the optic nerve."]}
{"Patient Personal Background": ["He had undergone trabeculectomy and 5-fluorouracil injection 1 month prior."], "Patient Symptoms": ["His eye pain worsened significantly, and ultrasound biomicroscopy showed scleral thickening (Figure 1A).", "His vision continued to decline to counting fingers because of the development of a dense cataract with retrolenticular plaque (Figure 1B).A, Episcleral and scleral thickening (yellow brackets) adjacent to normal tissue (white brackets) on ultrasound biomicroscopy."], "Examination and Results": ["On initial examination, his visual acuity was 20/25.", "He had diffuse conjunctival hyperemia without bleb purulence or leakage and more than 50 cells per high-power field of a 1\u2009\u00d7\u20091-mm area of light on slitlamp biomicroscopy.", "His eye pain worsened significantly, and ultrasound biomicroscopy showed scleral thickening (Figure 1A).", "He was admitted to the hospital and started intravenous vancomycin and piperacillin-tazobactam treatment.", "His vision continued to decline to counting fingers because of the development of a dense cataract with retrolenticular plaque (Figure 1B).A, Episcleral and scleral thickening (yellow brackets) adjacent to normal tissue (white brackets) on ultrasound biomicroscopy."], "Treatment": ["He was treated for blebitis with topical fortified antibiotics but subsequently developed vitritis.", "He underwent vitreous tap and injection of vancomycin and amikacin followed by pars plana vitrectomy with bleb revision.", "He was admitted to the hospital and started intravenous vancomycin and piperacillin-tazobactam treatment."], "Others": ["Separate vitreous samples from each procedure were sent for Gram stain and bacterial and fungal culture on chocolate and Sabouraud agar with no growth.", "B, Retrolenticular plaque (yellow arrowhead) and vitreous debris (white arrowhead) on inferotemporal longitudinal B-scan."]}
{"Patient Personal Background": ["The patient was not immunocompromised and denied any trauma to the area.", "In the 2 months prior, he had received multiple rounds of antibiotics from other health care professionals."], "Patient Symptoms": ["The patient presented to our clinic with an isolated right 2-cm fluctuant and tender mass overlying the parotid gland.", "The patient denied fevers or systemic symptoms."], "Examination and Results": ["Outside computed tomography of the face showed a 3-cm cystic structure in the superficial aspect of the right parotid gland with associated lymphadenopathy.", "There was no accompanying cervical lymphadenopathy, and facial nerve function remained fully intact.", "Results of laboratory evaluation revealed normal complete blood cell count and erythrocyte sedimentation rate levels with negative infectious workup results for Epstein-Barr virus, cytomegalovirus, HIV, and tuberculosis (TB).", "Magnetic resonance imaging showed a 1.9-cm peripherally enhancing, centrally necrotic lesion overlying the superficial right parotid gland with multiple subcentimeter necrotic lymph nodes within the right parotid gland (Figure 1).The T1-weighted, contrast-enhanced, and fat-suppressed axial (A) and coronal (B) magnetic resonance imaging scans demonstrate the enhancing right-sided lesions overlying the distal aspect of the parotid and extending deep into the parotid parenchyma."], "Treatment": ["An outside health care professional had attempted incision and drainage of the area with negative cultures."]}
{"Patient Personal Background": ["The patient was also being treated with subcutaneous interferon beta 1a for the multiple sclerosis."], "Patient Symptoms": ["When the arm was abducted to 90\u00b0, the patient denied pain but described a subtle tightness sensation on the arm."], "Examination and Results": ["Physical examination revealed 2 indurated and mobile subcutaneous nodules on the anterior surface of the arm 5 cm distal to the surgical scar, the larger of them measuring 15 mm in diameter (Figure, A) and the smaller of them measuring 4 mm.", "An excisional biopsy from the larger lesion was performed (Figure, B-D).A, Clinical image showing indurated and mobile subcutaneous nodule on the anterior surface of the arm."], "Treatment": ["An excision with 1-cm margins of the left arm demonstrated desmoplastic melanoma with a Breslow thickness of 1 mm, and a left axillary sentinel lymph node biopsy (SLNB) had been performed 3 weeks before under general anesthesia.", "An excisional biopsy from the larger lesion was performed (Figure, B-D).A, Clinical image showing indurated and mobile subcutaneous nodule on the anterior surface of the arm."], "Diagnosis": ["An excision with 1-cm margins of the left arm demonstrated desmoplastic melanoma with a Breslow thickness of 1 mm, and a left axillary sentinel lymph node biopsy (SLNB) had been performed 3 weeks before under general anesthesia."], "Others": ["Arrowheads highlight a subtle linear plaque adjacent to the nodule.", "B, Histopathologic image showing dilated and thrombosed lymphatic vessels in subcutaneous tissue with recanalization (hematoxylin-eosin).", "C, Histopathologic image of partially thrombosed vessels.", "D, Immunohistochemistry finding was positive for D2-40 (podoplanin)."]}
{"Patient Personal Background": ["He had a history of cardiac arrest after receiving adenosine for sustained supraventricular tachycardia and tachycardia-induced cardiomyopathy."], "Patient Symptoms": ["The patient was also noted to have episodes of atrial flutter."], "Examination and Results": ["Transthoracic echocardiogram displayed a left ventricular ejection fraction of 63% and mild aortic and mitral regurgitation.", "Cardiac magnetic resonance imaging in sinus rhythm showed mild left ventricle thickening (up to 14 mm) and was otherwise normal."], "Treatment": ["The patient was hospitalized for initiation of sotalol, given that he experienced frequent episodes of atrial arrhythmia."], "Others": ["Figure 1A shows sinus rhythm prior to sotalol initiation.", "Figure 1B shows telemetry during administration of sotalol."]}
{"Patient Personal Background": ["He had hit the right side of his head on a table 1 month before symptoms developed, but had no other recent trauma."], "Patient Symptoms": ["The mass had not changed in size, was not tender, and had no other associated symptoms.", "His parents had not noticed any change in vision."], "Examination and Results": ["At bedside, the patient was playful and in no acute distress.", "On examination, he fixed and followed in each eye.", "His pupils were equal and reactive to light without afferent pupillary defect.", "Both eyes were soft to palpation and his extraocular movements were full.", "Externally, his examination was notable for bilateral upper eyelid ecchymosis and edema, as well as a soft, well-circumscribed mass on the right temporal region (Figure 1).", "There was no obvious proptosis.", "He was also noted to have subconjunctival hemorrhage temporally on the right eye."]}
{"Examination and Results": ["His visual acuity was 20/400 OD and 20/20 OS.", "The anterior segments were quiet and vitreous was clear in both eyes.", "Fundus examination in the right eye revealed a solitary, elevated choroidal lesion with a creamy yellow appearance in the macular region involving the optic disc (Figure 1A).", "Ultrasonography confirmed a dome-shaped choroidal mass with intermediate echodensity measuring 14 mm in diameter and 4 mm in thickness (Figure 1B).", "Fluorescein angiography demonstrated scattered pinpoint hyperfluorescence of the mass and late leakage of the disc.", "Indocyanine green angiography revealed hypofluorescence in both early and late phases.", "Optical coherence tomography disclosed a choroidal mass with undulating surface and shallow subretinal fluid.", "Magnetic resonance imaging of the orbit revealed an intraocular mass with hyperintensity on T1-weighted and hypointensity on T2-weighted scans with contrast enhancement extending into the adjacent retrobulbar fat, suspicious for scleral invasion.", "Blood test results including a complete blood cell count, tuberculosis, syphilis, and angiotensin-converting enzyme were all negative.", "There were more pigments overlying the intraocular mass with prominent intraretinal hemorrhage along the optic disc compared with clinical findings at first presentation.A, A fundus photograph revealed a solitary, raised choroidal lesion with a creamy yellow appearance in the macular region extending nasally to the optic disc (area encircled by a dotted line)."], "Others": ["The patient then developed gingivitis with a white blood cell count up to 12\u202f350/\u03bcL (to convert to \u00d7109/L, multiply by 0.001) in the next 2 weeks that failed to respond to intravenous antibiotics."]}
{"Patient Personal Background": ["He had no history of other illnesses."], "Examination and Results": ["The echocardiogram was performed because of an abnormal electrocardiogram demonstrating sinus tachycardia accompanied by high QRS voltage with a strain pattern in the precordial leads.", "On physical examination, the patient was 154 cm tall and weighed 38 kg.", "The cardiovascular examination was unremarkable.", "Neurological examination showed mild cognitive impairment, poor coordination, and muscle weakness of the bilateral lower limbs.", "Blood test results revealed impaired glucose tolerance, hypothyroidism, and elevated levels of lactic acid (32.4 mg/dL) and pyruvate acid (1.91 mg/dL; to convert to micromoles per liter, multiply by 113.56).", "Review of the transthoracic echocardiogram showed diffuse hypertrophy, moderately decreased contractility of the left ventricle, and increased intramyocardial signal intensity (Video).", "On admission, brain magnetic resonance imaging demonstrated cerebellar atrophy.", "Cardiac magnetic resonance imaging demonstrated diffuse biventricular hypertrophy and moderately impaired left ventricular systolic function.", "A wide range of nodular and band-shaped late gadolinium enhancement was detected in the middle and epicardial layers of the left ventricular myocardium.", "Coronary angiography revealed no significant stenoses of the epicardial coronary arteries."], "Others": ["The patient was admitted to the hospital for further evaluation."]}
{"Patient Symptoms": ["Symptoms started a year before, after receiving dental implants for new lower dentures.", "The patient noted right upper and lower eyelid swelling most notable in the morning but denied associated fevers, chills, vision changes, dysphagia, headaches, urinary symptoms, or rashes."], "Examination and Results": ["Physical examination revealed a 3-cm round fluctuant area lateral to the right lateral canthus, mildly tender to palpation.", "No overlying warmth or erythema and no lymphadenopathy.", "The patient\u2019s dentures appeared to be well fitting, but mouth opening was at approximately 50% of expected.", "Laboratory results included an erythrocyte sedimentation rate (ESR) of 20 mm/h, and normal complete blood cell count, comprehensive metabolic panel results,  and lactate levels.", "Findings on magnetic resonance imaging (MRI) (Figure, A) were most consistent with osteomyelitis of the mandible with inflammation of surrounding soft tissues.", "Right temporalis muscle biopsy results for Gram stain and culture, fungal stain and culture, and acid-fast bacillus stain were unremarkable.", "Additional laboratory test results, including serum IgG4, SPEP, brucella AB, Q fever AB, RF, urinalysis, and microalbumin/creatinine levels, were all unremarkable.", "Results for p-ANCA and c-ANCA were negative.", "Repeated MRI findings showed progression of the inflammation and new involvement of the temporal lobe dura.", "Findings on positron emission tomographic computed tomography (PET-CT) scan showed nonspecific inflammatory changes to the bone, muscle, and brain meninges.", "A biopsy of the temporalis muscle, sphenoid wing, and dura was performed (Figure, B).A, Magnetic resonance image (MRI) showing inflammation involving the right mandibular ramus and greater wing of sphenoid with overlying myositis involving masticator space."], "Treatment": ["The patient\u2019s symptoms did not improve after 7 weeks of empirical intravenous ertapenem followed by 8 weeks of oral cefuroxime and minocycline."], "Diagnosis": ["Findings on magnetic resonance imaging (MRI) (Figure, A) were most consistent with osteomyelitis of the mandible with inflammation of surrounding soft tissues."]}
{"Patient Personal Background": ["B, Fluorescein angiography of the left eye demonstrating disc leakage (blue arrowhead) and blockage in the region of the macular lesion (pink arrowhead).His medical history included psoriatic arthritis, for which he had been taking adalimumab.", "Four months prior to presentation, he had traveled to Costa Rica on vacation and fallen ill with fevers, night sweats, and myalgias.", "After returning to the United States, he developed dyspnea with exertion.", "He was found to have an ejection fraction (EF) of 20% to 25% with 4-chamber dilation and was diagnosed with cardiomyopathy."], "Patient Symptoms": ["Four months prior to presentation, he had traveled to Costa Rica on vacation and fallen ill with fevers, night sweats, and myalgias.", "After returning to the United States, he developed dyspnea with exertion."], "Examination and Results": ["His visual acuity on presentation was 20/20 in the right eye and hand motion only in the left eye.", "Examination of the right eye was normal.", "Anterior segment examination of the left eye revealed around 30 cells per high-power field of a 1 mm\u2009\u00d7\u20091 mm light beam and diffuse stellate-appearing keratic precipitates.", "Posterior examination results showed a vitreous cell that precluded a clear view of the posterior pole and inferior snow banking.", "Most notable was a large, white, preretinal lesion in the inferior macula and a near-total retinal detachment with no identifiable retinal break and shifting subretinal fluid (Figure).A, Fundus photograph of the left eye showing vitritis, a near-total retinal detachment, and a fluffy, white, lesion in the inferior macula (arrow).", "B, Fluorescein angiography of the left eye demonstrating disc leakage (blue arrowhead) and blockage in the region of the macular lesion (pink arrowhead).His medical history included psoriatic arthritis, for which he had been taking adalimumab."], "Treatment": ["He started a 6-week course of oral ciprofloxacin and his adalimumab was discontinued."], "Diagnosis": ["He was found to have an ejection fraction (EF) of 20% to 25% with 4-chamber dilation and was diagnosed with cardiomyopathy."]}
{"Patient Personal Background": ["B, Widefield fundus photograph of the left eye showing scattered intraretinal hemorrhage and segmented periphlebitis (white arrowheads) with prominent venous sheathing and tortuosity and optic disc hyperemia (blue arrowhead).At the time of presentation, she had completed RIPE therapy and was taking mycophenolate mofetil with resolution of her ocular manifestations."], "Patient Symptoms": ["She complained of new bilateral lower extremity weakness with associated lower back pain.", "Clinical examination results revealed a wide-based Trendelenburg gait with right foot drop and diminished strength of lower extremity flexors."], "Examination and Results": ["Laboratory testing results showed a normal white blood cell count, vitamin B12, angiotensin-converting enzyme, lysozyme, C-reactive protein, and antinuclear antibody levels.", "She had negative test results for Lyme disease, syphilis, and HIV.", "Computed tomography showed small supraclavicular and mediastinal lymph nodes and an enlarged spleen.", "Magnetic resonance imaging demonstrated mild lacrimal gland prominence and low thoracic/high lumbar spine and cauda equina nerve roots hyperintensity and abnormal enhancement.", "Cerebrospinal fluid analysis revealed a lymphocytic pleocytosis with an elevated protein level, negative syphilis antibody results, and an absence of organisms on acid-fast bacilli smear, Gram stain, and culture."], "Treatment": ["Given a positive interferon-\u03b3 release assay, therapy was initiated with rifampin, isoniazid, pyrazinamide, ethambutol (RIPE) and corticosteroids for presumed tuberculosis.A, Late-frame fluorescein angiography showing hyperfluorescence of the optic nerve head, segmental vascular leakage and staining, and retinal nonperfusion downstream of obliterated vessels (pink arrowheads)."], "Others": ["A year prior, she was found to have bilateral panuveitis with occlusive retinal periphlebitis involving all quadrants of the central and peripheral retina with capillary nonperfusion (Figure 1).", "Her subsequent workup revealed elevated inflammatory markers and subcentimeter chest and abdominal lymph nodes."]}
{"Patient Personal Background": ["She denied joint pain, fever, fatigue, changes in urine color, use of other topical or systemic medications, or presence of rashes elsewhere.", "She was otherwise healthy without other medical history.On physical examination, she was well appearing with numerous 1- to 2-mm monomorphous pustules over background erythema on the medial cheeks, chin, and nose (Figure, A)."], "Patient Symptoms": ["She noted mild associated pruritus but denied burning sensation.", "The eruptions occurred intermittently, appearing as erythematous papules with prominent pustules, and were exacerbated by sunlight.", "On average, her lesions would resolve in 3 to 4 days with only mild background erythema by 5 to 7 days.", "Even mild sun exposure would induce the eruption, leading to frequent recurrences in summer months but long periods of remission in the fall through spring."], "Examination and Results": ["She was otherwise healthy without other medical history.On physical examination, she was well appearing with numerous 1- to 2-mm monomorphous pustules over background erythema on the medial cheeks, chin, and nose (Figure, A).", "No nail fold capillary changes or mucosal lesions were observed.", "Serum analysis results for antinuclear, anti-SSA/Ro, and anti-SSB/La antibodies were negative.", "A 4-mm punch biopsy was taken from a representative lesion along the right jawline (Figure, B-D).A, Pustular eruption of the face characterized by monomorphous 1- to 2-mm pustules over background erythema on the cheeks, chin, and nose appearing less than 24 hours after sun exposure.", "Punch biopsy of skin demonstrated intrafollicular (B and C) and subcorneal (B and D) pustule formation (hematoxylin-eosin)."], "Treatment": ["Trials with various broad-spectrum sunscreens in combination with topical and oral antibiotics and topical ivermectin did not prevent flares or mitigate severity of eruptions when they occurred."]}
{"Patient Personal Background": ["The patient had no other significant medical history and denied having a family history of similar lesions."], "Patient Symptoms": ["The papules and nodules appeared to grow as the boy grew, and some pedunculated lesions tended to fall off spontaneously."], "Examination and Results": ["Clinical examination findings revealed multiple skin-colored, nontender soft papules of varying sizes protruding from the skin surface on the right cheek, forehead, and jaw, as well as on the anterior surface of the scalp, distributed along Blaschko lines, with sparse vellus hairs and multiple hair follicles on the lesions (Figure, A and B).", "However, no hair was observed on the lesion because the patient had shaved the hair on his face.", "An incisional biopsy of a pedunculated lesion above the left eyebrow was performed (Figure, B).A and B, Papules, plaques, and nodules on the skin surface of the right cheek (A, B), forehead (B), intercilium (B), and jaw (B).", "C and D, Composition of hair follicles.", "Presence of sebaceous glands and the perifollicular fibrous sheath within a fibrotic stroma can be clearly seen (hematoxylin-eosin)."], "Treatment": ["White arrowhead indicates the biopsy site (B)."], "Others": ["He had not received any prior treatment."]}
{"Patient Personal Background": ["He had no significant history of cardiopulmonary disease."], "Examination and Results": ["Physical examination findings, including chest auscultation, were unremarkable.", "Measured hemoglobin was 15.3 g/dL (World Health Organization normal range, 13.8-17.2 g/dL).", "Chest computed tomographic imaging was unremarkable."]}
{"Patient Personal Background": ["She had traveled to northeastern Brazil 2 months before the onset of the neurological symptoms.On examination, she had a mild right-side hemiparesis with hyperreflexia and hemiataxia."], "Patient Symptoms": ["She denied any history of fever, head trauma, vomiting, diarrhea, abdominal pain, or cough.", "She could walk unassisted but presented with a broad base."], "Examination and Results": ["There were no meningeal signs.", "She did not present with hepatosplenomegaly of lymphadenopathy.", "Her cranial magnetic resonance imaging  showed a T2-weighted fluid-attenuated inversion recovery hyperintense lesion with heterogeneous gadolinium enhancement in the pons (Figure).", "There were no signs of diffusion restriction on diffusion-weighted imaging or hemorrhages on susceptibility-weighted imaging.Sagittal gadolinium-enhanced T1-weighted magnetic resonance imaging (MRI) (A) and sagittal T2-weighted fluid-attenuated inversion recovery (FLAIR) (B) showing the extent of the lesion.The laboratory test results showed a hemoglobin level of 15.3 g/dL (to convert to grams per liter, multiply by 10.0), total leukocyte count of 10\u202f390/uL (to convert to \u00d7109/L, multiply by 0.001), of which 1703 (16.4%) were eosinophils, and a platelet count of 284\u202f000/\u03bcL (to convert to \u00d7109/L, multiply by 0.001).", "The patient\u2019s liver and kidney function test results were normal.", "Computed tomography of the chest revealed bilateral patchy pulmonary infiltrates.Cerebrospinal fluid (CSF) analysis showed 640 cells, of which 57% were lymphocytes, 26% were eosinophils, and 13% were monocytes; protein levels were 70 mg/dL, and glucose levels were 46 mg/dL.", "Her blood cultures were found to be sterile."]}
{"Patient Symptoms": ["He had no fevers or night sweats.", "He started antiretroviral therapy with bictegravir/emtricitabine/tenofovir/alafenamide and chemotherapy with rituximab, etoposide, prednisone, vincristine, cyclophosphamide, and doxorubicin (R-EPOCH).Four weeks after initiation of chemotherapy, the patient developed sudden onset of bright red blood per rectum, tachycardia, and hypotension.", "Five weeks later, he developed blurred vision, and visual acuity testing revealed 20/50 vision in the left eye and 20/70 in the right eye."], "Examination and Results": ["Physical examination was notable for oral thrush and mild epigastric tenderness.", "Results of a fourth-generation HIV Ab/Ag combination assay were positive, and subsequent testing showed a CD4 cell count of 16/mm3 and an HIV viral load greater than 10 million copies/mL.", "Computed tomography of the abdomen and pelvis showed thickening of the walls of the stomach, duodenum, and colon as well as multiple masses in the right hepatic lobe measuring up to 6.9 cm in diameter.", "Mesenteric computed tomography angiography demonstrated active extravasation in the jejunum from a branch of the superior mesenteric artery.", "After unsuccessful coil embolization, he underwent open resection of 40 cm of distal small intestine; pathological examination of a stained section showed acute inflammation of the lamina propria, with crypt epithelial apoptosis and numerous cytoplasmic and nuclear inclusions with an \u201cowl eye\u201d appearance (Figure 1, left panel).", "A dilated retinal examination revealed extensive macular hemorrhage in the left eye, with peripapillary whitening and perivascular hemorrhage with whitening along the superior vascular arcade (Figure, right panel).Left, Representative section of patient\u2019s small bowel showing cytoplasmic and nuclear inclusions surrounded by a clear halo (\u201cowl eye\u201d sign, arrowheads) (hematoxylin-eosin, original magnification \u00d740)."], "Treatment": ["A core biopsy of one of the liver masses demonstrated diffuse large B-cell lymphoma.", "He started antiretroviral therapy with bictegravir/emtricitabine/tenofovir/alafenamide and chemotherapy with rituximab, etoposide, prednisone, vincristine, cyclophosphamide, and doxorubicin (R-EPOCH).Four weeks after initiation of chemotherapy, the patient developed sudden onset of bright red blood per rectum, tachycardia, and hypotension."], "Diagnosis": ["A core biopsy of one of the liver masses demonstrated diffuse large B-cell lymphoma."]}
{"Patient Personal Background": ["Prior to delivery, she underwent diagnostic ultrasound of the right breast, which showed a possible mass in the location of the palpable lesion that was most consistent with a normal island of fibroglandular tissue."], "Examination and Results": ["Follow-up mammogram and ultrasound of the right breast (without axillary evaluation) were performed 6 months later, which showed an irregular 17-mm mass with associated pleomorphic calcifications in the same area.", "On postbiopsy physical examination, the patient had a palpable 2.5-cm right breast mass at the 3-o\u2019clock position without palpable axillary lymphadenopathy.Surgical treatment with lumpectomy was recommended, and breast magnetic resonance imaging (MRI) was performed prior to surgery to evaluate the extent of disease (Figure).", "Axial T2-weighted MRI at the level of the axilla revealed edema surrounding 2 enlarged, morphologically abnormal right level-1 axillary lymph nodes; axial postcontrast T1 fat-saturated MRI of the right breast revealed an irregular mass with irregular margins at the site of biopsy-proven DCIS.", "The patient reported receiving her second dose of COVID-19 vaccine (Pfizer-BioNTech) in the right arm the day before the breast MRI.Top, Axial T2-weighted magnetic resonance imaging (MRI) at the level of the axilla."], "Treatment": ["Pathology showed high-grade, estrogen receptor\u2013positive ductal carcinoma in situ (DCIS)."], "Diagnosis": ["Pathology showed high-grade, estrogen receptor\u2013positive ductal carcinoma in situ (DCIS)."], "Others": ["Ultrasound-guided biopsy was performed.", "The patient reported receiving her second dose of COVID-19 vaccine (Pfizer-BioNTech) in the right arm the day before the breast MRI.Top, Axial T2-weighted magnetic resonance imaging (MRI) at the level of the axilla."]}
{"Patient Personal Background": ["Medical history included tertiary hyperparathyroidism related to end-stage kidney disease from chronic glomerulonephritis.", "The patient had successfully received an ABO-incompatible kidney transplant 1 year ago, but this was complicated by invasive fungal (Volvariella volvacea) infection of the central nervous system.", "Medications included tacrolimus (0.5 mg twice daily), prednisolone (10 mg daily), cinacalcet (12.5 mg daily), and voriconazole (500 mg daily)."], "Patient Symptoms": ["There was no history of alopecia, oral ulcers, rashes, or Raynaud phenomenon.", "She did not report preceding fever, diarrhea, or dysuria.", "There was no history of weight loss or anorexia.", "On examination, her fingers and toes were symmetrically and diffusely swollen and tender."], "Examination and Results": ["There was no rash, enthesitis, psoriatic nail changes, clubbing, or lower limb edema.", "The rest of the physical examination was unremarkable.Alkaline phosphatase level was elevated at 640 U/L (10.69 \u03bckat/L) (reference range, 40-130 U/L [0.67-2.17 \u03bckat/L]).", "Corrected calcium and parathyroid hormone levels were 10.88 mg/dL (2.71 mmol/L) (reference range, 8.6-10.2 mg/dL [2.15-2.55 mmol/L]) and 23.7 pmol/L (reference range, 1.3-9.3), respectively.", "Serum bilirubin, aspartate transferase, alanine transferase, creatinine, and phosphate levels were within reference ranges.", "Free thyroxine and thyrotropin levels were normal.", "Results of testing for rheumatoid factor and anti-citrullinated protein antibody were negative.", "Her chest radiograph was unremarkable.", "Radiography of her hands was performed (Figure)."]}
{"Patient Personal Background": ["He had been admitted for an upcoming bone marrow transplant."], "Patient Symptoms": ["The patient had floaters without flashes and denied any eye pain.", "A review of symptoms found chronic fatigue and a new, mild headache beginning a few days prior."], "Examination and Results": ["On examination, his visual acuity was 20/50 OU; intraocular pressures were 15 mm Hg OD and 13 mm Hg OS; and pupils were equal, round, and reactive, without a relative afferent pupillary defect.", "Extraocular movements, confrontational visual fields, and Ishihara color plates were full.", "An anterior segment examination had normal results.", "A fundus examination revealed clinically significant peripapillary intraretinal and preretinal hemorrhages obscuring the optic disc margins of both eyes (Figure 1)."]}
{"Patient Personal Background": ["His medical history was significant for dyslipidemia for which he took rosuvastatin."], "Patient Symptoms": ["He noticed colors surrounding the dark area that lasted 2 to 3 minutes at a time and occurred multiple times per day.", "He also reported feeling lethargic, with polydipsia and a dull mild holocephalic headache during this period."], "Examination and Results": ["Ophthalmological examination revealed a visual acuity of 20/20 OU, pupils were equal and reactive to light with no relative afferent pupillary defect, and color vision was normal.", "Dilated fundus examination was normal.", "Humphrey 24-2 Swedish interactive threshold algorithm fast visual field testing revealed a right homonymous hemianopia denser inferiorly (Figure, A).", "An urgent noncontrast computed tomography (CT) scan of the head was obtained and was normal (Figure, B)."]}
{"Patient Symptoms": ["The mass had gradually grown over 2 months and was tender to palpation."], "Examination and Results": ["She had an unremarkable ocular and medical history.On examination, visual acuity was 20/20 OD and 20/20 OS.", "Ocular motility was full and pupils were equal, round, and reactive to light.", "Her examination was notable for a 3-mm subcutaneous, firm, mobile, noncompressible lesion near the lateral canthus of the right eye without overlying erythema, warmth, telangiectasia, or ulceration (Figure 1)."], "Others": ["She denied any vision changes, facial trauma, redness, or discharge from the lesion."]}
{"Patient Personal Background": ["The patient had no history of weakness, incontinence, or severe headaches."], "Patient Symptoms": ["Initial presentation was notable for hand motion visual acuity with a 2+ relative afferent pupillary defect on the right; fundus examination revealed grade IV disc edema with obscuration of all major vessels on the disc (Figure, A).", "Two weeks after initial presentation, the visual acuity in the right eye progressed to no light perception."], "Examination and Results": ["Initial presentation was notable for hand motion visual acuity with a 2+ relative afferent pupillary defect on the right; fundus examination revealed grade IV disc edema with obscuration of all major vessels on the disc (Figure, A).", "A magnetic resonance image (MRI) of the brain with and without gadolinium contrast was degraded by motion and orthodontic artifact but was suggestive of optic nerve enhancement consistent with optic neuritis.", "The second MRI revealed a fusiform expansion of the right optic nerve and enhancement of the orbital, canalicular, and prechiasmatic segments of the right optic nerve, suggestive of an optic nerve glioma.", "Repeated MRI showed progression of the lesion with masslike expansion at the chiasm measuring 1.3 cm (anterior-posterior)\u2009\u00d7\u20091.5 cm (craniocaudal)\u2009\u00d7\u20091.1 cm (transverse)."], "Treatment": ["Results of serology tests and cerebral spinal fluid analysis were negative for infectious and inflammatory etiologies, including syphilis, sarcoidosis, Lyme disease, viral etiologies, multiple sclerosis, and lupus.The patient started treatment with intravenous methylprednisone and plasmapheresis for a presumptive diagnosis of optic neuritis; however, after 3 days there was minimal improvement and a second MRI of the brain and orbits was performed (Figure, B)."], "Diagnosis": ["The second MRI revealed a fusiform expansion of the right optic nerve and enhancement of the orbital, canalicular, and prechiasmatic segments of the right optic nerve, suggestive of an optic nerve glioma."]}
{"Patient Personal Background": ["The patient reported that when the lesion had begun to appear, approximately 10 years earlier, he had received 2 doses of intralesional steroid via injection on a small bald patch on the vertex.", "The patient denied any trauma history and had no history of connective tissue disease nor any evidence of systemic involvement, such as arthralgia, photosensitivity, or skin rashes."], "Patient Symptoms": ["Localized linear hair loss and hair thinning on the left scalp area were observed.", "Thereafter, the lesion gradually progressed to the frontal scalp and eventually made a linear furrow on the left side of his forehead.Physical examination revealed 2 long, curved-line, depressed, alopecic patches on the left side of the vertex and frontal scalp area extending to the left eyebrow (Figure, A and B)."], "Examination and Results": ["The lesions measured (length\u2009\u00d7\u2009width) 7\u2009\u00d7\u20092 cm and 6\u2009\u00d7\u20091 cm, respectively.", "Dermoscopic examination of the alopecic area revealed several short vellus hairs, yellow dots, and honeycomb hyperpigmentation; however, broken hairs were not seen.", "The result of a hair pull test was negative.", "Histopathologic findings of the 2 biopsy specimens were identical (Figure, C and D).A, Clinical image of annular arc from a longitudinally furrowed skin lesion on the left eyebrow and forehead to an alopecic lesion.", "B, Clinical image of the bandlike grooved alopecic lesion on the left side of the frontal scalp and vertex.", "C, Scanning view shows predominant lymphocytic infiltrates in perifollicular and periappendageal regions of the dermis and lobular panniculitis (hematoxylin-eosin staining)."], "Treatment": ["The patient reported that when the lesion had begun to appear, approximately 10 years earlier, he had received 2 doses of intralesional steroid via injection on a small bald patch on the vertex."], "Others": ["Skin biopsies were performed on the left side of the vertex and the forehead."]}
{"Patient Symptoms": ["He reported a 5-kg weight loss that he attributed to impaired intake owing to the oral lesions."], "Examination and Results": ["Results of a previous intestinal biopsy had shown unspecific findings and absence of apoptosis.", "Physical examination revealed whitish edematous lacy patches with erosions on the dorsal and lateral aspects of the tongue and buccal mucosa (Figure, A); skin and nails were not involved.", "The result of indirect immunofluorescence (IIF) testing, using monkey esophagus, salt-skin split, and rat bladder as substrates, was negative.", "Enzyme-linked immunosorbent assay (ELISA) and immunoblot analysis did not detect any desmoglein-1 or -3, bullous pemphigoid-180 or -230, collagen VII, desmocollin-1 to -3, laminin-332, envoplakin, or periplakin antibodies.", "Results were normal for liver function; negative for hepatitis B and C; indicative of hypogammaglobulinemia, with a decreased immunoglobulin (Ig) G serum level of 465 mg/dL (normal, 750-1600 g/L; for g/L, multiply by 0.01); and normal for IgA and IgM levels.", "Positron emission tomography revealed a 10-cm hypercapturing extrapulmonary mass (Figure, D).", "B, Epidermis with acanthosis, parakeratosis, necrotic keratinocytes, and dermal band lymphocytic infiltrate with effacement of the dermoepidermal junction (hematoxylin-eosin).", "C, Fibrogen deposition along the basement membrane.", "D, Hypercapturing, heterogeneous mass in the right anterior hemithorax."], "Treatment": ["A lingual biopsy specimen was obtained for pathologic evaluation and direct immunofluorescence (DIF; Figure, B and C).", "Surgical excision of the mediastinal mass was performed; its histopathologic features were consistent with a type AB thymoma, Masaoka-Koga stage 2A.A, Lacy, white erosive lesions on the tongue."], "Diagnosis": ["Surgical excision of the mediastinal mass was performed; its histopathologic features were consistent with a type AB thymoma, Masaoka-Koga stage 2A.A, Lacy, white erosive lesions on the tongue."], "Others": ["He was also being evaluated for a mediastinal mass detected in radiography of the chest performed for pneumonia."]}
{"Patient Symptoms": ["On presentation, the patient appeared anxious with a heart rate of 101 beats per minute, respiratory rate of 20 breaths per minute, blood pressure of 151/79 mm Hg, and pulse oximetry of 96% in room air."], "Examination and Results": ["On presentation, the patient appeared anxious with a heart rate of 101 beats per minute, respiratory rate of 20 breaths per minute, blood pressure of 151/79 mm Hg, and pulse oximetry of 96% in room air.", "His cardiopulmonary examination results, complete blood cell count, basic metabolic panel, and cardiac troponins were all within normal limits.", "His electrocardiogram on presentation and echocardiogram are shown in Figure 1 and the Video.A, 1-Lead electrocardiogram shows T wave inversions in V1 through V3."]}
{"Patient Personal Background": ["Notably, he had a 4-year history of an asymptomatic papular skin eruption with more lesions developing in the last 4 months."], "Patient Symptoms": ["Three weeks prior, he had developed acute urinary retention.", "The patient developed a sudden worsening of weakness in his legs 2 weeks after initial presentation.", "These were distributed on the neck, trunk, and limbs, sparing his face, scalp, and genitalia (Figure 1B)."], "Examination and Results": ["Neurological examination revealed weakness in bilateral lower limbs (Medical Research Council grade 4 on the right and grade 3 on the left), extensor plantar responses, and a sensory level at T6.", "Magnetic resonance imaging of his thoracic spine was performed 10 days after the onset of weakness and did not show any signal abnormalities or restricted diffusion.", "Cerebrospinal fluid analysis findings were remarkable for elevated protein (0.14 g/dL [to convert to grams per liter, multiply by 10]) but white cell count (5 cells/mm3) and glucose levels (54.05 mg/dL [to convert to millimoles per liter, multiply by 0.0555]) were normal.", "Cytology and flow cytometry were negative for malignancy.", "Antibodies to aquaporin 4 and myelin oligodendrocyte glycoprotein were not detected.", "Repeated thoracic spine imaging showed an area of T2 hyperintensity in the left posterolateral cord at T7, which did not enhance with contrast or show restricted diffusion (Figure 1A).", "Findings of extensive workup for malignancy, including full-body computed tomography scan, paraneoplastic antibody panel, and systemic autoimmune diseases (antinuclear antibody, antidouble stranded DNA, and myositis antibody panel), were negative.", "The skin papules were biopsied.T2-weighted magnetic resonance imaging (MRI) of the thoracic spine showing an area of hyperintensity in the left posterolateral cord at T7 (A) (arrowhead).", "These consisted of hypopigmented papules with central hyperpigmented umbilication and larger papules with typical central atrophic porcelain white scarring (B)."], "Others": ["Multiple papules were seen on the patient\u2019s abdomen."]}
{"Patient Personal Background": ["She had no history of recent travel or illicit drug use and was not taking any medications.On examination, her vital signs were normal."], "Patient Symptoms": ["She had no fevers, epistaxis, rhinorrhea, cough, shortness of breath, or hematuria.", "She had bilateral scleral injection and swelling and tenderness over the proximal interphalangeal joints bilaterally.", "Hemorrhagic vesicles and violaceous papules were present on her ears, nose, arms, and legs (Figure)."], "Examination and Results": ["She had been prescribed 4 days of prednisone (10 mg/d) without improvement.", "Laboratory studies revealed normal complete blood cell count, serum electrolyte levels, and liver enzyme levels.", "Urinalysis findings were normal and urine toxicology screen was negative.", "Punch biopsy of a papule on the right arm demonstrated a superficial perivascular infiltrate of neutrophils with leukocytoclasia, extravasation of erythrocytes, and fibrin in small blood vessel walls."], "Treatment": ["She had been prescribed 4 days of prednisone (10 mg/d) without improvement."]}
{"Patient Symptoms": ["She reported neck swelling and an occasional dry cough but no fevers, chills, trismus, headache, dyspnea, chest pain, abdominal pain, fatigue, or rash.", "One week prior to presentation, she visited an urgent care clinic for evaluation of pharyngitis and white exudates on her tonsils.", "Despite taking antibiotics for 7 days, she had no improvement in her symptoms."], "Examination and Results": ["Results of a rapid strep test and heterophile antibody test (monospot) were negative.", "One day prior to presentation, the urgent care clinic notified the patient that her throat culture results were negative.On presentation, the patient was in no acute distress and had normal vital signs.", "She had bilateral white tonsillar exudates and posterior cervical lymphadenopathy, but no exudate was observed elsewhere in the oral cavity and the uvula was midline (Figure).", "There was no axillary or inguinal adenopathy and no hepatomegaly or splenomegaly.", "The remainder of the physical examination was normal."], "Treatment": ["A throat culture was obtained and she was prescribed amoxicillin (500 mg twice daily for 10 days) for possible group A streptococcal infection."]}
{"Patient Personal Background": ["Aside from atopic dermatitis, his medical history was unremarkable."], "Examination and Results": ["Best-corrected visual acuity was 20/20 OU.", "Slitlamp examination of the right eye disclosed conjunctival hyperemia and ciliary congestion, anterior chamber flare 2+, and a few nongranulomatous keratic precipitates; the left anterior segment was quiet.", "Intraocular pressure was 15 mm Hg OU.", "Pupillary light responses were normal.", "Dilated fundus examination revealed 1+ of vitritis (binocular indirect ophthalmoscopy score) in the right eye and swelling of the optic disc in both eyes, to a greater extent in the right eye (Figure, A).", "Routine blood tests, including full blood cell count, plasma glucose levels, liver function test, and kidney function test, were performed on the same day and showed a serum creatinine level of 1.57 mg/dL (reference range: 0.5-1.0 mg/dL; to convert to micromoles per liter, multiply by 88.4).", "Antibodies anti\u2013Treponema pallidum were tested and the results were negative.Imaging findings at presentation.", "A, Color fundus photograph of the right eye shows mild hyperemia and swelling of the optic disc along with moderate venous vessels tortuosity.", "B, Late-frame fluorescein angiography of the right eye shows mild dye leakage of the optic disc and no other obvious abnormalities.Spectral-domain optical coherence tomography at presentation showed increased thickness of the retinal nerve fiber layer in both eyes, to a greater extent in the right eye.", "Fluorescein angiography revealed dye leakage of the right optic disc (Figure, B); no further abnormalities were found in both eyes."]}
{"Patient Personal Background": ["Recent computed tomography (CT) of the brain, conducted as part of her headache workup, had been reported as normal.On examination, visual acuity was 20/25 OU."], "Patient Symptoms": ["On further questioning, she reported a 1-week history of drooling when eating.", "She had no other associated neurological or constitutional symptoms."], "Examination and Results": ["Extraocular motility testing demonstrated no abduction of the left eye with corresponding large-angle incomitant esotropia increasing when looking to the left (Figure 1).", "There was 2 mm of left upper eyelid ptosis with preserved levator function.", "The left pupil was 1 mm smaller than the right in the light, with the difference increasing to 2 mm in the dark.", "There was no relative afferent pupillary defect.", "Cranial nerve examination demonstrated reduced sensation in the left V1-V3 distribution and mild flattening of the nasolabial fold.", "Corneal sensation was slightly decreased on the left."], "Others": ["No anhidrosis was noted."]}
{"Patient Personal Background": ["He had a history of dry eye disease for which he was treated with preservative-free artificial tears.", "He also noted a medical history of well-controlled HIV with highly active antiretroviral therapy.", "His last CD 4 lymphocyte count was 750 cells/mm3 with an undetectable viral load.", "The patient reported having unprotected sexual contact with multiple male partners in the past few years.On examination, his best-corrected visual acuity was 20/20 OU."], "Patient Symptoms": ["Both eyes appeared to be moderately tender to touch."], "Examination and Results": ["Intraocular pressure was 12 mm Hg OD and 14 mm Hg OS.", "Slitlamp examination demonstrated diffuse scleral injection in both eyes without any scleral thinning.", "The redness did not blanch after administration of phenylephrine, 10% (Figure 1).", "The rest of the anterior segment examination was within normal limits without any evidence of intraocular inflammation.", "Dilated fundus examination was also unremarkable in both eyes.Slitlamp photographs of the right and left eyes show significant diffuse scleral injection, which did not blanch following administration of phenylephrine, 10%."], "Treatment": ["He had a history of dry eye disease for which he was treated with preservative-free artificial tears."], "Others": ["A review of system produced negative results, including absence of weight loss, fevers, headache, joint pain, respiratory symptoms, or skin rash."]}
{"Patient Personal Background": ["Her ocular history was notable for indiscriminate trauma to her left eye, primary open-angle glaucoma in both eyes treated with dorzolamide hydrochloride and brimonidine tartrate, and pseudophakia in both eyes.", "Four years prior, an inferior cystic iris stromal lesion was discovered in the left eye that measured approximately 5\u2009\u00d7\u20092 mm in basal dimensions at the slitlamp."], "Examination and Results": ["Visual acuity was 20/20 OD and light perception OS.", "Intraocular pressure (IOP) was 15 mm Hg OD and 54 mm Hg OS.", "Anterior segment examination of the left eye was remarkable for a large cystic iris stromal lesion from the 2- to 7-o\u2019clock position with iris-cornea touch.", "The anterior chamber was shallow in the area of the enlarged cystic lesion with a large amount of pigmented cells.", "The pupil was irregular with blood at the pupillary margin.", "Her intraocular lens was not visible because of occlusion by a cystic lesion behind the iris (Figure 1)."], "Others": ["Fine-needle aspiration was negative for malignancy, and the lesion was managed by close follow-up.Anterior segment photograph of the left eye demonstrating sudden enlargement of a cystic iris stromal lesion from the 2- to 7-o\u2019clock position (arrowheads)."]}
{"Patient Personal Background": ["Her ocular history included pseudoexfoliation syndrome and glaucomatous optic neuropathy in the right eye.", "Past ocular surgery included uncomplicated trabeculectomy in the right eye treated with mitomycin C (3 months prior) and no ocular surgery history in the left eye.", "Her medical history included pulmonary Mycobacterium avium infection secondary to hypogammaglobulinemia.", "Computed tomography scan 2 months prior exhibited reactivation and she started treatment with clarithromycin (1000 mg/d), ethambutol (15 mg/kg/d), and rifabutin (300 mg/d).Best-corrected visual acuity was hand motions OD and 20/20 OS."], "Patient Symptoms": ["Intravitreal amikacin and vancomycin were administered after vitreous sampling was performed.", "Her visual acuity returned to 20/30.Two months later, she presented again with a similar acute vision loss in the left eye (counting fingers)."], "Examination and Results": ["Intraocular pressures were 4 mm Hg ODand 13 mm Hg OS.", "Anterior segment examination of the right eye showed substantial conjunctival hyperemia and substantial cellular response in the anterior chamber (2 to 3+) along with a 1-mm hypopyon.", "There was no leak at the trabeculectomy bleb (negative Seidel test).", "B-scan ultrasonography showed no retinal detachment or mass."], "Treatment": ["Pars plana vitrectomy was performed, including vitreous sampling, and showed very light growth of Staphylococcus aureus in 1 colony on 1 plate, which was highly suspicious for contaminant.", "Intravitreal amikacin and vancomycin were administered after vitreous sampling was performed.", "Postoperatively, the patient initiated treatment with topical antibiotics and corticosteroids."], "Diagnosis": ["Presumed diagnosis of bleb-related infectious endophthalmitis was made and she was referred for treatment."]}
{"Patient Personal Background": ["Pemigatinib treatment was initiated 2 months prior to the skin findings."], "Patient Symptoms": ["Physical examination revealed retiform purpura with areas of necrosis involving the bilateral lower extremities (Figure, A and B).", "A punch biopsy specimen from the right calf was obtained for histopathologic analysis (Figure, C and D).Early reticulated erythematous patches (A) that rapidly progressed to prominent retiform purpura with cutaneous necrosis (B)."], "Examination and Results": ["Laboratory evaluation demonstrated a mildly elevated D-dimer level at 578 ng/mL fibrinogen-equivalent units, prolonged prothrombin time of 12.7 seconds, elevated phosphorus level at 6.8 mg/dL (of note, phosphorus was 3.1 mg/dL 1 month prior), and normal calcium level and kidney function.", "Other laboratory tests to note include cryoglobulin and cryofibrinogen, which both had negative results.", "Calcium deposits within wall of a blood vessel in the subcutaneous tissue (C, white arrowhead) and pseudoxanthoma elasticum\u2013like changes with fragmented calcified elastic fibers (D, white arrowheads) in the dermis and subcutaneous tissue (hematoxylin-eosin\u2013stained sections; original magnification \u00d7200)."], "Treatment": ["Pemigatinib treatment was initiated 2 months prior to the skin findings.", "Within weeks, there was rapid progression with skin necrosis despite treatment initiation with rivaroxaban."]}
{"Patient Personal Background": ["The patient was otherwise healthy and was a never-smoker with no history of hypertension, atherosclerotic disease, or HIV.Physical examination revealed dark violaceous plaques, scattered subcutaneous nodules, and swelling to the mid-shin of the left lower extremity (Figure, A)."], "Patient Symptoms": ["The plaques had been present for years, but the patient noted enlargement and darkening for the past 5 years.", "The lesions were asymptomatic with no associated pruritus, bleeding, or pain."], "Examination and Results": ["There was mild warmth noted, but no palpable bruits.", "Complete metabolic panel, complete blood cell count, prothrombin, and serology were negative or within normal limits.", "A punch biopsy was performed and submitted for histopathologic analysis (Figure, B).A, Violaceous papules, plaques, and nodules on the left lower shin.", "B, Proliferation of superficial and deep vessels, with thickening of the endothelium (hematoxylin-eosin).", "C, Magnetic resonance angiogram demonstrating hypervascular soft tissue mass in the left lower extremity."], "Others": ["No treatments or diagnostic workup had been attempted prior to presentation."]}
{"Patient Symptoms": ["He reported episodic breathlessness, cough, and wheezing with expectoration of brownish sputum, exacerbated with exposure to hay dust, in the past 5 years.", "He also reported recent-onset headache while reading."], "Examination and Results": ["Physical examination revealed a depressed plaque measuring 6\u2009\u00d7\u20094 cm in the right infraorbital region, surrounded by multiple nodules of sizes ranging from 1\u2009\u00d7\u20091 cm to 5\u2009\u00d7\u20091 cm (Figure, A).", "The nodules were firm, mobile, and nontender on palpation.", "Local temperature was normal.", "There was proptosis of the right eye with mild restriction of extraocular movements on lateral gaze.", "Examination of the oral cavity revealed dental caries, while gingivolabial sulcus was free on bidigital examination.", "Nasal mucosa was normal.", "Respiratory system examination revealed occasional polyphonic wheeze.", "Chest radiography imaging showed nodular opacities in right upper zone and bronchiectasis.", "Punch biopsy from 1 nodule was sent for histopathological and microbiological examination (Figure, B and C).A, Destructive depressed plaque involving the medial half of the right side of the face surrounded by multiple nodules of varying sizes."]}
{"Examination and Results": ["On examination, she was normotensive, afebrile, and clinically euvolemic.", "Laboratory testing showed a hemoglobin level of 12.1 g/dL (to convert to grams per liter, multiply by 10), white blood cell count of 9900/\u00b5L (to convert to \u00d7109 per liter, multiply by 0.001), erythrocyte sedimentation rate of 76 mm/h, lactate dehydrogenase level of 139 U/L (to convert to microkatals per liter, multiply by 0.0167), and normal coagulation profile.", "Serum immunoglobulin quantitation showed normal immunoglobulin (Ig) G, IgA, and IgM levels of 1590 mg/L, 303 mg/L, and 94 mg/L, respectively (to convert to grams per liter, multiply by 0.01).", "Blood culture findings were negative.Transthoracic and transesophageal echocardiography (Figure 1 and Video) showed a large echogenic mass on the inferior aspect of the interatrial septum with infiltration of the coronary sinus, anterior mitral valve annulus, and aortic root.", "The mass protruded into the left ventricular outflow tract without causing valve obstruction.", "Cardiac magnetic resonance imaging confirmed a bilobed interatrial mass measuring 5.6\u2009\u00d7\u20093.1\u2009\u00d7\u20093.8 cm with patchy late gadolinium enhancement of the lesion.", "Contrast-enhanced computed tomography showed a left hilar mass encasing the left upper lobe bronchus with extension into the left main pulmonary artery, a nodular soft tissue lesion along the anterior nasal septum, and no abdominal or pelvic disease."]}
{"Patient Personal Background": ["He had immigrated from India to the US 15 years prior and worked as a software engineer.", "He last traveled to India 4 years earlier and had negative results for interferon gamma release assay on return.", "He reported no smoking history, recent animal contact, or unpasteurized animal product ingestion.His temperature was 38.05 \u00b0C; heart rate, 114/min; blood pressure, 132/85 mm Hg; and respiratory rate, 18/min."], "Examination and Results": ["There was no spinal or paraspinal tenderness.", "Findings on pulmonary and neurologic examinations were normal.", "Erythrocyte sedimentation rate was 84 mm/h (reference, <10 mm/h), and C-reactive protein level was 9.4 mg/dL (reference, <0.8 mg/dL).", "A chest radiograph showed prominent reticular markings in the left perihilar area, and chest computed tomography showed a 3.2\u2009\u00d7\u20092.6\u2013cm dense consolidation in the left lower lobe (Figure 1, left panel).", "Magnetic resonance imaging (MRI) of the spine showed signal abnormality and extensive contrast enhancement within the T6, T7, and T8 vertebral bodies, with sparing of the T6-7 and T7-8 disks (Figure 1, center panel), and a large paraspinal soft tissue mass with spinal cord compression (Figure 1, center and right panel).Case patient imaging studies."], "Others": ["Left, Axial computed tomography of the chest.", "Center, Postcontrast sagittal T1-weighted magnetic resonance imaging (MRI)."]}
{"Patient Personal Background": ["She had no known family history of polyneuropathy and no history of diabetes, alcohol misuse, known vitamin deficiency, hypothyroidism, or HIV."], "Examination and Results": ["A neurological examination demonstrated reduced pinprick sensation in both feet and absent vibratory sensation at the first toes.", "Mild weakness of ankle dorsiflexion and absent ankle jerk reflexes were noted bilaterally.", "She had a slightly wide-based gait, high-arched feet, and hammer toes.", "Nerve conduction studies (NCS) and needle electromyography (EMG) were performed.", "The results are shown in Table 1 and Table 2."]}
{"Patient Personal Background": ["His medical history included chronic kidney disease, chronic hepatitis C infection, cirrhosis, ischemic cardiomyopathy with an implantable cardioverter-defibrillator (ICD), and atrial fibrillation with prophylactic apixaban.", "He had recurrent staphylococcus bacteremia due to infection of an ICD lead and had been treated for the past 6 months with minocycline, 100 mg twice daily.", "He had no history of malnutrition and reported infrequent alcohol use.Physical examination showed dense blue-black skin pigmentation of his forearms, dorsal hands, legs, and dorsal feet, as well as blue discoloration of his sclerae and teeth (Figure 1)."], "Patient Symptoms": ["His arms had been purple and bruise-like for several years but turned a near black color 1 month ago."], "Examination and Results": ["He had no history of malnutrition and reported infrequent alcohol use.Physical examination showed dense blue-black skin pigmentation of his forearms, dorsal hands, legs, and dorsal feet, as well as blue discoloration of his sclerae and teeth (Figure 1).", "He had normal-colored nails and oral mucosa.", "Laboratory studies showed white blood cell count of 15\u202f800/\u03bcL (reference range, 4000-11\u202f000/\u03bcL), hemoglobin of 10.7 g/dL (reference, 13.5-17.5 g/dL), platelet count of 58\u202f000/\u03bcL (reference, 150\u202f000-400\u202f000/\u03bcL), and INR of 1.8 (reference, 0.8-1.1).", "Complete metabolic panel showed increased creatinine (1.51 mg/dL; reference, 0.64-1.27 mg/dL) and elevated total bilirubin (1.7 mg/dL; reference range, 0.3-1.2 mg/dL).", "His estimated glomerular filtration rate was 40 mL/min/1.73 m2."], "Treatment": ["He had recurrent staphylococcus bacteremia due to infection of an ICD lead and had been treated for the past 6 months with minocycline, 100 mg twice daily."], "Others": ["He reported no discoloration of his sweat or urine."]}
{"Patient Personal Background": ["She had no history of eye trauma, did not sleep in her CLs, and stopped using CLs at symptom onset.", "Of note, she had recently been swimming in a freshwater lake prior to the onset of the ulcer."], "Patient Symptoms": ["One week later, she presented with worsening pain and vision, which prompted referral to our cornea clinic where, 2 weeks after her initial presentation, her best-corrected visual acuity was 20/20 OD and 20/150 OS."], "Examination and Results": ["Left-eye examination demonstrated diffuse microcystic corneal edema and stromal thickening with no Descemet membrane folds (Figure 1A).", "A 2\u2009\u00d7\u20092-mm stromal opacity was noted paracentrally with no epithelial defects.", "The anterior chamber demonstrated 1+ cell.", "Intraocular pressure was 17 mm Hg OS."], "Treatment": ["She was initially treated with topical besifloxacin and followed up daily.", "She appeared to improve clinically with resolution of her epithelial defect after 3 days, and topical loteprednol was added."], "Others": ["Results of initial corneal cultures were negative.", "Corneal cultures for bacteria, fungi, and acanthamoeba were repeated, and in vivo confocal microscopy (IVCM) was performed on the stromal infiltrate (Figure 1B).", "After reviewing the IVCM images, what empirical treatment would you recommend while awaiting the results of the repeated corneal cultures?"]}
{"Patient Symptoms": ["Findings of Amsler grid testing were notable for a small area of distortion inferiorly in the left eye."], "Examination and Results": ["On examination, her best-corrected distance visual acuity was 20/40 OD and 20/60 OS (baseline 20/40 OU).", "Pupils were equally round and reactive, without afferent pupillary defect.", "Intraocular pressures (IOPs) were 13 mm Hg in both eyes.", "Findings of anterior segment examination were unremarkable.", "Findings of dilated fundus examination were notable for cup-disc ratio of 0.9 in the right eye and 0.85 in the left eye with temporal thinning, stable from prior, and new intraretinal thickening in the left eye.", "Optical coherence tomography (OCT) imaging of the left eye revealed schiticlike separation of the outer plexiform and outer nuclear layers extending from the temporal edge of the optic nerve head to the fovea (Figure 1A), continuous with the peripapillary nerve sheath.Optical coherence tomography (OCT) of macula demonstrating schisislike separation involving fovea (A) and OCT of optic nerve head, with optic pit marked with an arrowhead (B)."]}
{"Patient Personal Background": ["She had no history of longer-term use of medications."], "Patient Symptoms": ["Medical history was positive for bilateral sensorineural hearing loss with cochlear origin as determined by an otolaryngologist and headache since age 35 years."], "Examination and Results": ["Her best-corrected visual acuity was 20/20 OD and 20/63 OS.", "Her pupils were round and reactive.", "The anterior segment was unremarkable.", "Fundus examination confirmed the presence of bilateral macular atrophy.", "Fundus autofluorescence revealed a fairly symmetric loss of autofluorescence in the macula and in the regions surrounding the optic disc (Figure).", "In proximity of these areas of reduced autofluorescence, a speckled fundus autofluorescence pattern of alternating spots of increased and decreased autofluorescence was also noted.", "Optical coherence tomography displayed the presence of a bilateral atrophy of the outer retina and retinal pigment epithelium (Figure).", "The patient\u2019s family underwent a complete ophthalmologic evaluation, which did not display any alteration.A, Fundus photograph of the right eye demonstrates an area of pallor in the fundus (blue arrowheads) corresponding to the region of macular atrophy.", "B, Structural optical coherence tomography (inset image) and green fundus autofluorescence (main image) of the right eye show a macular atrophy that also involves the peripapillary region.", "The area of retinal pigment epithelium loss is featured by well-demarcated reduced autofluorescence (pink arrowhead) surrounded by speckled hyperautofluorescent areas (yellow arrowhead)."], "Others": ["There was no family history of hearing and vision loss in all immediate family members."]}
{"Patient Symptoms": ["One week later, the patient returned to our department due to multiple episodes of amaurosis fugax in left eye."], "Examination and Results": ["Visual acuity was 20/40 OD and 20/20 OS.", "Anterior segment, tonometry, and pupillary light reflex were unremarkable.", "Ophthalmoscopy of the right eye showed discretely blurred optic disc margins, tortuous and dilated retinal veins, and intraretinal hemorrhages in all quadrants; the left eye was unremarkable.", "An optical coherence tomography (OCT) scan showed a cystoid macular edema (CME) in the right eye; the left was unremarkable.", "Retinal nerve fiber layer thickness was 133 \u03bcm OD and 82 \u03bcm OS (reference value, 95.4\u2009\u00b1\u200910.48 \u03bcm).1 A fluorescein angiography was scheduled.", "By that time, ophthalmoscopy disclosed a mild optic disc swelling, tortuous venous vessels, and retinal hemorrhages bilaterally (Figure 1).", "The OCT scan showed a CME spontaneous resolution in the right eye while the left eye was unremarkable.", "Fluorescein angiography revealed a slight delay in venous filling but no capillary nonperfusion areas.", "In the left eye, a superficial optic nerve drusen (white arrowhead) was noted.A hypercoagulability and autoimmune workup\u2014including peripheral blood smear, complete blood cell count, serum hyperviscosity, total protein level, protein electrophoresis, factor V Leiden, prothrombin, protein C and S, antithrombin, anticardiolipin, and antineutrophil cytoplasmic antibodies\u2014gave normal results.", "A brain angiomagnetic resonance imaging scan was performed, which excluded central thrombosis."], "Diagnosis": ["These features were compatible with bilateral nonischemic central retinal vein occlusion (CRVO), with spontaneous reperfusion in the right eye.Fundus photography of the right and left eyes showing slightly elevated and blurred optic disc margins (asterisk), mildly tortuous and dilated retinal vessels (black arrowheads), and intraretinal hemorrhages (pink arrowheads) in all quadrants in both eyes."]}
{"Patient Personal Background": ["At age 8 months, she was treated with right enucleation and left eye radiotherapy (50.4 Gy).", "At age 4 years, she developed a recurrence of the retinoblastoma in the nasal cavity and was treated with 4 cycles of vincristine, doxorubicin, and cyclophosphamide followed by 1 cycle of cisplatin, etoposide, and intrathecal cytarabine.Primary care evaluation was prompted by her mother, as the patient had not noticed her lower extremity edema."], "Patient Symptoms": ["She had no fevers, weight loss, shortness of breath, chest pain, abdominal pain, or history of deep vein thrombosis."], "Examination and Results": ["Her physical examination was notable for firm, nonpitting edema to the hip.", "She did not have any associated tenderness, inguinal lymphadenopathy, or palpable abdominal masses.", "Her vital signs were within normal limits and she ambulated comfortably.", "Laboratory work results, including a complete blood cell count with a differential, comprehensive metabolic panel, and D-dimer levels, were within normal limits.", "Doppler ultrasonography of her right lower extremity showed no deep vein thrombosis.", "A computed tomography venogram demonstrated a 4.0\u2009\u00d7\u20093.5 cm mass of likely vascular origin that was extending into the right common iliac vein (Figure).Computed tomography venogram demonstrating a 4.0\u2009\u00d7\u20093.5 cm heterogeneously enhancing lobulated mass (arrowhead) extending into the right common iliac vein."], "Treatment": ["At age 4 years, she developed a recurrence of the retinoblastoma in the nasal cavity and was treated with 4 cycles of vincristine, doxorubicin, and cyclophosphamide followed by 1 cycle of cisplatin, etoposide, and intrathecal cytarabine.Primary care evaluation was prompted by her mother, as the patient had not noticed her lower extremity edema."]}
{"Patient Symptoms": ["She first noticed swelling that progressed to pressure and dyspnea while supine.", "She reported fatigue but denied pain, voice change, weight loss, hemoptysis, and dysphagia."], "Examination and Results": ["A physical examination revealed a visible and palpable fullness to the right neck without overlying cutaneous or sinus tract changes.", "Results of a complete blood cell count, a thyroid stimulating hormone test, triiodothyronine and levorotatory thyroxine testing, and a complete metabolic panel were normal.", "Ultrasonography showed a 7.9\u2009\u00d7\u20096.3-cm septate cystic mass lateral to the right thyroid gland.", "A contrast-enhanced computed tomography scan of the neck demonstrated a large, nonenhancing cystic-appearing lesion abutting the lateral and posterior margins of the right thyroid lobe and extending from the level of the piriform sinus to the thoracic inlet (Figure).", "Ultrasound-guided fine-needle aspiration revealed clear fluid with a parathyroid hormone (PTH) level of 67 pg/mL (reference range, <100 pg/mL; to convert to ng/L multiply by 1.00).", "A barium swallow study showed no communication between the cyst and the piriform sinus."], "Treatment": ["Excision in the operating room was performed, and right thyroid lobectomy was necessary because of the intimate association of the lesion to the thyroid lobe.Contrast-enhanced computed tomography scan of the neck with coronal (A) and axial (B) views demonstrating the right cystic neck mass."]}
{"Patient Symptoms": ["The patient\u2019s neck swelling, which initially decreased in size while undergoing chemotherapy, progressively enlarged shortly after concluding treatment."], "Examination and Results": ["He underwent magnetic resonance imaging and computed tomography of the neck that showed a clearly defined, bulky supraclavicular mass confined to left neck levels 3, 4, and 5 (Figure).A, Postcontrast coronal magnetic resonance imaging (MRI) demonstrated a bulky, cystic left neck mass at levels 3, 4, and 5.", "B, Axial computed tomography (CT) scan with contrast highlighted extensive septations and modularity within the mass."], "Treatment": ["He was treated with a right radical orchiectomy and 4 cycles of etoposide, ifosfamide, and cisplatin (VIP) chemotherapy with resulting reduction in metastatic tumor burden and normalization of \u03b1-fetoprotein and \u03b2-human chorionic gonadotropin."]}
{"Patient Personal Background": ["Fifteen months previously, he had undergone allogeneic stem cell transplant (allo-SCT) with a matched related donor for treatment of fms-like tyrosine kinase (FLT3) internal tandem duplication\u2013mutated acute myeloid leukemia (AML).", "The patient had been diagnosed with chronic gastrointestinal graft-vs-host disease after a workup for diarrhea."], "Patient Symptoms": ["Physical examination findings revealed no neck masses or abnormalities, but the patient was noted to be severely dysphonic and stridulous."], "Examination and Results": ["Results of a restaging bone marrow biopsy 2 weeks prior to presentation showed no evidence of leukemia.", "Flexible laryngoscopy findings demonstrated a right vocal fold neoplasm crossing the posterior commissure with associated bilateral vocal fold motion impairment and obstruction of the glottic airway (Figure, A).", "Histologic findings demonstrated diffuse infiltrate of large cells with irregular nuclear contours, vesicular chromatin, and prominent nucleoli (Figure, C).", "Immunohistochemical stains showed CD33, CD43, and CD117 positivity, with a subset positive for CD7 and myeloperoxidase.", "Stains were negative for CD3, CD20, and cytokeratin expression.Evaluation of the larynx from awake flexible laryngoscopy (A) including posterior commissure (A, inset) and operative microlaryngoscopy (B) with biopsy (C; original magnification \u00d740)."], "Treatment": ["Awake tracheostomy was performed for airway protection, and biopsy of the neoplasm was obtained via operative microlaryngoscopy (Figure, B)."]}
{"Patient Personal Background": ["Three months prior, pembrolizumab treatment was stopped because of a widespread morbilliform reaction, which had resolved completely 6 to 8 weeks before admission."], "Patient Symptoms": ["The new widespread, asymptomatic skin eruption had been ongoing for 1 to 2 weeks and appeared different from her pembrolizumab reaction.A complete blood cell count was notable for a normal white blood cell count of 4100/\u03bcL, normal absolute neutrophil count of 2940/\u03bcL, chronic normocytic anemia (hemoglobin level of 8.2 g/dL), and chronic thrombocytopenia (platelet count of 62 \u00d7103/\u03bcL)."], "Examination and Results": ["The new widespread, asymptomatic skin eruption had been ongoing for 1 to 2 weeks and appeared different from her pembrolizumab reaction.A complete blood cell count was notable for a normal white blood cell count of 4100/\u03bcL, normal absolute neutrophil count of 2940/\u03bcL, chronic normocytic anemia (hemoglobin level of 8.2 g/dL), and chronic thrombocytopenia (platelet count of 62 \u00d7103/\u03bcL).", "Blood culture results showed no growth at 1 week.", "Serum \u03b2-D-glucan, galactomannan, Coccidioides antibody by complement fixation, and immunodiffusion results were negative.", "Respiratory viral panel and SARS-CoV-2 test results were negative.", "Total body skin examination findings were notable for widespread, nontender, erythematous patches and thin plaques, some with prominent overlying telangiectases and hyperpigmentation (Figure, A).", "A punch biopsy of a representative lesion was performed (Figure, B-D).A, Physical examination findings were notable for widespread erythematous patches and thin plaques, some with prominent overlying telangiectases.", "D, CD56 immunostaining labels intravascular atypical cells."], "Others": ["B and C, Hematoxylin-eosin stained section."]}
{"Patient Personal Background": ["His history was notable for nonischemic cardiomyopathy with ejection fraction of 40% and idiopathic pulmonary fibrosis, for which he underwent single-lung transplant 9 years prior."], "Examination and Results": ["Following diuresis and medical optimization, repeated echocardiogram showed a newly depressed ejection fraction (30%).", "His electrocardiogram (ECG) was notable for alternating QRS morphologies (Figure 1A).", "Chest radiography revealed severe right pulmonary fibrosis leading to ipsilateral mediastinal shift and pacemaker lead position unchanged from implantation."], "Treatment": ["The left ventricular (LV) pacing vector was programmed from LV tip to right ventricular (RV) lead ring.", "During pacemaker threshold testing, a change in QRS morphology was observed as the output was reduced (Figure 1B)."]}
{"Patient Personal Background": ["About 2 weeks before the ulcerations developed, the patient had been admitted to the hospital for unstable angina, and coronary angiography was performed."], "Patient Symptoms": ["He had also experienced a burning sensation on the right side of his face, but denied headache, shoulder, or jaw pain and visual disturbance.", "Neurological examination revealed hypoesthesia of the right side of the face, while cold-warm sensation and motor function were intact."], "Examination and Results": ["Neurological examination revealed hypoesthesia of the right side of the face, while cold-warm sensation and motor function were intact.", "The erythrocyte sedimentation rate was 82 mm per hour (normal value, less than 15 mm per hour) and the serum C\u2013reactive protein concentration was 107 mg/L (normal value, less than 5 mg/L).", "Chest radiography showed bilateral perihilar infiltrates consistent with pneumonia.", "Magnetic resonance imaging of the brain revealed an extensive ischemic posterior circulation stroke involving the right occipital lobe, lower cerebellar peduncle, and pontomedullary boundary (Figure, B).Clinical and radiological findings in a man aged 66 years.A, Multiple ulcers limited to the right half of the face."], "Treatment": ["Immediately after the angiography, the patient developed left-sided hemiplegia and hemianopsia."], "Others": ["B, Magnetic resonance image showing brainstem involvement by the stroke (diffusion-weighted sequence)."]}
{"Patient Personal Background": ["She had a history of hyperlipidemia, hypertension, and migraine headaches.", "Her medications included atorvastatin, carvedilol, and norethindrone."], "Examination and Results": ["Dilated-fundus examination of the right eye showed a single cotton-wool spot (indicating local retinal ischemia), with intraretinal hemorrhage in the inferotemporal quadrant.", "Ultrawide-field imaging showed a cotton-wool spot on the left fundus (Figure 1A, right) and a peripheral arterial occlusion in the right eye (Figure 1A, left), and fluorescein angiographic study of the right eye demonstrated an area of blockage corresponding to intraretinal hemorrhage and venous hyperfluorescence (Figure 1B).", "The patient was afebrile, with pulse 110 beats/min and blood pressure of 188/99 mm Hg.", "Auscultation over the heart apex revealed a holosystolic ejection murmur (grade 2/6).", "Laboratory testing showed normal complete blood cell count and thyrotropin level and negative results for autoantibodies against Sm, SSA, SSB, Scl-70, Jo-1, centromere, chromatin, ribonucleoprotein, and antineutrophil cytoplasmic antibodies.", "Erythrocyte sedimentation rate was mildly elevated (30 mm/h).", "Results of testing for antinuclear antibodies were positive at low titer (1:40, homogenous pattern) with positive dsDNA (5.0 IU/mL; negative if <4.0 IU/mL).", "Blood cultures were negative for bacterial or fungal growth after 5 days.", "An echocardiogram revealed pedunculated and mobile aortic valve vegetations."]}
{"Patient Personal Background": ["He was otherwise healthy and did not take any regular medications."], "Patient Symptoms": ["Initially, he had horizontal diplopia on the first day that was worse at the end of the day, but this resolved when the right eyelid ptosis became complete.", "He denied any difficulty with his speech, swallowing, weakness, or sensory changes.He presented to the emergency department, and the emergency department physician reported a normal neurological examination result apart from the right-sided ptosis and limited eye movements."], "Examination and Results": ["He was referred to ophthalmology and had a visual acuity of 20/20 OU.", "Both pupils were equal sizes and reactive to light.", "He was found to only have a complete limitation of elevation of his right eye and a limitation of abduction in his left eye (Figure).", "He was orthophoric in primary position, and there were no eyelid twitches.", "Orbicularis oculi strength was reduced on both sides.", "A dilated fundus examination had normal results bilaterally."]}
{"Examination and Results": ["His extraocular movements were full, and he had no other neurologic deficits.", "His visual acuity was 20/400 OD and 20/30 OS, respectively, and his fundi were notable for bilateral optic nerve edema.", "Results of recent computed tomography and angiography of the head and neck and magnetic resonance imaging of the brain and orbits were reportedly normal, and lumbar puncture revealed an opening pressure of 26 cm H2O (normal range, 6 to 25 cm H2O) with elevated protein.", "He had an afferent pupillary defect in the right eye, and Humphrey visual fields (24-2) showed binasal inferior defects with a superior defect in the right eye that was considered an artifact of testing.", "According to the Ishihara color plates test, color vision was full in both eyes.", "Fundus examination was remarkable for pallor of both optic nerves, more notably in the right eye, without edema (Figure 1)."], "Treatment": ["The patient was given acetazolamide and referred to neuro-ophthalmology.On examination by neuro-ophthalmology 4 months later, his visual acuity was 20/50 OD and 20/20 OS."]}
{"Patient Symptoms": ["The patient continued to report severe and progressive headaches along with blurred vision."], "Examination and Results": ["Magnetic resonance imaging (MRI) of the brain with and without contrast, magnetic resonance angiography of the head, and magnetic resonance venography of the head were obtained and were unremarkable.", "The result of a lumbar puncture showed 101 white blood cells per high-power field (75% lymphocytes).", "Results of syphilis serologic tests were negative.", "There was no afferent pupillary defect, and an anterior segment examination was within normal limits.", "A dilated fundus examination showed numerous bilateral creamy-yellow lesions in the peripheral retina with discrete nummular lesions in the posterior pole (Figure 1A).", "Fundus autofluorescence showed focal areas of hypoautofluorescence with surrounding hyperautofluorescence in both eyes (Figure 1B).", "A review of systems was otherwise unremarkable.A, Left eye.", "Yellow placoid chorioretinal lesions extend from the posterior pole to the retinal periphery.", "A creamy chorioretinal lesion (blue arrowhead) signifies active disease.", "A corresponding lesion (white arrowheads) is visible on both images."], "Diagnosis": ["The patient was discharged with suspected viral meningitis.At a follow-up visit in an ophthalmology clinic 1 week after discharge, visual acuity was 20/25 OD and counting fingers OS."]}
{"Patient Symptoms": ["Four weeks following receipt of immunotherapy with ipilimumab and nivolumab, he developed acute abdominal pain in the setting of a rapidly rising lactic acid dehydrogenase levels, prompting hospital admission.", "Splenic infarct and portal/splenic vein thrombi were identified as etiologies of his acute pain and were presumed to be secondary to hypercoagulable state of malignancy.Over the next 3 days, he had rising serum creatinine (sCr) levels (baseline, approximately 1 mg/dL [to convert to \u03bcmol/L, multiply by 88.4]).", "The top differential diagnoses at this juncture included contrast-induced nephropathy or immune checkpoint inhibitor (ICI)\u2013induced acute interstitial nephritis, and empirical high dose steroids were prescribed.Despite observation and steroid treatment, his sCr levels continued to increase over the next 5 days, peaking at 5.8 mg/dL, and the patient progressed into anuric kidney failure, requiring hemodialysis."], "Examination and Results": ["Imaging results showed mild disease progression (new ascites and periportal metabolic lymph node).", "Splenic infarct and portal/splenic vein thrombi were identified as etiologies of his acute pain and were presumed to be secondary to hypercoagulable state of malignancy.Over the next 3 days, he had rising serum creatinine (sCr) levels (baseline, approximately 1 mg/dL [to convert to \u03bcmol/L, multiply by 88.4]).", "Ultrasonography results showed abnormal intraparenchymal flow to both kidneys without evidence of kidney artery stenosis.", "Urine studies were consistent with prerenal etiology, while the presence of casts suggested acute tubular necrosis."], "Treatment": ["Nephrotoxic medications (omeprazole/pantoprazole) were discontinued.", "The top differential diagnoses at this juncture included contrast-induced nephropathy or immune checkpoint inhibitor (ICI)\u2013induced acute interstitial nephritis, and empirical high dose steroids were prescribed.Despite observation and steroid treatment, his sCr levels continued to increase over the next 5 days, peaking at 5.8 mg/dL, and the patient progressed into anuric kidney failure, requiring hemodialysis.", "One week later, he received encorafenib, a BRAF inhibitor.1 Two weeks later, the patient\u2019s kidney function began to improve, and hemodialysis was discontinued."], "Diagnosis": ["Splenic infarct and portal/splenic vein thrombi were identified as etiologies of his acute pain and were presumed to be secondary to hypercoagulable state of malignancy.Over the next 3 days, he had rising serum creatinine (sCr) levels (baseline, approximately 1 mg/dL [to convert to \u03bcmol/L, multiply by 88.4]).", "The top differential diagnoses at this juncture included contrast-induced nephropathy or immune checkpoint inhibitor (ICI)\u2013induced acute interstitial nephritis, and empirical high dose steroids were prescribed.Despite observation and steroid treatment, his sCr levels continued to increase over the next 5 days, peaking at 5.8 mg/dL, and the patient progressed into anuric kidney failure, requiring hemodialysis."], "Others": ["The initial workup included ultrasonography and urinalysis.", "This prompted a kidney biopsy for definitive diagnosis (Figure)."]}
{"Patient Personal Background": ["He took linagliptin, valsartan, and 15 mg of methotrexate weekly.", "He was a nonsmoker and consumed very little alcohol.Clinical examination including flexible nasendoscopy revealed multiple shallow ulcers on the posterior wall of the nasopharynx."], "Patient Symptoms": ["He also complained of nasal regurgitation."], "Examination and Results": ["There was a large defect involving the entire soft palate on the left.", "There was no obvious mass or any exophytic lesion.", "The edges of the soft palate defect were smooth and clean (Figure 1).", "There were no cranial nerve palsies.", "There was no cervical, axillary, or inguinal lymphadenopathy.", "Findings of the remaining head and neck examinations were normal.Results of laboratory investigations, including lactate dehydrogenase level and autoimmune antibody tests, such as antinuclear antibody and antineutrophil cytoplasmic antibody, were negative.", "Screening test results for HIV and Treponema pallidum were also negative.", "The only positive result was immunoglobulin (Ig) G for Epstein-Barr virus (EBV).", "The IgM for EBV was not detected.Magnetic resonance imaging of the head and neck on short tau inversion recovery sequence confirmed the soft palate defect but also showed some thickening and hyperenhancement around the edges of the defect.", "There was no demonstrable nasopharyngeal mass.", "The hard palate was intact, and there were no significant cervical lymph nodes.", "The patient had biopsies taken from the ulcers and edges of the soft palate defect."], "Others": ["He denied having any systemic symptoms."]}
{"Patient Personal Background": ["Thyroid function test results were normal, and she did not take thyroid medications.", "A relative had received a diagnosis of papillary thyroid cancer at age 50 years.", "There was no other pertinent family history, including a history of multiple endocrine neoplasia."], "Examination and Results": ["Physical examination showed thyromegaly (right greater than left) with an approximately 5-cm palpable nodule in the right lobe.", "There was no tenderness or cervical lymphadenopathy.", "Ultrasonography results showed a multinodular goiter with a dominant 4.6-cm right thyroid nodule, 1.6-cm left-sided thyroid nodule, and suspect left level IV lymph node.", "Ultrasonography-guided fine-needle aspiration biopsy results showed papillary thyroid carcinoma (PTC) (Bethesda VI) with a BRAFV600E variation in the left nodule and lymph node, and atypia of undetermined significance (Bethesda III) with a suspicious Afirma genomic sequence classifier in the right nodule.", "Gross examination of the specimen showed a 2.9-cm pale-tan, partially circumscribed, soft nodule in the right thyroid lobe; a 1.4-cm pale-tan, fibrotic, centrally brown nodule in the left lobe; and a 1.8-cm pale-tan, rubbery, partially circumscribed nodule in the isthmus.", "Histologic examination of the right thyroid lesion was performed (Figure), with ancillary testing.A, The right-sided nodule showed an organoid zellballen pattern, with sharp demarcation from thyroid tissue (hematoxylin-eosin).", "B, At higher magnification, the tumor cells exhibited amphophilic granular cytoplasm, round to oval nuclei, and salt-and-pepper chromatin (hematoxylin-eosin)."], "Treatment": ["She underwent total thyroidectomy with modified left lateral neck dissection."], "Diagnosis": ["Ultrasonography-guided fine-needle aspiration biopsy results showed papillary thyroid carcinoma (PTC) (Bethesda VI) with a BRAFV600E variation in the left nodule and lymph node, and atypia of undetermined significance (Bethesda III) with a suspicious Afirma genomic sequence classifier in the right nodule."], "Others": ["There was no prior radiation exposure to the head and neck area."]}
{"Patient Personal Background": ["She did not have any known benign inflammatory conditions."], "Patient Symptoms": ["The patient otherwise felt well and denied malaise, weight loss, or any other symptoms."], "Examination and Results": ["Physical examination showed indurated plaques with multiple telangiectasias (Figure, A and B) on almost all the surface of the legs.", "Except for slightly elevated C-reactive protein levels, the results of other routine blood and urine tests were unremarkable.", "A skin biopsy specimen was obtained for histopathology examination (Figure, C and D).A, Indurated violaceous plaques with multiple telangiectasias on the lower limbs.", "C, Histopathologic analysis shows large round cells proliferating within dermal blood vessels (hematoxylin-eosin).", "D, Round cells with scanty cytoplasm and prominent nucleoli filling a vessel (hematoxylin-eosin)."], "Others": ["B, Prominent telangiectasia on the thigh."]}
{"Patient Symptoms": ["Skin examination showed ichthyosiform brownish plaques on his lower extremities and multiple erythematous confluent papules and plaques on his trunk and face (Figure, A and B).", "In addition, painful distal and proximal interphalangeal joints were noted for 2 years, and the patient could not clench his fists.", "Uveitis in both eyes was also diagnosed by an ophthalmologist."], "Examination and Results": ["Skin examination showed ichthyosiform brownish plaques on his lower extremities and multiple erythematous confluent papules and plaques on his trunk and face (Figure, A and B).", "Microscopic examination of his hair showed no trichorrhexis invaginata or trichorrhexis nodosa.", "A skin biopsy specimen was obtained and submitted for further histopathologic analysis (Figure, C and D).A, Diffuse erythematous papules and plaques with mild scaling and some confluence on the face, neck, and trunk.", "B, Ichthyosiform rashes predominantly distributed over the lower extremities.", "C, Tissue biopsy results revealed multiple circumscribed nests of granulomas that were infiltrating the dermis and subcutis (hematoxylin-eosin).", "D, At higher magnification, histologic findings showed noncaseating granulomas with multinucleated giant cells and neutrophil infiltration in the dermis and subcutis (hematoxylin-eosin)."], "Treatment": ["Topical steroid and pimecrolimus were administered, but their effects were limited."]}
{"Patient Symptoms": ["She reported recent physical and emotional stress from work and dizziness 2 days prior to presentation.", "She denied fever or palpitations."], "Examination and Results": ["Her blood pressure was 84/59 mm Hg.", "A harmonic, musical systolic murmur was heard at the left third intercostal space.", "An electrocardiogram (ECG; Figure 1A) showed diffuse ST-segment elevation, most prominently in the anterior precordial leads.", "Laboratory evaluation revealed elevated levels of troponin (1.33 ng/mL; normal range: \u22640.016 ng/mL [to convert to micrograms per liter, multiply by 1.0]), brain natriuretic peptide (376.5 pg/mL; normal range: \u226418.4 pg/mL [to convert to nanograms per liter, multiply by 1.0]), creatinine phosphokinase (96 U/L; normal range: 41-153 U/L), and D-dimer (0.68 \u03bcg/mL; normal range: \u22641.00 \u03bcg/mL [to convert to nanomoles per liter, multiply by 5.476]).", "Echocardiography showed left ventricular (LV) wall-motion abnormalities involving the mid and apical segments and an LV apical mass with protruding features.", "Noncontrast computed tomography confirmed the high-density LV mass (Figure 1B).", "Coronary angiography revealed mild to moderate coronary atherosclerosis without obstructive coronary artery disease.Noncontrast computed tomography and electrocardiogram obtained on initial admission to the emergency department.", "A, Electrocardiogram showing diffuse ST-segment elevation with ST depression in aVR and T-wave inversion in leads V1 to V5, with a QTc interval of 494 milliseconds.", "The sweep speed was 25 mm/s and 10 mm/mV."], "Others": ["B, Noncontrast computed tomography shows a high-density mass in the left ventricular apex."]}
{"Patient Symptoms": ["Despite unremarkable postoperative day 1 (POD1) examination findings, the patient presented on postoperative week 3 with a painless central scotoma and worsening floaters."], "Examination and Results": ["Her visual acuity was 20/400 OD and intraocular pressure was normal.", "There was no external hyperemia or chemosis, and the anterior chamber was deep and quiet with no cells or flare.", "On dilated fundus examination, there were 15 to 20 cells per high-power field (using a 1\u2009\u00d7\u20091-mm2 high-intensity incidental slit beam) and a white macular lesion with disc edema and scattered intraretinal and peripapillary hemorrhages and mixed venous and arterial sheathing.", "Optical coherence tomography of the macula showed atrophy, full-thickness hyperreflectivity, and a residual epiretinal membrane (Figure).Color fundus photograph (A) of the right eye demonstrating white macular lesion and optic disc edema with scattered intraretinal and peripapillary hemorrhages and vascular sheathing (white arrowheads)."], "Treatment": ["Diluted triamcinolone acetonide (TA) was used to stain the posterior hyaloid.", "After removal of 25-gauge trocar cannulas, subconjunctival TA and ceftazidime was injected.", "Owing to cystoid changes in the central macula, a short-acting gas tamponade with sulfur hexafluoride was used to tamponade any cystoid abnormalities that may have been unroofed."]}
{"Patient Personal Background": ["Current ophthalmic medications included topical prednisolone acetate, 1%, in the right eye 6 times per day."], "Patient Symptoms": ["The patient reported no improvement with the treatment."], "Examination and Results": ["On examination, his best-corrected visual acuity was 20/80 OD and 20/20 OS.", "Pupils were reactive without relative afferent pupillary defect, and intraocular pressures were 18 mm Hg in the right eye and 11 mm Hg in the left eye.", "A slitlamp biomicroscopic examination of the right eye revealed grade 2 to 3 diffuse central corneal edema and folds (Figure 1).", "The anterior chamber was deep and the posterior chamber intraocular lens was in good position within the capsular bag.", "Although the view to the posterior pole of the right eye was hazy owing to corneal edema, dilated fundus examination findings were unremarkable.", "Examination of the left eye revealed a few guttate."]}
{"Patient Personal Background": ["His active medical problems included atrial flutter on anticoagulation, antisynthetase syndrome (which was diagnosed based on the presence of autoantibodies against aminoacyl-tRNA synthetase), fever with negative infectious workup results, and interstitial lung disease that was managed with azathioprine."], "Patient Symptoms": ["Two weeks before the onset of sudden vision loss, the patient developed a rapidly evolving purpuric rash on his hands and feet that progressed to digital ischemia (Figure 1A).", "B, Montage fundus photograph of the left eye shows frosted branch angiitis with preretinal hemorrhages over the disc (arrowhead) and macula (arrowhead), intraretinal hemorrhages, perivenular exudates, and sheathing.On ophthalmic examination, visual acuity was 20/20 OD and hand motions OS (baseline from 2 weeks prior was 20/20 OU), with a briskly reactive right pupil and a left afferent pupillary defect."], "Examination and Results": ["B, Montage fundus photograph of the left eye shows frosted branch angiitis with preretinal hemorrhages over the disc (arrowhead) and macula (arrowhead), intraretinal hemorrhages, perivenular exudates, and sheathing.On ophthalmic examination, visual acuity was 20/20 OD and hand motions OS (baseline from 2 weeks prior was 20/20 OU), with a briskly reactive right pupil and a left afferent pupillary defect.", "Left eye examination revealed 2 or more anterior chamber cells, preretinal hemorrhage, frosted branch angiitis with diffuse intraretinal hemorrhages, and perivascular exudates (Figure 1B).", "Fluorescein angiography results revealed extensive vascular nonperfusion and late perivenular leakage.", "The right eye was normal.Laboratory workup results revealed an erythrocyte sedimentation rate of 85 mm per hour, C-reactive protein levels of 2.53 mg/dL (to convert to milligrams per liter, multiply by 10), negative antineutrophil cytoplasmic antibodies test result, antinuclear antibodies, cryoglobulins, syphilis serology, tuberculosis testing, and transthoracic echocardiogram.", "Skin biopsy results showed medium vessel vasculitis."], "Treatment": ["He was treated with intravenous methylprednisolone, which was completed 3 days before the onset of loss of vision and transitioned to treatment with azathioprine, 150 mg, and prednisone, 80 mg, that he was taking at the time of his vision loss.Cutaneous and retinal vasculitis."], "Diagnosis": ["A, Purpuric rash involving the left foot.", "Left eye examination revealed 2 or more anterior chamber cells, preretinal hemorrhage, frosted branch angiitis with diffuse intraretinal hemorrhages, and perivascular exudates (Figure 1B).", "Skin biopsy results showed medium vessel vasculitis."]}
{"Patient Personal Background": ["He had no history of malignant neoplasm or chemical exposure."], "Patient Symptoms": ["He denied having fever, chills, fatigue, night sweats, or weight loss."], "Examination and Results": ["Physical examination findings demonstrated numerous erythematous, indurated nodules involving the surface of his head, neck, torso, and extremities, without ulceration or scarring (Figure, A and B).", "Findings of systemic reviews were unremarkable, and there was no lymphadenopathy or peripheral nerve enlargement.", "Complete blood cell count with differential results were normal (white blood cell count, 6060/\u03bcL, normal range, 4500-10\u202f000/\u03bcL; absolute neutrophils, 3070/\u03bcL, normal range, 1800-8300/\u03bcL [to convert cell counts to \u00d7109/L, multiply by 0.001]).", "Serum lactate dehydrogenase level was elevated (279 U/L, normal range, 100-240 U/L [to convert to \u03bckat/L, multiply by 0.0167]).", "Biopsies from skin nodules (Figure, C) and bone marrow were obtained.Skin lesions on the patient with widespread, erythematous, indurated nodules involving his head and neck (A) and trunk (B).", "C, Histologic findings demonstrate diffuse dermal infiltrates, extending to the subcutis, with sparing of the upper papillary dermis (original magnification \u00d720).", "The infiltrates are characterized by immature myeloid cells (inset, original magnification \u00d7400)."]}
{"Patient Personal Background": ["His medical history was significant for several episodes of upper respiratory infection during the previous winter season, and he previously had an adenotonsillectomy several years prior and bilateral ear tubes placed 1 year before presentation."], "Patient Symptoms": ["The mass had been slowly enlarging and he had been experiencing mild intermittent pain, but no additional symptoms were reported."], "Examination and Results": ["Physical examination showed a mildly tender, nonmobile, left parotid mass near the angle of the mandible with no overlying skin changes or drainage around the mass.", "There was no lymphadenopathy or other lesions noted in the neck area, and cranial nerve VII was fully intact.", "Ultrasonography results of the neck showed a left 1.5-cm preauricular nodular mass with internal and marginal vascularity.", "A neck magnetic resonance imaging study without contrast performed at an outside institution revealed the 1.5-cm heterogeneous intraparotid nodule that was predominantly isotense to glandular tissue on T1 images with vague hypointensity of a small irregular central region, as well as vague hyperintensity on T2 images.", "He subsequently underwent fine needle aspiration biopsy to assess the lesion, which demonstrated benign-appearing salivary gland tissue and clusters of myoepithelial cells.", "Gross examination of the specimen demonstrated a 1.6\u2009\u00d7\u20091.5\u2009\u00d7\u20091.1\u2013cm tan-white, well-circumscribed lesion that was partially surrounded by salivary gland parenchyma (Figure, A).", "A, Serial sections of the intraparotid mass demonstrate a well-demarcated solid nodule with tan-white, glistening cut surfaces.", "B, Microscopic examination shows a multilobulated, complex lesion with prominent stromal fibrosis and collections of ductal structures with varying degrees of cystic change (hematoxylin-eosin).", "C, Acinar cells with brightly eosinophilic intracytoplasmic granules (hematoxylin-eosin)."], "Treatment": ["The mass was continuing to enlarge, and the patient\u2019s pain was increasing in that area, so the decision was made to perform left superficial parotidectomy with preservation of the facial nerve.", "Intraoperatively, the left parotid mass was noted to be just below the lower branches of the facial nerve.", "The excised parotid mass was sent to the pathology department for analysis."], "Others": ["Histologic examination of the nodule was performed (Figure, B and C).Gross and histologic findings."]}
{"Patient Personal Background": ["Her medical history included systemic lupus erythematosus, antiphospholipid antibody syndrome, and external hemorrhoids.", "Six months before admission, she underwent a deceased donor kidney transplant.", "Her immunosuppressive regimen at the time of dermatologic evaluation consisted of prednisone, 5 mg daily, and mycophenolate mofetil, 500 mg twice daily.On admission, she was afebrile and normotensive; laboratory results were notable for an elevated creatinine level of 1.43 mg/dL (reference range, 0.40-1.30 mg/dL) (to convert to micromoles per liter, multiply by 88.4) and thrombocytopenia (platelet count, 92\u2009\u00d7\u2009103/\u03bcL [reference range, 140-440\u2009\u00d7\u2009103/\u03bcL] [conversion to \u00d7109 per liter is 1:1)."], "Patient Symptoms": ["She developed diarrhea 1 day after admission."], "Examination and Results": ["Her immunosuppressive regimen at the time of dermatologic evaluation consisted of prednisone, 5 mg daily, and mycophenolate mofetil, 500 mg twice daily.On admission, she was afebrile and normotensive; laboratory results were notable for an elevated creatinine level of 1.43 mg/dL (reference range, 0.40-1.30 mg/dL) (to convert to micromoles per liter, multiply by 88.4) and thrombocytopenia (platelet count, 92\u2009\u00d7\u2009103/\u03bcL [reference range, 140-440\u2009\u00d7\u2009103/\u03bcL] [conversion to \u00d7109 per liter is 1:1).", "Fecal leukocytes were absent.", "Stool antigen test results for cryptosporidium, giardia, and rotavirus were negative.", "Polymerase chain reaction (PCR) test results for campylobacter, norovirus, salmonella, shigella, Shiga toxin\u2013producing Escherichia coli 1 and 2, Vibrio cholerae, and Yersinia enterocolitica in the stool were negative.", "Antigen and toxin test results for Clostridium difficile in the stool were positive.Total body skin examination was notable for 1- and 3-cm tender, round perianal ulcers with a clean base.", "There were no ocular or oral ulcers.", "A biopsy specimen of a perianal ulcer border was obtained for histopathologic analysis (Figure, B-D).Clinical and histologic images of multiple perianal ulcers.", "A, Two round ulcers, each with well-demarcated borders, were present perianally.", "A smaller, third ulcer was also noted in the intergluteal cleft.", "B, Microscopic examination of the punch biopsy on low magnification reveals epidermal ulceration and mixed dermal inflammation (hemoxylin-eosin.", "C, On higher magnification, the epidermis lacks viral cytopathic changes but there are enlarged dermal fibroblasts and endothelial cells (hemoxylin-eosin)."], "Treatment": ["One month before presentation, she was hospitalized for acute cellular transplant rejection managed with systemic corticosteroids, belatacept, mycophenolate mofetil, and tacrolimus therapies."], "Diagnosis": ["Antigen and toxin test results for Clostridium difficile in the stool were positive.Total body skin examination was notable for 1- and 3-cm tender, round perianal ulcers with a clean base."], "Others": ["Another 4-mm round ulcer was present at the superior intergluteal cleft (Figure, A)."]}
{"Patient Personal Background": ["The patient had immigrated to Israel 9 years before admission."], "Patient Symptoms": ["She was adamant that the lesion had been present since early childhood but had gradually increased with a recent appearance of foul-smelling otorrhea.", "Bloody otorrhea from the external auditory canal was seen."], "Examination and Results": ["On examination, the auricle was markedly enlarged, edematous, and encircled by an erythematous, indurated plaque partially covered with a fine scale (Figure 1A).", "Diascopy revealed an \u201capple jelly\u201d appearance.", "There was no local or distant lymphadenopathy; general physical examination findings were unremarkable.A, Clinical findings at presentation in 2008 showed an enlarged and edematous auricle encircled by an indurated erythematous plaque.", "B, Biopsy specimen showed superficial and deep diffuse granulomatous dermatitis (hematoxylin-eosin).", "C, Higher magnification demonstrated classic tuberculoid granuloma with histiocytes and Langhans giant cells surrounded by lymphoplasmacytic infiltrate (hematoxylin-eosin).Results of routine laboratory investigations, including complete blood cell count, biochemical profile, liver function tests, and chest radiography, were normal.", "An intradermal Mantoux test induced a 20-mm induration.", "Histopathologic evaluation of the cutaneous lesion revealed noncaseating granulomatous dermatitis involving the dermis (Figure 1B).", "High magnification demonstrated tuberculoid dermal granulomas composed of histiocytes and Langhans giant cells surrounded by lymphoplasmacytic infiltrate (Figure 1C).", "Results of polarized light examination and periodic acid\u2013Schiff, Ziehl-Neelsen, Giemsa, Gram, and Grocott methenamine silver stains were negative for microorganisms."], "Others": ["Image resolution was digitally enhanced."]}
{"Patient Personal Background": ["She had no specific medical or family history and had no treatment."], "Patient Symptoms": ["A resting electrocardiogram (ECG) while symptomatic showed a wide QRS complex rhythm at a rate of 81 beats per minute (Figure 1A)."], "Examination and Results": ["A resting electrocardiogram (ECG) while symptomatic showed a wide QRS complex rhythm at a rate of 81 beats per minute (Figure 1A).", "After a short walk, symptoms disappeared and another ECG was recorded (Figure 1B).", "Physical examination and transthoracic echocardiography results were normal.Twelve-lead electrocardiogram at rest during symptoms (A) and after walk test with symptoms resolution (B)."]}
{"Patient Personal Background": ["She had sustained a left radius fracture 6 months prior, which resulted in deconditioning and poor appetite.", "Past medical history included chronic nondeforming rheumatoid arthritis, hypothyroidism, and colon adenocarcinoma resected 10 years prior.", "Her medications were prednisolone (1 mg/d) and levothyroxine.On examination, she was afebrile, with blood pressure 90/46 mm Hg; pulse, 90/min and regular; and respirations, 18/min."], "Patient Symptoms": ["Her diet consisted of mostly vegetables, and she lost 4 kg (8.8 lb) during this time.", "Two months prior, she developed postprandial nonbloody diarrhea that occurred 5 times daily.", "Two weeks prior, a pruritic rash in her extremities emerged.", "She had no fever, night sweats, or abdominal pain.", "Glossitis and a scaly pruritic rash with an erythematous brawny peeling base on her neck and extremities were noted (Figure)."], "Examination and Results": ["Body mass index was 16.8 (calculated as weight in kilograms divided by height in meters squared).", "She was alert, cognitively intact, and appeared emaciated.", "Findings on cardiovascular, pulmonary, abdominal, and neurologic examinations were unremarkable.Left, Dorsum of the hands, exhibiting symmetric scaly eruption.", "Right, Bilateral lower extremities showing ruptured bullae on an erythematous brawny peeling base.Laboratory studies showed mild hyponatremia (132 mmol/L) and an otherwise normal basic metabolic panel.", "Other laboratory values were as follows: C-reactive protein, 0.58 mg/dL; erythrocyte sedimentation rate, 23 mm/h; total protein, 4.8 g/dL; and albumin, 1.8 g/dL.", "Her white blood cell count was 7200/\u03bcL (66.5% neutrophils, 30.4% lymphocytes); hemoglobin level, 9.9 g/dL; mean corpuscular volume, 96 fL; and platelet count, 332\u202f000/\u03bcL.", "Results of liver function tests, coagulation tests, urinalysis, thyroid function tests, measurement of serum vitamin B12 and folic acid levels, and cosyntropin stimulation tests were normal.", "Serum copper level was 46 \u03bcg (reference range, 66-130 \u03bcg) and zinc level was 23 \u03bcg (reference, \u226580 \u03bcg).", "Abdominal computed tomography revealed no abnormalities."]}
{"Patient Personal Background": ["He denied contact lens use."], "Patient Symptoms": ["Six days prior, he had presented with an inferior stromal infiltrate with an overlying epithelial defect, diffuse corneal edema, and a small hypopyon with no hemorrhage in the anterior chamber (Figure 1A).", "He also had patchy iris hemorrhages with no transillumination defects and areas of conjunctival ulceration nasally and temporally.", "While evaluating the new defect, the patient was also noted to have dull conjunctival reflexes and bulbar conjunctival lesions in both eyes (Figure 1B).", "Additionally, both eyes had patchy interpalpebral results on lissamine green staining of the conjunctiva and clinically significant punctate epithelial erosions of the cornea with fluorescein staining."], "Examination and Results": ["Corneal cultures grew Streptococcus pneumonia.", "He initially responded well with improvement of the stromal infiltrate and overlying epithelial defect.", "However, on day 6 of treatment, he had a new larger epithelial defect and subepithelial bullae in an adjacent location but no infiltrate."], "Treatment": ["Treatment with hourly topical vancomycin at 14 mg/mL and tobramycin at 25 mg/mL, as well as 1000 mg of oral valacyclovir 3 times a day, was initiated."], "Diagnosis": ["Given these findings, a presumed herpes zoster sine herpete1 with secondary bacterial infection was suspected."]}
{"Patient Personal Background": ["Her medical history was significant for hypothyroidism, treated with levothyroxine, as well as 2 forms of hematologic malignancy: retroperitoneal extranodal marginal zone lymphoma and indolent-phase T-cell prolymphocytic leukemia."], "Patient Symptoms": ["She had received no treatment for her hematologic malignancies, as she had been asymptomatic since her diagnoses 6 years prior.Ophthalmological examination revealed 27 mm of bilateral proptosis, conjunctival injection, chemosis, and bilateral lower eyelid retraction (Figure 1A).1 Visual acuity, color vision, and pupillary responses were normal."], "Examination and Results": ["Extraocular motility was full in all positions of gaze, and there was no associated pain.", "Upper eyelid retraction was minimal.", "Von Graefe sign (delayed descent of the upper eyelid with initiation of downgaze) and lagophthalmos were absent.", "Results of slitlamp examination and dilated fundus examination were normal, including the appearance of both optic nerves.A, Clinical photograph at presentation; bilateral proptosis, lower eyelid retraction, chemosis, and conjunctival injection are present.", "There is mild temporal retraction of both upper eyelids.", "B, Radiographic images documenting marked enlargement of all extraocular muscles bilaterally.", "The lateral rectus is especially enlarged on both sides.", "Using a measurement technique described by Dagi and colleagues,1 the maximal diameter of each extraocular muscle in this patient was as follows: right inferior rectus, 8.0 mm; right medial rectus, 9.1 mm; right superior muscle group, 9.7 mm; right lateral rectus, 9.3 mm; left inferior rectus, 8.1 mm; left medial rectus, 9.5 mm; left superior muscle group, 10.0 mm; and left lateral rectus, 9.6 mm.", "There is sparing of anterior tendinous insertions (arrowheads) of each medial rectus (MR) and lateral rectus (LR).", "However, the anterior portion of the muscle belly (brackets) appears uninvolved compared with the posterior portion, causing an acute taper of the muscle that is similar in shape to an amphora (inset).An orbital computed tomography scan revealed marked enlargement of all extraocular muscles (Figure 1B)."]}
{"Patient Personal Background": ["Her medical history included hypertension and right-sided trigeminal neuralgia."], "Patient Symptoms": ["On examination, her visual acuity with habitual correction had decreased to 20/60 OD and 20/40 OS from 20/30 OU 2 years prior."], "Examination and Results": ["A slitlamp examination revealed normal conjunctivae, nuclear sclerosis cataracts in both eyes, and deep and quiet anterior chambers.", "On a dilated fundus examination, there was 2+ vitreous cell and floaters in both eyes and a blonde fundus in both eyes.", "Optical coherence tomography imaging confirmed cystoid macular edema (CME) in both eyes; the right eye had cystoid spaces in the inner nuclear, outer plexiform, and outer nuclear layers, and the left eye had small cystoid spaces in the inner nuclear layer (Figure, A and B).", "Fluorescein angiography showed leakage of the optic nerve in the right eye, with petaloid leakage in the macular right eye worse than in the left eye.", "A uveitis workup had unremarkable or negative results for a basic metabolic panel, a complete blood cell count with a differential, Quantiferon gold test, Lyme antibody tests, an angiotensin-converting enzyme level, a serum erythrocyte sedimentation rate, and chest radiography.", "Additionally, 4 months prior, the patient developed trigeminal neuralgia, with a magnetic resonance image with contrast of the brain revealing an enhancing mass in the right middle cranial fossa, extending into the Meckel cave and abutting the right trigeminal nerve (Figure, C).A, Optical coherence tomography (OCT) image showing the right eye had cystoid spaces in the inner nuclear, outer plexiform, and outer nuclear layers."]}
{"Patient Symptoms": ["At the time of IAC, she had an upper respiratory tract infection (coughing, congestion, rhinorrhea, fever [temperature of 38.9 \u00b0C]).", "On postoperative day 3, she returned to the emergency department with left eye swelling, continued fever, and poor oral intake.", "On physical examination, her temperature was 40.2 \u00b0C, and periorbital swelling and erythema were present without drainage."], "Examination and Results": ["Dilated fundus examination at the bedside showed the known large retinoblastoma tumor.", "A large exudative retinal detachment was noted, which was not present prior to treatment.", "Blood bacterial culture testing showed no growth, respiratory viral testing revealed rhinovirus, and results of comprehensive metabolic testing were unremarkable.", "Complete blood cell count showed mild leukopenia (2700/\u03bcL [to convert to \u00d7109 per liter, multiply by 0.001]) and anemia (hemoglobin, 9.2 g/dL [to convert to grams per liter, multiply by 10]) but were otherwise within reference ranges.", "Computed tomography scan of the orbits, recommended by the on-call general ophthalmologist, demonstrated preseptal and periorbital soft tissue swelling and edema with subtle retrobulbar stranding, without substantial proptosis, along with retinal detachment (Figure, B).", "B, Orbital computed tomography on presentation, demonstrating preseptal and periorbital soft tissue swelling and edema with subtle retrobulbar stranding along with retinal detachment (arrowheads)."], "Treatment": ["On postoperative day 1, her temperature reached 39.4 \u00b0C, and she was diagnosed as having bilateral acute otitis media and discharged with amoxicillin therapy.", "She was admitted for intravenous fluids for her noted dehydration.A, Clinical appearance of the child on presentation, showing unilateral periorbital swelling and erythema."], "Diagnosis": ["On postoperative day 1, her temperature reached 39.4 \u00b0C, and she was diagnosed as having bilateral acute otitis media and discharged with amoxicillin therapy."], "Others": ["There was no substantial proptosis or orbital masses."]}
{"Patient Personal Background": ["Previously, he had been well, with morphological remission found on a recent bone marrow biopsy.", "The patient had no significant dermatological history, except an allergy to cashew nuts and a prior episode (6 mo) of urticaria during a platelet transfusion that had resolved with 1 dose of oral antihistamine.", "The patient\u2019s medications included ondansetron, aprepitant, prednisolone, and oxycodone (supportive care initiated with chemotherapy), and long-term posaconazole and trimethoprim/sulfamethoxazole treatment.Lesions were noted on day 2 of the fourth cycle of a chemotherapy regimen comprising fludarabine, cytarabine, and filgrastim (G-CSF)."], "Patient Symptoms": ["Initially present over the distal limbs, palms, and soles, the lesions progressed to the proximal limbs and lower trunk during 24 hours (Figure, A and B).", "The patient developed a fever, which we extensively investigated."], "Examination and Results": ["C, Hematoxylin-eosin\u2013stained specimen showing leukocytoclastic neutrophilic infiltrate in deeper dermis, around appendage structures and coiled eccrine glands, and into the interstitium.The results of a complete examination of blood drawn at lesion onset demonstrated a total white cell count of 6330/\u03bcL (to convert to 109/L multiply by 0.001) with absolute neutrophil count of 6140/\u03bcL, more than the previous day\u2019s counts of 3210/\u03bcL and 1720/\u03bcL, respectively.", "The blood film demonstrated increased neutrophil granulation with a left shift."], "Treatment": ["Intravenous cefotaxime was commenced, but because no infectious source was identified, the fever was thought to be secondary to cytarabine.A and B, Clinical images showing erythematous plaques and nodules on patient\u2019s palm and forearm."], "Others": ["A punch biopsy from the upper arm was performed (Figure, C)."]}
{"Patient Symptoms": ["He reported an edema of the lower lip that resolved spontaneously the day before.", "He had no dyspnea nor dysphagia, but did have a discrete dysphonia.", "He had no fever.", "Neck swelling was global, bilateral, and painless, and was most severe on the left side.", "There was a rash, the border of which was marked with a felt pen."], "Examination and Results": ["Nasofibroscopy results showed a normal airway with a posterior pharyngeal wall bulging.", "Oropharyngeal and oral cavity examination results were normal, with no trismus.A contrast-enhanced computed tomography (CT) scan showed a large retropharyngeal fluid accumulation of 2\u2009\u00d7\u200910\u2009\u00d7\u20096 cm that extended laterally to the vascular spaces, especially on the left side (Figure, A and B).", "This was associated with infiltration of the mediastinal fat and a thin left pleural effusion.", "There was no vascular thrombosis or dental abnormality.", "Hyperleukocytosis levels were 12\u202f000/mL.", "We did not have the result of the C reactive protein assay.Cervical computed tomography scan of the sagittal (A) and axial (B) planes.", "In the sagittal plane, there is retropharyngeal fluid accumulation, and in the axial plane, there is fluid accumulation in the retropharyngeal and vascular spaces with fat infiltration."], "Others": ["The patient had no traumatic or iatrogenic triggers."]}
{"Patient Personal Background": ["His complex medical history included factor V Leiden deficiency requiring therapeutic anticoagulation, heart failure with atrial fibrillation, and chronic obstructive pulmonary disease associated with 110-pack-year smoking history."], "Patient Symptoms": ["He denied chills, fever, neck stiffness, new medications, otalgia, sick contacts, trismus, and use of an angiotensin-converting enzyme inhibitor.", "On examination, the patient had substantial dysphonia, fullness in the left submandibular region, and ecchymosis of the lateral left neck extending toward the midline."], "Examination and Results": ["Laboratory studies demonstrated an international normalized ratio of 16.4, a prothrombin time of 118.1 seconds, and a partial thromboplastin time of 81.4 seconds.", "Contrast-enhanced computed tomography performed in the emergency department revealed a large, intermediate-density, modestly enhancing, left-sided submucosal lesion extending from the nasopharynx inferiorly to the glottis with encroachment on the airway (Figure).", "Flexible fiberoptic laryngoscopy demonstrated a large submucosal mass extending from the left posteroinferior nasopharyngeal wall to the left lateral and posterior pharyngeal walls, obstructing the view of the left supraglottis, glottis, and piriform sinus.", "The right side of the epiglottis was ecchymotic and edematous.", "The mass extended farther along the aryepiglottic fold to involve the arytenoid and interarytenoid space, as well as the false vocal fold on the left.", "The vocal cords were only partially visualized."], "Treatment": ["Given the important laryngoscopy findings, the decision was made to proceed with awake fiberoptic nasotracheal intubation in the operating room to secure the patient\u2019s airway.Contrast-enhanced computed tomography of the neck in the coronal (A) and axial (B) views demonstrating a large, predominantly left-sided, obstructive, submucosal, upper airway lesion extending from the nasopharynx to the glottis."]}
{"Patient Personal Background": ["She was born after an uncomplicated pregnancy and delivery, and her growth and development were appropriate for her age."], "Patient Symptoms": ["No associated symptoms such as fever, anorexia, or weight loss were noted."], "Examination and Results": ["Physical examination revealed multiple skin-colored and erythematous follicular papules, 1 to 2 mm in diameter, distributed in a segmental pattern on the right side of the forehead, as well as the dorsum and tip of the nose.", "A small, excoriated plaque was also noted on the right malar area (Figure 1A).", "No mucosal lesions were present, and the rest of the physical examination findings were unremarkable.", "A complete hematological and biochemical survey, including blood cell count, liver and renal function tests, C-reactive protein levels, thyroid function, rheumatoid factor, and antinuclear antibodies, disclosed no abnormalities.", "Representative histopathological features are shown in Figure 1B and C.Multiple skin-colored and erythematous follicular papules are seen coalescing into a linear plaque involving the patient\u2019s forehead, as well as the dorsum and tip of the nose (A)."], "Treatment": ["Two skin punch biopsies were taken from the forehead and nose."], "Others": ["Two skin punch biopsies were taken from the forehead and nose (B and C)."]}
{"Patient Personal Background": ["The patient\u2019s medical history was significant for dermal melanocytosis of the right hip and mid back, increased head circumference (97th percentile), and expressive language delay.", "There was no family history of congenital birthmarks or neurofibromatosis type 1 or 2.Physical examination revealed a well-appearing boy with normal vital signs and Fitzpatrick type III skin type."], "Patient Symptoms": ["The child's mother reported that, on discovery, the plaque was initially 1\u2009\u00d7\u20091 cm and had since grown in size with the child.", "She was uncertain if the plaque was present at birth."], "Examination and Results": ["On the left lower back, there was a 15\u2009\u00d7\u20095-cm indurated skin-colored to yellow, firm, multinodular plaque with hypertrichosis, extending from the midline to the left lower flank (Figure, A).", "There were additional blue-gray patches on the back and right hip, as well as a small caf\u00e9 au lait macule on the right lower back.", "Limited neurologic examination was within normal limits."], "Treatment": ["A 4-mm punch biopsy was performed for further diagnostic evaluation (Figure, B-D).A, Large, well-defined, firm yellow to skin-colored multinodular hypertrichotic plaque on the left lower back."], "Others": ["B, Hematoxylin-eosin staining demonstrates diffuse dermal infiltration of spindle cells, predominantly encircling terminal folliculosebaceous units (original magnification \u00d74).", "C, Higher-power magnification highlights a mix of partially fusiform melanocytes and dendritic cells with glassy, eosinophilic cytoplasm (hematoxylin-eosin, original magnification \u00d740).", "D, Immunohistochemical staining reveals diffuse and periadnexal S100 positivity in the mid to deep dermis (original magnification \u00d74)."]}
{"Patient Personal Background": ["He denied taking any medications or recent international travel."], "Patient Symptoms": ["A few days prior to presentation, he had developed palpitations, chest discomfort, and lower-extremity swelling."], "Examination and Results": ["In the emergency department, he had a normal blood pressure with an irregular heart rate at 104 beats per minute.", "On examination, he had bilateral basilar crackles and traces of lower extremity edema.", "An electrocardiogram revealed that he was experiencing atrial flutter.", "A computed tomographic angiogram showed an acute pulmonary embolism, multiple bilateral pulmonary nodules, mediastinal lymphadenopathy, and a right atrial mass.", "He then underwent a transthoracic echocardiogram with 2-dimensional speckle-tracking strain, which revealed a 4.5\u2009\u00d7\u20093.6\u2009\u00d7\u20093.1-cm pedunculated right atrial mass attached to the interatrial septum near the fossa ovalis (Figure 1A; Video).", "Left ventricular function was noted to be reduced and cardiac mechanics by 2-dimensional speckle-tracking strain were markedly abnormal, suggesting a more diffuse myocardial process (Figure 1B).A, Transthoracic echocardiogram image with 4-chamber view visualizing the right atrial mass measuring 4.5\u2009\u00d7\u20093.6\u2009\u00d7\u20093.1 cm.", "B, Bull\u2019s-eye plot showing globally abnormal longitudinal strain of \u22122.24%."], "Others": ["EndoGLS indicates endocardial global longitudinal strain; myoGLS, myocardial global longitudinal strain."]}
{"Patient Personal Background": ["Six weeks prior, he fell from a ladder and had right nondisplaced medial malleolar and comminuted talar fractures."], "Patient Symptoms": ["Erythema without warmth was present over the right ankle and dorsomedial foot, along with nontender, nonpalpable purpura over the dorsum of the foot and scattered petechiae over the right lower leg (Figure)."], "Examination and Results": ["On current presentation, his temperature was 38.2 \u00b0C (100.8 \u00b0F); heart rate, 88/min; respiratory rate, 18/min; and blood pressure, 102/65 mm Hg.", "He was well appearing with normal cardiopulmonary and abdominal examinations.", "There was trace right lower extremity edema localized to the ankle and normal pedal pulses."], "Treatment": ["The fractures were managed nonsurgically in a controlled ankle movement boot, with resolution of swelling and bruising."]}
{"Patient Personal Background": ["Her medical history included a red blood cell transfusion as a child and 2 uncomplicated pregnancies.The lesions started as small papules on the dorsal right great toe and left third toe that gradually spread across the dorsum of her feet over the following 12 months.", "On serologic testing, the patient was negative for HIV and positive for hepatitis C virus (HCV)."], "Patient Symptoms": ["An over-the-counter antifungal ointment was unhelpful.", "The lesions did not improve, and her foot pain worsened.", "She continued to have 6 of 10, dull, constant pain that was nonradiating, improved when she soaked her feet in water, and worsened with any type of topical pressure or wrapping."], "Examination and Results": ["Physical examination revealed multiple well-circumscribed, scaly plaques with cobblestone surfaces on the dorsal aspects of the forefoot and midfoot bilaterally.", "Findings were more severe on the right and left hindfoot (Figure, left panel).", "A punch biopsy of the right foot lesion revealed psoriasiform epidermal hyperplasia, parakeratosis, eosinophils, papillary dermal inflammation, and intraepidermal necrosis (Figure, right panel).Left, Dorsal aspects of bilateral forefoot and midfoot of a 32-year-old Nigerian woman."], "Treatment": ["Her primary care physician completed a biopsy, diagnosed verruca plantaris, and prescribed topical salicylic acid twice daily for 4 weeks.", "Subsequent treatment with topical liquid nitrogen cryotherapy was ineffective.Three months after cryotherapy, the patient presented to the dermatology clinic regarding the lesions on her feet."], "Diagnosis": ["Her primary care physician completed a biopsy, diagnosed verruca plantaris, and prescribed topical salicylic acid twice daily for 4 weeks."], "Others": ["The patient stated that the lesions had been stable in size for the previous 6 months, without bleeding, discharge, or change in color."]}
{"Patient Symptoms": ["He reported forgetfulness and word-finding difficulties for 3 years but performed all activities of daily living independently and was generally healthy."], "Examination and Results": ["Physical (including neurologic) examination, basic laboratory studies, and brain magnetic resonance imaging results were normal.", "The Short Test of Mental Status (STMS) score was 33 (maximal attainable score of 38 indicates best performance).", "Neuropsychological assessment showed average to above-average performance in all cognitive domains, accounting for age and education."], "Diagnosis": ["Results of his genetic testing for APOE were reported as follows: \u201cThis individual possesses an apolipoprotein E genotype (3 and 4) that indicates, with high specificity, that Alzheimer\u2019s disease is the cause of or a contributor to the observed dementia.\u201dObtain a brain fluorodeoxyglucose positron emission tomography (FDG-PET) scan.Order cerebrospinal fluid (CSF) testing for Alzheimer disease biomarkers.Reassure and address patient\u2019s concerns and follow up in 1 year."], "Others": ["His father and maternal great aunt developed dementia in their 70s."]}
{"Patient Personal Background": ["He had emigrated from Ghana 2 years before but denied any illness there."], "Patient Symptoms": ["His visual acuity without correction was 20/20 OD and 20/20 OS, although he had to manually elevate his eyelids to see the Snellen chart.", "He had no movement of the right eye past midline in elevation, adduction, depression, and abduction and no movement of the left eye past midline in elevation, depression, and abduction, with 50% deficit of adduction."], "Examination and Results": ["His external examination results were notable for a margin reflex distance 1 of \u22124 mm OU and a levator function of 0 OU.", "On funduscopic examination, his optic nerves were sharp and pink without atrophy, maculae and retinal vasculature were normal, and peripheral retina appeared normal without pigment abnormalities."]}
{"Patient Symptoms": ["Two days later, she was admitted to the hospital for headaches and vomiting; her temperature was 40 \u00b0C, and her blood pressure and pulse were normal.", "Two days later, she developed worsened headaches and blurry vision, prompting an ophthalmology evaluation."], "Examination and Results": ["An examination was remarkable for listlessness, a thickened erythematous and nonbulging right tympanic membrane, and significant right-sided hearing loss.", "Laboratory studies showed leukocytosis and thrombocytosis.", "A computed tomography scan of the head with intravenous contrast found no abnormalities.", "She began treatment with intravenous ceftriaxone and vancomycin.", "An examination was remarkable for visual acuities of 20/20 OU, symmetric pupils without a relative afferent pupillary defect, and bilateral abduction deficits worse in the right eye.", "She had bilateral optic disc swelling with obscuration of all borders and a peripapillary halo, as well as vessel obscuration (stage 3 papilledema1) without peripapillary hemorrhages.", "Magnetic resonance imaging and venography of the head with and without intravenous contrast were performed (Figure 1).Magnetic resonance T1 images post\u2013intravenous gadolinium infusion.", "A, Coronal view of right sigmoid sinus thrombosis next to the ear.", "Empty delta sign, a triangular area of enhancement with a low-attenuating center that represents the thrombosis, is shown (arrowhead).", "B, Axial view of bilateral confluent mastoiditis (arrowheads), greater on the right."], "Treatment": ["She began treatment with oral amoxicillin.", "She began treatment with intravenous ceftriaxone and vancomycin."]}
{"Patient Personal Background": ["He had experienced painless decrease of vision in both eyes for 6 years but did not seek medical care.", "He had had hypertension for 3 years, with amlodipine taken regularly.", "A sibling developed uremia in their 30s.", "A parent died of kidney failure in their 40s."], "Patient Symptoms": ["He had experienced painless decrease of vision in both eyes for 6 years but did not seek medical care."], "Examination and Results": ["On results of an ophthalmic examination, his best-corrected visual acuity was 20/50 OD and 20/40 OS, without visual field defects, dyschromatopsia, or relative afferent pupillary defect.", "Extraocular movements were intact.", "Neurologic examination findings were unremarkable except for mild cognitive impairment.", "Fundus fluorescein angiography showed retinal vasculitis (Figure, A).", "Enhanced magnetic resonance imaging (MRI) of the brain showed diffuse white matter hyperintensities\u2014leukoencephalopathy\u2014with multiple ring-enhancing lesions (Figure, B).", "Results of routine blood tests were significant for kidney insufficiency (proteinuria, 3.47 g of protein in 24 hours; estimated glomerular filtration rate, 38.5 mL/min).", "Angiotensin-converting enzyme level and serum tumor marker findings were normal.", "Infection panel screenings for hepatitis, HIV, syphilis, tuberculosis, and parasites were negative.", "Antinuclear antibodies and antineutrophil cytoplasmic antibodies were negative.", "Whole-body positron emission tomographic/computed tomographic (PET/CT) imaging detected no hypermetabolic changes.", "The cerebrospinal fluid (CSF) profiling, including cytologic analysis, was normal.", "Culture of the CSF and blood was negative for bacteria and fungus.Representative ophthalmic and neuroimaging results.", "The arrowheads indicate perivascular fluorescein leakage and hyperfluorescence of the vessel walls; the asterisk indicates the nonperfusion area.", "B, This enhanced magnetic resonance image (MRI) shows the ring-enhancing lesions (arrowheads)."], "Others": ["No other accompanying symptoms were reported.", "A, Fundus fluorescein angiography findings in the right eye."]}
{"Patient Personal Background": ["His ocular history included cataract surgery in the left eye, followed by yttrium-aluminum-garnet capsulotomy 2 months before his referral.", "Of note, he had recently undergone Mohs surgery and subsequent reconstruction for squamous cell carcinoma in situ of the lateral canthus in the fellow eye; he also had a medical history of multiple skin malignant neoplasms.Slitlamp examination findings were notable for a grayish cornea opacity that appeared to be lusterless, abutting the nasal limbus and extending into the visual axis (Figure 1A)."], "Patient Symptoms": ["His best-corrected visual acuity was 20/40 OS, and the patient reported that his vision had waxed and waned over several months."], "Examination and Results": ["There was no apparent conjunctival erythema or appreciable feeder vessels at the limbus.", "The rest of the examination findings, including the fundus, were unremarkable.", "Anterior segment optical coherence tomography (AS-OCT) indicated that the hyperreflective corneal lesion did not involve the cornea stroma (Figure 1B).Examination findings at presentation.", "A, Slitlamp photograph of the left cornea revealing a translucent gray, lusterless lesion that extends into the visual axis."]}
{"Patient Personal Background": ["He had a distant history of actinic keratoses on the scalp treated with liquid nitrogen but otherwise denied previous skin cancer."], "Examination and Results": ["Examination of the scalp revealed male pattern baldness, diffuse actinic damage, and multiple thick, yellow-brown crusts overlying erosions with purulent drainage (Figure 1).", "A wound culture was performed and grew methicillin-sensitive Staphylococcus aureus."], "Treatment": ["Five months earlier he began treatment with cetuximab, binimetinib, and encorafenib, complicated by a grade 1 acneiform eruption that was managed with doxycycline hyclate and topical hydrocortisone and clindamycin phosphate."], "Others": ["Oncologic therapy was withheld pending further evaluation of the scalp eruption.", "A shave biopsy was obtained."]}
{"Patient Personal Background": ["She had a history of a laryngeal tracheoesophageal fissure, intestinal hernia, and hearing loss because of an ossicular malformation."], "Patient Symptoms": ["From age 10 years, she was unable to catch up with conversation of curry smell."], "Examination and Results": ["Olfactory tests were performed, and T&T olfactometry1 results showed severe hyposmia (5.4/5.4; detection threshold/odor recognition threshold).", "On the card-type odor identification test, Open Essence,2 she only identified menthol correctly.", "Her Self-Administered Odor Questionnaire3 score was 20%.", "Her visual analog scale4 score was 10 for odor but 100 for taste.", "There were no unusual nasal findings on endoscopy or computed tomography.", "Because we suspected a congenital olfactory disorder, we recommended magnetic resonance imaging (MRI), which showed olfactory bulb (OB) atrophy (Figure, A).A, Coronal short-tau inversion recovery magnetic resonance imaging (MRI) of the olfactory bulb shows that the olfactory fissure remains aerated, but the olfactory bulb is slightly atrophied on both sides (arrowheads).", "There were no dysplastic signs in the frontal gyri.", "B and C, An axial MRI T2-weighted image of the pelvis shows vaginal defects and bilateral 1 layer\u2013differentiated uterine rudiments (arrowheads) that were 35 mm on the left and 37 mm on the right.", "Both ovaries are normal (equivalent to Mullerian duct anomaly class I).The patient also confirmed that she had not started menstruating.", "The results showed an atypical reaction to the insulin tolerance test.", "However, the results for adrenocorticotropic hormone/cortisol corticotropin-releasing hormone load test, diurnal variation, and urine accumulation were normal.", "The luteinizing hormone (LH)/follicle-stimulating hormone (FSH) values were normal as determined by LH-releasing hormone load tests."], "Others": ["After consulting the pediatric department, an endocrine test was performed.", "She was subsequently referred to the gynecology department."]}
{"Patient Personal Background": ["Her last dose of ipilimumab was 2 months prior, and she was scheduled to receive pembrolizumab with doxorubicin, carboplatin, and prednisone for treatment of her underlying malignant tumor."], "Patient Symptoms": ["The rash started as an erythematous papule on her right arm 2 months after initiation of a new immunotherapy regimen, then gradually enlarged and spread to involve both legs (Figure, A and B).", "She denied any new systemic symptoms associated with onset of the rash.", "She returned to the clinic 3 weeks later with resolution of pruritus but enlarging lesions."], "Examination and Results": ["Physical examination revealed erythematous annular plaques without scale on her right arm and bilateral legs.", "C, Hematoxylin and eosin stain demonstrating superficial and deep perivascular and interstitial inflammation.", "D, Hematoxylin and eosin stain demonstrating numerous scattered eosinophils."], "Treatment": ["A 4-mm punch biopsy was obtained from the patient\u2019s right arm (Figure, C and D), and she was prescribed fluocinonide, 0.05%, ointment.", "For management of her rash, the patient was prescribed betamethasone dipropionate, 0.05%, ointment (augmented).A, Erythematous annular plaques without scale on the left lower leg."], "Others": ["A recent trial of oral terbinafine for possible tinea corporis yielded no improvement.", "B, Erythematous annular plaques without scale on the right lower leg."]}
{"Patient Symptoms": ["The division of dermatology was consulted for evaluation of lesions on the face, chest, back, and arms that were gradually increasing in size and number over the past year.", "Physical examination revealed leonine facies with madarosis and an eschar on the nasal dorsum (Figure, A).", "The lesions were nontender and nonpruritic.", "The patient had a muffled voice and reported shortness of breath with exertion."], "Examination and Results": ["Red-to-brown dome-shaped papules coalescing into plaques were present on the upper extremities.", "Cervical and axillary lymph nodes were palpable.", "Results of laboratory investigation demonstrated marked leukocytosis with a white blood cell count of 77.5\u2009\u00d7\u2009103/uL with 76.5% lymphocytes.", "No blasts were present on peripheral smear.", "Computed tomography of the chest, abdomen, and pelvis demonstrated multiple enlarged mediastinal, axillary, subpectoral, abdominopelvic, and inguinal lymph nodes.", "Small pulmonary nodules were also detected.", "A punch biopsy was obtained from the right arm (Figure, B, C, and D).A, Infiltrative plaques and nodules obscuring normal facial architecture.", "B and C, Histopathologic images show normal epidermis with dense diffuse dermal lymphoid infiltrate composed of small to medium cells with irregular nuclear contours (hematoxylin-eosin stain).", "D, Immunohistochemistry shows diffusely positive cyclin D1 staining."]}
{"Examination and Results": ["Emergency department evaluation noted a heart rate of 64 beats per minute, blood pressure of 173/90 mm Hg, and a temperature of 37.1 \u00b0C.", "An electrocardiogram showed a sinus rhythm with complete heart block (CHB) and a narrow QRS junctional escape at 65 beats per minute (Figure, A).", "Investigation revealed an erythrocyte sedimentation rate of 30 mm/h (normal limits, 0-15 mm/h) and a C-reactive protein level of 6.3 mg/dL (reference range, 0.0-1.0 mg/dL [to convert to milligrams per liter, multiply by 10.0]).", "Tests for kidney function, hepatic function, a complete blood cell count, troponin T levels, creatine kinase levels, thyrotropin levels, antinuclear antibodies, and rheumatoid factor had normal results, and tests for anti\u2013streptolysin O and anti\u2013DNAse B titers, Lyme IgG and IgM titers, Coxiella burnetti and Bartonella serologies, Epstein-Barr virus serology, and cytomegalovirus quantification had negative results.", "A transthoracic echocardiogram showed no structural abnormalities, while fluorine 18\u2013labeledfluorodeoxyglucose positron emission tomography with computed tomography (FDG-PET\u2013CT) showed a small focal area of FDG uptake in the region of the membranous septum (Figure, B).", "Systemic FDG uptake was absent.", "A CT showed no hilar adenopathy or pulmonary parenchymal abnormalities.", "Over the next 48 hours, the patient\u2019s junctional rhythm accelerated to 90 beats per minute with ventriculoatrial block before acutely degenerating to a narrow complex escape rhythm of 45 beats per minutes associated with lightheadedness (Figure, C).A, A rhythm strip at presentation with a sinus rhythm with complete heart block."]}
{"Patient Personal Background": ["She was born in 1973 at 38th week of gestation followed by a normal delivery (weight, 3.15 kg and head circumference, 42 cm) to nonconsanguineous parents.", "The head size was normal at birth, and no other abnormalities were seen during her infancy.", "At age 2 years, her parents noticed that she had delayed motor and language milestones.", "She experienced a progressive developmental delay such as reduction of head growth, loss of acquired communication, and loss of motor functions between ages 9 and 12 years.", "She was referred to us at age 40 years with the characteristic features of growth deceleration (height, 142 cm; weight, 22 kg; body mass index, 11 [calculated as weight in kilograms divided by height in meters squared]), apraxia, left-sided hemiplegia, spasticity, sleep apnea, constipation, osteoporosis, hypoalgesia, and repetitive hand tapping (Video).", "The electrocardiogram showed sinus rhythm with T wave inversion (V3-V6), and echocardiography showed mild cardiomegaly."], "Patient Symptoms": ["She experienced a progressive developmental delay such as reduction of head growth, loss of acquired communication, and loss of motor functions between ages 9 and 12 years.", "She was referred to us at age 40 years with the characteristic features of growth deceleration (height, 142 cm; weight, 22 kg; body mass index, 11 [calculated as weight in kilograms divided by height in meters squared]), apraxia, left-sided hemiplegia, spasticity, sleep apnea, constipation, osteoporosis, hypoalgesia, and repetitive hand tapping (Video)."], "Examination and Results": ["Blood reports showed anemia (hemoglobin level of 9.1 g/dL; to convert to grams per liter, multiply by 10) and low levels of high-density lipoprotein cholesterol (47 mg/dL; to convert to millimoles per liter, multiply by 0.0259).", "The electrocardiogram showed sinus rhythm with T wave inversion (V3-V6), and echocardiography showed mild cardiomegaly.", "The brain magnetic resonance imaging studies showed a diffuse reduction in the corpus callosum involving splenium and enlarged right ventricle, resulting in cerebral lateral ventricular asymmetry (Figure, C).A, Characteristic features of a 42-year-old woman with microcephaly."], "Others": ["The severity of scoliosis increased with age, and she became a wheelchair user at age 18 years.", "There was no history of autistic behavior, vision or hearing impairments, or epilepsy.", "B, Severe scoliosis.", "C, Magnetic resonance imaging of the patient with reduced volume of corpus callosum (arrowhead), sagittal view."]}
{"Patient Personal Background": ["His medical history was notable for atopic dermatitis and diarrhea in infancy that prompted allergy testing at age 6 months; he was subsequently diagnosed with milk, egg, and peanut allergies.", "His parents avoided feeding him these foods, providing him only soy-based milk and formula, with improvement of dermatitis, until age 1 year.", "Since then his diet had consisted of multiple rice milk feeds daily, supplemented only with pureed fruits and vegetables, pasta, snack puffs, and sunflower butter.", "The patient had no history of meconium ileus or family history of cystic fibrosis."], "Patient Symptoms": ["Following an upper respiratory tract infection 1 month prior, he developed disseminated red, scaly patches and a progressive eruption of hyperpigmented and hypopigmented patches of skin.", "He had occasional nonbloody loose stools but no fevers or vomiting.", "Although he was otherwise well, his growth had fallen from the 75th to the 25th percentile for height and weight over the preceding 9 months, and he could speak only 2 words."], "Examination and Results": ["There was no recent travel and no changes to the home environment.On presentation, the patient was irritable, with normal vital signs.", "He displayed prominent scrotal swelling and pitting edema of the legs bilaterally.", "Skin examination was notable for erythematous, denuded patches with peeling scale and reticulate hyperpigmentation, accentuated on the abdomen, back, diaper area, and extensor extremities (Figure; left panel).", "Notably, his skin also demonstrated widespread patches of hypopigmentation, with an accompanying band of hypopigmentation proximally at the site of newest hair growth (Figure; right panel).Physical examination findings at presentation."], "Others": ["Left, Right abdomen, back, buttock, and thigh."]}
{"Examination and Results": ["In the emergency department, the patient\u2019s temperature was 36.7 \u00b0C (98.1 \u00b0F); blood pressure, 121/82 mm Hg; pulse, 74/min; respiratory rate, 15/min; and oxygen saturation, 99% on room air.", "Physical examination revealed petechiae within a poorly demarcated erythematous patch on the left dorsal foot (Figure 1, left panel), splinter hemorrhages on the right thumbnail (Figure 1, center panel), and petechial macules on the palms and soles, most numerous on the distal digits.", "There was no murmur or plop on cardiac auscultation.", "Neurologic examination findings were significant for left eye nystagmus and inability to adduct the right eye on left gaze, consistent with right-sided internuclear ophthalmoplegia.", "A computed tomography (CT) scan of the head showed 2 acute infarcts in the right cerebellum.", "Results of laboratory testing were notable for mild leukocytosis (12.2\u2009\u00d7\u2009109/L), mild thrombocytosis (439\u2009\u00d7\u2009109/L), and elevated troponin level (4.4 ng/mL); results of a comprehensive metabolic panel and the remainder of the complete blood cell count were normal.", "An electrocardiogram showed T-wave inversions in lead V2, consistent with a non\u2013ST-segment elevation myocardial infarction."], "Others": ["Transthoracic echocardiogram and cardiac CT angiography (Figure 1, right panel) were performed.Findings at presentation.", "Left, Left dorsal foot.", "Center, Right thumbnail.", "Right, Computed tomography angiography of the heart.", "LA indicates left atrium; LV, left ventricle; RA, right atrium; RV, right ventricle."]}
{"Examination and Results": ["Multiple prior office visits with referring ophthalmologists during which eyes were dilated showed normal results.", "Clinical examination revealed 180\u00b0 of left interior subconjunctival hemorrhage with overlying conjunctival elevation and mild fullness of the left lower eyelid (Figure 1A).", "Fixation was central, steady, and maintained bilaterally, with full ocular motility and absence of appreciable proptosis.", "Penlight anterior segment examination demonstrated normally formed anterior segment structures without inflammation or hyphema in either eye, although the left eye exhibited a small intraocular lightly pigmented lesion at the 5-o'clock limbus.", "Examination under anesthesia (EUA) was deemed appropriate and further demonstrated normal intraocular pressures bilaterally.", "Handheld slitlamp examination localized the left eye 2-mm limbal lesion on the posterior corneal surface.", "The surrounding corneal and iris structures were normal appearing without evidence of vascularization.", "Ultrasound biomicroscopy was used to further evaluate both the intraocular lesion and better characterize the left lower eyelid fullness.", "This demonstrated no iris, angle, or ciliary body involvement by the intraocular lesion.", "A 10-MHz contact B-scan examination showed a large inferior orbital lesion measuring more than 17 mm in the anterior-to-posterior dimension (Figure 1B)."]}
{"Patient Personal Background": ["The patient had no history of frequent sinusitis, trauma, or exposure to chemicals, but he did note poor dentition.On examination, visual acuity was 20/25 OD and 20/20 OS."], "Patient Symptoms": ["Worsening edema prompted his primary care physician to initiate a course of oral methylprednisolone and amoxicillin-clavulanic acid, which did not alleviate the symptoms.", "Because of persistent swelling, he was referred for further evaluation.", "The patient denied fevers, chills, purulent drainage, otalgia, or odynophagia."], "Examination and Results": ["Pupils were reactive, extraocular motility was full, and intraocular pressure was 19 mm Hg OD and 16 mm Hg OS.", "Exophthalmometer readings were 21 mm OD and 18 mm OS with a base of 120 mm.", "Inspection of the right upper eyelid was remarkable for a 2.2-cm fluctuant mass with surrounding erythema that was tender to palpation.", "Computed tomography (CT) of the face and head demonstrated a right supraorbital abscess with mass effect resulting in right hypoglobus, multiple communicating channels through inner and outer tables with cortical breakthrough in the frontal sinus, and advanced dental caries that communicated directly with the maxillary sinus owing to cortex erosion (Figure).Coronal sections of a computed tomographic image of the orbits with intravenous contrast.", "There is a 2.2-cm right supraorbital abscess with mass effect on the right globe leading to a hypoglobus (arrowhead).", "The abscess has a direct communication with the right frontal sinus.", "One of the channels that directly communicates with the right supraorbital abscess shows adjacent cortical breakthrough."], "Treatment": ["Worsening edema prompted his primary care physician to initiate a course of oral methylprednisolone and amoxicillin-clavulanic acid, which did not alleviate the symptoms."]}
{"Patient Symptoms": ["Otherwise, her condition was managed conservatively for presumed viral conjunctivitis.She self-presented 6 days later with intermittent visual blurring, mild eyelid swelling, and conjunctival chemosis."], "Examination and Results": ["The intraocular pressure (IOP) was raised (26 mm Hg) and was treated with a topical \u03b2-blocker.", "The IOP remained raised (24 mm Hg).", "An inflammatory or allergic etiology was suspected; therefore, topical corticosteroids and a prostaglandin analogue were also prescribed.One week later at planned follow-up, the patient had dilated and tortuous bulbar blood vessels (Figure 1)."], "Treatment": ["The intraocular pressure (IOP) was raised (26 mm Hg) and was treated with a topical \u03b2-blocker.", "An inflammatory or allergic etiology was suspected; therefore, topical corticosteroids and a prostaglandin analogue were also prescribed.One week later at planned follow-up, the patient had dilated and tortuous bulbar blood vessels (Figure 1)."], "Diagnosis": ["Otherwise, her condition was managed conservatively for presumed viral conjunctivitis.She self-presented 6 days later with intermittent visual blurring, mild eyelid swelling, and conjunctival chemosis."]}
{"Patient Personal Background": ["She had an unremarkable ocular and medical history."], "Patient Symptoms": ["She had no associated fever, chills, upper respiratory tract symptoms, lethargy, or changes in behavior.", "External examination revealed mild left-sided ptosis, axial proptosis, and upper eyelid fullness with no mass or tenderness to palpation (Figure, A)."], "Examination and Results": ["On examination, visual acuity was fix-and-follow in each eye.", "Both eyes were soft to palpation.", "Pupils were round, symmetric, and reactive to light without an afferent pupillary defect.", "Ocular movements were full, and the patient had grossly full visual fields to confrontation.", "Slitlamp and fundus examination results were unremarkable, and there was no left optic nerve edema or pallor.", "Magnetic resonance imaging (MRI) of the orbits revealed a left intraconal mass that was isointense relative to rectus muscles on T1-weighted images and hypointense with a hyperintense rim on T2-weighted images (Figure, B).A, Clinical photograph showing left upper eyelid fullness (arrowhead) and mild axial proptosis.", "B, Axial T2-weighted magnetic resonance image (MRI) of orbits with contrast showing a left intraconal hypointense mass with a hyperintense rim and peripheral enhancement (arrowhead) exerting mass effect on the intraconal contents."]}
{"Patient Personal Background": ["Her medical history was remarkable for congestive heart failure and schizophrenia."], "Patient Symptoms": ["The patient reported symptoms of joint and musculoskeletal pain and fatigue but denied fever, sore throat, abdominal pain, and kidney stones."], "Examination and Results": ["Neck examination revealed no meaningful findings except right thyroid enlargement.", "Results of laboratory evaluation demonstrated normal white blood cell count, borderline hypercalcemia (10.6 mg/dL), and elevated parathyroid hormone level (208 pg/mL).", "She underwent ultrasonography at an outside facility, and results demonstrated a 2.2-cm dominant right thyroid nodule with additional smaller thyroid nodules.", "Findings of preoperative technetium-99m (Tc-99m) sestamibi planar and single-photon emission computed tomographic/computed tomographic (SPECT/CT) imaging (Figure, A) were nonlocalizing for a parathyroid adenoma and showed increased uptake in the dominant right thyroid nodule (Figure, B).", "Results of an ultrasound-guided biopsy of the thyroid nodule demonstrated a benign colloid nodule with cystic changes.", "Computed tomography with intravenous contrast was obtained, and findings were initially reported as negative except for right multinodular goiter.", "However, on additional review, a well-circumscribed fat density mass measuring 3.0\u2009\u00d7\u20092.3\u2009\u00d7\u20091.1-cm was identified in the right retropharyngeal space posterior to the hypopharynx (Figure, C).A, Results of single-photon emission computed tomography/computed tomography (SPECT/CT) demonstrated relatively low radiopharmaceutical uptake superior to the expected area of the parathyroid glands.", "B, Findings of technetium-99m sestamibi SPECT/CT demonstrated increased radiopharmaceutical uptake in the previously identified dominant right inferior thyroid nodule (white arrowhead).", "C, A CT neck scan with contrast showing a mass in the right retropharyngeal space with complex internal areas of increased attenuation (red circle)."]}
{"Patient Personal Background": ["The patient\u2019s history was notable for an 8-year history of right maxillary first premolar impaction."], "Patient Symptoms": ["The patient denied any drainage from the site but reported worsening swelling and pain over the past several weeks."], "Examination and Results": ["On physical examination, there was noted intraoral swelling involving the buccal and palatal aspects of the posterior maxilla.", "The lesion was soft and fluctuant with no appreciable drainage.", "Findings from computed tomography of the head demonstrated a relatively spherical 4-cm growth of the right anterior maxilla abutting the maxillary sinus and orbital floors, and enclosing an impacted premolar at the superior margin of the growth (Figure, A).", "There was no proptosis or visual field changes associated with the lesion.", "An incisional biopsy was performed via an intraoral approach, and results demonstrated a thickly encapsulated proliferation of odontogenic epithelial cells with pseudoglandular elements (Figure, B and C).", "Following diagnostic confirmation, the patient was taken to the operating room, and a midface (Weber-Ferguson) incision was used to access the maxillary lesion for complete removal.A, Sagittal computed tomography (CT) of the head and neck demonstrating an expansile, 5.0-cm mass enclosing an impacted first maxillary premolar (white arrowhead).", "B, Neoplastic proliferation of swirls and anastomosing cords of odontogenic epithelium with formation of psuedoglandular structures (black arrowheads; hematoxylin-eosin).", "C, High-powered view of ductlike structures (black arrowhead; hematoxylin-eosin)."], "Treatment": ["Following diagnostic confirmation, the patient was taken to the operating room, and a midface (Weber-Ferguson) incision was used to access the maxillary lesion for complete removal.A, Sagittal computed tomography (CT) of the head and neck demonstrating an expansile, 5.0-cm mass enclosing an impacted first maxillary premolar (white arrowhead)."]}
{"Patient Symptoms": ["Two weeks after treatment initiation, multiple tender nodules developed over the palms and interphalangeal joints, and flexion contractures continued (Figure, A)."], "Examination and Results": ["Results of autoimmune serology, including antinuclear antibody, C3 and C4, rheumatoid factor, and Scl-70 antibody tests, were negative.", "Raynaud phenomenon was not seen.", "There was an absence of nailfold capillary changes and distal digital pitting.The patient was treated with nonsteroidal anti-inflammatory drugs, systemic steroid therapy, and disease-modifying antirheumatic drugs (ie, hydroxychloroquine), but symptoms persisted.", "Results of the CT demonstrated bilateral ovarian tumors with highly suspect peritoneal metastases.A, Clinical image of erythematous and edematous changes of bilateral hands and multiple nodules on palms and interphalangeal joints.", "B and C, Hematoxylin-eosin\u2013stained specimen showing increased fibroblasts with fibrosis from dermis to subcutis."], "Treatment": ["There was an absence of nailfold capillary changes and distal digital pitting.The patient was treated with nonsteroidal anti-inflammatory drugs, systemic steroid therapy, and disease-modifying antirheumatic drugs (ie, hydroxychloroquine), but symptoms persisted."]}
{"Patient Personal Background": ["The patient described the spontaneous onset of the lesion and reported no previous history of trauma or any other systemic symptoms; he had previously applied a topical antifungal cream but observed no lesion improvement."], "Patient Symptoms": ["The patient described the spontaneous onset of the lesion and reported no previous history of trauma or any other systemic symptoms; he had previously applied a topical antifungal cream but observed no lesion improvement."], "Examination and Results": ["Physical examination revealed a nonindurated and well-defined 10\u2009\u00d7\u20098-cm reddish-brown annular plaque with peripheral ecchymosis.", "No local lymphadenopathy was observed.", "Two biopsy specimens were obtained from different areas of the lesion for immunohistochemical studies; vascular channel endothelial cells were positive for CD31, CD34, and D2-40 and negative for human herpesvirus 8 (HHV-8) (latent nuclear antigen) and Wilms tumor 1 (WT1).", "Serologic tests for HIV and hepatitis B and C were negative.Clinical image of the left axilla showing an asymptomatic, reddish hematomalike plaque with a brownish peripheral border."]}
{"Patient Personal Background": ["Four years ago while pregnant, she had recurrent endocarditis complicated by severe symptomatic mitral regurgitation, but she was successfully brought to term and had a cesarean delivery.", "Post partum, her symptoms resolved, but she had persistent marked mitral regurgitation related to a severely deformed posterior leaflet.", "She wished to have another child, and after extensive counseling she elected to undergo a complex redo MV repair (annuloplasty) 2 years ago.", "She developed perioperative atrial fibrillation but declined anticoagulation and has not had further arrhythmias."], "Patient Symptoms": ["She had mild exertional dyspnea, a right ventricular (RV) heave, and elevated jugular venous pulsation."], "Examination and Results": ["Serial transthoracic echocardiograms have demonstrated normal biventricular function and pulmonary pressures.", "Her postoperative MV gradient was 10 mm Hg (heart rate, 90 beats per minute [bpm]) and has been stably elevated since surgery.At presentation, the patient was 19 weeks pregnant at presentation.", "Transthoracic echocardiogram demonstrated normal biventricular function, mild RV dilation, RV systolic pressure of 84 mm Hg, normal left atrial size, and mean MV gradient of 18 mm Hg at a heart rate of 97 bpm.", "Transesophageal echocardiogram revealed mean MV gradient of 21 mm Hg at a heart rate of 100 bpm (Figure).", "She strongly desired this pregnancy and declined termination.A, Color wave doppler demonstrating a mean mitral valve gradient of 21 mm Hg at a heart rate of 100 beats per minute.", "B, Three-dimensional mitral valve area (1.22 cm2) as measured by planimetry."]}
{"Patient Symptoms": ["Initially, she experienced fever and sore throat.", "The mother reported that the patient lost 3.2 kg in 2 months, without any chills or night sweats, difficulty swallowing or breathing, change in voice, abdominal pain, recent travel, or exposure to animals or pets.Magnetic resonance imaging (MRI) demonstrated extensive unilateral right-sided neck adenopathy, the largest nodes measuring approximately 4 cm at level IB; an approximately 2-cm destructive mass involving the left maxillary malar eminence; and additional lesions involving the T4 vertebra and upper sternum (Figure, A and B)."], "Examination and Results": ["Physical examination findings demonstrated minimally tender and nonmobile 4-cm right submandibular space swelling.", "Laboratory examination findings were significant for leukocytosis with neutrophilia (white blood cell count, 19.8 K/\u03bcL; neutrophil count, 18.2 K/\u03bcL [to convert to \u00d7109/L, multiply by 0.001]), anemia (hemoglobin level, 9.6 g/dL [to convert to g/L, multiply by 10.0]), elevated erythrocyte sedimentation rate (>130 mm/h), and elevated C-reactive protein level (3.1 mg/dL [to convert to mg/L, multiply by 10]).", "Ultrasonography revealed multiple enlarged hyperemic lymph nodes within the right side of the neck, the largest measuring 3.4\u2009\u00d7\u20092.4\u2009\u00d7\u20092.1 cm in the submandibular space.", "Ultrasonography at 1-month follow-up revealed interval enlargement of the lymph nodes, which appeared rounded in shape, without preservation of internal architecture.", "Fluorodeoxyglucose 18F-labeled positron emission tomography with computed tomography (FDG PET/CT) demonstrated extensive FDG-avid right-sided cervical lymphadenopathy and innumerable FDG-avid lytic foci involving the axial and appendicular skeleton (Figure, C).A, Postcontrast T1-weighted fat-suppressed magnetic resonance imaging (MRI) of the brain demonstrated an approximately 2-cm destructive mass involving the left malar eminence of maxilla with homogeneous enhancement.", "B, Axial T2-weighted fat-suppressed MRI through the neck demonstrated unilateral right-sided neck adenopathy.", "C, Fluorodeoxyglucose F18-labeled positron emission tomography whole-body imaging demonstrated avid right cervical lymphadenopathy and innumerable avid foci involving the axial and appendicular skeleton."], "Treatment": ["She was treated with oral antibiotics without improvement."]}
{"Patient Symptoms": ["The ceritinib was then shifted to crizotinib, 500 mg/day, when the reimbursement of crizotinib as a first-line therapy was approved by Taiwan's National Health Insurance system.Three weeks after the first dose of crizotinib, the patient developed a dry cough without fever or purulent sputum.", "There was no significant finding on physical examination except mild crackles over the right lung field, although chest radiography results showed a new consolidation lesion over the right upper lobe."], "Examination and Results": ["A chest computed tomography (CT) scan showed a right upper lobe lung mass with multiple lymphadenopathies (N3), and bone scan and brain magnetic resonance imaging results showed multiple metastatic foci.", "There was no significant finding on physical examination except mild crackles over the right lung field, although chest radiography results showed a new consolidation lesion over the right upper lobe.", "Meanwhile, the results of mycobacterial and bacteriologic surveys were unremarkable.", "The tumor marker carcinoembryonic antigen level decreased from an initial 14.76 to 0.71 ng/mL (reference range, 0-5.00 ng/mL [to convert to micrograms per liter, multiply by 1]).", "A CT scan was arranged, and developing lung cancer with lymphangitic carcinomatosis was highly suspected by the radiologist (Figure, A).", "A bronchoscopy with bronchial brushing and biopsy was performed, and no pathogen was identified.A, The comparison of the chest computed tomographic (CT) scan of the new consolidation lesion (red arrowheads) mimicking recurrence (right panel) with the primary tumor (yellow arrowhead) in the initial CT scan (left panel).", "Granulomatous inflammation or sarcoid-like reaction with predominant T-cell infiltration (hematoxylin and eosin stain, magnification \u00d7200) and less B cell infiltration."], "Treatment": ["The patient received ceritinib, 450 mg/day, and his tumor and brain and bone metastatic lesions subsequently decreased in size.", "The ceritinib was then shifted to crizotinib, 500 mg/day, when the reimbursement of crizotinib as a first-line therapy was approved by Taiwan's National Health Insurance system.Three weeks after the first dose of crizotinib, the patient developed a dry cough without fever or purulent sputum.", "B, Microscopic findings of a CT-guided biopsy (left panel) and CT scan after resuming ceritinib treatment (right panel)."], "Diagnosis": ["A chest computed tomography (CT) scan showed a right upper lobe lung mass with multiple lymphadenopathies (N3), and bone scan and brain magnetic resonance imaging results showed multiple metastatic foci.", "A biopsy was performed, and the pathologic report showed a poorly differentiated lung adenocarcinoma with ROS1 rearrangement identified by immunohistochemical staining (clone: D4D6; H-score: 280) and further confirmative fluorescence in situ hybridization.", "A CT scan was arranged, and developing lung cancer with lymphangitic carcinomatosis was highly suspected by the radiologist (Figure, A)."], "Others": ["A bronchoscopy with bronchial brushing and biopsy was performed, and no pathogen was identified.A, The comparison of the chest computed tomographic (CT) scan of the new consolidation lesion (red arrowheads) mimicking recurrence (right panel) with the primary tumor (yellow arrowhead) in the initial CT scan (left panel).", "Inset: double immunohistochemical staining showing abundant T cells (CD3, red staining; red arrowheads) and rare B cell infiltration (CD20, brown staining; yellow arrowhead)."]}
{"Patient Personal Background": ["His prenatal course was complicated by maternal drug use, hepatitis C, and lack of routine prenatal care."], "Patient Symptoms": ["At the age of 5 weeks, a swollen right eye with a foggy cornea and conjunctival vascular anomaly were noted.", "A soft, mobile, right parotid mass had doubled in size.Ocular B-scan ultrasonography revealed a large subretinal lesion with multiple intralesional, hyperechoic foci extending temporally from the optic disc to the periphery."], "Examination and Results": ["Intraocular pressure of the right eye was elevated to 31 mm Hg (normal pressure, <20 mm Hg).", "Parotid ultrasonography demonstrated a lobulated solid vascular mass measuring 2.1 cm.", "Results of magnetic resonance imaging (MRI) showed an intraocular mass in the right eye, with faint contrast enhancement thought to represent intratumoral calcification or hemorrhage, and a well-circumscribed, 3.1-cm, right superficial parotid mass with faint enhancement (Figure 1).", "18F-fludeoxyglucose\u2013positron emission tomography (FDG-PET) showed hypermetabolic masses at the posterior aspect of the right globe, the lateral aspect of the orbit, and the right parotid gland.", "Computed tomography of the chest, abdomen, and pelvis provided no evidence of distant metastasis.", "Cerebral spinal fluid analysis and examination of a bone marrow biopsy specimen showed no suspicious findings.", "A pathological specimen from the parotid gland featured small blue cells with a fine chromatin granular pattern and complete loss of integrase interactor 1 (INI-1).Axial magnetic resonance image showing a right orbital mass (arrowhead) with faint contrast enhancement."], "Others": ["The infant was referred to the ophthalmology and otolaryngology service."]}
{"Patient Personal Background": ["Medications included liraglutide, metformin, apixaban, sotalol, metoprolol, levothyroxine, venlafaxine, lisinopril, ranitidine, and magnesium oxide (400 mg, 2 times/d)."], "Examination and Results": ["Her blood pressure was 148/68 mm Hg, heart rate 96/min, and weight 106.4 kg.", "Her prior serum magnesium levels ranged from 1.4 mg/dL to 1.6 mg/dL and a recent hemoglobin A1c level was 10.8%."], "Treatment": ["Following baseline blood testing (Table), the patient collected a 24-hour urine sample after discontinuing magnesium supplements for 24 hours.Evaluate for alcoholism as the cause of hypomagnesemia.Improve glycemic control due to urinary magnesium loss from polyuria.Start insulin to promote magnesium reabsorption at the proximal convoluted tubule.Stop ranitidine due to concern for reduced gastrointestinal magnesium absorption."]}
{"Patient Personal Background": ["Following neoadjuvant chemoradiotherapy, low anterior resection, and 6 cycles of adjuvant FOLFOX therapy (fluorouracil, leucovorin, and oxaliplatin), he had developed a lung metastasis (KRAS wild type) 1 year later.", "He subsequently developed multiple lung metastases treated with palliative local interventions (lobectomy, radiofrequency ablation) and 4 lines of chemotherapy."], "Patient Symptoms": ["He had no shortness of breath or noisy breathing, dysphagia, voice change, or hemoptysis."], "Examination and Results": ["After 9 months, contrast computed tomography restaging scans noted a new, 1-cm posterior subglottic lesion of unclear origin (Figure, A).", "A partial response was maintained without evidence of progression of lung disease.A, An axial computed tomographic image reveals a new posterior subglottic lesion (pink arrowhead) of unclear etiology.", "The differential diagnosis based on imaging included a mass vs inspissated mucus.", "Examination using distal-chip flexible laryngoscopy revealed a 1-cm, broad-based, exophytic mass along the posterior wall of the subglottis with prominent vasculature.", "No other anatomic abnormalities in the upper aerodigestive tract or cervical lymphadenopathy were noted.", "Examination revealed a subglottic mass that did not extend inferiorly beyond the caudal aspect of the cricoid cartilage."], "Treatment": ["Owing to symptomatic lung disease, he was enrolled in a clinical trial (NCT03502733) following informed consent and achieved a confirmed partial response.", "The decision was made to proceed to the operating room for definitive endoscopic biopsy under general anesthesia (Figure, B).", "The mass was debulked and sent to pathology for analysis, including hematoxylin-eosin and immunohistochemical staining (Figure, C)."], "Others": ["B, In the operating room, the larynx was exposed with a Lindholm laryngoscope, and a Hopkins rod-lens endoscope was used to photograph the lesion under apneic conditions.", "C, Photomicrograph (original magnification \u00d720) of a section of the mass stained for CDX2 via standard immunohistochemical techniques.Otolaryngology was consulted to assess the lesion."]}
{"Patient Symptoms": ["She was standing and laying out a blanket for her dog before passing out.", "She denied prodromal symptoms and reported this was her first syncopal episode.", "She reported a few episodes of dizziness in the couple days prior to presentation but denied chest pain, shortness of breath, palpitations, or the recent use of illicit drugs or new medications.", "Shortly after arrival at the emergency department, she had a 50-second run of polymorphic ventricular tachycardia."], "Examination and Results": ["Her vital signs and the results of her physical examination were normal.", "Troponin levels, thyroid levels, and the results of a complete blood cell count and metabolic panel were all normal.", "The results of imaging studies, including echocardiography, computed tomography (CT) pulmonary angiography, and brain CT, were also unremarkable.", "Coronary angiography found no evidence of obstructive coronary disease.", "The results of the urine toxicology test were negative."]}
{"Patient Personal Background": ["Her medical history was unremarkable, and she had no allergies."], "Patient Symptoms": ["She had been well until 2 hours before the flight home, when at the Havana airport, she developed generalized weakness, increased sweating, severe nausea, and vomiting.", "In flight, she had lethargy, vomiting, and urinary incontinence.", "On arrival to the emergency department, she was stuporous and required intubation.", "The patient was alert but disoriented.", "Her muscle tone was normal, and she had mild proximal muscle weakness with occasional bilateral upper extremity and lower extremity fasciculations and jerky movements."], "Examination and Results": ["Initial laboratory tests showed a hemoglobin level of 10.9 g/dL (reference range, 12.0-15.2 g/dL [to convert to grams per liter, multiply by 10.0]), a creatinine level of 1.31 mg/dL (reference range, 0.51-1.08 [to convert to micromoles per liter, multiply by 88.4]), and a pH of 7.22 with a normal anion gap.", "Serum electrolyte levels; a white blood cell count; levels of glucose, creatine kinase, lactic acid, and thyrotropin; coagulation studies; and liver function tests had normal results.", "An electrocardiogram showed sinus bradycardia at 53 bpm and borderline QT interval prolongation (QTc; 465 milliseconds).", "A urine toxicology screen had negative results for acetaminophen, salicylates, opiates, barbiturates, benzodiazepines, cocaine, and ethanol.", "Cerebrospinal fluid was clear, with normal levels of glucose, total protein, and white blood cells and negative microbiology and cytology testing results.", "A malaria smear and antigen test, respiratory viral assay, and cultures of cerebrospinal fluid, blood, and urine had negative results.", "Computed tomography of the head showed bilateral hyperdensity of the globus pallidi (Figure 1).", "Her blood pressure was 99/61 mm Hg; pulse, 80 bpm; temperature, 37.6 \u00b0C; and oxygen saturation, 99% on room air.", "The pupils were 2 mm and reactive.", "Involuntary facial muscle twitching was noted.", "Deep tendon reflexes were normal, with flexor plantar responses."], "Treatment": ["On arrival to the emergency department, she was stuporous and required intubation.", "Within several hours, her level of consciousness improved spontaneously, and she was extubated."]}
{"Patient Symptoms": ["The patient reported headaches and loss of vision in the right eye, which started several months earlier."], "Examination and Results": ["She had no history of trauma, neurosurgical procedures, or lumbar puncture.Examination findings were notable for visual acuities of 20/30 OD and 20/20 OS with an approximate correction of \u22126.50 D. An afferent pupillary defect of 2+ was detected in the right eye, and color vision was diminished in both eyes (1/13 Ishihara plates OD, 5/13 OS).", "Findings on slitlamp examination were normal.", "Applanation tonometry revealed an intraocular pressure of 10 mm Hg in both eyes.", "Findings on dilated fundus examination were notable for small, tilted discs without pallor, hyperemia, or elevated margins; tilting of the nerves precluded estimation of cup-disc ratio.", "Automated 24-2 Humphrey visual field testing revealed diffuse depression in the right eye (mean deviation, \u221226.97 decibels [dB]) and a dense inferior nasal defect in the left eye (mean deviation, \u22128.05 dB) (Figure).Optic disc photographs of the right (A) and left (B) eyes show small, tilted optic nerves with peripapillary atrophy but no hemorrhage, edema, hyperemia, or pallor.", "The temporal edge of the optic nerve is designated by the black arrowhead; the edge of the scleral crescent, by the white arrowhead; and the edge of peripapillary atrophy with hyperpigmentation, by the yellow arrowhead."], "Treatment": ["Selective laser trabeculoplasty and application of 4 topical agents in both eyes reduced intraocular pressure to the high single digits, yet visual field deterioration had continued."], "Diagnosis": ["Her ocular history was notable for open-angle glaucoma in both eyes, diagnosed 3 months previously."], "Others": []}
{"Patient Personal Background": ["Her medical history was unremarkable apart from an allegedly benign breast nodule resection in her teenage years.", "In addition, her father died of metastatic cutaneous melanoma at 83 years old.Clinically, there was an ill-defined, infiltrated plaque with a normochromic, exophytic nodule on her scalp vertex measuring 4.2\u2009\u00d7\u20093.8 cm (Figure, A)."], "Patient Symptoms": ["She was born with the lesion but noticed some growth following a minor local trauma a couple of months prior to seeking medical evaluation.", "The patient denied local inflammation, purulent discharge, and systemic symptoms."], "Examination and Results": ["It had a waxy surface with irregular transverse furrows and overlying alopecia.", "Dermoscopic evaluation findings revealed a homogeneous yellow hue with no visible vascular or pigmented structures and absence of follicular ostia.", "The lesion was firm and mildly tender to the touch and seemed adherent to the underlying bone.", "There were no palpable lymph nodes.", "B, Paramedian sagittal gadolinium-enhanced T1-weighted brain magnetic resonance imaging (MRI).", "C, Cellular infiltration in the reticular dermis (hematoxylin-eosin, original magnification \u00d7100).", "D, Monomorphic cells in a syncytial configuration surrounding collagen bundles (hematoxylin-eosin, original magnification \u00d7400)."], "Others": ["A brain magnetic resonance imaging was performed for further elucidation (Figure, B), as well as a punch biopsy (Figure, C and D).A, Clinical image of the lesion on the scalp."]}
{"Patient Personal Background": ["She had a 25-year history of bulimia and was purging almost daily.", "She reported an inability to go more than 3 days at a time without purging and noted a reduction in the pressure and size of her lesions with respite from these daily episodes.", "The patient first noticed these lesions 15 years ago in association with a subconjunctival hemorrhage on the left side."], "Patient Symptoms": ["She denied any vision changes or pain but did report a sensation of pressure in the location of the lesions, which was relieved when prone.", "She reported an inability to go more than 3 days at a time without purging and noted a reduction in the pressure and size of her lesions with respite from these daily episodes."], "Examination and Results": ["An orbital magnetic resonance image obtained at the time of that episode demonstrated a 2\u2009\u00d7\u20090.6-cm focus of enhancement along the inferior and inferolateral palpebral tissues anterior to the left globe, suggestive of lymphangioma, hemangioma, or vascular malformation without other focal abnormalities.", "The anterior segment examination showed bilateral superior (Figure, A) and inferior (Figure, B) large dilated blood vessels underlying the palpebral conjunctivae.", "Complete ophthalmic and orbital examinations revealed no other abnormalities.Eyelids of the patient demonstrating vascular lesions visible within the palpebral tissue at the time of presentation.", "A, Atypical vascular dilation along the superior peripheral arcade of the right eye.", "The left eye had similar findings.", "B, Atypical vascular dilation along the inferior palpebral arcade of the left eye."]}
{"Patient Symptoms": ["Surgical drainage was performed, but the swelling persisted.", "Two months later, nontender preauricular fullness was noted, which prompted the patient to seek a second opinion.", "The left upper eyelid was thickened (Figure 1A).", "Eyelid eversion was not possible in the clinic because of mass effect, but a small portion of the tumor was visualized at the supranasal eyelid margin.", "A nontender left preauricular mass of 1 cm in diameter was palpable."], "Examination and Results": ["In the interim, magnetic resonance imaging of her orbit and parotid glands revealed focal enhancement in the left upper eyelid and superficial lobe of the left parotid gland.", "She was referred to us for diagnosis and treatment.On examination, visual acuity was 20/20 in the right eye and 20/30 in the left eye.", "Ocular motility was full, and proptosis was absent.", "All eyelashes were intact.", "The remainder of the findings on eye examination were unremarkable.", "After eyelid eversion in the operating room, the mass measured 35 mm in basal diameter and 5 mm in thickness and demonstrated an amelanotic appearance with a hairpin-shaped vascular pattern suggestive of an epithelial tumor (Figure 1B).A, External photograph demonstrating left upper eyelid fullness."], "Treatment": ["Surgical drainage was performed, but the swelling persisted.", "B, Everted left upper eyelid showing a diffuse, multinodular tarsal mass with hairpin-shaped vessels."]}
{"Patient Symptoms": ["At presentation she had a 3-week history of a striking pruritic and generalized cutaneous eruption.", "The patient otherwise felt well and denied fever, malaise, insect bites, or starting new drug treatments."], "Examination and Results": ["Except for leukopenia and a slightly elevated C-reactive protein level, results of other routine blood and urine tests were unremarkable.", "Physical examination revealed an erythematous eruption composed of small indurated and edematous papules (Figure, A and B).", "Confluent papules leading to large urticariform plaques, some with annular configuration, were present on the flanks, lower legs, breasts, and scalp.", "Hyperpigmented patches and focal areas of bruiselike discoloration were seen adjacent to acute lesions.", "Mucous membranes, palms, and soles were spared.", "B, Large erythematous plaques involving the scalp and ear.", "C, Hematoxylin-eosin\u2013stained histologic specimen showing a superficial and deep dermal perivascular and interstitial mononuclear infiltrate with numerous eosinophils (original magnification \u00d740).", "D, Higher magnification of C showing an abundant number of eosinophils in the infiltrate (original magnification \u00d7400)."], "Others": ["A biopsy specimen was obtained (Figure, C and D).A, Erythematous indurated and edematous papules and plaques on the thighs with some residual discoloration."]}
{"Patient Personal Background": ["She was born in Guatemala and had immigrated to the US approximately 1 year ago, without subsequent international travel.", "She took no medications."], "Patient Symptoms": ["She denied fevers or chills.", "She was somnolent and confused without focal neurologic deficits."], "Examination and Results": ["On examination, she was afebrile (36.8 \u00b0C) and hemodynamically stable, with heart rate 70/min and blood pressure 95/53 mm Hg.", "Serum white blood cell count was elevated to 14.9 \u00d7109/L (86% segmented neutrophils, 9% lymphocytes, 5% monocytes, 0% basophils/eosinophils).", "A computed tomography scan of her brain was notable for diffuse ventriculomegaly and sulcal effacement consistent with hydrocephalus and cerebral edema.", "Laboratory analysis of cerebrospinal fluid (CSF) obtained from the ventriculostomy was notable for 40 red blood cells/mm3; 3 nucleated cells/mm3; protein level, 11 mg/dL; and glucose level, 73 mg/dL.", "Magnetic resonance imaging (MRI) of the brain with and without contrast demonstrated ventriculomegaly of the lateral and third ventricles, with a 0.4\u2009\u00d7\u20090.4\u2009\u00d7\u20090.6\u2013cm nonenhancing lesion obstructing the aqueduct of Sylvius (Figure 1A).", "No abnormal meningeal enhancement or parenchymal lesion was identified.", "Repeat MRI demonstrated resolved hydrocephalus, a patent aqueduct of Sylvius, and the aforementioned nonenhancing lesion now located in the fourth ventricle (Figure 1B).Left, Sagittal T2-weighted noncontrast magnetic resonance imaging (MRI) image at presentation."], "Treatment": ["Given her diminished level of consciousness, a ventriculostomy was placed emergently."], "Others": ["On hospital day 5, in the midst of an ongoing infectious diseases workup, the measured intracranial pressure and rate of CSF drainage from the ventriculostomy suddenly decreased.", "Right, Sagittal T2-weighted noncontrast MRI image obtained on day 5 after sudden decrease in intracranial pressure and cerebrospinal fluid drainage."]}
{"Patient Personal Background": ["He was taking amlodipine (5 mg daily) and ipratropium bromide nasal spray twice daily.On examination, he was afebrile."], "Patient Symptoms": ["Over the same period, he also developed thickened, brittle, and discolored fingernails and toenails.", "More recently, he developed progressive exertional dyspnea and edema of both lower extremities.", "He had yellow discoloration and thickening of his fingernails and toenails (Figure 1A).", "A few nails showed distal onycholysis.", "He had partially nonpitting edema of the lower extremities (Figure 1B)."], "Examination and Results": ["Heart rate was 66/min; blood pressure, 132/72 mm Hg; respiratory rate, 18/min; and oxygen saturation by pulse oximetry, 97% on room air.", "Auscultation revealed diminished breath sounds at the lung bases but no rhonchi or crackles.", "Percussion of the lung bases and vocal resonance were normal.", "Cardiac and abdominal examination findings were unremarkable.A, Yellow discoloration and thickening of fingernails and toenails.", "B, Partially nonpitting edema of the lower extremities with a positive Stemmer sign (difficulty pinching the skin on the dorsum of the toes), suggestive of lymphedema.Laboratory testing revealed normal complete blood cell count, comprehensive metabolic panel, and thyrotropin level.", "Erythrocyte sedimentation rate was 2 mm/h; C-reactive protein level was 0.1 mg/dL.", "Antinuclear antibody (ANA) was positive (1:160, nucleolar pattern), but results of testing for antibodies to extractable nuclear antigens and double-stranded DNA were negative.", "He had mildly low C3 complement level (63 mg/dL [reference range, 79-152 mg/dL]), but normal C4 complement level (20 mg/dL [reference range, 16-38 mg/dL]).", "Immunoglobulin levels were normal.", "A chest radiograph performed within the last 6 months to evaluate his chronic cough did not reveal any obvious cardiopulmonary disease.", "His electrocardiogram was normal."], "Others": ["He had no joint pain or swelling and no chest pain.", "Few nails showed distal onycholysis."]}
{"Patient Symptoms": ["His diarrhea was nonbloody, woke him up from sleep, was accompanied by crampy abdominal pain, and was not associated with nausea or vomiting."], "Examination and Results": ["His physical examination results revealed normal vital signs and a mildly tender abdomen with hyperactive bowel sounds, but no peritoneal signs.", "His laboratory workup results were notable for severe hypokalemia and hypomagnesemia, as well as positive fecal lactoferrin and elevated fecal calprotectin levels of 646 \u03bcg/g.", "His infectious workup results were unremarkable.", "A computed tomography scan of the abdomen/pelvis revealed diffuse long-segment wall thickening involving nearly the entire terminal ileum (Figure, A).", "An ileocolonoscopy revealed erythematous and congested mucosa with scattered erosions and ulcerations throughout the examined terminal ileum (Figure, B)."], "Treatment": ["The diarrhea persisted despite treatment with combinations of loperamide, atropine/diphenoxylate, colestipol, and tincture of opium.", "He required repeated intravenous infusions for fluid and electrolyte repletion."]}
{"Patient Personal Background": ["She had been treated for glaucoma for approximately 1 year.", "Her medical history included hyperlipidemia, obesity, and prior cataract surgery in both eyes."], "Examination and Results": ["On examination, best-corrected visual acuity was 20/20 OD and 20/80 OS.", "The patient\u2019s pupils were equal, round, and reactive to light without a relative afferent pupillary defect.", "Intraocular pressure was 11 mm Hg bilaterally without medication.", "Slitlamp findings were notable for patent peripheral iridotomies, open angles on gonioscopy, and an asymmetrically enlarged cup-disc ratio with mild pallor of the left optic nerve.", "Color vision was decreased in the left eye.", "Visual field (VF) testing as well as ganglion cell layer (GCL) segmentation by optical coherence tomography (OCT) were obtained for both eyes (Figure 1).Optical coherence tomography ganglion cell layer thickness map shows nasal thinning of the right eye (A) and diffuse thinning of the left eye (B).", "In the right eye, the relative thinning within the nasal macula compared with the temporal macula suggests injury to the papillomacular bundle.", "In the left eye, the diffuse thinning suggests diffuse optic nerve injury (Heidelberg Spectralis; Heidelberg)."], "Others": ["Review of systems was negative for previous episodes of eye pain, redness, or emesis."]}
{"Patient Personal Background": ["He noted a medical history of hyperthyroidism, coronary artery disease, hypertension, and type 2 diabetes mellitus.", "He also noted a history of substantial blood glucose elevation after taking oral prednisone.A review of systems had negative results, including the absence of joint pain, fevers, chills, weight loss, and rashes."], "Patient Symptoms": ["After strabismus surgery, he was noted to have a nonhealing conjunctival epithelial defect inferiorly, which later developed underlying scleral thinning."], "Examination and Results": ["His best-corrected visual acuity was 20/20 OD and counting fingers OS, and his intraocular pressures were 13 mm Hg OD and 4 mm Hg OS.", "Slitlamp examination of the left eye revealed marked inferior redness, including large-caliber episcleral vessels and scleral thinning that was greatest inferonasally (Figure 1A).", "There was an epithelial defect overlying the thinned sclera, scleral tenderness to palpation, 16 to 25 cells per high-power field in the anterior chamber, and iris neovascularization.", "The view to the posterior pole was hazy, and B-scan ultrasonography revealed an inferior retinal detachment (Figure 1B)."], "Treatment": ["He was being treated with topical moxifloxacin, 0.5%, every 2 hours in the left eye."], "Others": ["Examination of the right eye had unremarkable results.A, Slitlamp photograph of the left eye demonstrates focal scleral thinning inferonasally."]}
{"Patient Personal Background": ["He denied any pain, swelling, or paresthesia, and his medical history was unremarkable."], "Patient Symptoms": ["A consultation with a dentist 1 year prior revealed an impacted mandibular canine (No.", "Clinical examination revealed fullness on the mentolabial fold but no gross facial asymmetry or mental nerve paresthesia."], "Examination and Results": ["Intraorally, there was an expansile mass of the left anterior mandible with ill-defined margins, which crossed the midline and obliterated the gingivolabial sulcus.Results of dental cone beam computed tomography imaging revealed a 4.3\u2009\u00d7\u20094.0-cm radiolucent mandibular lesion with an unerupted mandibular canine in the center of the lesion, cortical destruction, and root deviation of teeth Nos.", "23 through 26 (Figure, A).", "Histological sections from the resection demonstrated nests and cords of polygonal cells with clear to eosinophilic cytoplasm embedded in a dense collagenous stroma (Figure, B).", "The lesion was centered in the cortical bone (Figure, C) and extended into the surrounding mucosa (Figure, D), fibroadipose tissue, and skeletal muscle.", "Perineural invasion was identified (Figure, E), and lymphovascular invasion was absent.", "Immunohistochemistry findings revealed the tumor cells were positive for p40.", "Fluorescence in situ hybridization  studies demonstrated an EWSR1 gene rearrangement in 60% of the tumor cells (Figure, F).A, Dental cone beam computed tomography (CT) scan showing 4.3\u2009\u00d7\u20094.0-cm radiolucent lesion in the anterior mandible with impacted mandibular canine at the center of the lesion.", "B, Nests and cords of polygonal cells with clear to eosinophilic cytoplasm (hematoxylin-eosin stain).", "C, Lesion centered in the bone (hematoxylin-eosin stain).", "D, Tumor cells extending beyond the cortex of the mandible to involve the gingival mucosa (hematoxylin-eosin stain).", "E, Perineural invasion is present (hematoxylin-eosin stain)."], "Treatment": ["An incisional biopsy was performed, and the patient underwent radical mandibular resection 2 months later."], "Others": ["22).", "The tumor involved multiple margins."]}
{"Patient Personal Background": ["Her medical and family history was unremarkable."], "Patient Symptoms": ["The lesion started as a small eczematous, pink-to-brown plaque.", "As the lesion was asymptomatic and slow growing, she did not initially seek treatment.", "Recently, the color of the lesion had changed to an alarming dark brown color (Figure, A)."], "Examination and Results": ["No breast mass or lymphadenopathy was observed.", "A skin biopsy specimen was obtained and submitted for further histopathologic analysis.A, Clinical presentation of pigmented plaque in the axilla with well-demarcated margins.", "B, Histologic findings revealed an intraepidermal neoplasm consisting of pagetoid cells, characterized by round, pale, vacuolated cytoplasm, and large pleomorphic nuclei (hematoxylin-eosin; original magnification \u00d7200).", "C, Immunohistochemical findings showed positive staining for EMA (original magnification \u00d7200).", "D, The lesion was surrounded by numerous reactive dendritic HMB-45\u2013positive melanocytes scattered among the tumor cells (original magnification \u00d7200)."]}
{"Patient Symptoms": ["There were no systemic complaints, history of arthropod bite, immunosuppression, travel abroad, or contact with animals in the recent past."], "Examination and Results": ["Physical examination revealed a skin-colored, firm, nontender, freely mobile 2\u2009\u00d7\u20091.5-cm nodule with overlying normal skin on the right occipital region of the scalp (Figure, A).", "There was no lymphadenopathy.", "No other cutaneous lesions were present.A, Clinical photograph shows a 2\u2009\u00d7\u20091.5-cm skin-colored nodule on the occiput.", "B, Epidermis is unremarkable.", "A nodular lesion surrounded by a fibrous capsule is seen in the dermis with cross-sections of many parasites along with pink material in the nodule (hematoxylin-eosin, original magnification \u00d72).", "C, The parasite morphology depicts a thick cuticle, well-developed inner muscular layer, tubular structures containing microfilariae, and necrotic debris (hematoxylin-eosin, original magnification \u00d720).", "Cross-sections of parasites were present, surrounded by a fibrous capsule (Figure, B).", "The cuticle demonstrated a wavy pattern of longitudinal ridges on its outer surface (Figure, D).", "The fibrous capsule contained mixed inflammatory infiltrate of lymphocytes, eosinophils, histiocytes, and plasma cells.", "Findings of slitlamp examination and fundoscopy of the eyes were normal.", "Findings of routine hematologic and biochemical investigations were normal.", "No microfilaria was seen in peripheral blood.", "Findings of chest radiography and abdomen ultrasonography were unremarkable."], "Treatment": ["D, Higher magnification shows spinous processes on the outer surface of the cuticle (hematoxylin-eosin, original magnification \u00d720).The nodule was completely excised and sent for histopathologic examination, which revealed a nodule in the dermis with an unremarkable epidermis."], "Others": ["The parasite showed an outer cuticle, muscle layer underneath, and gravid uterus filled with microfilariae (Figure, C)."]}
{"Patient Symptoms": ["Despite having taken multiple courses of oral antibiotics, he saw no improvement in his symptoms.", "Over the course of 3 months, the patient went on to notice swelling and redness of his left ear (Figure 1A) that would resolve and recur every few weeks.Clinical photographs demonstrating auricular chondritis (A) and saddle nose deformity (B).Bothered by his hoarse voice and sore throat, he consulted a private otolaryngologist, who performed a nasoendoscopy, the results of which showed severe Reinke edema and chronic laryngitis.", "In addition, his hoarseness of voice worsened during a 2-week span and was now associated with difficulty breathing when he laid supine.", "He was unable to speak a full sentence without drawing a deep, labored breath."], "Examination and Results": ["In our otolaryngology clinic, physical examination results revealed a saddle-nose deformity, left pinna perichondritis, and a soft inspiratory stridor.", "Laboratory test results showed elevated C-reactive protein levels of 143 mg/L, erythrocyte sedimentation rate of 97 mm/h, and a microcytic hypochromic anemia of hemoglobin level of 12.1 g/dL (to convert to grams per liter, multiply by 10)."], "Treatment": ["He was treated with a short course of oral prednisolone that alleviated all his symptoms.However, on cessation of oral steroids, the patient noticed a saddle-shaped deformity on his nose (Figure 1B) that appeared without any antecedent trauma."]}
{"Patient Personal Background": ["She had no relevant medical history, was not taking any systemic or ocular medications, and denied a history of floaters.", "The patient denied any known history of sickle cell disease or trait and any family history of sickle disease."], "Examination and Results": ["Her visual acuity was 20/40 OU, and her intraocular pressure was 18 mm Hg OU.", "An anterior segment examination was unremarkable in both eyes.", "Ophthalmoscopy findings were notable for a vitreous hemorrhage in the right eye.", "Salmon-patch intraretinal hemorrhages were noted in the temporal peripheral retina of both eyes (Figure 1).", "Widefield fluorescein angiography revealed retinal capillary nonperfusion of the peripheral retina with neovascularization elsewhere, in a sea fan\u2013like pattern, in both eyes.", "Scatter laser photocoagulation was performed on the nonperfused temporal retina in the right eye, and the left eye was observed.A, Fundus photograph of the right eye with media opacity consistent with vitreous hemorrhage and, in the far temporal retinal area, evidence of ischemia and vascular attenuation and ghosting.", "There is also evidence of multiple salmon-patch hemorrhages (arrowheads)."], "Treatment": ["Scatter laser photocoagulation was performed on the nonperfused temporal retina in the right eye, and the left eye was observed.A, Fundus photograph of the right eye with media opacity consistent with vitreous hemorrhage and, in the far temporal retinal area, evidence of ischemia and vascular attenuation and ghosting."]}
{"Patient Personal Background": ["Both parents had a history of latent tuberculosis infection treated after immigrating to the US from Syria shortly after the patient\u2019s birth."], "Patient Symptoms": ["The patient\u2019s pediatrician diagnosed him with reactive airway disease and adenotonsillar hypertrophy.", "He was sent to the emergency department, where he was stridulous and afebrile with a normal white blood cell count and an elevated erythrocyte sedimentation rate."], "Examination and Results": ["He was referred to the otolaryngology clinic, where flexible laryngoscopy revealed diffuse upper airway lymphoid hyperplasia and supraglottic edema.", "A computed tomography scan of the neck revealed diffuse edema and contrast enhancement of the nasopharynx, oropharynx, hypopharynx, and supraglottis.", "A chest radiograph was normal.The patient was taken urgently to the operating room for direct microlaryngoscopy (Figure 1A and B) and intubated.", "Results of biopsies and cultures of the tonsils, adenoids, and supraglottis revealed diffuse non-necrotizing granulomas (Figure 1C) and oropharyngeal flora with negative acid-fast bacilli and Grocott methenamine silver stains.", "During this time, he had a normal angiotensin-converting enzyme (ACE) level and normal titers for antinuclear antibody (ANA), cytoplasmic antineutrophilic cytoplasmic antibody, perinuclear antineutrophilic cytoplasmic antibody, antimyeloperoxidase antibody, antiproteinase 3 antibody, anti\u2013double-stranded DNA antibody, Smith antibody, Sjogren antibodies, and histoplasma antibodies.", "He also had normal results on tuberculin purified protein derivative and interferon-\u03b3 release assay (QuantiFERON; Qiagen).A, View with laryngoscope blade in vallecula, revealing only a profoundly swollen epiglottis."], "Treatment": ["He remained intubated, and treatment with systemic corticosteroids and antibiotics was initiated."], "Others": ["B, View with laryngoscope blade beneath epiglottis, revealing edema and distortion of supraglottic structures that obscured the glottis (* indicates left arytenoid; **, right aryepiglottic fold; ***, right arytenoid).", "C, Supraglottic biopsy specimen demonstrating non-necrotizing granulomas in a background of lymphoid tissue; hematoxylin-eosin stain, original magnification \u00d7200."]}
{"Patient Personal Background": ["Her medical history was unremarkable.", "Her immunizations were up to date, and she had had an uncomplicated prenatal and delivery course.", "Her ocular history and family history were unremarkable."], "Examination and Results": ["On examination, the patient\u2019s visual acuity was 20/25 OU and pupillary responses and intraocular pressures were normal.", "The anterior segments were normal, the lenses were clear, and there was no inflammation in either eye.", "On a dilated fundus examination, the vitreous was clear bilaterally.", "A single, superonasal, white retinal mass with no visible calcification or subretinal fluid was present in the right eye (approximately 2.5 disc diameters away from the optic nerve), with associated retinal pigment epithelium changes at the edge of the lesion (Figure 1) and a normal optic disc and posterior pole."], "Others": ["The left posterior segment was normal.Right eye fundus photograph at presentation: ultra-widefield image obtained in the clinic.", "Peripheral image artifacts include the nose and eyelashes (inverted)."]}
{"Patient Personal Background": ["The patient had a history of uterine fibroids and a right-sided ovarian cyst for 5 years, but she denied symptoms, including abdominal pain, abnormal defecation, abnormal vaginal bleeding, fever, or weight loss.", "She had no history of intravenous drug use."], "Examination and Results": ["A physical examination was notable for jugular venous pulsations and a grade 3/6 systolic murmur best heard at the fifth intercostal space in the left side of the sternum.", "Laboratory studies revealed normal serum chemistry levels.", "A complete blood cell count showed a hemoglobin level of 12.7 g/dL (reference, 11.3-15.1 g/dL [to convert to grams per liter, multiply by 10]), a white blood cell count of 7400 cells/\u03bcL (reference, 4000-10\u202f000 cells/\u03bcL [to convert to cells \u00d7109 per liter, multiply by 0.001]), and a platelet count of 42\u2009\u00d7\u2009103 cells/\u03bcL (reference, 100\u2009\u00d7\u2009103 to 300\u2009\u00d7\u2009103 cells/\u03bcL [to convert to cells \u00d7109 per liter, multiply by 1.0]).", "The prothrombin time was 16.5 seconds (reference, 10-14 seconds); activated partial thromboplastin time, 47.5 seconds (reference, 23-35 seconds); fibrinogen level, 52 mg/dL (reference, 185-350 mg/dL [to convert to grams per liter, multiply by 0.01]); and D-dimer, 5190 \u03bcg/mL (reference, <590 \u03bcg/mL [to convert to nanomoles per liter, multiply by 5.476])."]}
{"Patient Personal Background": ["After 1 month of ongoing rash, pembrolizumab was discontinued."], "Patient Symptoms": ["Her pruritic eruption persisted over the next 5 months despite treatment with up to 80 mg/d of oral prednisone.", "The eruption continued to worsen when the patient was not receiving systemic corticosteroids, with blisters developing 7.5 weeks after their discontinuation, prompting her presentation to the emergency department.On examination, the patient was afebrile and hemodynamically stable.", "She had tense bullae and indurated papules and plaques involving the face, trunk, and extremities (Figure, left), and oral mucosal erosions (Figure, right)."], "Examination and Results": ["She did not report fever during this period.", "A shave biopsy performed while the patient was receiving systemic corticosteroids demonstrated spongiotic dermatitis with a mixed-cell infiltrate suggesting an incipient autoimmune bullous process.", "Blood pressure was elevated to 136/98 mm Hg; other vital signs were within normal limits.", "Laboratory findings were notable for erythrocyte sedimentation rate and C-reactive protein level being elevated to 25 mm/h and 16.8 mg/dL, respectively, with a normal white blood cell count.Patient presentation.", "Left, Bullae on bilateral lower extremities."], "Treatment": ["Her pruritic eruption persisted over the next 5 months despite treatment with up to 80 mg/d of oral prednisone.", "A shave biopsy performed while the patient was receiving systemic corticosteroids demonstrated spongiotic dermatitis with a mixed-cell infiltrate suggesting an incipient autoimmune bullous process."], "Others": ["Results of follow-up direct immunofluorescence (DIF) performed on a sample taken 15 days after steroid discontinuation were negative."]}
{"Patient Personal Background": ["The patient had cardiovascular risk factors including arterial hypertension and a family history of CAD.", "With antihypertensive therapy, her blood pressure was 119/79 mm Hg.", "Blood lipids were as follows: total cholesterol, 167 mg/dL (abnormal >200 mg/dL); low-density lipoprotein cholesterol, 80 mg/dL (abnormal >100 mg/dL); high-density lipoprotein cholesterol, 55 mg/dL (abnormal <60 mg/dL); and triglycerides, 80 mg/dL (abnormal >150 mg/dL)."], "Examination and Results": ["A 20% pretest probability of coronary artery disease (CAD) was estimated, considering sex, age, and type of chest pain.1 Functional tests performed 3 months earlier were inconclusive: a stress electrocardiogram (ECG) showed ST-segment depressions at 100 W of \u22120.2 mV in lead I and \u22120.15 mV in V5, while stress magnetic resonance (MR) perfusion imaging had negative results.", "To evaluate for CAD, she underwent coronary computed tomography (CT) angiography (Figure).Evaluation for the presence of coronary artery disease using computed tomography angiography.", "Patient\u2019s imaging: A, right coronary artery (RCA); B, left circumflex coronary artery (LCX); C, left anterior descending coronary artery (LAD); D, LAD displayed as curved multiplanar reformations and 3-dimensional views; and large field of view of an axial slice, E, and coronal slice, F, to identify extracardiac findings.No coronary stenosis.", "If symptoms persist, recommend a follow-up CT and perfusion imaging.No coronary stenosis.", "Because of the chest pain, recommend further functional testing.No stenosis or plaque.", "Because of high negative predictive value, no further testing is necessary.Relevant coronary stenosis cannot be excluded by CT."], "Others": ["Recommend invasive coronary angiography."]}
{"Patient Symptoms": ["Similar symptoms subsequently spread to the left hallux and ankle, and he developed a fever.", "Despite many medical consultations and various attempts at treatment with nonsteroidal anti-inflammatories, the patient developed widespread arthritis within the following month, which was predominant in the knee, shoulder, and hip.", "In the month before presentation the articular symptoms worsened, the joints had become tender, and ill-defined skin nodules had appeared predominantly on the legs (Figure, A and B).", "An acute abdominal pain in the left hypochondrium developed, accompanied by nausea and vomiting, which led to a diagnosis of pancreatitis."], "Examination and Results": ["Laboratory test results revealed strikingly high levels of lipase and amylase, as well as normal levels of cancer antigen 19-9.", "Bone computed tomography (CT) of the right shoulder and knee demonstrated cortical bone destruction and intraosseous medullary necrosis (Figure, C and D)."], "Treatment": ["The patient was admitted to the hospital and clinical measures relieved the pain."], "Diagnosis": ["An acute abdominal pain in the left hypochondrium developed, accompanied by nausea and vomiting, which led to a diagnosis of pancreatitis."]}
{"Examination and Results": ["Her best-corrected visual acuity was 20/25 OD and 20/20 OS.", "There was no afferent pupillary defect, her Ishihara color plate findings were 10/10, and extraocular movements were intact in both eyes.", "An anterior slitlamp examination had unremarkable findings.", "A fundus examination showed hemorrhagic optic disc edema, peripapillary and subfoveal subretinal fluid, tortuous and dilated retinal vasculature, many intraretinal hemorrhages in all 4 quadrants, and far peripheral temporal inner retinal whitening in both eyes (Figure 1A).", "Optical coherence tomography demonstrated peripapillary and subfoveal subretinal fluid, intraretinal fluid, and swollen optic nerve heads in both eyes (Figure 1B).", "A fluorescein angiogram showed markedly delayed venous filling (1 minute) in all quadrants and far peripheral capillary nonperfusion in both eyes.Images of the right eye at presentation.", "B, Optical coherence tomography of the right macula showing intraretinal fluid (arrowheads) and subretinal fluid tracking from the optic disc and involving the fovea (dotted arrow).A workup for the optic nerve edema included magnetic resonance imaging and venography, which showed mild cerebral leptomeningeal enhancement and no occlusive thrombosis.", "A lumbar puncture revealed an elevated opening pressure of 50 cm H20 (38 mm Hg; normal range, 6-25 cm H20), an elevated cerebrospinal fluid white blood cell count (41 cells/\u03bcL; normal range, 0-5 cells/\u03bcL; to convert to cells\u2009\u00d7\u2009109 per liter, multiply by 0.001), and negative cerebrospinal fluid culture results.", "A complete blood cell count found severe anemia (hemoglobin, 3.4 g/dL; normal range, 12.0-15.5 g/dL; to convert to grams per liter, multiply by 10.0), and a peripheral blood smear showed lymphocytosis with predominantly atypical lymphocytes.", "Serum protein electrophoresis revealed an IgM level of 5850 mg/dL (normal range, 57-237 mg/dL; to convert to grams per liter, multiply by 0.01)."], "Others": ["A, Optic nerve edema (dotted circle), vascular tortuosity (asterisks), intraretinal hemorrhages in all 4 quadrants (solid circles), and far peripheral retinal whitening (arrowheads)."]}
{"Patient Personal Background": ["The patient reported that this cyst had been drained 2 years before with resolution of her symptoms."], "Examination and Results": ["On examination, she had an approximately 1.5-cm mucosally covered mass on her left lateral pharyngeal wall that was cystlike in appearance.", "The remainder of her examination findings were normal.", "Contrasted computed tomographic (CT) imaging of her head and neck was obtained, which revealed a pharyngeal cyst that extended to the atlantoaxial joint (Figure, A).", "Further magnetic resonance imaging (MRI) of the area was obtained, which demonstrated communication of the cyst with the atlantoaxial joint (Figure, B and C).Computed tomographic (CT) image (A) and magnetic resonance images (MRIs) (B and C) of the neck show a pharyngeal cyst (all images) that is communicating with the left atlantoaxial joint (B) at the level of the second cervical vertebra (C)."]}
{"Examination and Results": ["On examination, visual acuity was 20/30 OU.", "Intraocular pressure (IOP) was 16 mm Hg OD and 41 mm Hg OS.", "The anterior segment was normal in the right eye.", "Anterior examination of the left eye revealed 10% hyphema.", "Two days later, IOP was 16 mm Hg OD and 10 mm Hg OS.", "Slitlamp biomicroscopy revealed resolved hyphema and abnormal blood vessels at the superotemporal pupillary margin of the iris, prompting referral for further evaluation.On further examination, visual acuity was 20/40 OD and 20/50 OS, and IOP was 15 mm Hg OD and 16 mm Hg OS.", "Slitlamp examination results in the right eye appeared normal, whereas the left eye demonstrated subtle, multifocal ectatic vascular channels arranged circumferentially at the pupillary margin (Figure 1A, arrowheads).", "On fluorescein angiography (FA), both the right and left irises displayed multifocal, pinpoint areas of hyperfluorescence at the pupillary margin and was more noticeable on the left iris (Figure 1B, arrowheads).", "The remainder of the eye examination was unremarkable, and there was no sign of neovascularization of the retina or disc.A, Slitlamp photograph of the left eye depicting a vascular lesion at the 2 o\u2019clock position in the pupillary margin (inset, arrowheads)."], "Treatment": ["The patient was prescribed cyclopentolate, 1%, and prednisolone acetate, 1%, to reduce inflammation and lower the IOP in the left eye."]}
{"Patient Personal Background": ["Her medical history had negative results for allergic rhinitis, asthma, chronic rhinosinusitis, epistaxis, nasal trauma, or surgery.", "Her family history was noncontributory."], "Patient Symptoms": ["The patient denied systemic symptoms, including oral ulcers, sicca, photosensitivity, dermatitis, or arthralgias."], "Examination and Results": ["An in-office nasal endoscopy demonstrated synechiae bridging from the septum to the lateral nasal walls, polypoid changes, and yellow crusting bilaterally.Her immune workup showed elevated complement C3 (200 mg/dL) and total hemolytic complement (CH50; >60 U/mL) levels, with otherwise unremarkable levels of C4, C-reactive protein, erythrocyte sedimentation rate, rheumatoid factor, Sj\u00f6gren antibodies, angiotensin-converting enzyme, antinuclear antibody, antineutrophil cytoplasmic antibody, bullous pemphigoid IgG antibodies, and quantitative immunoglobulins and IgG subclasses (IgG4, 53 mg/dL [to convert to grams per liter, multiply by 0.01]).", "Nasal cultures had positive results for methicillin-resistant Staphylococcus aureus and Bacteroides.", "Preoperative computed tomography showed no evidence of paranasal mucosal disease or bone erosion.", "An operative endoscopy with elevation of the mucoperichondrial flaps revealed an absence of the quadrangular cartilage caudal struts and irregular, friable tissue along the cartilage and perichondrium.", "Surgical pathology examination demonstrated prominent lymphoplasmacytic infiltrate (Figure, A), angiocentric fibrosis with a relative lack of eosinophils (Figure, B), and increased IgG4 absolute count (up to 50 cells per high-power field), although an IgG4-IgG ratio that was only slightly elevated (0.2) (Figure, C and D).Histopathologic findings: A, hematoxylin-eosin (original magnification \u00d740); B, hematoxylin-eosin (original magnification \u00d7100); C and D, original magnification \u00d7200."]}
{"Patient Symptoms": ["She noted a 5-kg weight loss in the preceding 3 months."], "Examination and Results": ["Examination revealed nonreproducible chest tenderness, bibasilar crackles, and no extra heart sounds.", "Testing revealed leukocytosis (white blood cell count, 16\u202f900 cells/\u03bcL [to convert to \u00d7\u2009109 cells/L, multiply by 0.001]) with a differential of 6% neutrophils and 59% eosinophils, an elevated N-terminal pro B-type natriuretic peptide of 3963 pg/mL (reference level, <900 pg/mL [to convert to ng/L, multiply by 1.0]), and an elevated initial troponin T of 0.36 ng/mL, which later peaked at 0.41 ng/mL (to convert to micrograms per liter, multiply by 1.0).", "Her C-reactive protein level was 3.09 mg/dL (normal, <0.5 mg/dL [to convert to milligrams per liter, multiply by 10]).", "Subsequent plasma flow cytometry demonstrated 65% eosinophils, and a bone marrow biopsy with immunohistochemistry showed eosinophilia without evidence of clonal expansion.", "Cardiac magnetic resonance imaging was performed (Figure 1B; Video).A, Normal sinus rhythm with left-axis deviation, low voltages, inferior Q waves, and poor R-wave progression."], "Others": ["A 12-lead electrocardiogram is shown in Figure 1A."]}
{"Examination and Results": ["Examination showed coalescing annular, arcuate, and serpiginous red scaling plaques in a concentric pattern diffusely involving the chest, back, and abdomen with extension to proximal extremities (Figure, A and B).", "Punch biopsies from the chest (Figure, C and D) and back were obtained for histopathology and tissue culture.", "C, Histopathology of skin biopsy from the chest reveals epidermal hyperplasia with spongiosis and parakeratosis (hematoxylin-eosin, original magnification \u00d7400).", "There is a superficial dermal and epidermotropic infiltrate of atypical lymphocytes focally distributed along the dermal-epidermal junction and aggregated in Pautrier microabscesses."], "Treatment": ["Treatment with topical corticosteroids under wet dressings was associated with partial improvement in the eruption and pruritus.A and B, Clinical images show concentric annular, arcuate, and serpiginous red scaling plaques diffusely involving the back and right flank."]}
{"Patient Personal Background": ["He had a history of high myopia and a family history of glaucoma in a female family member.", "He denied other prior ocular history, trauma, or eye surgery."], "Patient Symptoms": ["The patient noted 4 years of progressive, decreased, patchy pigmentation of both eyes; constant photophobia; and constant decreased visual acuity."], "Examination and Results": ["A review of systems had no remarkable findings, and the patient denied a prodromal viral illness.On presentation, his best-corrected visual acuity was 20/20-2 OD and 20/25 OS, with a refraction of \u22126.25 OD and \u22125.50 OS (spherical equivalent).", "The intraocular pressure was 18 OU.", "Gonioscopy showed openness to the ciliary body with 1+ trabecular meshwork pigmentation, without synechiae or angle recession in either eye.", "A slitlamp examination demonstrated quiet conjunctiva, clear corneas, deep and quiet anterior chambers, mid-dilated round pupils, patchy iris atrophy, and transillumination defects bilaterally (Figure).", "Ophthalmoscopy showed an 0.8 cup-disc ratio without notching bilaterally but had otherwise normal results.", "Retinal nerve fiber layer optical coherence tomography showed borderline thinning with normal Humphrey visual fields in both eyes.Anterior segment photographs of the right eye (A) and left eye (B) showing clear corneas, patchy iris atrophy of both irides (arrowheads), and round mid-dilated pupils without posterior synechiae."]}
{"Examination and Results": ["Fine-needle aspiration results showed metastatic p16-positive squamous cell carcinoma.", "No mucosal primary site was identified with positron emission tomography, computed tomography, or a head and neck examination.", "Pathology results revealed a 1.8-cm primary cancer in the right tonsil, and the patient received a stage designation of T1 N1 M0.", "The tumor was intracapsular, and all surgical margins were negative.", "Imaging results revealed an enhancing structure at the skull base adjacent to the carotid sheath (Figure).Computed tomography of the neck with contrast and the axial (A) and coronal (B) views revealing an enhancing structure at the skull base along the carotid sheath (arrowheads)."], "Treatment": ["The patient underwent direct laryngoscopy with directed biopsies and bilateral tonsillectomy.", "Multidisciplinary tumor board discussion concluded that surgical and nonsurgical treatment options were available, and the patient elected to proceed with further surgery, which would entail additional directed biopsies at the primary site with additional resection if necessary and selective neck dissection of levels Ib to IV.", "In preparation for the neck dissection, computed tomography of the neck with contrast was obtained."], "Diagnosis": ["Fine-needle aspiration results showed metastatic p16-positive squamous cell carcinoma.", "Pathology results revealed a 1.8-cm primary cancer in the right tonsil, and the patient received a stage designation of T1 N1 M0."]}
{"Patient Personal Background": ["She had a medical history of patchy hair loss and a violaceous maculopapular rash on the face and upper extremities for 5 years, which was well controlled with topical corticosteroids.", "Family history was notable for antiphospholipid syndrome in her mother."], "Patient Symptoms": ["She reported new, sharp headaches in a headband distribution, exacerbated by lights, sounds, and neck flexion.", "One week prior to presentation, she experienced a subjective fever and recurrence of the facial rash.", "She denied experiencing eye pain, blurry vision, or light sensitivity."], "Examination and Results": ["Results of a comprehensive review of systems were otherwise negative.", "Best-corrected visual acuity was 20/25 OU.", "Results of an anterior segment examination, pupil examination, and tonometry were unremarkable.", "During dilated ophthalmoscopy, both eyes revealed diffuse intraretinal hemorrhages in the posterior pole and temporal retinal neovascularization, worse in the right eye with associated macular traction and striae."]}
{"Patient Personal Background": ["She maintained a healthy diet and denied any history of malnutrition, gastrointestinal procedures, recent ocular infections, or chemical exposures.", "Her ocular history was notable for cataract extraction with intraocular lens implantation in both eyes."], "Patient Symptoms": ["Ocular hypertension was noted after corticosteroid treatment, and the patient started brimonidine-timolol drops twice daily in the left eye.At presentation, the patient\u2019s corrected distance visual acuity was 20/20 OD and 20/60 OS.", "She denied diplopia."], "Examination and Results": ["Results of slitlamp examination revealed very mild shortening of the fornix inferonasally in the right eye."], "Treatment": ["Shortly after cataract surgery in the left eye, performed 1 year prior to presentation, the patient developed cystoid macular edema treated with a sub-Tenon injection of triamcinolone acetonide.", "Ocular hypertension was noted after corticosteroid treatment, and the patient started brimonidine-timolol drops twice daily in the left eye.At presentation, the patient\u2019s corrected distance visual acuity was 20/20 OD and 20/60 OS."]}
{"Patient Personal Background": ["Her medical history included diabetes, hyperlipidemia, and hypertension that were well controlled with simvastatin, chlorthalidone, hydralazine hydrochloride, lisinopril, and verapamil hydrochloride.", "She had been taking these medications for 5 years with no new exposures.", "Age-appropriate cancer screening was up to date."], "Patient Symptoms": ["Notable symptoms included 4 months of extreme fatigue, 20.4 kg weight loss, and a recent episode of hematochezia.", "On hospital day 2, she developed bright red blood per rectum, necessitating transfusion."], "Examination and Results": ["She was afebrile and hemodynamically stable, but laboratory evaluation revealed that she had leukocytosis, normocytic anemia, elevated erythrocyte sedimentation rate, hematuria, and proteinuria.", "A computed tomography of the chest, abdomen, and pelvis revealed parenchymal lung nodules.", "On admission, punch biopsies of the skin were performed for both histological examination and bacterial, fungal, and acid-fast bacterial cultures (Figure, C and D).A, Edematous, ulcerated pink plaques confluent on forehead and cheeks with sharp demarcation at nasolabial fold are shown.", "B, Retiform purpuric plaque is shown on the left leg with overlying desquamation.", "C and D, Biopsy specimen findings (hematoxylin-eosin)."], "Treatment": ["On hospital day 2, she developed bright red blood per rectum, necessitating transfusion."]}
{"Patient Symptoms": ["He also noted bilateral hand pain along the metacarpophalangeal (MCP) and proximal interphalangeal (PIP) joints and prolonged morning stiffness lasting approximately 45 minutes."], "Examination and Results": ["Family history was notable for a brother with osteoarthritis, hypogonadism, and type 2 diabetes.Vital signs were within normal limits (heart rate, 92/min; blood pressure, 136/84 mm Hg; respiratory rate,  16/min; oxygen saturation, 97%; temperature, 37.0 \u00b0C).", "Musculoskeletal examination revealed swelling of the second, third, and fifth MCP joints and second and third PIP joints bilaterally as well as decreased knee and hip range of motion with minimal knee effusions.", "Lower back flexion was decreased with only 4-mm excursion on the modified Schober test.", "Results of cardiopulmonary, abdominal, neurologic, and dermatologic examinations were unremarkable.Results of laboratory testing, including complete blood cell count, basic metabolic panel, and liver function tests, were within normal limits, and results for HLA-B27 were negative.", "Erythrocyte sedimentation rate was 8 mm/h and C-reactive protein level was 0.5 mg/dL.", "A plain radiograph of the hands (Figure, left panel) showed hook-like osteophytes at the second and third MCP joints bilaterally as well as asymmetric joint swelling in multiple MCP and PIP joints."]}
{"Patient Personal Background": ["She denies any significant medical history, takes only multivitamins, and mentions a childhood heart murmur that was never evaluated.On examination, her blood pressure was 125/85 mm Hg, with a heart rate of 71/min and respiratory rate of 18/min."], "Patient Symptoms": ["She has no chest pain but was experiencing heart palpitations a few times per week."], "Examination and Results": ["Physical examination revealed a fixed split S2 and a 2/6 systolic murmur at the left upper sternal border.", "An electrocardiogram demonstrated sinus rhythm with incomplete right bundle-branch block.", "Transthoracic echocardiography demonstrated an enlarged right atrium and right ventricle; results of contrast echocardiography were negative."], "Others": ["A chest radiograph was obtained (Figure 1)."]}
{"Patient Personal Background": ["His medical history was significant for hyperlipidemia, familial polyposis, and acute myelogenous leukemia (AML) for which he had undergone an allogenic hematopoietic stem cell transplant 13 months earlier."], "Patient Symptoms": ["The patient had not attempted measures to alleviate the nodules and denied experiencing exacerbating factors or pain."], "Examination and Results": ["Cutaneous examination revealed green-gray nodules and plaques on the left and right upper chest (Figure 1).", "Bilateral cervical, axillary, and inguinal lymph node chains were negative for adenopathy.", "Biopsies of the skin lesions were performed.A, Representative dusky, green-gray nodule located on the upper chest.", "B, A prominent green hue is present at the base of a lesion following shave biopsy."]}
{"Patient Personal Background": ["The patient\u2019s medical history was unremarkable besides mild intermittent whole-body itching starting 9 months prior."], "Patient Symptoms": ["The patient\u2019s medical history was unremarkable besides mild intermittent whole-body itching starting 9 months prior."], "Examination and Results": ["Physical examination revealed mild proximal pyramidal weakness of the left leg (Medical Research Council grade 4/5), with brisk reflexes and extensor plantar response as well as hypoesthesia below the T2 level without sphincter disturbances.", "In addition, mild decrement in position sense and marked decrement of vibration sense were observed in both lower extremities.", "No skin lesions were detected, while cervical and supraclavicular lymph nodes were enlarged.", "Multiple enhancing lesions were observed on brain and cervical spine magnetic resonance imaging (MRI) (Figure).", "Cerebrospinal fluid (CSF) was acellular, and eosinophils and oligoclonal bands were not detected, while proteins, glucose, and angiotensin-converting enzyme (ACE) levels were within normal range.", "Test results for B-cell clones, viral, and fungal infections were all negative.", "Routine blood test results were unremarkable besides an elevated eosinophilic count (2.76 K/\u03bcL;17.6%).", "Antibodies for AQP4, MOG, and paraneoplastic syndromes were not detected.", "Whole-body fluorodeoxyglucose positron emission tomography demonstrated generalized lymphadenopathy without any other pathological findings.", "Whole-body gallium scan, chest high-resolution computed tomography, and bone marrow biopsy results were normal, while axillary and inguinal lymph node biopsies revealed nonspecific reactive lymphadenopathy.", "Parasitic infections were excluded by plasma and CSF antibodies testing with enzyme-linked immunosorbent assay, stool, and lymph node microscopy.", "Extensive diagnostic workup for malignancies and systemic autoimmune diseases was also inconclusive.Fluid-attenuated inversion recovery (FLAIR) images presenting bilateral subcortical lesions in the brain (A) and T2-weighted images demonstrating multiple lesions and swelling of the cervical cord (C)."]}
{"Patient Personal Background": ["She had poorly controlled hypertension for 10 years.", "There was no history of tobacco, alcohol, or drug consumption."], "Patient Symptoms": ["She had mild weight loss but denied symptoms of anorexia, vomiting, heartburn, chest pain, dyspepsia, hematemesis, or hemoptysis."], "Examination and Results": ["Chest radiography results before admission revealed multiple exudative foci in both lungs.", "Physical examination results on admission showed wheezes and rales in both lung fields and were otherwise normal.", "There were no abnormalities on routine blood tests."]}
{"Patient Symptoms": ["Her symptoms started 1 day after she rubbed her left eye with her hands after handling the milky latex (a fluid found in 10% of flowering plants) of a plant in her garden."], "Examination and Results": ["She had no recent history of recent eye surgery, eye trauma, cold sores, or new illnesses.On presentation, her visual acuity was 20/40 OD and 20/200 OS.", "Her pupils were equal, round, and reactive in both eyes.", "Her intraocular pressures were 16 mm Hg OD and 19 mm Hg OS.", "On anterior segment examination, she was found to have pinpoint epithelial defects, thickened stroma, and dense Descemet folds, along with a nuclear sclerotic cataract (Figure 1).", "Central pachymetry in the left eye measured 706 \u03bcm, which was elevated from the mean expected pachymetry values of 540 to 560 \u03bcm.", "A posterior pole examination was limited by corneal edema, but there was evidence of a vitreous hemorrhage.", "The fellow eye had no corneal edema and was pseudophakic, with prior panretinal photocoagulation scars in the peripheral retina."]}
{"Patient Symptoms": ["Three weeks prior, the patient had noted severe left-sided facial pain."], "Examination and Results": ["Following a workup with unremarkable results, the patient presented to the Bascom Palmer emergency department for a second opinion.On initial examination, his best-corrected visual acuity was 20/20 OU.", "Intraocular pressure, ocular motility, and confrontational visual fields were normal.", "There was no axial proptosis or enophthalmos by exophthalmometry.", "The pupil was 5 mm OD and 4 mm OS.", "No afferent pupillary defect was observed.", "External examination demonstrated a left-sided ptosis (Figure 1).", "Anhidrosis was not observed.", "Anterior and posterior examination, including of the optic nerve head, had normal results in both eyes.", "The cranial nerve, gross motor, and gross sensory examination had otherwise unremarkable results."], "Others": ["He denied any diplopia, decreased vision, or recent trauma.", "The patient had previously been evaluated by his primary care physician and referred to a neuroophthalmologist.", "During the course of the workup, the patient had undergone computed tomography (CT) of the head and chest, magnetic resonance imaging (MRI) of the brain, and carotid duplex ultrasonography."]}
{"Patient Symptoms": ["Immediately following workup with noncontrast abdominal ultrasonography, he experienced intense flushing and vomiting."], "Examination and Results": ["Subsequent contrast-enhanced magnetic resonance imaging identified a 5-cm thoracic paraspinal mass (Figure, A).", "Computed tomography\u2013guided biopsy of the paraspinal mass revealed a dense cellular infiltrate on histopathology composed of cells with round nuclei and abundant pale cytoplasm (Figure, B).A, Axial postcontrast T1-weighted magnetic resonance imaging of the spine identifying a paraspinal soft-tissue mass (bracketed by white arrowheads) encasing the descending aorta with neural foramen extension (pink arrowhead).", "B, Computed tomography\u2013guided biopsy sample (original magnification \u00d7400) showing a monomorphic infiltrate of small- to medium-sized round cells with uniform angulated nuclei and abundant amphophilic hypogranular cytoplasm."]}
{"Patient Symptoms": ["Four weeks after the transplant, the patient developed acute vision loss of the left eye.", "Pain worsened, intraocular pressure elevated into the mid-40s mm Hg, visual acuity waned to no light perception, and intraocular inflammation and subretinal infiltrates continued to worsen, producing nearly closed funnel retinal detachments in both eyes, including developing orbital cellulitis in the right eye despite broad-spectrum antimicrobials."], "Examination and Results": ["Visual acuity was 20/20 OD and hand motion OS.", "Anterior segment was remarkable for 1+ hyperemia and 4+ anterior chamber (AC) cell in the left eye.", "Posterior segment was notable for retinal whitening and occlusive vasculitis in the right eye and more extensive retinal whitening associated with an exudative retinal detachment in the left eye.", "Microbial and broad-range polymerase chain reaction (PCR) analysis and culture results of the AC and vitreous were negative as well as numerous blood cultures and serum fungitell.", "During this period, the patient remained afebrile; however, the patient\u2019s white blood cell count was uptrending, raising concern for systemic spread of the infection.A, Intraoperative images from the diagnostic vitrectomy and subretinal biopsy performed on the left eye showing substantial hemorrhagic retinitis with subretinal infiltrate (white arrowhead)."], "Treatment": ["Despite broad-spectrum intravenous (ie, vancomycin and piperacillin/tazobactam) and intravitreal antibiotics (vancomycin and ceftazidime), antifungals (amphotericin B and voriconazole), and antivirals (foscarnet), the patient\u2019s visual acuity and intraocular inflammation worsened in both eyes to light perception.", "Owing to the diagnostic dilemma, a pars plana vitrectomy with subretinal biopsy was performed in the left eye, and again, microbiological analysis including culture and PCR analysis was inconclusive."], "Others": ["Over a week, the areas of retinal whitening became elevated owing to enlarging subretinal infiltrates (Figure, A) that were nearly kissing in the right eye (Figure, B)."]}
{"Patient Personal Background": ["There was no relevant medical history.", "The family reported living in a rural area on the Mediterranean coast.A, Erythematous nodule on the proximal nail fold."], "Patient Symptoms": ["This lesion had started as a light erythema a few months before, initially oriented as a bacterial paronychia or herpetic whitlow and treated with an oral antibiotic (amoxicillin) and antiviral (acyclovir) without improvement.", "No other fingers were affected."], "Examination and Results": ["B, Inflammatory erythematous plaque with a central shiny orange crust on the left index.", "C, Diffuse dermatitis with epithelioid granulomas (hematoxylin-eosin stain).", "D, Intracellular amastigotes in the dermal macrophages (hematoxylin-eosin stain).Physical examination findings revealed an inflammatory erythematous plaque with a central shiny orange crust on the left index finger (Figure, B)."], "Treatment": ["This lesion had started as a light erythema a few months before, initially oriented as a bacterial paronychia or herpetic whitlow and treated with an oral antibiotic (amoxicillin) and antiviral (acyclovir) without improvement."], "Others": ["There were no systemic symptoms or family history of similar lesions."]}
{"Patient Symptoms": ["B, Cytomegalovirus endotheliitis\u2013associated coin-shaped lesion (arrowhead) superior to an F-stamp of the DMEK graft.Five weeks later, there was a painless decrease in BCVA to 20/80.", "Small keratic precipitates (KPs) were noted.", "Six weeks later, while taking prednisolone 6 times daily, the patient developed new KPs in coin-shaped aggregates (Figure 1B) along with new anterior chamber (AC) inflammation."], "Examination and Results": ["Her best-corrected visual acuity (BCVA) improved to 20/40 two weeks later, limited because of a preexisting corneal scar.A, Pre\u2013Descemet membrane endothelial keratoplasty (DMEK) photograph of edema and bullous keratopathy, and superficial scar.", "Central corneal thickness was 758 \u03bcm.", "Her intraocular pressure (IOP) increased to 25 mm Hg.", "No vitritis or infiltrates were in the graft-host interface or capsular bag."], "Treatment": ["Because the patient admitted to inconsistent adherence to the topical steroid regimen, rejection was suspected.", "Prednisolone acetate, 1%, was increased from 4 times to 8 times daily.", "Five days later the KP resolved and a slow taper of the prednisolone was initiated."], "Diagnosis": ["B, Cytomegalovirus endotheliitis\u2013associated coin-shaped lesion (arrowhead) superior to an F-stamp of the DMEK graft.Five weeks later, there was a painless decrease in BCVA to 20/80."]}
{"Patient Personal Background": ["She denied nasal disturbance, prior sinus surgery, asthma, or acetylsalicylic acid (aspirin) sensitivity."], "Patient Symptoms": ["Symptoms included a several-year history of frontal pain, pressure, clear nasal discharge, and progressive nontender facial swelling above her glabella.", "Symptoms were refractory to treatment with several rounds of oral antibiotics and oral steroids."], "Examination and Results": ["Physical examination findings revealed symmetric facial movement with prominent glabellar swelling and soft tissue thickening.", "Nasal endoscopy findings revealed a soft tissue mass anterior to the axilla of the middle turbinates bilaterally, with normal-appearing mucosa overlying.", "Computed tomography and magnetic resonance imaging (MRI) scans were obtained for further evaluation (Figure, A).", "Adjacent soft tissue thickening noted on skin overlying frontal sinus and nasal bones.", "No intracranial extension noted.", "B, Hematoxylin-eosin stain (original magnification \u00d710) results showed lobules of neoplastic cells with whorled architecture (arrowhead).", "C, Hematoxylin-eosin stain (original magnification \u00d720) results showed intranuclear inclusions (arrowhead)."], "Treatment": ["Recommendations were made to proceed to the operating room for biopsy of the nasal mass."], "Others": ["Pathology results revealed uniform, epithelioid cells arranged in a whorled, lobulated growth pattern without atypia, necrosis, increased cellularity, or diffuse growth pattern (Figure, B and C).A, T1-Weighted postcontrast magnetic resonance imaging scan, sagittal view, showed hyperintense soft tissue mass on anterior septum with extension into frontal sinus."]}
{"Patient Symptoms": ["His 3-month posttreatment fluorodeoxyglucose (FDG) positron-emission tomography/CT (FDG-PET/CT) imaging results demonstrated resolution of the activity at the base of tongue mass and the involved cervical lymph nodes, consistent with complete treatment response.In July 2019, the patient presented with a palpable left supraclavicular lymph node."], "Examination and Results": ["Biopsy of the mass demonstrated metastatic p16-positive (human papillomavirus [HPV]-related) squamous cell carcinoma.", "Examination revealed a large left base of tongue mass filling the vallecula.", "Computed tomography (CT) demonstrated an enhancing mass within the left base of tongue and bilateral cervical adenopathy.", "His 3-month posttreatment fluorodeoxyglucose (FDG) positron-emission tomography/CT (FDG-PET/CT) imaging results demonstrated resolution of the activity at the base of tongue mass and the involved cervical lymph nodes, consistent with complete treatment response.In July 2019, the patient presented with a palpable left supraclavicular lymph node.", "Restaging FDG-PET/CT demonstrated avid supraclavicular and anterolateral neck adenopathy.", "Additionally, there was moderately intense activity isolated to the left thyroid lobe.", "Ultrasonography of the thyroid demonstrated a 4-cm mass within the gland, and subsequent biopsy was performed with immunohistochemistry staining positive for p16, CK5, and p40 and negative for thyroid transcription factor 1 (TTF-1) (Figure, A, B).", "C, Lesional specimen showing tumor cells arranged in irregular nests and cords invading the thyroid parenchyma; normal thyroid tissue shown by the arrowhead (original magnification \u00d74)."], "Treatment": ["The patient was treated with concurrent radiation therapy and cetuximab, completing treatment without breaks in November 2018.", "After multidisciplinary review of the case, the patient was offered salvage left modified radical neck dissection and total thyroidectomy."], "Diagnosis": ["Biopsy of the mass demonstrated metastatic p16-positive (human papillomavirus [HPV]-related) squamous cell carcinoma.", "Surgical pathology confirmed the diagnosis (Figure, C).Fine-needle aspiration of the left thyroid lesion showing sheets and clusters of tumor cells with indistinct cell borders, with immunohistochemical staining positive for p16 (A) and negative for TTF-1 (B) (both panels, original magnification \u00d720)."]}
{"Patient Symptoms": ["Six months prior to presentation, she developed a dull pain in her left calf while climbing stairs.", "After climbing 2 flights of stairs, she had to stop and rest for approximately 15 seconds.", "She reported no pain at rest.", "The patient\u2019s symptoms worsened and began interfering with her work."], "Examination and Results": ["On physical examination, her heart rate was 82/min and blood pressure was 140/89 mm Hg.", "Her lower extremities were warm, with strength for femoral, popliteal, dorsalis pedis, and posterior tibial pulses at 2+ bilaterally.", "She had no history of spinal degenerative disease and did not have lower extremity arterial bruits, wounds, sensory deficits, edema, or hair loss."]}
{"Patient Personal Background": ["She was not taking any medications."], "Patient Symptoms": ["She had no fevers, nausea, vomiting, diarrhea, constipation, blood in the stool, or weight loss."], "Examination and Results": ["On examination, her temperature was 36.9 \u00b0C; heart rate, 72/min; blood pressure, 132/68 mm Hg; and body mass index, 25 (calculated as weight in kilograms divided by height in meters squared).", "Results of complete blood cell count and serum chemistries were unremarkable, with no leukocytosis and normal differential count.", "Abdominal examination demonstrated mild distention without fluid wave and mild right lower abdomen and suprapubic tenderness.", "Computed tomography (Figure 1) and magnetic resonance imaging demonstrated pelvic ascites and an enhancing lesion at the base of the cecum.", "Two attempts at ultrasound-guided paracentesis were nondiagnostic because of acellular specimens."]}
{"Patient Personal Background": ["The medical history was unremarkable, and findings of a review of systems were negative.", "The patient had been treated in the past with topical steroids without improvement, and the size of the lesion had continued to grow slowly."], "Patient Symptoms": ["The patient had been treated in the past with topical steroids without improvement, and the size of the lesion had continued to grow slowly."], "Examination and Results": ["Physical examination findings revealed a solitary, well-circumscribed pink plaque with overlying yellow-white micaceous scale with interspersed punctate hemorrhagic crusts (Figure, A).", "Lymphadenopathy was not identified.", "Punch biopsy for histopathologic examination was performed, with representative sections shown (Figure, B and C).A, Well-circumscribed pink, scaly plaque on the right elbow.", "B and C, Hematoxylin-eosin\u2013stained sections reveal psoriasiform epidermal hyperplasia overlying suppurative granulomatous infiltrates with multinucleate giant cells and rare eosinophilic spheroid forms."], "Treatment": ["The patient had been treated in the past with topical steroids without improvement, and the size of the lesion had continued to grow slowly."]}
{"Patient Personal Background": ["On arrival, his blood pressure was 222/120 mm Hg, which subsequently normalized with administration of his home regimen for hypertension."], "Patient Symptoms": ["The patient noted an elevated blood pressure and took clonidine hydrochloride without effect, so he called emergency medical services.", "His chest pressure resolved after administration of sublingual nitroglycerin en route to the emergency department.", "Following initial angioplasty, the patient abruptly became hypotensive without chest discomfort despite quick balloon inflations and robust thrombolysis in myocardial infarction grade 3 flow down both the LAD and LCX.", "Unfortunately, his blood pressure continued to rapidly decline, and he experienced an asystolic cardiac arrest."], "Examination and Results": ["An electrocardiogram showed sinus rhythm with a preexisting left bundle-branch block.", "The troponin I level was initially undetectable but subsequently peaked at 1.3 ng/mL (conversion to micrograms per liter is 1:1).", "A transthoracic echocardiogram showed normal left ventricular systolic function with regional wall motion abnormalities suggestive of ischemia in the area supplied by the left anterior descending coronary artery (LAD).", "The patient was taken to the cardiac catheterization laboratory the following day for further management of his non\u2013ST-segment elevation myocardial infarction.Coronary angiography revealed a high-grade distal left main coronary artery (LM) bifurcation lesion extending predominantly into the LAD (Figure 1A); the remainder of his coronary tree showed no evidence of obstructive disease."], "Treatment": ["The patient noted an elevated blood pressure and took clonidine hydrochloride without effect, so he called emergency medical services.", "His chest pressure resolved after administration of sublingual nitroglycerin en route to the emergency department.", "On arrival, his blood pressure was 222/120 mm Hg, which subsequently normalized with administration of his home regimen for hypertension.", "Given the patient\u2019s low SYNTAX (synergy between percutaneous coronary intervention [PCI] with taxus and cardiac surgery) score and preference to avoid surgery, he underwent transradial PCI of the LM-LAD using a provisional approach for the left circumflex coronary artery (LCX).", "There was no evidence of coronary dissection or perforation.", "The LM-LAD was quickly stented (Figure 1B) as intravenous fluids and escalating doses of intravenous dopamine hydrochloride and epinephrine drips were administered.", "Cardiopulmonary resuscitation was initiated and the patient was emergently intubated, but he remained in asystole.Selective left coronary angiography before (A) and after (B) percutaneous coronary intervention (PCI) of the left main coronary artery and the left anterior descending coronary artery."], "Diagnosis": ["The patient was taken to the cardiac catheterization laboratory the following day for further management of his non\u2013ST-segment elevation myocardial infarction.Coronary angiography revealed a high-grade distal left main coronary artery (LM) bifurcation lesion extending predominantly into the LAD (Figure 1A); the remainder of his coronary tree showed no evidence of obstructive disease."]}
{"Patient Symptoms": ["He reported throat tightness after significant voice use and consistent voice roughness that worsened over several weeks.", "The patient continued to report dysphonia and increased vocal effort."], "Examination and Results": ["On examination, he had moderate to severe dysphonia with predominant roughness and strain.", "Follow-up videostroboscopy findings demonstrated resolution of the fungal laryngitis but revealed residual fullness of the left false vocal fold and appearance of prolapsed ventricular mucosa obstructing the lateral extent of the left true vocal fold.", "There was a reduction of lateral excursion of the mucosal wave on the left.", "A computed tomography scan with contrast showed no specific abnormalities.", "Intraoperatively, there was a firm lesion in the left paraglottic space extending to the lateral aspect of the true vocal fold (Figure, A).", "A subtle but similar finding was seen on the right true vocal fold, not causing any mass effect (Figure, B)."], "Treatment": ["Videostroboscopy findings were consistent with fungal laryngitis; a 2-week course of fluconazole was administered.", "This revealed a cartilaginous lesion, which was removed using an AcuBlade CO2 laser (Lumenis) and cup forceps until the cartilaginous edge was smooth within the paraglottic space (Figure, C and D)."], "Diagnosis": ["Follow-up videostroboscopy findings demonstrated resolution of the fungal laryngitis but revealed residual fullness of the left false vocal fold and appearance of prolapsed ventricular mucosa obstructing the lateral extent of the left true vocal fold."], "Others": ["A direct laryngoscopy for evaluation and treatment was planned.", "The histologic specimen showed fragments of cartilage with no nuclear atypia or mitosis (Figure, E and F).", "At 3-months\u2019 follow-up, the patient reported improvement in his voice with decreased effort and strain, which correlated with improvement in the Voice Handicap Index score and objective assessment by the clinicians.Direct laryngoscopy intraoperative images demonstrating left lesion (A), right lesion (B), submucosal firm, white mass excised with a CO2 laser (C), and postoperative view (D); hematoxylin-eosin stain of the left lateral vocal fold lesion showing fragments of cartilage (arrow indicates a peripheral thin fibroblastic rim with a transition to mature chondrocytes of the fibroelastic cartilage toward the center of the nodule) (E) and cartilage with mild nuclear atypia without mitosis (F)."]}
{"Patient Symptoms": ["The lesion was of unknown duration and was reported by the patient to be asymptomatic, although he did endorse occasional pruritus."], "Examination and Results": ["An extraoral examination was performed without any abnormal findings.", "On intraoral soft tissue examination, a brown pigmented patch located predominantly on the hard palate was observed.", "The lesion had well-defined but irregular borders, measured 2\u2009\u00d7\u20091.2 cm in size, and was nontender to palpation (Figure, A).", "Findings of the remainder of the intraoral soft tissue examination were within normal limits.", "B and C, Medium-magnification and high-magnification hematoxylin-eosin\u2013stained images demonstrate slender, elongated dendritic melanocytes (marked by arrows) throughout the epithelium.Histologic examination findings revealed soft tissue covered by benign-appearing stratified squamous epithelium, focally spongiotic and acanthotic.", "Within the epithelium, numerous benign dendritic melanocytes were identified (Figure, B and C).", "The underlying connective tissues were unremarkable."], "Treatment": ["An incisional biopsy was performed, and the specimen was sent for microscopic diagnosis.A, Intraoral photograph demonstrating the brown pigmented palatal patch with irregular, albeit sharply demarcated borders."]}
{"Patient Personal Background": ["The patient had no significant medical history; prior surgical history was notable for tonsillectomy."], "Patient Symptoms": ["The hypoesthesia was limited to the distribution of the mandibular branch of the left trigeminal nerve (V3).", "On review of systems, the patient denied experiencing visual changes, dizziness, headaches, oral or neck pain, voice changes, weight or appetite changes, or swallowing dysfunction; however, he did report biting his lip occasionally due to the numbness."], "Examination and Results": ["On examination, there were no palpable masses noted in the head, neck, or face.", "Aside from the V3 sensory deficit, the patient had no cranial nerve deficits.", "Magnetic resonance imaging of the face revealed a T1 isointense, T2 hyperintense 5.9-cm lesion in the left masticator space, which appeared to be centered in the lateral pterygoid muscle with benign-appearing remodeling of the posterior maxillary wall (Figure).A, The lesion (indicated by the arrow) is isointense on T1-weighted magnetic resonance imaging (MRI) without contrast.", "B, The lesion enhances with contrast on fat-suppressed T1-weighted imaging.", "C, The mass is hyperintense on the T2-weighted sequence.", "D, Computed tomography imaging reveals bony erosion and expansion of the lesion into the maxillary sinus."]}
{"Patient Symptoms": ["No fever, odynophagia, dysphagia, otalgia, or other constitutional symptoms were reported."], "Examination and Results": ["Physical examination findings demonstrated a palpable, soft, nontender left level II/III neck mass.", "Clinical examination findings of the thyroid and upper aerodigestive tract were unremarkable.", "Contrast-enhanced neck computed tomography (CT) showed a large avidly enhancing mass centered at the left carotid bifurcation splaying the internal and external carotid arteries and extending cranially along the cervical internal carotid artery.", "The left internal jugular vein was displaced posteriorly.", "There was also a smaller mass with similar appearance at the right carotid bifurcation (Figure 1A).", "Contrast-enhanced abdominal CT showed several enhancing masses in the liver (not shown).", "Based on CT findings, gallium Ga 68 (68Ga) dotatate positron emission tomography (PET)/magnetic resonance imaging (MRI) was performed; results demonstrated intense radiotracer avidity in bilateral carotid space masses, hepatic masses, and numerous CT occult osseous lesions (Figure 1B).A, Axial contrast-enhanced neck computed tomography (CT) demonstrates large left (black asterisk) and small right (white arrowhead) avidly enhancing bilateral carotid space masses.", "The left tumor circumferentially encases the left external carotid artery (black arrowhead) and partially encases the left internal carotid artery (yellow arrowhead).", "B, Coronal gallium 68 dotatate positron emission tomography/magnetic resonance imaging (PET/MRI) demonstrates intense radiotracer uptake of bilateral carotid space masses (left, black asterisk; right, white arrowhead), hepatic masses (black arrowhead), and CT occult osseous lesions as seen in the right femoral neck (yellow arrowhead)."], "Treatment": ["The patient had been treated presumptively for infection with antibiotics, with no improvement."]}
{"Patient Personal Background": ["His medical history was significant for Crohn disease controlled with monthly injections of ustekinumab (Stelara; Janssen Biotech Inc)."], "Patient Symptoms": ["Symptoms of fever, headache, and myalgia began 1 week prior following a tick bite.", "While hospitalized, he developed acute bilateral central scotoma."], "Examination and Results": ["He was found to be anemic (hemoglobin concentration, 6.7 g/dL; normal concentration, 13.5-17.5 g/dL) (to convert hemoglobin concentration to g/L, multiply by 10), requiring transfusion.", "Magnetic resonance imaging of the orbit and brain with and without contrast was unremarkable.", "Infectious serology test results for Lyme disease, syphilis, malaria, Anaplasma species, Cryptococcus species, Rocky Mountain spotted fever, and rickettsia were negative.", "Rheumatologic serology test results for antinuclear antibodies, including Sj\u00f6gren anti-Ro and anti-La, anti-DNA, and anti-Smith, were also negative.", "Antineutrophil cytoplasmic antibody testing revealed elevated proteinase 3 antibody level.", "Polymerase chain reaction results for babesiosis later returned as negative.Ocular examination revealed uncorrected distance acuity of 20/50 OD and 20/60 OS.", "Intraocular pressure values were normal, and there was no afferent pupillary defect.", "Slitlamp evaluation showed bilateral rare anterior vitreous cell.", "Dilated fundus examination revealed bilateral reddened foveal lesions and irregular macular pigmentation."], "Treatment": ["He was prescribed oral doxycycline hyclate for suspected Lyme disease.", "Owing to persistent fever while receiving oral doxycycline hyclate, he was admitted for intravenous administration of doxycycline hyclate, and the fever resolved.", "Peripheral blood smear and polymerase chain reaction were performed; empirical therapy of azithromycin, 500 mg daily, plus atovaquone, 750 mg twice daily, was initiated."], "Diagnosis": ["In the setting of anemia, infectious-disease consultants raised concern for babesiosis."]}
{"Patient Symptoms": ["He denied having any symptoms of increased intracranial pressure (ICP), including headaches, pulsatile tinnitus, and transient visual obscurations."], "Examination and Results": ["Findings on computed tomography of the brain without contrast were unremarkable.", "He was then seen by an ophthalmologist who confirmed bilateral severe optic nerve edema and requested magnetic resonance imaging of the brain and orbits without contrast.", "It demonstrated signs of increased ICP, including empty sella, posterior flattening of the globes, and widened optic nerve sheaths, but no other abnormalities (Figure 1A).A, Axial T2-weighted magnetic resonance imaging (MRI) showing flattening of the posterior margin of the globes at the insertion point of the optic nerves (white arrowhead) and dilatation of the subarachnoid space along the optic nerve sheaths (yellow arrowhead), which are signs of elevated intracranial pressure.", "These findings are symmetrical between the 2 eyes.", "B, Fundus photograph demonstrating grade 3 to 4 optic nerve edema of the left eye.", "The visualized retinal vessels and retina are normal.", "The right eye had a similar appearance.On examination, best-corrected central acuities were 20/20 OD and 20/25 OS.", "There was no relative afferent pupillary defect.", "Findings of color vision testing with Ishihara isochromatic plates were normal in each eye (17 of 17 plates identified).", "Dilated ophthalmoscopic examination revealed severe optic nerve edema bilaterally with normal-appearing macula and retinal vasculature (Figure 1B).", "Visual fields (Humphrey 24-2 algorithm) were normal in each eye.", "Optical coherence tomography of the peripapillary retinal nerve fiber layer demonstrated increased retinal nerve fiber layer thickness bilaterally (mean of 246 \u03bcm OD and 252 \u03bcm OS).", "Fundus autofluorescence imaging did not demonstrate optic nerve head autofluorescence."]}
{"Patient Personal Background": ["He had a medical history of hypertension, anxiety, and posttraumatic stress disorder, for which he took amlodipine, lorazepam, citalopram, and quetiapine.", "He smoked 1.5 packs of cigarettes per day for the past 30 years and had a history of substantial alcohol use, drinking 2 to 3 L of wine per day.", "Because of excessive alcohol intake, he only ate 1 meal per day."], "Examination and Results": ["His family history was unremarkable for optic nerve conditions or unexplained blindness.On examination, his visual acuity was 20/400 OU, there was no relative afferent pupillary defect, and his anterior segment examination results were normal.", "Dilated fundus examination results revealed bilateral optic nerve hyperemia, blurred margins, and subtle telangiectatic vessels on the surface of the optic nerve bilaterally.", "Humphrey 24-2 Swedish Interactive Testing Algorithm fast visual field testing showed central scotomas in both eyes (Figure).", "Optical coherence tomography results of the macula were normal in both eyes.", "Neurological examination results revealed otherwise normal cranial nerves, normal sensation in the extremities, normal reflexes, and normal strength.Humphrey 24-2 Swedish Interactive Testing Algorithm fast visual fields demonstrating central scotomas in both eyes."]}
{"Patient Personal Background": ["Prior surgeries included cataract surgery in both eyes, selective laser trabeculoplasty in both eyes, trabectome in the right eye (NeoMedix), and mitomycin trabeculectomies in both eyes.", "Medications included latanoprost in both eyes once daily, dorzolamide-timolol in the right eye twice daily, and brimonidine in the right eye once daily without complications until a few months prior to presentation when netarsudil in both eyes once a day was added for high intraocular pressures of 21 mm Hg OD and 17 mm Hg OS.", "Netarsudil was used in both eyes after a monocular trial of netarsudil in the right eye, which was judged successful owing to a 9\u2013mm Hg pressure reduction in the right eye relative to the left eye."], "Patient Symptoms": ["A few weeks later, the patient returned with worsening pain in the right eye, and visual acuity was 20/500 OD and 20/250 OS."], "Examination and Results": ["On presentation, his visual acuity was 20/50 OD and 20/200 OS with correction (1 line worse from baseline in the right eye).", "Pressures were 18 mm Hg OU.", "Slitlamp examination revealed conjunctival hyperemia and papillae in both eyes.", "The right cornea had 1.5 mm of inferonasal microcystoid epithelial edema with neovascularization.", "Cup-disc ratios were 0.8 OD and 0.9 OS.", "Dorzolamide in the right eye was discontinued.", "There was diffuse microcystoid epithelial and stromal edema in both eyes, worsening reticular changes in the right eye (Figure 1), a new inferocentral wavelike superficial opacification in the left eye, and high pressures (28 mm Hg OD and 13 mm Hg OS).A, Netarsudil-associated reticular epithelial edema was most marked inferior nasally in the right eye (white arrowhead), although diffuse microcystoid epithelial and stromal edema were present in both eyes."], "Treatment": ["Medications included latanoprost in both eyes once daily, dorzolamide-timolol in the right eye twice daily, and brimonidine in the right eye once daily without complications until a few months prior to presentation when netarsudil in both eyes once a day was added for high intraocular pressures of 21 mm Hg OD and 17 mm Hg OS.", "Dorzolamide in the right eye was discontinued."]}
{"Patient Symptoms": ["On review of systems, she reported hair loss, dryness of the eyes and mouth, and mild esophageal dysphagia.", "She reported no oral ulcers, pleuritic chest pain, shortness of breath, hemoptysis, decreased urine output, hematuria, joint pain, fevers, or weight change.On examination, she was afebrile."], "Examination and Results": ["Heart rate was 60/min; blood pressure, 100/70 mm Hg; respiratory rate, 18/min; and Spo2, 100%.", "Her hands and fingers were mildly edematous, and the fingertips variably showed purple discoloration, distal pitting scars, and ischemic ulcers (Figure, panel A).", "There was periungual erythema with dilated nailfold capillaries but no splinter hemorrhages.", "She had no evidence of sclerodactyly or proximal skin thickening, with hands and face showing fine wrinkles and normal-appearing skin folds.", "Results of initial laboratory studies were notable for white blood cell count 3270/\u03bcL; hemoglobin level, 14.5 g/dL; platelet count, 143 \u00d7103/\u03bcL; creatinine level, 1.0 mg/dL (88.4 \u03bcmol/L); and C-reactive protein level, 0.1 mg/dL.", "Computed tomography angiography (CTA) of the bilateral upper extremities showed normal vasculature.", "Antinuclear antibodies (ANA) were positive at 1:640 or greater by indirect immunofluorescence in a composite nuclear and nucleolar fine speckled staining pattern (Figure, B).", "Subserologic testing showed high positive anti-Ro52 (176; <20), anti-Ro60 (563; <20), and anti\u2013Scl-70 antibodies (786; <20).A, Digital changes observed in patient."]}
{"Patient Personal Background": ["She took no medications and her medical history was significant for a first-trimester miscarriage.", "She was a schoolteacher and had not traveled outside of the country in the past 10 years.Physical examination of her lower extremities revealed erythematous and indurated plaques, some with overlying coarse scale (Figure, A and B)."], "Patient Symptoms": ["The plaques began around her ankles and spread proximally, reaching the upper thighs by the time of presentation.", "She also noted new lesions on her arms and abdomen in the preceding weeks.", "The eruption was asymptomatic, and the plaques were preceded by lower extremity edema and weakness, resulting in difficulty ambulating and frequent falls.", "The patient also reported allodynia, tingling, and numbness in her lower legs."], "Examination and Results": ["Her neurological examination showed symmetric 4/5 strength and decreased reflexes in her lower extremities.", "Sensation to light touch and proprioception were diminished below the knee.", "Two punch biopsies were performed for histologic review (Figure, C and D).A, Dark brown, coarse, ichthyosiform scale on the bilateral lower legs.", "B, Firm pink plaques with overlying coarse scale.", "C, Granulomatous inflammation throughout the dermis with mild hyperparakeratosis around a hair follicle (hematoxylin-eosin).", "D, Well-formed, epithelioid granulomas (hematoxylin-eosin)."]}
{"Patient Personal Background": ["No remarkable medical history was noted."], "Patient Symptoms": ["Physical examination findings revealed a 4\u2009\u00d7\u20092-cm erythematous, violaceous, indurated, scaly plaque with some papules on his right upper eyelid (Figure, A)."], "Examination and Results": ["Results of routine blood tests and biochemistry analysis were within normal limits.", "A biopsy sample was obtained for histopathologic examination (Figure, B).A, A 4\u2009\u00d7\u20092-cm erythematous, violaceous, indurated, scaly plaque with some papules on the right upper eyelid.", "B, Lesional specimen (original magnification \u00d750).", "C, High-power magnification of histopathologic examination; arrows indicate atypical lymphocytes (hematoxylin-eosin).", "D, Lymphocytic infiltrates predominantly positive for CD4.Histopathologic analysis revealed perifollicular lymphocytic infiltrates around cystically dilated follicular infundibula and exocytosis of atypical lymphocytes into the epithelium, with admixed plasma cells, eosinophils, and multinucleate giant cells (Figure, C).", "Alcian blue staining showed focal mild follicular mucin deposition.", "Immunohistochemical analysis showed lymphocytic infiltrates positive for CD3, CD4, CD5, and CD7 and negative for CD8, CD20, CD30, CD79a, and CD56 (Figure, D).", "The ratio of CD4 to CD8 cells within hair follicles was greater than 7:1.", "Monoclonal T-cell gene rearrangement was demonstrated."]}
{"Patient Personal Background": ["She had been diagnosed with hormone receptor\u2013positive right breast cancer 8 years prior and underwent lumpectomy and treatment with an aromatase inhibitor, with remission since.", "Five years later, she subsequently developed left inguinal adenopathy, which biopsy results showed was follicular lymphoma."], "Examination and Results": ["Magnetic resonance imaging (MRI) of the brain was performed, demonstrating T2 fluid-attenuated inversion recovery hyperintensity in the left occipital and temporal lobes, crossing the corpus callosum and extending into the right occipital lobe without enhancement (Figure).A, Axial T2 fluid-attenuated inversion recovery precontrast magnetic resonance imaging (MRI) of the brain.", "B, Axial T1 magnetization-prepared rapid acquisition gradient-echo postcontrast MRI of the brain."], "Treatment": ["At that time, she was treated with a course of bendamustine and rituximab with subsequent maintenance treatment with rituximab for 2 years."], "Diagnosis": ["She had been diagnosed with hormone receptor\u2013positive right breast cancer 8 years prior and underwent lumpectomy and treatment with an aromatase inhibitor, with remission since.", "Five years later, she subsequently developed left inguinal adenopathy, which biopsy results showed was follicular lymphoma."]}
{"Patient Personal Background": ["Two years prior to presentation, the patient was presumptively diagnosed with viral myocarditis at an outside hospital after experiencing a ventricular fibrillation arrest.", "He was subsequently scheduled to undergo endomyocardial biopsy but was lost to follow-up."], "Patient Symptoms": ["Two weeks prior to the date of the presenting ECG, he was admitted to the hospital for symptomatic bradycardia and found to be in sinus rhythm with complete atrioventricular block."], "Examination and Results": ["A dual-chamber pacemaker was implanted, with active fixation leads placed in the right atrium and right ventricular apex.", "An ECG obtained immediately after the procedure showed an atrial-ventricular\u2013paced rhythm.", "His vital signs were documented as a blood pressure of 119/69 mm Hg, a heart rate of 51 beats per minute, a respiratory rate of 16 breaths per minute, and an oxygen saturation of 100% on room air."], "Treatment": ["A dual-chamber pacemaker was implanted, with active fixation leads placed in the right atrium and right ventricular apex.", "The postimplantation course was uncomplicated, and he was subsequently discharged."], "Others": ["He presented for routine postprocedure outpatient follow-up, at which time this ECG (Figure 1) was obtained.", "He was asymptomatic."]}
{"Examination and Results": ["On arrival to the hospital, the patient had a computed tomography scan performed; results demonstrated an obstructive laryngeal mass but no signs of local invasion or lymphadenopathy.", "Findings of a direct laryngoscopy demonstrated violaceous nodules of the base of the tongue as well as a mass of the infraglottis and subglottis, which was nearly completely obstructing the airway (Figure, A and B).", "Full physical examination findings also demonstrated violaceous nodules involving the patient\u2019s lower extremities.", "Results of an excisional biopsy demonstrated a subepithelial spindle cell lesion with extravasation of erythrocytes and stained strongly for human herpesvirus-8 (Figure, C).Left base of tongue mass with a violaceous hue (A), obstructive mass of the subglottic airway (B), and subepithelial spindle cell lesion with extravasation of erythrocytes and stained strongly for human herpesvirus-8 (hematoxylin-eosin; original magnification \u00d710) (C)."], "Treatment": ["The patient was taken urgently to the operating room where an awake tracheostomy was performed without complication."]}
{"Patient Personal Background": ["She had no prior medical or surgical history and took no medications."], "Examination and Results": ["Ultrasonography demonstrated a solid and hypoechoic mass, 1.5\u2009\u00d7\u20091.0\u2009\u00d7\u20090.9 cm, in the inferior right parotid gland with minimal vascularity and without extraparotid extension.", "No lymph node abnormality was observed.", "Fine-needle aspiration was performed, and the smear was extremely cellular and showed sheets and clusters of bland polygonal epithelial cells admixed with bright pink filamentous matrix.", "Abundant bubbly secretion was present within these microcystic spaces, and this material was positive for periodic acid\u2013Schiff (Figure, C).", "Immunohistochemically, there was positivity for epithelial membrane antigen, cytokeratin (CK) 7 and CK19, S100 protein, and gross cystic disease fluid protein 15 (GCDFP-15).", "Stains for gastrointestinal stromal tumors 1 (DOG1) and p63 were negative.", "The patient underwent a right parotidectomy I to IV1 and a level II superselective neck dissection.A, Hematoxylin-eosin, original magnification \u00d740.", "Tumor cells with oval and rounded nuclei with fine chromatin and centrally localized nucleolus, with papillary architecture.", "B, Microcystic growth pattern (hematoxylin-eosin, original magnification \u00d740).", "C, The secretory material stains positive for periodic acid\u2013Schiff; original magnification \u00d720."], "Treatment": ["Because of the size and location, extracapsular dissection II was carried out.1 The final pathology of the lesion showed histologic findings compatible with salivary gland carcinoma, with microcystic and papillary architecture (Figure, A and B).", "There was perineural invasion without evidence of neoplastic emboli in the peritumoral lymphovascular spaces."], "Diagnosis": ["Because of the size and location, extracapsular dissection II was carried out.1 The final pathology of the lesion showed histologic findings compatible with salivary gland carcinoma, with microcystic and papillary architecture (Figure, A and B)."], "Others": ["The tumor appeared to be contained within the surgical excision margins."]}
{"Patient Symptoms": ["B, Optical coherence tomography showed generalized undulating choroidal thickening in a so-called seasick pattern.A relook at the anterior segment in the left eye revealed a faint conjunctival thickening at the limbus suggestive of lymphoid tumor."], "Examination and Results": ["On examination, his visual acuity was 20/20 OD and 20/40 OS.", "Intraocular pressures were normal in each eye.", "Anterior segment and fundus examination results were normal in the right eye.", "In the left eye, the media were clear, and there were multiple patchy, yellow choroidal lesions with obliteration of the normal choroidal vasculature throughout the entire fundus (Figure 1A).", "Ocular ultrasonography revealed diffuse ciliochoroidal thickening measuring 2.9 mm in elevation.", "Optical coherence tomography disclosed generalized, undulating choroidal infiltration in a seasick pattern, so to speak, given its resemblance to a stormy ocean surface, with overlying draping of the retina in the foveal region (Figure 1B).A, A healthy man in his 60s with decreased visual acuity in the left eye was found to have multiple patchy, yellow choroidal foci with loss of the choroidal vascular detail throughout the entire fundus."], "Others": ["There was no sign of vitritis or retinitis and no history of previous trauma, uveitis, sarcoidosis, or cancer."]}
{"Patient Symptoms": ["The lesion was not painful but was associated with ipsilateral facial numbness.", "There was notable hypoesthesia in the distribution of the trigeminal maxillary branch."], "Examination and Results": ["On examination, he manifested a 9\u2009\u00d7\u20096-mm ulcerated marginal lesion of the central right lower eyelid with surrounding edema and erythema (Figure 1).", "There was no associated lash loss and the region was nontender to palpation.", "On examination, his best-corrected visual acuity was 20/20 OU.", "The pupils were round and brisk without an afferent pupillary defect.", "He manifested full extraocular movements.", "The anterior segment examination, applanation tonometry, and dilated fundus examination results were within normal limits.External photograph demonstrating left lower eyelid ulcerated lesion with overlying black eschar and surrounding edema and erythema."], "Treatment": ["He was seen by an outside ophthalmologist and prescribed oral amoxicillin/clavulanic acid (675 mg/125 mg) and ophthalmic tobramycin for presumed bacterial infection without improvement."], "Others": []}
{"Patient Symptoms": ["In addition, the right eye had developed 2+ anterior chamber cell, keratic precipitates, and a possible branch vein occlusion."], "Examination and Results": ["Her Snellen visual acuities were 20/25 OD and 20/20 OS.", "Her intraocular pressures were 21 mm Hg OD and 14 mm Hg OS.", "The right eye had a relative afferent pupillary defect and mild optic nerve edema.", "To rule out optic neuritis, a magnetic resonance imaging scan of the brain and orbits was obtained; the results were unremarkable.", "Six days after symptom onset, her visual acuity decreased to 20/70 OD and the disc edema increased.", "At this time the patient was referred to our clinic.", "On presentation 1 day later, visual acuity was light perception OD and still 20/20 OS.", "The right eye had 3+ anterior chamber cell, inferior keratic precipitates, and 1+ vitreous cell.", "The right optic nerve had grade 4 disc edema with flame-shaped peripapillary hemorrhages.", "The fundus examination results of the right eye revealed the following superior quadrant retinal findings: extensive intraretinal and preretinal hemorrhages along vessels, arteriolar attenuation and sheathing, venous engorgement, and tortuosity.", "The inferior midperiphery had numerous small areas of deep retinal whitening (Figure 1).", "Examination results of the left eye were normal.An Optos color photograph of the right eye of a woman in her 40s with grade 4 disc edema and associated flame-shaped peripapillary hemorrhages.", "Also noted are diffuse intraretinal and preretinal hemorrhages in the superior peripheral retina.", "The retinal arteries are attenuated with box carring throughout the retina.", "There is extensive vascular sheathing involving predominantly the retinal venules, which are also dilated and tortuous (arrowhead)."]}
{"Patient Personal Background": ["There was no history of trauma.", "He did not use tobacco, alcohol, or drugs.", "His parents and both siblings were reportedly healthy with no history of ocular disease."], "Patient Symptoms": ["The patient reported slowly progressive difficulty with night driving as well as perceiving objects in the periphery over the past 5 years.", "The patient was an avid basketball player and was forced to quit recently when he was unable to locate his teammates during play."], "Examination and Results": ["His visual acuity was 20/20 OU, with no afferent pupillary defect.", "The Farnsworth D-15 dichotomous test results were normal in the right eye and tritan deficient in the left eye.", "His intraocular pressure was normal in both eyes.", "Refraction revealed hyperopic astigmatism in both eyes.", "His anterior examination results were unremarkable with no evidence of intraocular inflammation.", "The dilated fundus examination results showed minimal optic nerve pallor, vascular attenuation in both eyes, and a subtle area of increased pigmentation in the superior retina of the right eye only (Figure 1A).", "The fundus autofluorescence results showed bilateral peripheral mottled hypoautofluorescence contrasting a ring of hyperautofluorescence around the macula (Figure 1B).", "Automated perimetry was reliable and showed symmetrical severe bilateral field constriction with a remaining island of 6\u00b0 of central vision.Right eye.", "A, Widefield photograph (Optos) showing vascular attenuation, with reduced vessel caliber in the macula (asterisks) and vessels sclerosis in the periphery (black arrowhead).", "There is a small area of hyperpigmentation in midperiphery just superior to the optic nerve (white arrowhead)."]}
{"Patient Personal Background": ["He was not taking any ocular medications, and his only systemic medication was an oral \u03b2-blocker.", "He was otherwise healthy, and his family history was noncontributory.On a slitlamp examination, multiple brown masses were noted at the pupillary margin in both eyes, encroaching on the central visual axis (Figure)."], "Patient Symptoms": ["He was unaware of any recent changes in the size or number of these lesions.", "The patient had noticed progressive visual obscuration in his left eye."], "Examination and Results": ["His visual acuity measured 20/25 (6/7.5) OU, and his intraocular pressures were 14 mm Hg OU.", "There was no inflammation in the anterior chamber or vitreous."]}
{"Patient Symptoms": ["Transbronchial biopsy histopathology showed acute and chronic inflammation, granulation tissue and necrosis, and negative fungal and AFB stains.Two weeks later, the patient reported worsening right-sided chest pain provoked by palpation, right arm movement, and deep inspiration.", "She developed hypoxemia and required intubation."], "Examination and Results": ["Lung tissue was sent for bacterial, fungal, mycobacterial, and Nocardia cultures and for histopathology.", "BAL cultures grew 100 colony-forming units (CFUs)/mL of group B streptococci and 1 CFU/mL of Aspergillus niger.", "Results of acid-fast bacilli (AFB) smear and GeneXpert MTB/RIF testing were negative.", "Voriconazole was added to her treatment.", "Repeat chest CT demonstrated cavitary mass enlargement with possible pleural invasion (Figure 1, left).", "A right-sided tension pneumothorax developed and required emergency chest tube placement, which yielded charcoal-colored pleural fluid (Figure 1, right).Left, Computed tomography scan of the chest demonstrating large right upper lobe cavitary lesion, layering debris, and bronchial wall thickening.", "Right, Charcoal-black appearance of the pleural fluid seen in the atrium of the patient\u2019s right-side chest tube placed for tension pneumothorax."], "Treatment": ["She was treated empirically with intravenous vancomycin and piperacillin-tazobactam.", "Voriconazole was added to her treatment."], "Others": ["Bronchoscopy with bronchoalveolar lavage (BAL) and transbronchial biopsy was performed."]}
{"Patient Personal Background": ["She had no other medical history.", "The patient provided the report of a skin biopsy performed 2 years before presentation."], "Patient Symptoms": ["She had been treated with topical corticosteroids with no control of the symptoms."], "Examination and Results": ["Physical examination revealed erythematous papules, some of them crusted, and some excoriations located over the trunk and upper extremities (Figure 1A).", "In addition, some scales and fissures were seen on her lower lip (Figure 1B), sparing the surrounding skin, as well as inner mouth and upper lip."], "Diagnosis": ["It was described as indicating spongiotic dermatitis.", "A new biopsy sample was taken to rule out actinic cheilitis.A, Clinical image of actinic prurigo in the skin of the patient showing unspecific erythematous papules on the arm.", "B, Clinical image of actinic prurigo cheilitis in the patient showing scales, crusts, and fissures on the lower lip."]}
{"Patient Symptoms": ["She was diagnosed as having pancreatic adenocarcinoma in September 2019 after developing right upper quadrant pain and jaundice, which prompted imaging and a subsequent endoscopic biopsy of a pancreatic head mass."], "Examination and Results": ["Several hypodense lesions in the apex of her heart were appreciated on review of her previous chest computed tomography scan (Figure 1A).", "A subsequent transthoracic echocardiogram (Figure 1B) was obtained and revealed several discrete, partially mobile frondlike masses originating from her cardiac apex.", "Both services requested cardiac magnetic resonance imaging for further clarification of her imaging findings.A, An axial slice from the patient\u2019s chest computed tomography with contrast.", "B, A 4-chamber view from the patient\u2019s transthoracic echocardiography."], "Treatment": ["She established oncologic care in Kentucky and received 1 dose of gemcitabine plus nanoparticle albumin-bound (nab)\u2013paclitaxel in early October 2019.", "Her infusion port (right sided) was subsequently removed, and she was given 1.5 mg/kg of enoxaparin daily for anticoagulation.After her transfer, the oncology department was consulted regarding treatment options for her pancreatic cancer."], "Diagnosis": ["She was diagnosed as having pancreatic adenocarcinoma in September 2019 after developing right upper quadrant pain and jaundice, which prompted imaging and a subsequent endoscopic biopsy of a pancreatic head mass."], "Others": ["Her posttreatment course was complicated by elevated levels of transaminases, significant fatigue, and an infusion port thrombosis.", "The cardiology and cardiothoracic surgery departments were consulted for input pertaining to her case.", "The arrowheads denote atypical lesions in the left ventricle of the patient.", "The arrowhead denotes the largest of the 3 frondlike masses emanating from the apex of her heart."]}
{"Patient Personal Background": ["His cardiomyopathy followed a diagnosis of myocarditis after repeated putative chest colds and chest pain at age 14 years, at which time the ejection fraction was reported to be 30%."], "Patient Symptoms": ["His chest pain and dyspnea were chronic and had recently increased in frequency."], "Examination and Results": ["The results of a graded exercise stress test at 22 years were unremarkable.On examination, he was afebrile.", "His heart rate was 68 beats per minute, his blood pressure was 114/77 mm Hg, and his examination was notable for an absence of jugular venous distension, peripheral edema, and murmurs or extra heart sounds.", "His electrocardiogram, shown in Figure 1, was notable for right bundle branch block and left anterior fascicular block, unchanged from his electrocardiogram at age 14 years.", "Transthoracic echocardiography revealed an ejection fraction of 40%.", "An exercise nuclear stress test revealed a fixed, severe apical defect, a partially reversible severe anterior wall defect, moderate global hypokinesis, and severe hypokinesis of the distal anterior wall and apex.", "His ejection fraction was estimated to be 32%."]}
{"Patient Personal Background": ["Medical history was notable for coronary artery disease, hypothyroidism, and prostate cancer in remission.On ophthalmic examination, visual acuity was hand motion OU (baseline from 9 months prior was 20/50 OD and 20/30 OS), with briskly reactive left pupil and trace right relative afferent pupillary defect."], "Examination and Results": ["He could detect 2/4 gross colors in the right eye and 1/4 gross colors in the left eye.", "Confrontation visual fields revealed dense right homonymous hemianopia with additional asymmetric deficits on Goldmann perimetry (Figure 1).", "Extraocular movements were full with gaze-evoked nystagmus.", "Horizontal vestibulo-ocular reflex, assessed by head impulse testing, was normal.", "Slitlamp and dilated fundus examination revealed pseudophakia and mild epiretinal membrane in the right eye and mild nuclear sclerosis in the left eye.Goldmann perimetry (V4e stimulus) of left (A) and right (B) eyes shows right homonymous hemianopia, left inferotemporal visual field loss, and right nasal paracentral visual field loss.Neurologic examination showed full motor strength, decreased vibration sense and proprioception in the feet, positive Romberg sign, and inability to tandem walk.", "Mini-Mental State Examination score was 6 of 30.Magnetic resonance imaging brain and orbits with and without contrast and magnetic resonance angiography head and neck were unremarkable.", "An electroencephalogram showed no localizing signs.", "Syphilis screen was negative.", "Serum thiamine, vitamin B12, and thyrotropin levels were normal.", "Cerebrospinal fluid composition, infectious studies, cytology, flow cytometry, and paraneoplastic panel showed only mildly elevated protein."]}
{"Patient Symptoms": ["The patient was otherwise asymptomatic, and a complete review of systems was negative."], "Examination and Results": ["The results of her physical examination were notable for left-sided blepharoptosis with a palpable mass of the upper eyelid laterally.", "Eyelid eversion examination findings showed a yellow nodular lesion along the tarsal conjunctiva (Figure, A).", "Histopathologic examination results showed amorphous acellular proteinaceous deposits that positively stained with Congo red (Figure, B, inset).", "Polarized microscopy of the deposits showed apple-green birefringence (Figure, B).A, Everted upper eyelid examination results reveal an elevated yellow, waxy mass along the tarsal conjunctiva (arrowhead).", "B, Histopathologic appearance of the lesion.", "Amyloid deposits show apple-green birefringence under polarized light (original magnification \u00d710) when stained with Congo red (inset, area with dashed outline) (original magnification \u00d710)."], "Treatment": ["An incisional biopsy was performed."]}
{"Patient Symptoms": ["However, unnoticed by the patient, her BCVA had worsened to 20/200 OD and 20/40 OS.", "Similar findings were present in the left eye.One week later, the BCVA worsened to E at 3 feet OD and 20/200 OS."], "Examination and Results": ["Her best-corrected visual acuity (BCVA) was 20/30\u2009+\u20092 OD and 20/20 OS.", "Her intraocular pressure, extraocular motility, and pupillary light reactions were normal.", "An examination demonstrated trace anterior cells in the right eye; otherwise, the examination had normal results.", "No vitreous cells were present.", "An examination demonstrated new subretinal fluid in the macula in the right eye (Figure 1A).", "Fluorescein angiography showed peripapillary speckled pinpoint areas of hyperfluorescence in the right eye.", "Indocyanine green showed early choroidal vessel hyperfluorescence and several posterior focal hypofluorescent spots in the midphase in both eyes.", "Autofluorescence showed patchy hyperautofluorescence in both eyes.", "Tuberculosis and syphilis testing had negative results.", "A complete blood cell count was unremarkable.", "A, Optical coherence tomography of the right eye demonstrates posterior vitreous cells (white arrowheads), subretinal fluid, and choroidal corrugation (yellow arrowheads).", "B, Fundus photograph of the right eye demonstrates multifocal, demarcated exudative retinal detachments, including in the macula.", "An examination now revealed 2+ vitreous cells and extensive exudative retinal detachments in both eyes (Figure 1B)."], "Treatment": ["Topical prednisolone was started for presumed acute anterior uveitis.One week later, the photophobia had improved.", "The topical prednisolone was stopped.Findings on presentation and follow-up."], "Diagnosis": ["A diagnosis of central serous retinopathy (CSR) was made."]}
{"Patient Personal Background": ["Her medical history and family history were unremarkable."], "Examination and Results": ["A potassium hydroxide preparation had negative results for fungal elements.", "An examination found a 1-cm nummular plaque with centralized micaceous scale and a smooth erythematous border on the right lateral lower leg (Figure, A).", "Histopathological testing revealed an epidermis featuring elongated rete ridges, keratinocyte enlargement, and a few Civatte bodies, with overlying parakeratotic crust and neutrophilic cell debris.", "Marked epidermotropism of atypical lymphocytes with irregular nuclear contours and halos, both singly and in small collections (Pautrier microabscesses) were also observed (Figure, B and C).", "Also, lymphocytes were present along the epidermal side of the dermoepidermal junction.", "Periodic acid\u2013Schiff stained sections failed to show fungal or yeast elements.", "Immunohistochemical staining was markedly positive for CD3, CD5, and CD8 (Figure, D); CD4 reactivity was less robust and mainly restricted to dermal lymphocytes.", "Also, CD20 was present in 5% of dermal lymphocytes, and CD30 showed variable staining of 5% of lymphocytes.A, Image of a solitary plaque on the right lateral lower leg.", "B, Scanning view with hyperkeratosis, epidermal hyperplasia, and a lichenoid-like lymphoid infiltrate (hematoxylin-eosin).", "C, Biopsy results with marked epidermotropism of atypical lymphocytes (hematoxylin-eosin).", "D, Biopsy results with robust CD8 signal (magnification \u00d7100)."], "Treatment": ["Prior treatments included triamcinolone ointment and frankincense with no improvement.", "A tangential-shave biopsy was performed to characterize the lesion."]}
{"Patient Personal Background": ["In her early 20s the area of hyperpigmentation started to spread slowly over the above-mentioned areas and became more and more intense."], "Patient Symptoms": ["A slight atrophy of the hyperpigmented skin was palpable without any signs of induration.Clinical images show slightly atrophic hyperpigmented macules following the lines of Blaschko on the right side of the (A) trunk and (B) upper arm.", "Histopathologic images of punch biopsy specimen show (C) normal epidermis and dermis with a slight hyperpigmentation of the basal epidermis layer (hematoxylin-eosin stain), and (D) preserved elastic fibers in the reticular dermis (Elastic van Gieson stain).The first onset was in her childhood, at the age of 6 years, with a small hyperpigmentation on the right side of her lower chest remaining stable for years.", "In her early 20s the area of hyperpigmentation started to spread slowly over the above-mentioned areas and became more and more intense."], "Examination and Results": ["A slight atrophy of the hyperpigmented skin was palpable without any signs of induration.Clinical images show slightly atrophic hyperpigmented macules following the lines of Blaschko on the right side of the (A) trunk and (B) upper arm.", "Histopathologic images of punch biopsy specimen show (C) normal epidermis and dermis with a slight hyperpigmentation of the basal epidermis layer (hematoxylin-eosin stain), and (D) preserved elastic fibers in the reticular dermis (Elastic van Gieson stain).The first onset was in her childhood, at the age of 6 years, with a small hyperpigmentation on the right side of her lower chest remaining stable for years."], "Treatment": ["Intravenous penicillin G therapy with 10 million units 3 times daily over 1 week combined with a UV-A1 phototherapy in 18 sessions with a maximum dose of 40 J/cm2 and a cumulative overall dose of 670 J/cm2 showed no effects."], "Others": ["A punch biopsy was obtained (Figure, C and D)."]}
{"Patient Personal Background": ["He denied a history of facial flushing."], "Patient Symptoms": ["The patient was initially treated for rosacea at an outside hospital with topical 1% metronidazole cream for 1 month without improvement and developed acute facial purpura after 1 day of treatment with oral doxycycline, which was discontinued.", "On examination, the patient had asymmetric, centrofacial, erythematous-violaceous indurated telangiectatic and ecchymotic plaques over a phymatous background (Figure, A)."], "Examination and Results": ["A series of punch biopsies were performed (Figure, B-D).A, Clinical image showing erythemato-violaceous plaques with ecchymotic areas.", "B, Histopathologic image showing ectatic vessels with plump endothelia involving the deep dermis and hypodermis (hemotoxylin-eosin).", "C, On higher magnification, ectatic vascular channels were lined by atypical plump endothelial cells (hemotoxylin-eosin).", "D, Immunohistochemistry was negative for Human herpesvirus 8 (original magnification \u00d7100)."], "Treatment": ["The patient was initially treated for rosacea at an outside hospital with topical 1% metronidazole cream for 1 month without improvement and developed acute facial purpura after 1 day of treatment with oral doxycycline, which was discontinued."], "Others": ["Because of the eruption\u2019s rapid onset and violaceous appearance, as well as empirical treatment failure, the patient was referred for further evaluation."]}
{"Patient Personal Background": ["She had no history of tobacco, alcohol, or drug use.She had hyperhidrosis and tachypnea on admission."], "Patient Symptoms": ["Sudden episodes of painful involuntary spasms first appeared in her abdominal muscles 2 weeks after a cold.", "Soon after, spasms spread to all of her axial muscles and both lower limbs.", "These paroxysmal episodes lasted a few seconds, occurred up to 20 times a day, and were exacerbated by external stimuli.", "Neurological examination results disclosed an abnormal mental status.", "She demonstrated marked myoclonus on tactile and acoustic stimulation."], "Examination and Results": ["Cranial nerve examination results demonstrated slow saccades.", "Motor system examination results revealed a symmetric and severe hypertonia and rigidity throughout her trunk and all 4 extremities.", "Further notable occurrences were severe spasms (Figure, A; Video 1) and patella clonus associated with brisk deep tendon reflexes (Video 2).", "Extensor plantar responses were present bilaterally.A, Patient experiencing spasms.", "B, Electromyography examination of the patient.Laboratory results were significant for an elevated level of thyroperoxidase antibodies (50.85 IU/mL; normal, <5.16 IU/mL) and thyroglobulin antibodies (88.35 ng/mL; normal: <4.11 ng/mL; to convert to micrograms per liter, multiply by 1).", "Cerebrospinal fluid testing results revealed normal protein level and cell counts, as well as absent oligoclonal bands or evidence of infection.", "Her paraneoplastic panel results were negative.", "Cranial and spinal magnetic resonance imaging yielded no abnormalities.", "Needle electromyography (EMG) results showed a continuous firing of normal motor unit potentials at rest within the axial and lower limb muscles (Figure, B; Video 3).", "A routine electroencephalogram (EEG) showed mild background slowing without periodic discharges.", "Computed tomography scan results of the thorax, abdomen, and pelvis were negative.", "An electrocardiogram showed sinus tachycardia."], "Diagnosis": ["A review of her previous records revealed a diagnosis of Hashimoto thyroiditis 1 month earlier."]}
{"Patient Symptoms": ["The lesions appeared as erythematous nodules on the left leg with tenderness and pruritus and rapidly progressed to both legs.", "Marked lower-leg edema was noted 20 days prior to the visit.", "She also had an intermittent fever during the past 3 months that did not respond to antibiotic therapy."], "Examination and Results": ["The patient\u2019s medical history was unremarkable.Physical examination revealed ill-defined, indurated erythematous-violaceous plaques on the lower extremities with substantial edema (Figure, A and B).", "Complete blood cell count revealed a normal white blood cell count with moderate anemia (hemoglobin level, 87 g/L; normal range 115-150 g/L).", "Additional laboratory tests demonstrated an elevated level of serum lactate dehydrogenase (749 U/L; normal range 100-240 U/L) (to convert to \u03bckat/L, multiply by 0.0167).", "Quantification of Epstein-Barr virus (EBV) DNA in sera showed a high viral load of EBV in peripheral blood (1\u202f800\u202f000 copies/mL, normal range <500 copies/mL).", "C, Lesional skin biopsy specimen revealed dilated vessels filled with atypical large lymphoid cells throughout the dermis (hematoxylin-eosin)."], "Others": ["A skin biopsy specimen was obtained from a violaceous plaque (Figure, C).A and B, Ill-defined, irregular erythematous plaques with substantial edema of lower extremities."]}
{"Patient Symptoms": ["When at full term, a planned vaginal delivery was complicated by breached position of the fetus, fetal distress, and new onset of fever.", "She had progressive dyspnea, mild pulmonary congestion noted on chest radiography, and an elevated brain-type natriuretic peptide level greater than 800 pg/mL (conversion to ng/L is 1:1)."], "Examination and Results": ["Troponin levels were normal.", "A vascular ultrasound study ruled out deep vein thrombosis in the lower extremities.", "A non\u2013electrocardiogram (ECG)-gated computed tomography angiogram showed no pulmonary embolism but was otherwise not diagnostic owing to motion artifacts (Figure 1A).", "Physical examination findings showed a new heart murmur.", "A transthoracic echocardiogram (TTE) was performed, which showed a normal-sized left ventricle and preserved left ventricular ejection fraction, severe aortic regurgitation (AR), and a mildly dilated aortic root (Figure 1B and Video).", "The patient was afebrile at that point, and her white blood cell count was within normal limits.A, Non\u2013electrocardiogram-gated computed tomography angiography."], "Treatment": ["The delivery was converted to a cesarean birth, which was uncomplicated."], "Others": ["Perioperatively, she had an episode of chest pain that resolved spontaneously.", "The patient was transferred to our institution for further treatment.", "B, Transthoracic echocardiography shows the aortic root anatomy and aortic regurgitation.", "bpm Indicates beats per minute."]}
{"Patient Personal Background": ["One year prior to presentation, the patient had undergone coronary artery bypass grafting (CABG).", "He was discharged with amiodarone and used the medication for 6 weeks.", "He did not use amiodarone for the 10 months prior to presentation.", "Prior to his CABG procedure, the patient only used a low dose of lisinopril until he began experiencing progressive dyspnea and fatigue.", "He was found to have a 5-vessel blockage once he became symptomatic.", "His symptoms resolved after the CABG surgery, and he remained otherwise healthy.", "He denied any other symptoms, including headache, rash, joint pain, or chest pain.", "His medications at time of presentation were aspirin, atorvastatin, and carvedilol."], "Examination and Results": ["His best-corrected visual acuity was 20/20 OD and 20/25 OS.", "A slitlamp examination revealed bilateral corneal verticillata and numerous fine anterior stromal crystals (Figure).", "He had mild nuclear sclerosis in both eyes."]}
{"Patient Personal Background": ["Her home medications were hydrocodone and ibuprofen."], "Patient Symptoms": ["The patient started receiving oral acetazolamide, 500 mg, twice daily for presumed idiopathic intracranial hypertension (IIH) and transferred to our institution.On admission, she was noted to have near-complete vision loss in both eyes, severe postural headaches, and nausea with vomiting.", "Visual acuity was hand motion OD and no light perception OS."], "Examination and Results": ["Bilateral disc edema was noted on examination, and neuroimaging was obtained.", "Noncontrast head computed tomography (CT) and CT angiogram were remarkable only for bilateral optic nerve head abnormalities.", "Magnetic resonance imaging was concerning for prominent optic nerves (Figure, A).", "There was no evidence of intracranial masses, hydrocephalus, or bleed.", "Lumbar puncture revealed cerebrospinal fluid opening pressure of 40 cm of water.", "Cerebrospinal fluid protein, glucose, IgG, and oligoclonal band levels were within normal limits.", "Renal function was normal.", "Fundoscopic examination revealed severe papilledema (Frisen grade 4-5 OD; grade 5 OS).", "A magnetic resonance venography was performed and revealed bilateral filling defect of the transverse sinuses, suggestive of bilateral nonocclusive dural venous sinus thromboses (DVST) (Figure, B)."], "Treatment": ["The patient started receiving oral acetazolamide, 500 mg, twice daily for presumed idiopathic intracranial hypertension (IIH) and transferred to our institution.On admission, she was noted to have near-complete vision loss in both eyes, severe postural headaches, and nausea with vomiting."], "Diagnosis": ["The patient started receiving oral acetazolamide, 500 mg, twice daily for presumed idiopathic intracranial hypertension (IIH) and transferred to our institution.On admission, she was noted to have near-complete vision loss in both eyes, severe postural headaches, and nausea with vomiting."]}
{"Patient Symptoms": ["There was right upper and lower eyelid edema with mild erythema and 3 mm of proptosis.", "There was trace vasodilation and chemosis of the conjunctiva in the right eye."], "Examination and Results": ["The patient\u2019s visual acuity, color vision, and pupillary examination results were within normal limits, and intraocular pressures were 28 mm Hg OD and 20 mm Hg OS.", "The extraocular movements and confrontational visual fields were normal.", "The remainder of the slitlamp and dilated fundus examination results were within normal limits.", "Computed tomography of the orbits and magnetic resonance imaging (MRI) of the brain and orbits showed a large lesion of the right greater wing of the sphenoid bone extending toward the orbital apex with edema and enhancement of the right temporal lobe of the brain (Figure 1).A, Axial computed tomography (CT) of the orbits with contrast shows a large destructive lesion in the right sphenoid bone and anterior aspect of the middle cranial fossa.", "B, A T1-weighted magnetic resonance image (MRI) of the brain and orbits without contrast shows the involvement of the right temporal lobe.", "The lesion can be seen also involving the right side of the sphenoid bone, orbital apex, and scalp anteriorly."], "Treatment": ["The patient was previously treated with an oral combination of amoxicillin and clavulanic acid and topical gentamicin therapy without any improvement."], "Others": ["The scale across the bottom of each image is measured in centimeters.", "A indicates anterior; R, right."]}
{"Patient Personal Background": ["Her medical history was notable for chronic kidney disease and genital herpes simplex virus (HSV).", "She reported no history of genital warts, HIV, or inflammatory bowel disease."], "Patient Symptoms": ["The patient felt well otherwise and denied experiencing fevers, chills, sweats, weight loss, or malaise."], "Examination and Results": ["A biopsy was performed, and results were consistent with a noninfectious, granulomatous ulcer.", "Findings from colorectal surgical evaluation of the internal anal mucosa were negative for malignant neoplasm.At referral, physical examination findings revealed a 5\u2009\u00d7\u20097-cm verrucous, exophytic tumor with scant yellow drainage on the right medial buttock extending to the perianal skin (Figure 1A).", "Findings from the remaining skin examination were normal.", "Superficial bacterial cultures were obtained from the lesion and grew methicillin-resistant Staphylococcus aureus.", "An incisional biopsy was performed for diagnostic clarification (Figure 1B and C).A, Clinical image of 5\u2009\u00d7\u20097-cm verrucous, exophytic tumor with scant yellow drainage on the right medial buttock extending to the perianal skin.", "B, Hematoxylin-eosin stain image from the incisional biopsy featuring a hyperplastic epidermis with ulceration, necrosis, and a very dense inflammatory infiltrate.", "C, Hematoxylin-eosin stain demonstrating plasma cells composing the infiltrate while the epithelium shows focal multinucleated keratinocytes, some with gray-blue cytoplasm."], "Treatment": ["Based on the clinical appearance and prior pathologic findings, the patient received treatment of oral antibiotics, intralesional steroids, topical steroids, and immunomodulators, without improvement."]}
{"Patient Symptoms": ["Within 2 months, she developed isolated, painful tumors.", "She then received liposomal doxorubicin, although skin involvement continued to progress rapidly, with ulcerating tumors making up as much as 80% of her total body surface area.", "She was hospitalized for worsening disease and pain (Figure, A)."], "Examination and Results": ["Histopathological testing demonstrated an epidermotropic infiltrate of hyperchromatic, convoluted, atypical CD3+, CD4\u2212, and CD8+ lymphocytes with haloed nuclei with basilar tagging and papillary dermal fibrosis.", "Studies of T-cell gene rearrangements identified a clonal population.", "Blood-flow cytometry did not reveal aberrant T-cell immunophenotypes.", "A second biopsy was performed, which was notable for an epidermotropic infiltrate of CD3+, CD4\u2212, and CD8\u2212 weak lymphocytes, which were positive for TIA-1, granzymes, and B factor (Bf) 1 and negative for CD30 and CD56.", "The results of flow cytometry and imaging were unremarkable.", "Repeated histopathologic analysis was done (Figure, B, C, and D).A, Clinical image.", "B, Original magnification \u00d750.", "C, Considerable lymphocytic epidermotropism in a pagetoid reticulosis\u2013like pattern without striking Pautrier microabscesses (original magnification \u00d7230)."], "Treatment": ["She was treated initially with topical and intralesional corticosteroids and narrow band UV B phototherapy.", "Oral bexarotene was subsequently added for recalcitrant disease.", "After an initial favorable response with chlorambucil, she developed expanding ulcerated tumors complicated by a polymicrobial superinfection.", "Chlorambucil was discontinued in favor of antimicrobial treatment.", "She then received liposomal doxorubicin, although skin involvement continued to progress rapidly, with ulcerating tumors making up as much as 80% of her total body surface area."]}
{"Patient Symptoms": ["No inciting events, such as arthropod bite or trauma, were noted.", "No other cutaneous abnormalities were noted.", "A punch biopsy specimen of the left medial forehead was obtained, and histological and immunohistochemical analyses were performed (Figure, B and C).A, Erythematous patch with central inflammatory papules on the forehead."], "Examination and Results": ["A punch biopsy specimen of the left medial forehead was obtained, and histological and immunohistochemical analyses were performed (Figure, B and C).A, Erythematous patch with central inflammatory papules on the forehead.", "B, Histopathological results revealed dissecting vascular channels (black arrowheads) and spindle cells (white arrowheads) (hematoxylin-eosin).", "C, Immunohistochemical staining revealed CD31 and diffuse expression of FLI-1 and ERG in the vascular and spindle cell components."], "Treatment": ["She was initially treated for presumed shingles with valacyclovir, cephalexin, gabapentin, and hydrocortisone 2.5% topical ointment with no improvement in appearance or symptoms."]}
{"Patient Symptoms": ["Following a long flight 6 weeks prior, she had developed left calf tightness and pain, followed by shortness of breath for 1 week and then a syncopal event the day of admission."], "Examination and Results": ["On physical examination, she appeared anxious, with a temperature of 36.8\u00b0C, a heart rate of 102 beats/minute, blood pressure of 128/66 mm Hg, a respiratory rate of 20 breaths/minute, and pulse oximetry of 98% on room air.", "Her heart and lung sounds were normal.", "Her laboratory results were notable for a troponin level of 0.07 ng/mL (to convert to \u03bcg/L, multiply by 1.0), and a fibrin D-dimer level of more than 2000 \u03bcg/mL (to convert nmol/L, multiply by 5.476).", "Her electrocardiogram on presentation showed sinus tachycardia and was otherwise normal.", "Computed tomography of the chest was performed, which showed multiple large bilateral pulmonary emboli (Figure, A), with deviation of the interventricular septum toward the left ventricle."], "Diagnosis": ["Computed tomography of the chest was performed, which showed multiple large bilateral pulmonary emboli (Figure, A), with deviation of the interventricular septum toward the left ventricle."]}
{"Patient Personal Background": ["The patient\u2019s medical history was notable for severe obstructive sleep apnea (OSA) diagnosed in the fall of 2017, when he presented with snoring, progressive daytime fatigue, and several years of migraines.", "Since his diagnosis, he had been adherent to use of nightly continuous positive airway pressure (CPAP)."], "Patient Symptoms": ["However, he had persistent daytime fatigue and morning headaches.", "Several months before presentation, the patient noticed that his bite changed from an overbite to an underbite (Figure, A), which had been attributed to dental malocclusion from his CPAP machine.", "On further review of systems, the patient reported growth in his tongue and feet and intermittent swelling with numbness in his hands over the past year.A, Clinical image of the patient, who reported change in bite."], "Examination and Results": ["Examination findings of the oropharynx showed an oropharynx score of a Mallampati 4, with 3-plus tonsils and macroglossia without scalloping of the tongue (Figure, B).", "Nasopharyngolaryngoscopic examination findings showed that the tonsils did not approximate at midline, with a narrow anterior-to-posterior dimension of the airway owing to macroglossia and no retrognathia.", "B, Oral cavity and oropharynx showing macroglossia and bilateral tonsillar hypertrophy."], "Treatment": ["Since his diagnosis, he had been adherent to use of nightly continuous positive airway pressure (CPAP)."]}
{"Patient Personal Background": ["The patient had an unremarkable medical, surgical, and social history and no known infectious exposures."], "Patient Symptoms": ["After a period of conservative management, he developed a sore throat and fever.", "When he presented to our facility, he was found to have an asymptomatically enlarged left level 2/5A neck mass that was nontender and fixed."], "Examination and Results": ["His primary care physician initially obtained an ultrasonographic image, which demonstrated a left, level 2 lymph node measuring 4.0\u2009\u00d7\u20091.5\u2009\u00d7\u20092.8 cm.", "He subsequently underwent a computed tomographic scan of the neck and chest with contrast, which demonstrated an isolated, enlarged, homogenously enhancing left-neck level 2B lymph node measuring 3.4\u2009\u00d7\u20092.8\u2009\u00d7\u20092.1 cm (Figure 1A).", "A white blood cell count and C-reactive protein level were both elevated, at 11\u202f310 cells/\u03bcL (to convert to cells\u2009\u00d7\u2009109 per liter, multiply by 0.001) and 56.2 mg/L (to convert to nanomoles per liter, multiply by 9.524), respectively.", "Studies for influenza A and B, HIV, cytomegalovirus, American foulbrood, Bartonella henselae, infectious mononucleosis, and Epstein-Barr virus had negative results.", "Fine-needle aspiration and flow cytometry had negative results for lymphoproliferative disorders or a malignant condition.", "A tissue culture had negative results.", "Intraoperative frozen sections did not show a malignant process.", "On final analysis, a pathologic examination of the largest lymph node was performed (Figure 1B).A, Axial computed tomographic (CT) scan of neck with contrast, showing homogenously enhancing 3.4-cm left level 2B neck mass."], "Treatment": ["The patient then underwent several courses of antibiotic treatment, but the mass persisted.", "An ultrasonography-guided needle biopsy was performed.", "Given the inconclusive diagnosis, the patient underwent a left neck dissection of levels 2A, 2B, and 5A."]}
{"Patient Personal Background": ["Notably, 2 weeks prior to presentation, she had started taking cobimetinib therapy as part of a clinical trial for her breast cancer.Fundus autofluorescence (A) demonstrating multiple, discrete hyperautofluorescent lesions throughout the posterior pole, concentrated along the superior arcades; spectral-domain optical coherence tomography (B) shows small, localized subretinal fluid pockets at the site of these lesions."], "Patient Symptoms": ["The spots were stationary; she denied any floaters or photopsias.", "The onset was simultaneous in both eyes, with no associated eye pain or photophobia."], "Examination and Results": ["There was no ocular history, and a recent comprehensive eye examination had normal results.", "Her visual acuity was 20/20 OU.", "An anterior segment examination had unremarkable results.", "There was no vitritis, and her optic nerves were pink and sharp.", "A dilated fundus examination revealed multifocal, hypopigmented, cream-colored spots scattered throughout the posterior pole in both eyes.", "These spots were hyperautofluorescent on fundus autofluorescence and localized to the subretinal space (Figure 1)."], "Treatment": ["Notably, 2 weeks prior to presentation, she had started taking cobimetinib therapy as part of a clinical trial for her breast cancer.Fundus autofluorescence (A) demonstrating multiple, discrete hyperautofluorescent lesions throughout the posterior pole, concentrated along the superior arcades; spectral-domain optical coherence tomography (B) shows small, localized subretinal fluid pockets at the site of these lesions."]}
{"Patient Personal Background": ["His parents reported that he had recently been hospitalized for a suspected overdose with the medications atomoxetine, quetiapine, melatonin, fluoxetine, bupropion, and clonazepam, and shortly after, he reported central visual acuity loss.", "His medical history included attention-deficit/hyperactivity disorder, depression, generalized anxiety disorder, posttraumatic stress disorder, and learning disabilities.", "His medications included atomoxetine, quetiapine, melatonin, and fluoxetine.", "The patient was adopted, and a detailed family history was unknown.", "A social history was limited.", "The patient was born full term."], "Patient Symptoms": ["His parents reported that he had recently been hospitalized for a suspected overdose with the medications atomoxetine, quetiapine, melatonin, fluoxetine, bupropion, and clonazepam, and shortly after, he reported central visual acuity loss."], "Examination and Results": ["A dilated fundus examination with normal results had been documented 6 months prior to our examination.His ocular history was unremarkable.", "His biological sister has learning and attention difficulties but had a normal fundus examination result.The patient\u2019s best-corrected visual acuity was 20/50 OD and 20/60 OS.", "His intraocular pressure, pupils, extraocular movements, visual fields, and color testing results were normal.", "The anterior segments were unremarkable.", "The vitreous, optic nerve, and retinal vasculature were normal.", "A bilateral maculopathy was present, with focal areas of gray-brown discoloration (Figure 1A).", "Optical coherence tomography (OCT) exhibited an intact foveal depression with subfoveal disruption of the ellipsoid layer and hyperreflective material extending into the Henle layer (Figure 1B).", "No subretinal or intraretinal fluid was present.A, Fundus photograph of the left eye demonstrates a central maculopathy with focal gray discolored lesions and yellow-orange pigmentation.", "B, Scanning laser ophthalmoscopy and spectral-domain optical coherence tomography (SD-OCT) of the same eye reveal ellipsoid zone disruption and vertical hyperreflective bands."]}
{"Patient Personal Background": ["His medical history was remarkable for diabetes mellitus of 40 years\u2019 duration complicated by end-stage renal disease requiring a renal transplant and ongoing immunosuppression."], "Patient Symptoms": ["His visual acuity was no light perception OD and 20/40 OS.", "The right eye exhibited an amaurotic pupil, severe generalized restriction of extraocular movement, and ptosis with poor levator function."], "Examination and Results": ["His intraocular pressures were normal.", "At a base of 104 mm, exophthalmometer measurements were 24 mm OD and 20 mm OS.", "The results of a slitlamp examination were noncontributory in both eyes.", "A dilated fundus examination revealed a pale optic disc in the right eye and panretinal laser scars in both eyes.", "Cranial nerves V and VII-XII were intact bilaterally.", "The patient was afebrile, with vital signs within normal limits.", "His leukocyte count was 2200 cells/\u03bcL (to convert to \u00d7109/L, multiply by 0.001).Noncontrast computed tomography and magnetic resonance imaging of the orbit demonstrated highly attenuating debris and bony irregularities throughout the paranasal sinuses and fat stranding in the right orbital apex (Figure).", "Magnetic resonance venography of the head had unremarkable results.", "Results of a sinus biopsy by the otolaryngology service demonstrated fungal hyphal elements."], "Treatment": ["Systemic therapy was initiated, and the otolaryngology service planned urgent surgical nasosinal debridement."], "Others": ["Contrast-enhanced magnetic resonance imaging was withheld pending stabilization in the patient\u2019s renal status.Orbital noncontrast imaging studies.", "Noncontrast computed tomography (CT) (A) and magnetic resonance imaging (B), images of the orbit.", "Computed tomography demonstrates inflammatory changes of the right medial orbital wall (arrowhead).", "Magnetic resonance imaging demonstrates inflammatory changes at the right orbital apex (arrowhead)."]}
{"Examination and Results": ["There was a family history of cutaneous melanoma in his 2 sisters, daughter, and nephew and breast cancer in his mother and sister.", "We completed genetic testing of family members and found no genetic mutations in sera samples to predispose them to melanoma skin cancer or breast cancer.", "The main genes tested were the breast cancer type 1 susceptibility (BRCA1), breast cancer 2\u2013DNA repair associated (BRCA2), partner and localizer of BRCA2 (PALB2), checkpoint kinase 2 (CHEK2), and tumor protein p53 (TP53) genes.", "A dermoscopic examination of the patient showed a translucent lesion with arborizing vessels and erosion (Figure, B)."], "Treatment": ["A punch biopsy was performed."]}
{"Patient Symptoms": ["She described occasional pain and intermittent bleeding from the site."], "Examination and Results": ["Physical examination showed a discrete, reddish-brown, noncompressible, smooth nodule within the umbilicus (Figure, A).", "There was no change in size with the Valsalva maneuver.Clinical image and punch biopsy specimen.", "A, Smooth reddish-brown nodule within the umbilicus.", "B, Low-power view showing glandular and stromal tissue within the dermis (hematoxylin-eosin).", "C, Higher-power view demonstrating a spindle-cell stroma with hemorrhage and hemosiderin-laden macrophages (hematoxylin-eosin).", "D, Glandular epithelium showing prominent decapitation secretion (hematoxylin-eosin).Histopathologic examination revealed stromal tissue and glandular epithelium within the dermis (Figure, B).", "The stroma tissue was characterized by small spindle cells, hemorrhage, and numerous hemosiderin-laden macrophages (Figure, C).", "Glandular epithelium composed of basophilic cuboidal cells and showing decapitation secretion was also present (Figure, D).", "Computed tomography scan of the abdomen showed a well-circumscribed nodule within the umbilicus without intrabdominal extension or herniation."], "Treatment": ["Prior treatment with intralesional triamcinolone injections for a presumed keloid yielded no improvement.", "Surgical excision followed by umbilical reconstruction was performed."]}
{"Patient Personal Background": ["Her medical history included atrial fibrillation and lung adenocarcinoma (a lung lobectomy was performed 8 years ago)."], "Patient Symptoms": ["Bibasilar coarse crackles and pretibial edema were also noted."], "Examination and Results": ["Her blood pressure was 112/60 mm Hg, her heart rate was 100 beats per minute, her respiratory rate was 37 breaths per minute, her body temperature was 36.6\u00b0C, and her oxygen saturation was 100% while breathing 10 L of oxygen.", "A cardiac examination was clinically significant for an irregular rhythm, an increased pulmonic closure sound, and jugular venous distension.", "A complete blood count had results within normal limits.", "The serum lactate dehydrogenase level was 278 U/L (to convert to microkatal per liter, multiply by 0.0167).", "A chest radiographic image showed bibasilar infiltrates.", "An electrocardiogram was notable for atrial fibrillation, and echocardiography revealed normal left ventricular function, mild right atrial and ventricular dilatation, and severe tricuspid regurgitation (transtricuspid pressure gradient, 40 mm Hg).", "A contrast-enhanced computed tomography image revealed bilateral ground-glass opacities and right basilar consolidations, with no evidence of thromboembolisms (Figure, A).", "Para-aortic and inguinal lymphadenopathies were also noted."], "Treatment": ["The patient began receiving dobutamine and furosemide, but she continuously required 2 to 10 L of oxygen, and further invasive evaluations could not be performed."], "Diagnosis": ["Presumptive diagnoses of pulmonary hypertension (PH) and right-sided heart failure were made."], "Others": ["An echocardiogram identified aggravating PH (transtricuspid pressure gradient, 57 mm Hg).", "A thorough physical examination identified scaly, crusty genital skin lesions pathologically compatible with extramammary Paget disease.", "The patient deteriorated and died despite treatment.", "An autopsy was performed (Figure, B).A, The chest computed tomography showed ground-glass opacities (white arrowheads) and consolidative lesions (a yellow arrowhead), but no evidence of thromboembolism was obtained.", "B, Hematoxylin-eosin stain of the lung showed proliferation of intimal fibromuscular cells with (yellow arrowheads) or without (black arrowheads) the presence of Paget cells.", "Yellow arrowheads show embolized Paget cells."]}
{"Patient Personal Background": ["She had a medical history of end-stage renal disease secondary to autosomal dominant polycystic kidney disease, after renal transplant 5 years prior.", "She had concomitant polycystic liver disease and had undergone right hepatectomy and cyst fenestration, plus inferior vena cava (IVC) stent placement for intrahepatic caval compression due to hepatic cysts 9 years earlier."], "Examination and Results": ["Initial laboratory evaluation results revealed elevated creatinine levels with concern of renal graft failure.", "Physical examination results revealed a blood pressure of 96/65 mm Hg, an elevated jugular venous pressure with blunted Y-descent, Kussmaul sign, and distant heart sounds.", "Chest radiography results revealed cardiomegaly and the IVC stent was evident, adjacent to her heart (Figure, A).", "Echocardiography (Video 1 and Figure, B) revealed a large circumferential pericardial effusion, diastolic right ventricular collapse, and exaggerated respiratory variation (>25%) in the mitral inflow velocity but a normal inferior vena cava size.Chest radiography and transthoracic echocardiogram illustrating cardiomegaly and pericardial effusion in addition to visualization of the inferior vena cava stent."]}
{"Patient Symptoms": ["The patient chose observation vs further workup at that time.The patient returned 6 months later with worsening symptoms."], "Examination and Results": ["There were no respiratory symptoms, and results of a complete head and neck physical examination were unremarkable.", "Flexible nasolaryngoscopy was performed and revealed erythema and swelling to the right arytenoid.", "Repeat flexible nasolaryngoscopy was performed and revealed significant edema of the right arytenoid extending into the aryepiglottic fold, limiting the mobility of the right vocal fold (Figure 1).", "Permanent sections showed unremarkable squamous mucosa.", "Flow cytometry revealed mixed inflammatory infiltrate and an increased plasma cell component.", "Results of stains for infectious organisms were negative."], "Treatment": ["A 2-week course of doxycycline was completed for presumed infectious supraglottitis without a change in symptoms.", "Microdirect laryngoscopy and biopsy under general anesthesia was performed, and a specimen was sent to the pathology department for permanent section analysis and flow cytometry."], "Diagnosis": ["Further immunohistochemical analysis confirmed the diagnosis."], "Others": ["A biopsy and culture of the lesion was then collected in the office and revealed inflammatory disease but ultimately was nondiagnostic.", "A full-body nuclear magnetic resonance positron emission tomography/computed tomography scan was performed to rule out systemic disease."]}
{"Patient Personal Background": ["Prior to presentation, she had been prescribed fluticasone and loratadine for allergic rhinitis without resolution of symptoms.", "She was a nonsmoker and nondrinker."], "Patient Symptoms": ["She reported feeling a mass in her right nostril that had not changed in size, as well as associated nasal tenderness to the external nose, worsening pain with exposure to cold temperatures, and frequent sneezing."], "Examination and Results": ["On physical examination, her external nose had no visible lesions.", "A rhinoscopy revealed normal mucosa with a submucosal, round, firm, tender lesion, measuring approximately 1 cm and located on the right anterior nasal septum.", "No drainage was visualized.", "Her turbinates appeared normal."], "Treatment": ["The patient underwent surgical excision of the septal lesion under general anesthesia for definitive diagnosis."], "Others": ["The specimen measured 1.1\u2009\u00d7\u20090.7\u2009\u00d7\u20090.2 cm and was erythematous, soft, vascular, and adherent, with a broad base to the anterior superior nasal septal mucosa just inferior to the upper lateral cartilage (Figure 1A and B).", "The lesion was excised down through the perichondrium.Endoscopic photographs.", "A, Intraoperative view and intraoperative photograph of a mucosal lesion on the anterior septum after the initial incision.", "B, Elevation with a suction shows attachments to the underlying perichondrium."]}
{"Patient Personal Background": ["He was diagnosed with asthma 2 years earlier when he first started experiencing shortness of breath and had partial relief with inhaled albuterol treatments only."], "Patient Symptoms": ["He had no history of fevers, dysphagia, odynophagia, cough, or allergies.On physical examination, moderately severe dysphonia characterized primarily by roughness with mild breathiness as well as mild inspiratory stridor were noted."], "Examination and Results": ["He had no history of fevers, dysphagia, odynophagia, cough, or allergies.On physical examination, moderately severe dysphonia characterized primarily by roughness with mild breathiness as well as mild inspiratory stridor were noted.", "Anterior rhinoscopy demonstrated large, bilateral obstructive nasal polyps.", "Flexible laryngoscopy revealed smooth, lobulated masses involving the epiglottis and right aryepiglottic fold.", "The epiglottic component extended inferiorly along the petiole, involving and obstructing the anterior glottis.", "The vocal fold mucosa was thickened, but bilateral mobility was intact with an adequate posterior glottic airway.Computed tomography demonstrated homogenous, isodense, laryngeal lesions that correlated with the previously mentioned laryngoscopy findings, but also showed subglottic stenosis approximately 2 cm in length secondary to the thickened intraluminal soft tissue (Figure, A).", "The cartilaginous laryngotracheal framework was preserved.", "The chest radiograph was unremarkable.", "The patient was taken to the operating room for direct laryngoscopy with endoscopic airway dilation and laryngeal mass biopsy (Figure, B, C, and D).A, Subglottic stenosis was noted on computed tomography (yellow arrowhead).", "Multifocal laryngeal masses were also observed, with the largest mass involving the epiglottic petiole and extending to obstruct the anterior glottis (black arrowhead).", "B, The arrowhead points to a smooth, lobulated mass involving the epiglottis and anterior glottis.", "C, Cotton-Meyer grade II subglottic stenosis was noted.", "D, Laryngeal mass biopsy results showed vacuolated macrophages with bacilli (yellow arrowhead) and eosinophilic inclusions within plasma cells (black arrowhead) (hematoxylin-eosin)."], "Treatment": ["The patient was taken to the operating room for direct laryngoscopy with endoscopic airway dilation and laryngeal mass biopsy (Figure, B, C, and D).A, Subglottic stenosis was noted on computed tomography (yellow arrowhead)."]}
{"Patient Symptoms": ["The patient first presented to her dentist with a complaint of \u201cit feels like there is something on the roof of [her] mouth.\u201d She was never aware of the palatal lesion before her initial presentation.", "She denied any pain or discomfort from the site, and stated that the increasing size of the mass was what first alerted her to its presence.The extraoral examination results were within normal limits, with no evidence of swelling, expansion, trismus, or lymphadenopathy."], "Examination and Results": ["She denied any pain or discomfort from the site, and stated that the increasing size of the mass was what first alerted her to its presence.The extraoral examination results were within normal limits, with no evidence of swelling, expansion, trismus, or lymphadenopathy.", "Intraoral examination revealed a focally ulcerated, fluctuant 2.5\u2009\u00d7\u20092\u2009\u00d7\u20091-cm pink-red submucosal swelling in the right palatal mucosa (Figure, A).", "The lesion involved almost the entire right side of the hard palatal mucosa and soft palate and terminated at the palatal midline.", "Imaging studies were unremarkable.A, A clinical image shows a diffuse, right-sided palatal swelling with a focal ulceration.", "B, A photomicrograph shows sheets of large lymphocytes with a moderate amount of cytoplasm and round to oval nuclei containing vesicular chromatin and 2 to 3 small nucleoli (hematoxylin-eosin, original magnification \u00d7200).", "The lesional cells stained positively with CD20 (inset) (original magnification, \u00d7400).An incisional biopsy of the lesion was performed and showed fibrous connective tissues infiltrated by inflammatory cells arranged in a diffuse, sheetlike pattern.", "The cells were large with a moderate amount of cytoplasm and appeared to be round to oval vesicular nuclei with vesicular chromatin and 2 to 3 small nucleoli (Figure, B).", "The cells stained positively with CD45, CD20 (Figure, B, inset), CD79, CD21, BCL6, and BCL2 antibodies."]}
{"Patient Personal Background": ["Importantly, the patient noted that he was capable of a \u201cparty trick\u201d which involved puffing out his cheeks to force air into his neck with subsequent decompression of air back into his oral cavity by pushing behind his ear.", "This became a habitual behavior, which the patient performed multiple times per day."], "Patient Symptoms": ["C. Frothy air bubbles milked from the parotid duct with external massage of the parotid gland.On evaluation, the patient noted a week of worsening facial swelling, neck pain, dysphagia, and odynophagia.", "On examination, there was a tender, fluctuant pocket of the left neck near the angle of the mandible without significant crepitus (Video)."], "Examination and Results": ["He was discharged after being prescribed oral antibiotics but continued to have worsening symptoms and returned to the outside facility, where a noncontrasted computed tomographic (CT) scan of the neck and chest showed significant subcutaneous emphysema of the neck and mediastinum (Figure, A and B).", "Intraluminal air in the left parotid duct with associated pneumoparotid and dissection of air into the left parapharyngeal and masticator spaces.", "Pneumoparotid is also noted on the right.", "Inferior dissection of subcutaneous emphysema resulting in pneumomediastinum.", "Air has dissected around the left common carotid artery near its origin from the aortic arch."], "Treatment": ["He was subsequently transferred to our facility for additional treatment.A."], "Diagnosis": ["B."]}
{"Patient Personal Background": ["Her medical history was notable for keratoconjunctivitis sicca, Hashimoto thyroiditis, and anti\u2013interferon-\u03b3 autoantibody syndrome treated with 6 monthly rituximab infusions (375 mg/m2 with 100 mg of methylprednisolone acetate).", "Infusions were given weekly for the first 3 weeks and then every 6 to 8 months based on a CD20 count.", "This treatment concluded 2\u00bd years before presentation.", "In addition, she had a long-standing history of arthralgias with intermittent arthritis treated with hydroxychloroquine, 300 mg/d, that was discontinued 2 years before presentation."], "Patient Symptoms": ["On examination, she had no visual concerns."], "Examination and Results": ["Her visual acuity was 20/20 OU.", "Conjunctivas were normal, lenses were clear, and anterior chambers were deep and quiet.", "The results from the slitlamp examination showed numerous bilateral, peripheral light brown corneal opacities.", "The opacities were located in the far posterior corneae and were present circumferentially (Figure, A).", "There was no associated keratitis or corneal neovascularization.", "Anterior segment optical coherence tomographic findings showed focal areas of hyperreflectivity anterior to the Descemet membrane.", "Confocal microscopy revealed variably shaped, hyperreflective clusters of opacities just anterior to the endothelium (Figure, B).Imaging of the right eye of a patient with rifabutin-related posterior corneal deposits."], "Others": ["She had previously been diagnosed with disseminated Mycobacterium avium complex (MAC) infection requiring 2 years of treatment with rifabutin, 300 mg/d; ethambutol hydrochloride, 1000 mg/d; and clarithromycin in a divided dose, 500 mg twice a day.", "A, Slitlamp photograph with arrowhead highlighting one of numerous bilateral peripheral, small corneal light brown opacities.", "B, Confocal microscopic image captured at a slightly oblique angle illustrates normal endothelial cells (yellow arrowhead).", "Just anterior to the endothelium, the drug deposit appears as variably shaped, hyperreflective clusters of opacities (white arrowhead)."]}
{"Patient Symptoms": ["The onset of vision decrease coincided with muscle pain, joint swelling, and headache.", "All of the symptoms except blurry vision resolved spontaneously after 3 days.", "Over the preceding 5 months, he had had approximately monthly similar episodes consisting of a few days of flulike symptoms and blurry vision, with full recovery between episodes.", "At the time of evaluation, the vision was decreased in the left eye, with pain in both eyes and deep throbbing in the back of the left eye.Visual acuity was 20/20 OD and counting fingers at 1 ft OS, with visual field constriction and a relative afferent pupillary defect in the left eye."], "Examination and Results": ["The examination of the anterior segment bilaterally was unremarkable, as was the posterior segment examination of his right eye.", "However, the fundus examination of the left eye showed extensive optic nerve swelling, with nerve fiber layer hemorrhage at the inferior temporal disc margin and peripapillary subretinal fluid extending to the macula (Figure 1).", "Magnetic resonance imaging (MRI) of the orbits showed anterior swelling of the left optic nerve without masses or hyperintensity of the retrobulbar optic nerve.", "Brain MRI results were normal.Optic nerve imaging at time of presentation.", "Optical coherence tomography (A) and fundus photography (B) of the left optic nerve at time of presentation showing broad optic nerve swelling with nerve fiber layer hemorrhage and fluid extending to macula."]}
{"Patient Personal Background": ["The patient\u2019s medical history was significant for type 2 diabetes diagnosed in her 30s and managed with metformin therapy, hypertension, mild hearing loss, and thyroid cancer that was in remission following thyroidectomy and radiotherapy.", "The patient denied exposure to retinotoxic drugs.On examination, her best-corrected visual acuity was 20/20 OU."], "Patient Symptoms": ["The patient reported having difficulty with night driving owing to glare."], "Examination and Results": ["The anterior segment examination findings were unremarkable except for trace nuclear sclerosis in each eye.", "Dilated fundus examination revealed peripapillary atrophy and scattered macular pigment clumps in each eye.", "Fundus autofluorescence imaging showed a reticular pattern of hyperautofluorescence with sparing of the central macula (Figure).", "Optical coherence tomography of the macula demonstrated hyperreflective retinal pigment epithelial (RPE) lesions with no intraretinal or subretinal fluid.", "Full-field electroretinography (ERG) testing was suggestive of mild cone system dysfunction in each eye.A, Color fundus image of right eye shows scattered deep pigment clumps."], "Others": ["She reported no other ocular history.", "The patient had been told that radioactive iodine therapy damaged her pancreas and predisposed her to diabetes."]}
{"Examination and Results": ["Visual acuity was 20/20 OU with normal intraocular pressures.", "The results from the slitlamp examination of the right eye were within normal limits (Figure 1A).", "Examination results of the left eye demonstrated 2+ diffuse conjunctival hyperemia, 1+ anterior chamber cell, and a vascularized iris infiltrate (Figure 1B).", "Results of the dilated fundus examination were within normal limits in both eyes.", "Ultrasound biomicroscopy of the left eye demonstrated areas of ciliary body thickening 360\u00b0 and a thickened iris pupillary margin superiorly and nasally.", "A full review of systems was negative for other abnormalities including skin lesions."], "Treatment": ["The patient had previously been treated with topical corticosteroid therapy, which provided temporary relief of his symptoms."], "Others": []}
{"Patient Personal Background": ["She reported no medications or comorbidities."], "Patient Symptoms": ["She reported no heartburn, nausea, vomiting, abdominal pain, weight loss, or changes in bowel habits.", "Despite taking ranitidine (150 mg twice daily), she continued to have bothersome daily dysphagia, prompting her primary care clinician to order esophagogastroduodenoscopy (EGD)."], "Examination and Results": ["Physical examination was unremarkable.", "Results of a recent complete blood cell count were normal.", "The EGD showed vertical furrows and circumferential rings in the esophagus (Figure 1A), while the stomach and duodenum appeared normal.", "Four biopsies each were taken from the proximal and distal esophagus (Figure 1B).Left, Esophagus at initial esophagogastroduodenoscopy (EGD).", "Right, Esophageal biopsy sample from initial EGD (hematoxylin-eosin, original magnification \u00d7400)."], "Treatment": ["Despite taking ranitidine (150 mg twice daily), she continued to have bothersome daily dysphagia, prompting her primary care clinician to order esophagogastroduodenoscopy (EGD)."]}
{"Patient Personal Background": ["C, Histopathologic examination of lesional skin (hematoxylin-eosin).Over the past 5 years, the patient\u2019s medications consisted of metoprolol and acetylsalicylic acid for treatment of established ischemic heart disease.", "Nine months prior to being referred to our department, he was given oral furosemide and amiloride and then underwent median sternotomy and coronary artery bypass surgery 2 months later."], "Patient Symptoms": ["Four days after the operation, he developed a red patch at the area of the incision that was accompanied by mild pruritus."], "Examination and Results": ["Physical examination findings revealed a 20-cm\u2013diameter plaque that consisted of multiple concentric annular formations with raised erythematous margins and studded with numerous blisters and pustules, some coalescing into lakes of pus (Figure 1A).", "Nikolsky sign was not elicited, and oral, ocular, and genital mucosa involvement was absent.", "The patient did not report other symptoms, and findings of the overall physical examination were normal.A, A crusted, focally vesiculating, well-demarcated erythematous plaque at the area of median sternotomy.", "Over the following months, the lesion showed a marked tendency for centrifugal extension over the chest area.Results of routine laboratory studies, Mantoux test, chest radiography, and chest computed tomography of the area were within the normal range.", "Gram stain, periodic acid\u2013Schiff stain, and tissue culture results were negative (Figure 1B and C)."], "Others": ["B, Histopathologic examination of lesional skin (hematoxylin-eosin)."]}
{"Patient Symptoms": ["The patient initially had improvement in her skin, but she again noticed enlargement of the soft tissue with thickening of the overlying skin on her right cheek and right side of her nose several months later.Clinical examination revealed slightly hyperplastic soft tissue with dilated patulous follicles involving the right medial malar cheek and right nasal ala in addition to deviation of the nasal tip (Figure, A)."], "Examination and Results": ["The surgical pathology specimens from her septorhinoplasty were obtained and reviewed.A, Clinical image shows facial asymmetry with deviation of the nasal tip.", "B, Hematoxylin-eosin stain of an interstitial proliferation of spindle cells within mature adipocytes that extends between bundles of skeletal muscle.", "C, Hematoxylin-eosin stain of mature adipocytes that are separated by a proliferation of spindle cells associated with fragments of thickened collagen."], "Treatment": ["She underwent a septorhinoplasty 6 months prior to presentation because of collapse of her right nasal ala. During the surgical procedure, the surgeon noted a significant amount of submucosal tissue in the right nasal cavity, which was removed; histopathological analysis was performed, and the results were reported as fibroadipose tissue and vascular proliferation.", "A skin biopsy was performed at the time of the surgical procedure and was interpreted as sebaceous hyperplasia."], "Others": ["She had been seen by several dermatologists and otolaryngologists and had undergone nondiagnostic skin biopsies."]}
{"Patient Personal Background": ["Bowel and bladder movements were normal.", "The child had an older sibling who had no skin ailments, and none of the other family members were affected.On examination, multiple tense, angulated vesicles and bullae on a background of erythema were seen over the face, trunk, and extremities (Figure, A and B)."], "Patient Symptoms": ["The lesions initially started over the trunk and subsequently progressed to involve the face, hands, and feet.", "The episodes of skin blisters were accompanied by pruritus and redness all over the body.", "The ruptured bullae were healing with hypopigmentation with accompanying scarring and discrete milia formation."], "Examination and Results": ["Few urticated papules and wheals were seen in isolation over the trunk.", "The mucosae and nails were normal.", "No contractures or webbing of fingers was noted.", "A punch biopsy from a vesicle was subsequently performed (Figure, C and D).A, Multiple angulated vesicles and tense bullae over the forehead and chin.", "Background erythema can be appreciated.", "B, Tense bullae over the trunk with superficial erosions and postinflammatory hypopigmentation, which are healing with scarring and discrete milia formation.", "Few urticated papules and plaques can also be appreciated.", "C, Subepidermal bulla with bandlike mast cell infiltrate in the upper dermis (hematoxylin and eosin stain).", "D, Higher magnification showing dense infiltrate of mast cells in the upper dermis."], "Others": ["There was no history of oral erosions or difficulty in feeding.", "There was no organomegaly."]}
{"Patient Personal Background": ["Her mental state had deteriorated progressively over the previous 12 months, following the death of her father.", "On arrival in the United Kingdom, her family claimed asylum and moved into a small apartment in a high-rise building in central London.", "Although there was no reported developmental delay, she had struggled academically at school and was bullied for having overweight.", "She left school without qualifications at age 16 years and worked as a shop assistant.", "She left this job about a year prior to her referral to psychiatry after a period of sick leave following the death of her father.", "She was a nonsmoker, did not drink alcohol, and denied illicit drug use.", "A paternal relative was reported to have a diagnosis of schizophrenia."], "Patient Symptoms": ["After a period living alone, she had returned to the family home 4 months prior to her presentation and had been noted to be socially withdrawn, preoccupied, and distractible.", "Her family subsequently sought advice from the family physician when the patient was noted to be speaking to herself, expressing concerns about people meaning her harm, and professing the belief that she could hear other peoples\u2019 thoughts.The patient had been born in Sierra Leone after a complicated delivery and had traveled to the United Kingdom as a child with her family, who were fleeing from a civil war.", "She denied feeling low in mood or suicidal and was objectively euthymic.", "She reflected that over the preceding few months, she had experienced a sensation of detachment from her immediate environment, as though it was not real, making her world similar to that of a video game.", "She explained this was because 6 was associated with the number of the devil.", "She reported hearing her neighbors commenting negatively about her appearance.", "On returning home, her paranoia regarding her previous neighbors worsened, resulting in her rarely leaving the house."], "Examination and Results": ["There was no comorbid physical illness.On review, the patient was kempt and had overweight.", "Eye contact was fleeting, and she presented as anxious, with a degree of psychomotor agitation.", "Her speech was normal in rate, volume, and tone, although tangential.", "There was no other evidence of thought disorder.", "There was some sleep disturbance, with the patient reporting being fearful to go to sleep owing to persecutory beliefs regarding her neighbors."], "Treatment": ["Her family physician, suspecting a depressive episode, had prescribed citalopram up to a dosage of 40 mg once daily, to no effect."], "Others": ["She reported that in the apartment where she had previously been living, she had realized that something was amiss and had become convinced that the door number of her neighbor\u2019s flat, number 6, signified that they meant her harm.", "These distressing experiences prompted her to return to her family home, but she continued to hear her neighbors\u2019 voices making derogatory comments about her appearance and began to hear them commenting on her actions and thoughts in the third person as well."]}
{"Patient Symptoms": ["The patient was admitted with fever of unknown origin with a surge of the inflammatory syndrome and pancytopenia.", "He reported night sweats beginning 3 weeks prior associated with fever and unintentional weight loss."], "Examination and Results": ["The pleural fluid was transudative and sterile, and the pericardium contained focal lymphoplasmacytic aggregates.", "No lymphadenopathy was noted.Laboratory evaluations demonstrated a C-reactive protein level of 133 mg/L (reference range, <10 mg/L); ferritin level of 2607 ng/mL (reference, 30-300 ng/mL); lactate dehydrogenase (LDH) level of 289 U/L (reference, 135-214 U/L); pancytopenia with a hemoglobin level of 9.3 g/dL (reference, 13.3-17.7 g/dL), white blood cell count of 2700/\u03bcL (reference, 4000-10\u202f000/\u03bcL), and platelet count of 99 \u00d7103/\u03bcL (reference, 150-350 \u00d7103/\u03bcL); and prerenal acute kidney injury (Acute Kidney Injury Network stage 1) with a serum creatinine level of 1.4 mg/dL (reference, 0.7-1.2 mg/dL).", "Results of a comprehensive serologic workup were negative.", "Gastroscopy results showed mycotic distal esophagitis.The patient was readmitted 3 weeks later with fever and hypotension without improvement despite broad-spectrum antibiotics and antifungals.", "Computed tomography (CT) results showed a splenomegaly without evidence of metastatic disease or lymph node enlargement.", "Positron emission tomography (PET)\u2013CT imaging (Figure, A and B) and a bone-marrow biopsy (Figure, C and D) were performed.", "A rapidly evolving sepsislike syndrome led to the patient\u2019s death.Fluorodeoxyglucose/positron emission tomography\u2013computed tomography imaging results show diffuse hypercaptation in the bone marrow (A) and spleen (B).", "The entire skeleton is highly metabolic, which suggests advanced bone-marrow involvement.", "C, Bone-marrow biopsy results show a diffuse infiltrate of large lymphoid cells with scattered residual hematopoietic elements (immunoperoxidase, original magnification \u00d7200)."], "Treatment": ["Attempts to taper immunosuppressive drugs failed because of a recrudescence of the inflammatory syndrome and pericardial effusion.", "Gastroscopy results showed mycotic distal esophagitis.The patient was readmitted 3 weeks later with fever and hypotension without improvement despite broad-spectrum antibiotics and antifungals."], "Diagnosis": ["Considering the increase in ferritin and LDH levels and pancytopenia, a hematologic disease was suspected."], "Others": ["The patient did not report any bone pain."]}
{"Patient Personal Background": ["She reported no family history of sudden cardiac death or unexplained premature death."], "Patient Symptoms": ["When emergency responders arrived, the patient was responsive but groggy.", "She was oriented but slow to respond."], "Examination and Results": ["An electrocardiogram (ECG) in the field demonstrated a regular wide complex tachycardia.", "En route to the hospital, 6 mg of adenosine followed by 12 mg of adenosine were administered intravenously, without a change in her rhythm.On arrival to the emergency department, she was in a regular wide complex tachycardia with a heart rate of 225 beats per minute (Figure, A), with an initial blood pressure of 108/77 mm Hg.", "Her initial laboratory evaluation revealed hypokalemia (2.8 mEq/L; to convert to millimoles per liter, multiply by 1.0), hypomagnesemia (3.6 mEq/L; to convert to millimoles per liter, multiply by 0.50), and an elevated serum troponin (0.13 nanograms per milliliter; to convert to micrograms per milliliter, multiply by 1.0).", "A transthoracic echocardiogram showed normal biventricular size and function.Twelve-lead electrocardiograms (ECGs) obtained on presentation (A) and immediately after electrical cardioversion (B)."], "Treatment": ["After sedation, a synchronized, biphasic, 200-J shock converted her to sinus rhythm with bigeminy (Figure, B), which settled to normal sinus rhythm.", "An intravenous amiodarone infusion was administered.", "Potassium and magnesium replacement was administered orally and intravenously."]}
{"Patient Personal Background": ["The pregnancy was uncomplicated, and prenatal ultrasonography results were normal."], "Patient Symptoms": ["After spontaneous vaginal delivery at 37 weeks\u2019 gestation, the neonate immediately developed tachypnea, severe retractions, barking cough, hoarse cry, and dusky appearance with oxygen desaturations to 60%, which required continuous positive airway pressure."], "Examination and Results": ["The intubating clinician noted a large flesh-colored laryngeal mass and placed a size 3.5 uncuffed endotracheal tube.", "Ear, nose, and throat evaluation noted that the neonate was intubated and ventilating easily.", "No craniofacial abnormalities or obvious oral cavity, oropharyngeal, or neck masses were present.", "Chest radiography was obtained, and results were normal.", "Intraoperative evaluation revealed a large submucosal mass involving the left side of the epiglottis, false fold, aryepiglottic fold, and arytenoid that was soft and fluctuant on palpation (Figure 1).Direct laryngoscopy revealed a large mass involving the left side of the epiglottis, false fold, aryepiglottic fold, and arytenoid."], "Treatment": ["After spontaneous vaginal delivery at 37 weeks\u2019 gestation, the neonate immediately developed tachypnea, severe retractions, barking cough, hoarse cry, and dusky appearance with oxygen desaturations to 60%, which required continuous positive airway pressure.", "Despite respiratory support, she was intubated within the first hour of life.", "The patient was subsequently taken to the operating room for direct laryngoscopy and bronchoscopy."]}
{"Patient Personal Background": ["Ten years later, he developed a second primary tumor in the hypopharynx requiring total laryngectomy and bilateral neck dissection."], "Patient Symptoms": ["He presented with new-onset headaches, left ear pain, and persistent unsteadiness during the previous month."], "Examination and Results": ["There was no palpable lymphadenopathy, neurological deficits, or mastoid tenderness, and otoscopic examination results of the tympanic membrane appeared normal.Magnetic resonance imaging of the head showed an enhancing lesion in the left infratemporal fossa (3.4\u2009\u00d7\u20093.4\u2009\u00d7\u20092.8 cm) abutting the cerebellum, and subsequent computed tomographic imaging of the head demonstrated osseous destruction of the left temporal bone extending along the left internal jugular vein (Figure, A).", "Fine-needle aspiration of the left mastoid showed atypical spindle cells.", "Histopathologic assessment demonstrated myogenin-positive spindle cells with no tumor necrosis (Figure, B and C).", "In addition, the tumor expressed desmin-positive and CD34-positive cells.", "The tumor focally infiltrated into the fibrous tissue, skeletal muscle, and bone.A, Axial computed tomography of the head and neck demonstrating osseous destruction of the left temporal bone.", "B and C, Histopathologic test results.", "B, High-powered view of hematoxylin-eosin stain (original magnification \u00d740) demonstrating spindle cell morphologic features with admixed fragments of bone (pink-red areas).", "C, High-powered view of myogenin stain (original magnification \u00d740) depicting small-cell or spindle cell morphologic features with rare positive results for myogenin (brown cells)."], "Treatment": ["The patient underwent tumor excision with a left infratemporal approach.", "A large mass with rubbery texture was noted, extending into the jugular foramen and adherent to the dura mater without evidence of intradural invasion.", "The lower cranial nerves were identified, and the mass was resected to the external wall of the jugular bulb.", "The patient tolerated the procedure without complications or neurological deficits."]}
{"Patient Personal Background": ["The infant had no other congenital anomalies and had been meeting all major developmental milestones."], "Patient Symptoms": ["No associated pain or pruritus was noted, and the papule had never bled or produced other fluid or debris."], "Examination and Results": ["On clinical examination, a superficial, white-yellow papule was identified on the anterior surface of the neck, situated at the midline superior to the sternal notch.", "It measured 6 mm in diameter and was not associated with overlying surface changes or evident discharge.", "Dermoscopy results showed scattered telangiectatic vessels over the papule, accentuated peripherally.A smooth, subcutaneous papule with a yellow tint is present above the suprasternal notch and exposed with retraction of skinfolds of the anterior neck.Ultrasonography was performed to further characterize the papule, and imaging results exhibited a superficial cutaneous lesion without evidence of tracking into deeper layers of subcutaneous tissue or fluid collection."], "Treatment": ["Active nonintervention was recommended, but because of continued parental concern, the lesion was shaved off in clinic and sent for histopathologic evaluation to rule out malignant neoplasm and other morbid diagnoses."]}
{"Patient Personal Background": ["The patient had a history of polycystic ovarian syndrome with insulin resistance and a migraine disorder and reported experiencing 1 to 2 migraine episodes per week since early high school."], "Patient Symptoms": ["She believed that the neck mass made these episodes worse than normal.", "After 2 weeks, the neck swelling persisted despite the resolution of other symptoms.", "The patient reported new symptoms, including waxing and waning pain that radiated to the back of her neck, headaches, and intermittent dysphagia."], "Examination and Results": ["Her physician noted visible swelling in the right neck and clinically interpreted the finding as enlarged lymph nodes associated with the infection.", "She also noted periods during which the mass would fluctuate in size.Otolaryngologic examination findings were within normal limits except for a single, nontender, compressible right neck mass deep to the sternocleidomastoid muscle and extending into level V. The patient underwent a computed tomography (CT) scan prior to presentation at the Dartmouth-Hitchcock Medical Center\u2019s otolaryngology clinic.", "The scan showed a fatty-appearing tumor within the right carotid space.", "Gross pathologic examination demonstrated yellowish-brown, homogenous, lobular adipose tissue covered by a thin, tan, transparent membrane (Figure, A).", "Histopathologic examination showed relatively uniform univacuolar and multivacuolated, granular eosinophilic cells with centrally placed nucleoli (Figure, B and C).", "B and C, Histologic results show uniform univacuolar to multivacuolated granular eosinophilic cells with centrally placed nucleoli (hematoxylin-eosin)."], "Treatment": ["She was subsequently treated with a course of antibiotics, which did not result in any improvement.", "The patient underwent surgical excision, and a mass measuring 8.0\u2009\u00d7\u20096.5\u2009\u00d7\u20094.7\u2013cm was removed from the carotid space (Figure, A).", "Additional material from the mass was excised at the level of the base of the skull."], "Others": ["The patient was otherwise previously healthy until she developed an upper respiratory infection.", "The mass slowly enlarged over the next 6 months.", "In addition, several level II and level III lymph nodes were excised, all of which were found to be benign.A, The 8.0\u2009\u00d7\u20096.5\u2009\u00d7\u20094.7\u2013cm mass was surgically excised from the patient\u2019s carotid space."]}
{"Patient Symptoms": ["Review of systems was positive for fever, tachycardia, odynophagia, productive cough with wheezing, and marked peripheral edema in upper extremities and negative for headache, nausea, vomiting, dysacusis, meningismus, or skin changes.Fundus photographs and optical coherence tomography 4 days from presentation demonstrating bilateral choroidal effusions with serous retinal detachment and white centered intraretinal hemorrhages."], "Examination and Results": ["Laboratory test results were remarkable for pancytopenia.", "On initial examination, his visual acuity was count fingers at 3 ft in both eyes.", "Intraocular pressures were 10 mm Hg OD and 11 mm Hg OS.", "Pupils were round and reactive without a relative afferent pupillary defect.", "Color plates were 1 of 8 OU, with 50% brightness desaturation in the right eye and no red desaturation.", "Extraocular movements were full.", "Slitlamp examination was negative for any signs of inflammation.", "Dilated fundus examination demonstrated bilateral choroidal effusions with diffuse serous retinal detachments (RD) involving the macula without vitritis as well as white centered intraretinal hemorrhages along peripapillary and superior and inferior arcade distributions in both eyes (Figure, A).", "Optical coherence tomography demonstrated irregular inner retinal surface and subretinal fluid with septae with loss of the ellipsoid zone (Figure, B).", "Left eye results shown.", "A, Left eye color fundus photograph demonstrates peripheral choroidal effusion with areas of stippled subretinal fluid in the macula, areas of intraretinal hemorrhages scattered throughout the posterior pole as well as far temporal periphery."], "Treatment": ["Hospital course was complicated by neutropenic fever, receiving cefepime, acyclovir, vancomycin, and voriconazole for prophylaxis."]}
{"Patient Personal Background": ["He had a history of well-controlled type 2 diabetes and diffuse large B-cell lymphoma that was diagnosed 3 years earlier.", "The lymphoma was initially treated with chemotherapy, followed by a relapse that required additional chemotherapy and ultimately autologous bone marrow transplant 3 months before presentation.", "At the time of presentation, he was taking no immunosuppressive medications and was taking prophylactic acyclovir, 800 mg twice daily, and sulfamethoxazole/trimethoprim (800 mg/160 mg) 3 times weekly.Snellen visual acuity measured 20/40 OD and 20/20 OS."], "Examination and Results": ["Intraocular pressure (IOP) measured 24 mm Hg OD and 12 mm Hg OS.", "There was no afferent pupillary defect.", "Right eye examination results revealed 1+ anterior chamber inflammation, iris neovascularization, keratic precipitates, vitritis, and a granular necrotizing retinitis (Figure, A).", "Left eye examination results were unremarkable.", "Fluorescein angiography of the right eye demonstrated panretinal occlusive vasculopathy with severe peripheral nonperfusion (Figure, B).", "His white blood cell count was moderately low at 3.1 kilos/\u03bcL (to convert to \u00d7109/L, multiply by 0.001; reference range, 4.0-10.0 kilos/\u03bcL); a complete blood count and serum chemistry panel were otherwise normal.", "Human immunodeficiency virus (HIV) testing results were negative.", "An aqueous tap was performed and sent for culture and polymerase chain reaction.A, Wide-field fundus photograph demonstrating vitreous haze, vascular attenuation, macular cotton wool-spots, diffuse intraretinal hemorrhages, and superior granular necrotizing retinitis."], "Treatment": []}
{"Patient Personal Background": ["The lack of response to oral prednisone therapy led to suspicion of a possible malignant neoplasm, and the patient was referred for our opinion.The patient\u2019s medical history was notable for chronic lymphocytic leukemia/small lymphocytic lymphoma (CLL/SLL) with transformation to large B-cell lymphoma that was treated with rituximab, adriamycin, vincristine sulfate, and prednisone chemotherapy 4 years earlier.", "Two years before referral, bladder cancer was diagnosed and was treated surgically and with multiple rounds of intravesical BCG immunotherapy.", "The most recent BCG treatment was 5 months before presentation to the Ocular Oncology Service at Wills Eye Hospital, Philadelphia, Pennsylvania.On examination, visual acuity was 20/25 OD and 20/40 OS."], "Patient Symptoms": ["The patient noted redness, pain, and a foreign body sensation on his right eye for 2 weeks."], "Examination and Results": ["The chest radiographic findings and blood work results were unremarkable.", "Anterior segment examination findings were remarkable for a limbal-based amelanotic lesion of the nasal conjunctiva measuring 5 mm in basal diameter and 1.5 mm thick and fed by large dilated conjunctival and episcleral vessels (Figure 1).", "Ocular ultrasonography revealed no intraocular involvement."], "Treatment": ["The general ophthalmologist prescribed a 3-week course of oral prednisone, 20 mg/d, that reduced surrounding inflammation and pain, but the lesion did not change in appearance."]}
{"Patient Personal Background": ["The patient had an ocular history of herpes simplex (HSV) keratitis with a previous perforation of the right eye repaired with a patch graft, advanced open-angle glaucoma in the right eye, and ocular hypertension of the left eye, and he was receiving brimonidine 3 times a day in both eyes and acetazolamide, 250 mg, 3 times a day.On examination, his visual acuity without correction was 20/200 OD and 20/50 OS, with pinhole acuity measured at 20/80 OD and 20/40 OS."], "Patient Symptoms": ["An external examination revealed severe eczematous skin changes and thinning of the eyebrows and eyelashes.", "A slitlamp examination showed madarosis, mild eyelid edema, and conjunctival injection, which were greater in the left eye than the right eye."], "Examination and Results": ["His intraocular pressure was 9 mm Hg OD and 42 mm Hg OS.", "The right cornea had inferior pannus, scarring, and neovascularization.", "The left cornea revealed microcystic edema and central ulceration (Figure 1).", "The anterior chambers of both eyes were quiet.", "A fundus examination was notable for cup-disc ratios of 0.8 OD and 0.4 OS.Examination at presentation.", "External photograph of the right eye with neurotrophic cornea with neovascularization and scarring (A) and external photograph of the left eye with epithelial dendritic lesion with corneal edema (B).Bacterial cultures, a viral polymerase chain reaction, and potassium hydroxide preparations were obtained from the ulcer of the left cornea.", "The results of the viral polymerase chain reaction and potassium hydroxide tests were negative, while bacterial cultures had positive results for methicillin-resistant Staphylococcus aureus and Escherichia coli."]}
{"Patient Personal Background": ["Over 2 years, he was prescribed various therapies including prednisone, methotrexate, tumor necrosis factor inhibitors, abatacept, and anakinra; he experienced intermittent improvement in his joint pain but had persistently elevated levels of inflammatory markers."], "Patient Symptoms": ["He continued to experience asymmetric small- and large-joint polyarthralgias and later developed intermittent fevers (temperatures up to 38.3\u00b0C [101\u00b0F]) along with a 50-lb (22.7-kg) unintentional weight loss over the course of a few months.On examination, there was subtle synovitis in bilateral metacarpophalangeal joints.", "Over the next several months, he developed intermittent abdominal pain, steatorrhea, protein-losing enteropathy, and symmetric bilateral lower extremity edema requiring diuresis."], "Examination and Results": ["Findings on cardiac, pulmonary, and neurologic examinations were unremarkable.", "Laboratory evaluation was notable for a normocytic anemia and elevated C-reactive protein level (7.7 mg/dL [73.3 nmol/L]).", "Results of esophagogastroduodenoscopy with gastric biopsies and bone marrow biopsy were unremarkable.", "Findings on further workup including transthoracic echocardiography to assess for endocarditis, carotid magnetic resonance angiography to assess for vasculitis, and abdominal fat pad biopsy for amyloidosis were also unremarkable.", "Results of infectious stool studies, celiac serology, and fecal elastase testing were normal."], "Treatment": ["Tocilizumab was initiated."], "Others": ["Repeat esophagogastroduodenoscopy (Figure, panel A) was performed, with gastric and duodenal biopsies (Figure, panels B and C).A, Duodenal segment on esophagogastroduodenoscopy.", "B, Histologic examination of duodenal mucosa (hematoxylin-eosin, original magnification \u00d7100; sample obtained using cold forceps)."]}
{"Patient Personal Background": ["She had immigrated from Chuuk, Micronesia, to Hawaii 10 years ago and had not traveled overseas since.", "She denied alcohol use or contact with animals such as pigs.On examination, her temperature was 38.5\u00b0C (101.3\u00b0F); pulse rate, 104/min; blood pressure, 205/92 mm Hg; and respiratory rate, 33/min with normal saturation."], "Patient Symptoms": ["The pain was sharp, intermittent without radiation, and not exacerbated by eating.", "She had no subjective fevers, nausea, vomiting, diarrhea, or weight loss.", "Mild conjunctival icterus and a positive Murphy sign were noted."], "Examination and Results": ["She denied alcohol use or contact with animals such as pigs.On examination, her temperature was 38.5\u00b0C (101.3\u00b0F); pulse rate, 104/min; blood pressure, 205/92 mm Hg; and respiratory rate, 33/min with normal saturation.", "Laboratory evaluation showed a white blood cell count of 16.4\u2009\u00d7\u2009109/L (neutrophils, 87.4%; eosinophils, 0.5% [absolute count, 82/\u03bcL]); hemoglobin level, 14.9 g/dL; platelet count, 254\u2009\u00d7\u2009109/L; aspartate aminotransferase level, 514 U/L; alanine aminotransferase level, 236 U/L; alkaline phosphatase level, 208 IU/L; total bilirubin level, 2.5 mg/dL; direct bilirubin level, 1.1 mg/dL; and lipase level, 247 U/L.", "Results of serologic testing for hepatitis A, B, and C were negative.", "Abdominal ultrasound showed no cholecystitis or pancreatohepatobiliary abnormalities.", "Magnetic resonance cholangiopancreatography was notable for a linear filling defect within the common bile duct extending through the left hepatic duct (Figure, left panel).", "During endoscopic retrograde cholangiopancreatography (ERCP), numerous worms were discovered within the biliary trees, with 1 visible outside the ampulla of Vater (Figure, right panel).Left, Findings on magnetic resonance cholangiopancreatography."]}
{"Patient Personal Background": ["She had experienced a similar eruption at the same site with spontaneous resolution 1 year previously, after she had taken a cold medication containing ibuprofen.", "Her medical history was otherwise unremarkable.", "She took no prescription medications; however, she did occasionally take over-the-counter ibuprofen."], "Examination and Results": ["On examination, she was well-appearing and afebrile.", "There were tense confluent blisters in a 4-cm area on and around the lower lip (Figure 1) and no other skin or mucosal lesions.Tense confluent blisters on the lower lip area."]}
{"Patient Personal Background": ["The patient was born and lived in a rural village in Malawi.", "Her medical and family history were unremarkable."], "Patient Symptoms": ["She did not report fever or malaise."], "Examination and Results": ["Physical examination revealed a polypoid, rubbery tumor measuring 1.5 cm located on her right labium majus, which obliterated the right labium minus (Figure, A).", "She did not present with enlarged lymph nodes, and results of the physical examination were otherwise unremarkable.", "An incisional lesional biopsy was taken (Figure, B and C).A, Polypoid nodule on the right labium majus obliterating the labium minus.", "B-D, Hematoxylin-eosin\u2013stained lesional specimens.", "B, Histopathologic analysis of the nodule showed pseudoepitheliomatous hyperplasia with transepidermal elimination of basophilic oval-shaped structures in the epidermis and a dense acute and chronic dermal infiltrate in the dermis.", "C, Numerous dermal structures surrounded by a dense acute and chronic inflammatory cell infiltrate with granuloma formation.", "D, High-power magnification of the oval parasitic structures with a typical terminal spine."]}
{"Patient Personal Background": ["He had no relevant medical history.", "The patient reported no history of lesions or foreign bodies at this location."], "Examination and Results": ["On medical examination, a reddish, smooth, superficial nodule with small dimples and a soft consistency that measured approximately 1.5 cm in diameter was seen on the left earlobe (Figure, A).", "It was not painful to the touch.", "A biopsy specimen was obtained for histopathologic analysis (Figure, B and C).A, Clinical photograph of a pruriginous, reddish tumor on the earlobe.", "B and C, Histopathologic findings reveal mixed diffuse dermatitis involving the reticular dermis, with small-vessel vasculitis, characteristic sparing of a superficial dermal grenz zone as well as the dilated vessel luminal, and mixed leukocytic infiltrate with eosinophils, lymphocytes, and neutrophils involving the full thickness of the vessel wall (hematoxylin-eosin)."]}
{"Patient Personal Background": ["He was a vegetarian, nonsmoker, and nondrinker.", "He denied a history of drug addiction.On examination, he was confused."], "Patient Symptoms": ["He had had 2 episodes of seizures that were characterized by tonic head and eye deviation to the left, followed by a brief period of tonic-clonic activity of all 4 limbs and postictal confusion for 10 to 15 minutes.", "He had facial flushing and grade III clubbing in his fingers and toes."], "Examination and Results": ["His chest and cardiovascular examination results were normal.", "He had ptosis in his right eye.", "The right eye was deviated laterally secondary to right-medial rectus palsy.", "His pupil size and pupillary light reactions were normal.", "He also had grade II papilledema.", "His motor and sensory examination results were normal; however, he had brisk deep-tendon jerks and extensor planter responses.", "There were no meningeal signs.His cranial magnetic resonance image showed 2 ring-enhancing lesions in the right frontal and left parietal cortexes, along with surrounding brain edema and mass effects.", "Both lesions showed a thin-walled, contrast-enhancing rim with a central liquefaction (Figure, A).", "The central liquefaction showed restricted diffusion on diffusion-weighted magnetic resonance images.A, Cranial T1-weighted postcontrast magnetic resonance image showing ring-enhancing lesions in the right frontal and left parietal lobes.", "B, Chest radiography showing a radiolucent nodular shadow in left middle lung field.His hemoglobin level was 19.3 grams per deciliter (to convert to grams per liter, multiply by 10.0), his total leukocyte count was 13\u202f500/\u03bcL (to convert to cells\u2009\u00d7\u2009109/L, multiply by 0.001), his hematocrit was 62.4% (to convert to a proportion of 1.0, multiply by 10), and his platelet count was 210\u202f000/\u03bcL (to convert to cells\u2009\u00d7\u2009109/L, multiply by 0.001).", "He had normal liver and renal function test results.", "An enzyme-linked immunosorbent assay for HIV was nonreactive.", "The 2-dimensional echocardiogram did not show any evidence of congenital heart disease."], "Others": ["A radiograph of his chest showed a nodular shadow in the left middle field of the lung (Figure, B)."]}
{"Patient Symptoms": ["Two years prior, he had no obvious inducement and gradually developed indifference, glassy eyes, lethargy, and poor memory.", "One year prior, the patient\u2019s personality changed dramatically, with notably decreased memory formation but intact short-term memory.", "He was short-tempered, irritable, hyperactive, and exhibited slight balance instability while walking."], "Examination and Results": ["On admission, physical examination showed unstable balance while walking in a straight line, positive ankle clonus bilaterally, positive Babinski sign bilaterally, positive Chaddock sign bilaterally, positive Romberg sign, and painless lumps of about 8.2 cm in diameter in both Achilles tendons.", "Routine laboratory test results showed that the patient\u2019s triglyceride level was elevated at 342.48 mg/dL (to convert to millimoles per liter, multiply by 0.0013 mg/dL; normal levels are considered to be 30.97-150.44 mg/dL).", "A brain magnetic resonance imaging (MRI) indicated multiple bilateral, symmetric abnormal signals in the genus of the internal capsules, posterior limbs of internal capsules, cerebral peduncles, pons, and cerebellar dentate nuclei (Figure, A).", "Genetic testing indicated a known pathogenic mutation c.1214G>A (p.Arg405Gln; Hom) in the CYP27A1 gene.", "An MRI of the ankle joints revealed an enlargement of the left Achilles tendon with abnormal signal, and the right Achilles tendon was circumscribed by a fusiform enlargement with abnormal signal (Figure, B).A, Brain magnetic resonance imaging (MRI) suggested multiple symmetrical abnormal signals (bilateral genus of internal capsule and posterior limbs of internal capsule, bilateral cerebral peduncles, pons, and cerebellar dentate nucleus)."]}
{"Patient Symptoms": ["Over a 4-week period, he developed dyspnea with moderate levels of physical activity that were occasionally associated with brief episodes of lightheadedness.", "He also reported orthopnea but no paroxysmal nocturnal dyspnea or leg edema.", "There was no chest pain, palpitations, cough, fever, or hemoptysis."], "Examination and Results": ["He had tachypnea with a respiratory rate of 24 breaths per minute with a normal oxygen saturation, temperature, heart rate, and blood pressure.", "A soft (I/VI) systolic murmur with a brief diastolic component was appreciated over the apex.", "Jugular venous distension was present; there were no pulmonary rales, abdominal distention, or leg edema.", "Workup results demonstrated leukocytosis (white blood cell count, 39\u202f800/\u03bcL [to convert to \u00d7109 L, multiply by 0.001]; 15920/\u03bcL eosinophils [44%]), with a hemoglobin level of 12.4 g/dL (to convert to grams per liter, multiply by 10) and a platelet count of 153 \u00d7103/\u03bcL (to convert to \u00d7109 L, multiply by 1).", "A basic metabolic panel yielded normal results and troponin was undetectable.", "His chest radiography results were suggestive of pulmonary vascular congestion.", "The echocardiogram results demonstrated a normal left ventricular ejection fraction with no substantial wall motion abnormalities.", "There was an echogenic band traversing the apical portion of the left ventricle with increased echogenicity compared with the adjacent myocardium (Video).", "Representative frames of the echocardiogram are shown in Figure 1.Representative apical 4-chamber view in diastole (A) and systole (B) demonstrating an echogenic band traversing the apical portion of the left ventricle with increased echogenicity compared with the adjacent myocardium."]}
{"Patient Personal Background": ["She had a left vocal fold polyp that was removed 2 months earlier at an outside institution, with benign pathology reported."], "Patient Symptoms": ["However, her voice worsened with therapy, and she returned to the otolaryngology clinic after a few weeks."], "Examination and Results": ["Subsequent stroboscopy revealed a hemorrhagic-appearing polyp (2-3 mm).", "A larger, 6- to 7-mm, irregular, left vocal fold mass was noted.", "Preoperative imaging was nonspecific, revealing a small soft-tissue density along the true vocal fold.", "After the final pathology results were obtained, the patient was taken back to the operating room for cordectomy with negative margins.A, The left vocal fold lesion has a hemorrhagic exophytic mass that has prolapsed into the subglottis.", "B, Lesional spindled, fibroblastic-myofibroblastic, and inflammatory cells (both plasma cells and lymphocytes) appear in a myxoid background with abundant blood vessels.", "The overlying squamous epithelium demonstrates only minimal reactivity with some acanthosis and parakeratosis.", "Cellular proliferation was present in a myxomatous and focally fibrous-appearing stroma."], "Treatment": ["She was sent for preoperative voice therapy, with plans for excision.", "The patient was taken to the operating room for excision (Figure, A).", "These findings were confirmed at the time of the initial excision."], "Others": ["Even within this field, the denser collagenized stroma interrupts looser edematous areas.", "C, Neoplastic, spindled, fibroblastic-myofibroblastic cells have diffuse, strong, granular cytoplasmic staining with the ALK1 (D5F3 clone).", "The intralesional blood vessels and inflammatory cells and overlying epithelium do not stain.Pathologic results revealed spindle-shaped cells with variable atypia noted and inflammatory cells, including lymphocytes and plasma cells (Figure, B).", "Immunohistochemical analysis revealed that the lesional cells were negative for desmin, S100, P63, and cytokeratin (Figure, C).", "They were reactive for vimentin and anaplastic lymphoma kinase 1 (ALK1).", "She has had no recurrent disease for the past 3 years."]}
{"Patient Personal Background": ["He had been diagnosed prenatally with cerebellar hypoplasia, so a magnetic resonance imaging study of the brain was performed at 1 month of age."], "Examination and Results": ["This study demonstrated an incidental solid, homogenous mass in the subcutaneous fat of the right occiput with irregular borders and infiltration into the paraspinal musculature (Figure, A).", "On examination, the upper posterior neck mass was deep to palpation without overlying skin changes.", "The arrowhead points to a 1.1-cm \u00d7 0.8-cm \u00d7 1.7-cm right occipital soft tissue mass with irregular borders and infiltration into the deep paraspinal musculature.", "B and C, Hematoxylin-eosin\u2013stained images demonstrating cells with oval nuclei and multiple small nucleoli surrounded by a pale eosinophilic and slightly fibrillary stroma.At 7 months of age, the patient underwent ultrasonography to assess interval change of the lesion, which confirmed a 3.4-cm \u00d7 1.6-cm \u00d7 3.7-cm mass that had grown proportionally with the patient and was relatively avascular.", "Shortly thereafter, the mass was excised en bloc along with a cuff of adjacent posterior neck muscle and subcutaneous tissue.", "Histologic examination revealed cells with oval nuclei and multiple small nucleoli surrounded by a pale eosinophilic and slightly fibrillary stroma (Figure, B and C).", "Immunohistochemical studies were diffusely positive for glial fibrillary acidic protein and vimentin, and focally positive for S100, NeuN, and synaptophysin."], "Treatment": ["Grossly, the lesion was firm, round, and white in color with a smooth intact border but no discrete capsule."], "Others": ["The patient had no discomfort, and neck movement was not restricted.A, Axial T2-weighted magnetic resonance imaging of the neck without contrast."]}
{"Patient Symptoms": ["On postoperative day 2, she developed isolated dysphagia and dysphonia."], "Examination and Results": ["Her Glasgow Coma Score (GCS) was 11 M5V4E2 on admission, and a computed tomographic (CT) scan showed a right frontal epidural hematoma with a maximum thickness of 19 mm and a volume of 30 cm3 (Figure 1A).", "Laryngoscopic examination revealed right vocal cord paralysis (Figure 1B).A, Computed tomographic (CT) image of the head shows a right frontal epidural hematoma.", "B, Clinical laryngoscopic image at day 2 shows right vocal cord palsy.", "C and D, Computed tomographic images with contrast show a thrombosis of the right sigmoid-jugular complex (yellow arrowheads), which causes acute compression of the recurrent nerve as it follows the course of the cranial accessory nerve then the vagus nerve."], "Treatment": ["The hematoma was evacuated by neurosurgery, and her GCS improved to 14 postoperatively."]}
{"Patient Personal Background": ["Her medical history included eczema treated with triamcinolone acetonide cream.", "Otherwise, the patient had no family history or exposure to tobacco or alcohol.On physical examination, a 2-cm, nontender, mobile retroauricular mass with superficial excoriations was palpable over the right mastoid cortex."], "Patient Symptoms": ["The patient denied bleeding from the mass, ear pain, trauma, fever, fatigue, night sweats, or recent illnesses."], "Examination and Results": ["The patient had no hearing deficits and no fistula into the external auditory canal.", "There was no palpable head and neck lymphadenopathy.", "Serologic studies revealed an elevated absolute eosinophil count of 790/\u03bcL  (reference range, <700/\u03bcL; to convert to \u00d7109 per liter, multiply by 0.001) and an eosinophilia percentage of 9.7% (reference range, <6.0%).", "The T1-weighted postcontrast magnetic resonance imaging of the head and neck showed a heterogeneously enhancing mass with irregular borders in the right retroauricular space, with a tract coursing anteriorly toward the parotid gland (Figure, A).A, Axial T1-weighted postcontrast magnetic resonance image of the head and neck.", "B, Lesional specimen of the excised mass (original magnification\u2009\u00d710).The excised mass was an enlarged, 2.2\u2009\u00d7\u20091.5\u2009\u00d7\u20092.2-cm lymph node with a smooth, pale core and no hemorrhage or necrosis.", "The capsule was moderately thickened by collagen fibrosis with focal areas of interstitial fibrosis.", "Reactive follicular hyperplasia was present with prominent eosinophilia in the interfollicular areas and within follicles, forming eosinophilic microabscesses and follicular cysts (Figure, B).", "A few small and ill-defined granulomas were present.", "Results of Gomori methenamine silver and acid-fast stains were negative."]}
{"Patient Personal Background": ["She had a history of stage IV breast cancer treated with letrozole after a mastectomy 5 years prior."], "Patient Symptoms": ["She had decreased right-sided hearing and tinnitus, a moderate right-sided frontal headache, and an unsteady gait.", "She did not have diplopia, facial numbness, or paresthesias.", "Over the ensuing 5 years, she had multiple similar presentations that also included facial pain and paresthesias."], "Examination and Results": ["On an initial examination, her best-corrected visual acuity was 20/50 OD and 20/25 OS, with dyschromatopsia, relative afferent pupillary defect, and visual-field defects on the right side.", "Her extraocular movements were full.", "A dilated fundus examination demonstrated a pale right optic nerve.", "Magnetic resonance imaging (MRI) of the brain was reported to have normal results, but on review, we noted thickening and enhancement of both optic nerves (with the right eye larger than the left eye) (Figure 1A), cranial nerve III in the right eye, cranial nerve V bilaterally, the pituitary infundibulum, and the hypothalamus, as well as adjacent cavernous sinuses.", "Leptomeningeal thickening over the convexities of the anterior frontal lobes was also evident (Figure 1B).", "The patient\u2019s cerebrospinal fluid contained a small population of polyclonal CD19+ B cells and CD4+ and CD8+ T cells.", "An extensive laboratory workup, including tests for HIV, antinuclear antibodies, anti\u2013double-stranded DNA, antineutrophil cytoplasmic antibodies, serum protein electrophoresis, erythrocyte sedimentation rate, C-reactive protein, complete blood cell count, antiganglioside antibodies, anti\u2013myelin-associated glycoprotein antibodies, and angiotensin-converting enzyme, gave normal results.", "A computed tomographic (CT) scan of the thorax and a whole-body positron emission tomography (PET)/CT scan revealed no abnormalities.Initial magnetic resonance imaging of the brain."], "Treatment": ["B, Leptomeningeal thickening over the convexities of anterior frontal lobes was also evident.Clinically, she initially responded to corticosteroids.", "She also developed a chronic small-fiber peripheral neuropathy and was treated with mycophenolate mofetil, cyclophosphamide, and intravenous immunoglobulin at various points."]}
{"Patient Symptoms": ["However, she experienced recurrences of symptoms after therapy discontinuation.", "She subsequently started treatment with topical prednisolone acetate, moxifloxacin, and systemic azithromycin.Patient presented with recurrent left eye ptosis, erythema, blepharedema, chronic discharge, and knifelike pain over the past 4 years (arrowhead).Two weeks after the initial consultation, the patient reported persistent but improved symptoms in the left eye."], "Examination and Results": ["Her visual acuity was 20/30 OD and 20/100 OS.", "Deep superior conjunctival fornices were noted in both eyes (Figure 1), and eversion of the left upper eyelid revealed a pseudomembrane of the tarsal conjunctiva.", "Cultures of the copious discharge demonstrated many gram-negative Serratia marcescens.", "At this follow-up visit, her visual acuity was 20/30 OD and 20/200 OS."], "Treatment": ["Previous treatment included topical steroids, antibiotics, and serum tears, with temporary relief.", "Additional treatment included weekly bandage contact lenses for many months, which made the left eye pain tolerable.", "She subsequently started treatment with topical prednisolone acetate, moxifloxacin, and systemic azithromycin.Patient presented with recurrent left eye ptosis, erythema, blepharedema, chronic discharge, and knifelike pain over the past 4 years (arrowhead).Two weeks after the initial consultation, the patient reported persistent but improved symptoms in the left eye."], "Others": ["A dacryocystogram of the left lacrimal system indicated partial dacryostenosis, but compression of the canaliculi and lacrimal sac did not exacerbate discharge.", "A prior computed tomography scan of the orbits and sinuses showed no abnormalities."]}
{"Patient Personal Background": ["Her medical history revealed hypertension, type 2 diabetes mellitus, and hyperlipidemia.On examination, her visual acuity was 20/40 OD and 20/30 OS."], "Patient Symptoms": ["The patient first noted an erythematous, tender swelling with yellow discharge, which later evolved to the pigmented mass."], "Examination and Results": ["There was a sausage-shaped, darkly pigmented (black), focally ulcerated nodule involving the medial upper eyelid margin and measuring 8\u2009\u00d7\u20096\u2009\u00d7\u20094 mm.", "Associated madarosis, eyelid margin notching, and telangiectasia were noted (Figure 1).", "The remainder of the anterior segment and a dilated fundus examination were unremarkable.A, The multilobular pigmented mass is noted along the superomedial upper eyelid margin."], "Others": ["Her ocular history was unremarkable."]}
{"Patient Personal Background": ["He was nonadherent with medications and denied drug and alcohol abuse.On examination, he appeared comfortable."], "Patient Symptoms": ["At presentation, he was experiencing psychosis and being treated in an inpatient psychiatric ward.", "On both lower extremities, there was peripheral edema with widespread hematomas, scattered ecchymosis, petechiae, and diffuse perifollicular purpura (Figure)."], "Examination and Results": ["His blood pressure was 150/67 mm Hg; heart rate, 77/min; temperature, 36.7\u00b0C (98.1\u00b0F); respiratory rate, 16/min; and oxygen saturation, 99% on room air.", "The remainder of the examination was unremarkable.", "Laboratory test results showed a normocytic anemia (hemoglobin level, 5.2 g/dL [reference, 13.5-17.5 g/dL]; mean corpuscular volume, 85 fL [reference, 80-100 fL]); normal platelet count (thrombocytes, 285 \u00d7109/L [reference, 150-400 \u00d7109/L]); and a mild leukopenia (leukocytes, 3.9 \u00d7109 [reference, 4.3-10 \u00d7109/L]).", "Folic acid level was low (3 nmol/L [reference, \u22655 nmol/L]) and vitamin B12 level was normal (478 pg/mL [reference, 193-982 pg/mL]).", "Results for iron panel, reticulocyte count, prothrombin time (PT), activated partial thromboplastin time (APTT), international normalized ratio, liver function tests, and levels of indirect bilirubin, haptoglobin, fibrinogen, and creatine kinase were all within reference range.", "Chest radiographs and computed tomography of the head were negative for any acute pathology.", "A 12-lead electrocardiogram revealed no abnormalities."]}
{"Patient Personal Background": ["His warfarin had been managed via point-of-care (POC) testing for the past 4 years with a goal international normalized ratio (INR) of 2.0 to 3.0.", "His warfarin dosage was 36 mg/wk (3 mg every Wednesday and Saturday and 6 mg all other days) for the past year."], "Patient Symptoms": ["He reported no extra warfarin doses, medication changes, dietary nonadherence, or bleeding."], "Examination and Results": ["On presentation, his POC INR was 3.7.", "The Table shows the patient\u2019s laboratory test results.Continue current warfarin dosing and perform a point-of-care (POC) international normalized ratio (INR) test in 1 week.Skip 2 doses of warfarin then resume current dosage and perform a POC INR test in 2 weeks.Skip 2 doses of warfarin, reduce weekly dosage by 10%, and perform a POC INR in 2 weeks.Perform a plasma INR test to confirm POC INR test results."]}
{"Patient Personal Background": ["He had similar symptoms 1 year ago and was diagnosed with and treated for supraventricular tachycardia (SVT).", "A subsequent outpatient echocardiogram revealed a structurally normal heart; results of a follow-up electrocardiogram (ECG) were also normal (Figure 1, top).Patient\u2019s baseline 12-lead electrocardiogram (top) and on presentation (bottom).On presentation to the emergency department, the patient\u2019s temperature was 38.2\u00b0C; blood pressure, 125/67 mm Hg; and pulse, 241/min."], "Patient Symptoms": ["He had been experiencing sore throat, fevers, and myalgias for the past day.", "He became alarmed when he awoke from sleep with strong palpitations and a heart rate greater than 200/min documented on his smartwatch."], "Examination and Results": ["A subsequent outpatient echocardiogram revealed a structurally normal heart; results of a follow-up electrocardiogram (ECG) were also normal (Figure 1, top).Patient\u2019s baseline 12-lead electrocardiogram (top) and on presentation (bottom).On presentation to the emergency department, the patient\u2019s temperature was 38.2\u00b0C; blood pressure, 125/67 mm Hg; and pulse, 241/min.", "Physical examination was notable for an erythematous oropharynx, tonsillar exudates, a tachycardic, regular heart rhythm, and clear lungs.", "An ECG was obtained (Figure 1, bottom)."], "Treatment": ["A modified Valsalva maneuver1 failed to convert the rhythm.", "He was subsequently given a series of doses of intravenous adenosine (6 mg, 12 mg, 12 mg), followed by direct current cardioversion at 200 J, which converted the rhythm to sinus for approximately 3 minutes.", "Intravenous metoprolol and intravenous diltiazem bolus and drip were then administered, which slowed the heart rate but did not terminate the arrhythmia."]}
{"Patient Personal Background": ["She was obese and multiparous."], "Examination and Results": ["Examination of the rest of the integument, systemic examination, and investigations including fundoscopy, electrocardiogram, and stool examination for occult blood revealed no significant abnormalities.", "Dermoscopic examination was performed (polarized mode, Dinolite) as shown in Figure 1B.", "B, Polarized dermoscopic image (Dinolite) showing curvilinear brown pigment lines (black arrowhead) with accentuation of normal pigmentary network (green box) without follicular plugging (red circle) or linear vessels (original magnification \u00d7200).", "C, Lesional specimen (original magnification \u00d7100) showing clumped eosinophilic elastic fibers (asterisk) in the middermis (inset, original magnification \u00d740)."], "Treatment": ["We obtained a 4-mm punch biopsy from one of the papules for diagnostic clarification (Figure 1C).A, Coalescent yellowish periumbilical papules."]}
{"Patient Personal Background": ["She had no history of cancer or chronic diseases."], "Examination and Results": ["No cutaneous nodules were present.", "Physical examination did not show adenopathies, hepatosplenomegaly, or other remarkable findings.", "Peripheral blood test results were within normal limits.", "Tests for tumor markers including cancer antigen (CA) 15-3, carcinoembryonic antigen, CA 19-9, and CA 125 were unremarkable.", "No palpable breast masses were identifiable.", "Breast ultrasonography and mammography did not reveal parenchymal nodules."], "Treatment": ["A local steroid therapy was administered, with no benefit."], "Others": ["A biopsy of the skin lesion was performed (Figure, B and C).A, Clinical image of the cutaneous breast lesion shows a large, erythematous, and slightly infiltrated patch in the periareolar region.", "B and C, Hematoxylin-eosin\u2013stained lesional specimens show a dense dermal infiltrate of cells with focal epidermis involvement (B) and large atypical cells with scanty cytoplasm (C)."]}
{"Patient Symptoms": ["At age 23 years, he began experiencing involuntary orofaciolingual movements and vocalizations.", "At age 27 years, he developed dysphagia, dysarthria, and involuntary tongue- and lip-biting.", "This oral dyskinesias worsened while eating.", "Orofacial dyskinesia (Video 1), involuntary vocalizations, and mild dysarthria were exhibited.", "Fundus examination results were normal."], "Examination and Results": ["No neuropsychiatric symptoms or seizures were exhibited.Neurological examination results revealed mild cognitive decline, with a Montreal Cognitive Assessment score of 18/30.", "His muscle strength and tone were normal, but his deep reflexes were diminished or absent.", "The patient\u2019s sensory and coordination examination results were unremarkable, and bilateral Babinski signs were negative.", "The patient\u2019s gait was mildly wide based (Video 2).", "Laboratory examination results, including blood electrolytes and lactate, liver, kidney, and thyroid function, antinuclear antibodies, ceruloplasmin levels, and vitamin A and E levels were normal.", "Routine and biochemical examination results, oligonucleotide band, antibodies against antiaquaporin 4, and autoimmune encephalitis-related antibodies (ie, N-methyl-d-aspartate, \u03b1-amino-3-hydroxy-5-methyl-4-isoxazoleproprionic, \u03b3-aminobutyric acid-B, leucine-rick glioma inactivated 1, contactin-associated protein 2, and IgLON5) of cerebrospinal fluid were normal.", "Creatine kinase (CK) levels were significantly elevated at 2304 U/L (to convert to microkatals per liter, multiply by 0.0167; normal range, 25-200 U/L).", "Low-density lipoprotein and apolipoprotein B levels were slightly decreased at 61 mg/dL (to convert to micromoles per liter, multiply by 0.0357; normal range, 80-119 mg/dL) and 58 mg/dL (to convert to grams per liter, multiply by 0.01; normal range, 66-133 mg/dL), respectively.", "Acanthocytes were found in the blood smear via Wright staining (Figure, A).", "Electrophysiological examination results revealed reduced compound muscle action potential and sensory nerve action potential of bilateral median and ulnar nerves.", "Electromyogram results showed neurogenic damage in lower limb muscles."], "Treatment": ["However, a handkerchief in the mouth markedly reduced involuntary tongue-biting and mouth movements."]}
{"Patient Personal Background": ["This was the second stroke he had in 6 months.", "The patient\u2019s other medical problems included well-controlled hypertension and diabetes.", "Seven months before this admission, a dual-chamber pacemaker was implanted at an outside institution for sick sinus syndrome."], "Examination and Results": ["Device interrogation revealed no atrial fibrillation and normal lead parameters.", "Electrocardiogram results showed atrial pacing with capture and intrinsic ventricular conduction.", "Magnetic resonance angiography results of carotid, vertebral, and cerebral arteries were normal.", "Chest radiography was taken (Figure 1).Chest radiography.", "A, In the posterior-anterior projection, the ventricular lead curves more superiorly than usual and lacks the expected indentation as it traverses the tricuspid valve.", "B, Lateral projection demonstrates a posterior orientation of the lead that is suspicious for left ventricular placement."]}
{"Patient Personal Background": ["She had a medical history of vomiting and emaciation in her early 40s.", "She claimed that her younger brother died of liver cancer and her mother had lost vision because of vitreous hemorrhage and glaucoma."], "Examination and Results": ["She denied any history of systemic disorders.On initial examination, best-corrected visual acuity was measured at 0.1 (20/200) OU.", "Intraocular pressure was 14 mm Hg OD and 16 mm Hg OS.", "Her anterior segment examination results were within normal limits.", "Dilated fundus examination demonstrated bilateral vitreous opacity without cells (Figure).", "The peripheral residual vitreous cortex in the left eye was as cloudy as the cortex in the right eye.", "Fundus was not visible in the right eye and was normal in the left eye.", "A bilateral ocular ultrasonography showed normal results except for vitreous opacity.", "The patient weighed 37.0 kg and was 155 cm tall.", "Her blood pressure was 113/70 mm Hg.", "Mild anemia (hemoglobin level 10.5 g/dL vs a normal range of 11.0-15.0 g/dL [to convert to grams per liter, multiply by 10]) was found in routine blood test results.", "Liver and renal functions were normal according to serum test results."], "Treatment": ["Pars plana vitrectomy (PPV) had been done for her left eye owing to vitreous opacity half a year prior."]}
{"Patient Personal Background": ["His medical history was notable for stage III non-Hodgkin follicular lymphoma in the hilar and axillary nodes, which was asymptomatic and actively monitored by oncology, prostate cancer treated surgically that was in remission, and atrial fibrillation managed with medication (digoxin and warfarin)."], "Patient Symptoms": ["There were no other concerning features noted, such as orange pigment or associated subretinal fluid.At presentation, the patient was asymptomatic with no diplopia, pain, constitutional symptoms, or blurred vision."], "Examination and Results": ["The choroidal nevus had been observed for the past 2 years; ultrasonography from 2 years prior revealed dimensions of 1.9 (height)\u2009\u00d7\u20099.3 (base) mm with medium internal reflectivity.", "His best-corrected visual acuity was 20/30 OU.", "Pupils were reactive without a relative afferent pupillary defect, extraocular motility was full, and intraocular pressures were normal.", "His slitlamp and fundus examination results were unremarkable aside from the choroidal nevus in his right eye, which appeared similar to previous examinations (Figure 1A).", "Proptosis, resistance to retropulsion, conjunctival injection, and strabismus were notably absent.", "However, a new retro-orbital hypoechoic cavity causing right globe deformation was noted on B-scan ultrasonography (Figure 1B).A, Color fundus photography of the right eye illustrates a hyperpigmented choroidal nevus (arrowhead) in the macula."]}
{"Patient Personal Background": ["On further questioning, the patient reported a 9 pack-year smoking history.", "She had no known history of malignant conditions.", "She denied recent fevers, chills, weight loss, night sweats, and travel to foreign countries, and she was otherwise feeling well.A, Color fundus photograph of the right eye demonstrates a large, solitary amelanotic choroidal mass (arrowheads) with overlying subretinal fluid."], "Examination and Results": ["Her visual acuity with correction was 20/40 OD and 20/25 OS.", "Her intraocular pressures were 14 mm Hg OD and 15 mm Hg OS.", "A dilated fundus examination of the right eye was notable for an amelanotic choroidal mass with overlying subretinal fluid (Figure 1A).", "Results of a dilated fundus examination of the left eye were unremarkable.", "Results of fluorescein angiographic imaging of the right eye showed late leakage corresponding to the choroidal mass; the left eye was unremarkable.", "Optical coherence tomography demonstrated a choroidal mass with an irregular surface contour and a mild overlying vitreous cell.", "On B-scan ultrasonography of the right eye, a superotemporal choroidal mass with an irregular surface contour and medium internal reflectivity was observed (Figure 1B)."]}
{"Patient Personal Background": ["The patient had no notable medical history, including dyskeratosis congenita, trauma, sun exposure, radiation exposure, chemical exposure to tar or arsenic or exposure to minerals, chronic immunosuppression, or chronic infection."], "Patient Symptoms": ["Physical examination revealed a subungual nodule with some exudation and crusts.", "The distal nail plate had been destroyed and showed onycholysis with obvious separation from the nail bed (Figure, A)."], "Examination and Results": ["The lesion was initially believed to be an infection; however, results of both mycological and bacteriologic examinations were unremarkable.", "Pertinent laboratory results (complete blood cell count, liver panel, kidney panel) were within normal limits.", "Lesional biopsy was also performed (Figure, B and C).A, Clinical photograph shows a subungual nodule with exudation and crusts as well as destruction of the distal nail plate with onycholysis.", "B, Lesional biopsy results show proliferation of atypical squamous cells invading the dermis.", "C, Large atypical squamous cells with hyperchromatic, pleomorphic, and atypical mitosis (B and C, hematoxylin-eosin)."]}
{"Patient Symptoms": ["This was accompanied by fever, night sweats, and fatigue.", "Her purpuric patches improved initially after the first cycle of chemotherapy; however, in the weeks before the second cycle, they recurred more extensively, involving her right cheek and bilateral ears, arms, and legs.", "This time she also experienced pain in those areas as well as lower extremity edema.On presentation to the outpatient infusion suite, she appeared well, and her temperature was 37\u00b0C (98.6\u00b0F); heart rate, 91/min; blood pressure, 114/58 mm Hg; respiratory rate, 18/min; and blood oxygen saturation, 98%."], "Examination and Results": ["This time she also experienced pain in those areas as well as lower extremity edema.On presentation to the outpatient infusion suite, she appeared well, and her temperature was 37\u00b0C (98.6\u00b0F); heart rate, 91/min; blood pressure, 114/58 mm Hg; respiratory rate, 18/min; and blood oxygen saturation, 98%.", "Diffuse, symmetric patches and soft, thin plaques of retiform purpura with minimally erythematous borders covered her extremities and acral surfaces, some with overlying bullae (Figure 1).", "A complete blood cell count showed an elevated white blood cell count (18\u202f860/\u03bcL with 13% neutrophils, 43% lymphocytes, 9% monocytes, 33% others); hemoglobin, 7.2 g/dL; hematocrit, 21.8%; and platelet count, 142 \u00d7103/\u03bcL.", "Results of a comprehensive metabolic panel were unremarkable.", "Fibrinogen level, prothrombin level, and partial thromboplastin time were within normal limits."], "Treatment": ["She was found to have clinical and radiologic progression of her lymphoma and began receiving R-CHOP (rituximab\u2009+\u2009cyclophosphamide\u2009+\u2009doxorubicin hydrochloride\u2009+\u2009vincristine [Oncovin]\u2009+\u2009prednisone) chemotherapy."], "Others": ["Blood was sent for cultures.Skin findings on examination of patient\u2019s lower extremities."]}
{"Patient Personal Background": ["He had been treated by a rheumatologist for polyarticular inflammatory arthritis involving the wrists, metacarpophalangeal joints, and proximal interphalangeal joints, as well as fatigue and dyspnea on exertion.", "His pulmonary and joint symptoms were relieved by daily oral prednisone and flared with taper below 10 mg. Other medications prescribed included hydroxychloroquine, 400 mg, daily for 18 months and weekly adalimumab injections for 7 months, without improvement.A, Pink-purple papules on the extensor surface of the arms."], "Patient Symptoms": ["He had been treated by a rheumatologist for polyarticular inflammatory arthritis involving the wrists, metacarpophalangeal joints, and proximal interphalangeal joints, as well as fatigue and dyspnea on exertion.", "The patient reported a 5- to 7-kg weight loss without fever or sweats."], "Examination and Results": ["Examination revealed numerous, pink-purple dermal papules on the trunk and extremities, with preference for the extensor surfaces of the arms (Figure, A) and legs.", "No lymphadenopathy was noted.", "D, Biopsy results show low CD4 signal and robust CD8 signal (magnification \u00d720).Pulmonary function testing revealed mild restrictive disease with decreased forced vital capacity and total lung capacity.", "Results of a complete blood cell count and metabolic panel; hemoglobin A1c; viral and rheumatologic panels, including HIV blood tests; chest radiograph; high-resolution chest computed tomographic scan; echocardiography; endoscopic studies; hand radiographs; and serum and urine protein electrophoresis were normal or otherwise unremarkable.", "The results of lesional skin biopsies obtained from multiple involved sites initially revealed nonspecific granulomatous dermatitis before a diagnostic biopsy was performed (Figure, B, C, and D)."], "Treatment": ["His pulmonary and joint symptoms were relieved by daily oral prednisone and flared with taper below 10 mg. Other medications prescribed included hydroxychloroquine, 400 mg, daily for 18 months and weekly adalimumab injections for 7 months, without improvement.A, Pink-purple papules on the extensor surface of the arms."]}
{"Patient Personal Background": ["Medical history and family history were unremarkable."], "Examination and Results": ["Physical examination revealed grouped and circumscribed, firm, skin-colored, 1- to 3-mm papules with a central punctate dark core (Figure, A and B).", "A 4-mm punch biopsy from a papule on the palm was performed (Figure, C and D).A and B, Grouped, dome-shaped, skin-colored, punctate papules with central keratotic plugging localized to the right palm and finger.", "C and D, Dilated follicular infundibulum with keratinous core and absent hair shaft (hematoxylin-eosin)."], "Treatment": ["Prior treatments included cryotherapy, pulsed dye laser, and 40% salicylic acid, with partial improvement reported but never complete clearance."]}
{"Patient Symptoms": ["The numbness progressed over 10 months to involve his entire right arm, patches of his left arm, and his distal lower extremities.", "He also developed right-hand incoordination and imbalance.", "B, A brain coronal T1 postgadolinium MRI from 10 months later with persistent yet evolving enhancement and mild size increase in brainstem lesion and ongoing dural enhancement.He sought neurological reconsultation 9 months later, reporting progressive blurred vision bilaterally, dysphagia, dysarthria, and urinary and bowel urgency.", "His gait had worsened, requiring a cane and, for 6 months, a walker."], "Examination and Results": ["A magnetic resonance image (MRI) of the brain is shown in Figure 1A.", "A complete blood cell count with a differential; liver function testing; tests for HIV, rapid plasma reagin, serum aquaporin-4 antibody, and antinuclear antibodies; and levels of sodium, calcium, creatinine, glucose, thyroxine, and vitamin B12 were unremarkable.", "Examinations of the cerebrospinal fluid had normal results twice, including for white blood cell count with a differential, glucose level, total protein level, IgG index, oligoclonal bands, cultures, and cytology testing.A, A brain coronal T1 postgadolinium magnetic resonance image (MRI), showing a lobulated heterogeneously enhancing mass in the brainstem and dural enhancement.", "A neurologic examination revealed decreased visual acuity (20/50 OU) with normal pupillary responses and discs; cerebellar dysarthria, dysmetria, and dysdiadochokinesia; and decreased proprioception in the toes with positive Romberg testing.", "A follow-up brain MRI (Figure 1B) showed persistent enhancement plus bilateral optic nerve enhancement (not shown)."], "Others": ["A physical examination was otherwise unremarkable, except for mild lower-extremity edema.", "He could not tandem walk."]}
{"Patient Personal Background": ["He was discharged and prescribed ticagrelor, 90 mg twice daily, in addition to his home regimen of aspirin and metoprolol tartrate.", "He had no history of syncopal episodes or arrhythmias."], "Patient Symptoms": ["Three months later, he experienced worsening exertional dyspnea and had multiple episodes of syncope."], "Examination and Results": ["His baseline transthoracic echocardiogram results demonstrated normal systolic function and no significant valvular disease.", "Ambulatory electrocardiogram (ECG) monitoring results showed 31 episodes of high-grade atrioventricular (AV) block (AVB), with ventricular pauses ranging from 3.0 to 13.0 seconds occurring during the day and at night (Figure 1)."], "Treatment": ["He was discharged and prescribed ticagrelor, 90 mg twice daily, in addition to his home regimen of aspirin and metoprolol tartrate."]}
{"Patient Symptoms": ["The patient did not require positive pressure or intubation, but he had intermittent stridor associated with desaturations.", "He had feeding difficulty and failure to thrive."], "Examination and Results": ["On physical examination, the newborn had facial dysmorphism, including a broad and flat nasal dorsum and mild micrognathia.", "Flexible fiberoptic laryngoscopy revealed a cystic lesion consistent with a vallecular cyst.", "A modified barium swallow study demonstrated laryngeal penetration and aspiration of thin and nectar-thick liquids.", "A diffuse, soft, palpable mass was present along the right neck.Magnetic resonance imaging (MRI) demonstrated a multispatial mildly enhancing mass within the bilateral retropharyngeal, parapharyngeal, and carotid spaces, with a mildly hyperintense signal relative to muscle on T1-weighted and T2-weighted images and associated restricted diffusion.", "The mass was largest on the right side, with convex borders, mild superior displacement of the right parotid gland, and posterior displacement of the right sternocleidomastoid muscle (Figure, A, B).", "The T2-weighted MRI also demonstrated a hyperintense, nonenhancing lesion within the base of the tongue consistent with a vallecular cyst.", "The thyroid appeared normal and in its expected location, but no thymus was present in the mediastinum.", "B, Axial fat-saturated MRI shows the mass (arrowheads), with encasement of the left internal and external carotid arteries.", "C, Biopsy results reveal a polymorphic population of lymphocytes, fibroadipose tissue, and a concentric island of squamous cells with central keratinization (arrowhead)."], "Treatment": ["The patient was taken to the operating room for excision of the vallecular cyst, and a fine-needle aspiration biopsy of the right neck mass was performed for cytopathological analysis (Figure, C, D).A, Axial magnetic resonance image (MRI) of the neck shows a mildly hyperintense mass (arrowheads) with posterior displacement of the right sternocleidomastoid muscle."], "Others": ["D, Reference specimen from a study set of the tissue shown in panel C demonstrates islands of squamous cells in a background of small mature lymphocytes (hematoxylin-eosin)."]}
{"Patient Personal Background": ["She had no relevant medical, family, or ocular history.", "There was no history of trauma or ocular surgery."], "Patient Symptoms": ["One month prior to presentation, she had developed fevers, chills, and coughing.", "After several days, she had developed redness, pain, photophobia, and blurry vision in her left eye, and she had subsequently developed similar symptoms in her right eye."], "Examination and Results": ["On presentation, her visual acuity was counting fingers OU.", "Intraocular pressures were 14 mm Hg OU.", "A slitlamp examination revealed mild conjunctival redness, 2+ anterior chamber cell, and flare in both eyes, as well as mild posterior synechiae.", "Pigment was present on the anterior lens capsule.", "A fundus examination demonstrated a moderate amount of vitreous cell, hyperemia and edema of the optic disc, and retinal detachments in both eyes (Figure).", "The detachments were inferior and shifted with the patient\u2019s head position, suggesting serous detachments."], "Others": ["The cornea was clear without keratic precipitates, and there were no iris nodules."]}
{"Patient Personal Background": ["He had no significant medical history aside from documented allergies to \u03b2-lactam, macrolide, and cephalosporin antibiotics resulting in rashes, angioedema, and hives.The patient was febrile on admission, and results from chest radiography were consistent with pneumonia."], "Patient Symptoms": ["He complained of a cough, sore throat, and ocular itching.", "He denied prior ocular history and reported no visual changes."], "Examination and Results": ["Bedside ophthalmic examination revealed bilateral limbus-sparing conjunctival hyperemia that blanched minimally with phenylephrine, bilateral nasal and temporal conjunctival epithelial ulcerations, and inferior forniceal pseudomembranes (Figure, A).", "There were no symblephara or eyelid margin defects.", "Examination of the face revealed erosions with hemorrhagic crusts on the lip mucosa (Figure, B) but no associated cutaneous lesions or desquamation.", "Findings from the remainder of the ophthalmologic examination, including visual acuity, intraocular pressure, and dilated fundus examination, were unremarkable.", "Mycoplasma pneumoniae IgG and IgM titers were obtained and found to be within normal limits.A, Peripheral conjunctival ulceration.", "Inset, peripheral conjunctival ulceration highlighted with fluorescein under cobalt blue light."]}
{"Patient Personal Background": ["Medical history was otherwise unremarkable."], "Examination and Results": ["On examination, his best-corrected visual acuity was 20/20 OU, although his vision was slightly eccentric.", "His pupils were round and reactive.", "The slitlamp examination of the anterior segment was unremarkable.", "Dilated fundus examination revealed subtle bilateral yellow foveal spots."]}
{"Patient Symptoms": ["Her parents noticed the left eye turning out for the past year."], "Examination and Results": ["On examination, she fixed and followed with her right eye but not with the left, with 5.0-diopter exophoria at near in the left eye.", "Penlight examination results showed left leukocoria.", "Intraocular pressure and motility were normal bilaterally.", "On subsequent examination under anesthesia, the left optic nerve was obscured by a whitish mass.", "While the optic nerve itself was obscured, a pigmented crescent could be seen surrounding it (Figure, A).", "Ultrasonography results demonstrated an elevated retinal mass overlying an excavated optic nerve head.", "A small focus of hyperechogenicity was noted at the optic nerve head, consistent with calcium (Figure, B).", "Fluorescein angiography results demonstrated staining of the central whitish mass, which was obscuring the underlying retinal vessels.", "On fluorescein angiography results, no vessels were seen within the central whitish mass itself.A, Retinal fundus photograph of the left eye demonstrating a whitish mass obscuring the optic nerve with a surrounding pigmented crescent."]}
{"Patient Personal Background": ["Her initial symptoms started 1 month after the initiation of nivolumab, which was 1 year prior to the index visit."], "Patient Symptoms": ["Treatment with nonsteroidal anti-inflammatory drugs failed, and the patient had a partial response to intra-articular steroids.", "Evaluation showed fixed swan neck deformities in multiple fingers (Figure, A)."], "Examination and Results": ["There was evidence of chronic synovial hypertrophy with no active synovitis on examination.", "The results of a comprehensive autoantibody blood panel, including antinuclear antibody, rheumatoid factor, and anti-citrullinated peptide antibody, were unremarkable.", "Plain radiographs of the hands demonstrated diffuse osteopenia, joint space narrowing, and multiple deformities.", "Magnetic resonance imaging of both hands revealed multifocal osseous erosions (Figure, B), synovitis, and tenosynovitis.Erosive deforming inflammatory arthritis."], "Treatment": ["Treatment with nonsteroidal anti-inflammatory drugs failed, and the patient had a partial response to intra-articular steroids.", "Despite the joint symptoms, nivolumab treatment was continued for a year."], "Diagnosis": ["Magnetic resonance imaging of both hands revealed multifocal osseous erosions (Figure, B), synovitis, and tenosynovitis.Erosive deforming inflammatory arthritis."], "Others": ["She refused systemic therapies owing to concern about diminishing the effectiveness of nivolumab.", "A, Fixed swan neck deformities in multiple fingers (arrowheads).", "B, Magnetic resonance images of both hands reveal multifocal osseous erosions (arrowheads)."]}
{"Patient Personal Background": ["His only medication was acetaminophen as needed for pain."], "Patient Symptoms": ["He had no fever, skin rash, headaches, vision changes, or urinary symptoms.", "He reported occasional bruising around his eyes."], "Examination and Results": ["His vital signs were normal.", "No joint tenderness, warmth, or fluid collections were present, and skin examination was normal.", "The presence of raised soft tissue masses around the sternoclavicular joints (Figure, left panel) and scapulae (Figure, right panel) were noted.", "Laboratory evaluation revealed normal results for complete blood cell count, erythrocyte sedimentation rate (ESR), and levels of electrolytes, creatinine, and C-reactive protein.", "A spot urinalysis showed a protein level of 220 mg/dL (reference range, <26 mg/dL), and a 24-hour urine collection revealed 1.8 g of albumin (reference range, <229 mg/24 h).", "Magnetic resonance imaging (MRI) of the shoulders and hips showed synovial and capsular thickening.Left, Soft tissue masses (arrowheads) around the sternoclavicular joints."]}
{"Patient Personal Background": ["He reports no symptoms of hyperglycemia, such as frequent urination, increased thirst, fatigue, or visual changes, and had no known family history of diabetes."], "Examination and Results": ["His body mass index (BMI) is 33.9 and his blood pressure is 160/90 mm Hg."], "Others": ["A series of blood tests had recently been obtained (Table).", "The patient wants to know if a test could be done in the office to determine if he has diabetes.Perform a laboratory-based glucose test to determine the patient\u2019s glycemic status.Perform a point-of-care (POC) hemoglobin A1c (HbA1c) test via fingerstick to determine the patient\u2019s glycemic status.Perform a laboratory-based HbA1c test to determine the patient\u2019s glycemic status.Do not perform glycemic testing because it is not indicated for this patient."]}
{"Patient Personal Background": ["The patient was otherwise healthy and denied a family history of inherited ichthyosis or atopy."], "Patient Symptoms": ["Multiple nodules appeared on the upper back 1 year previously and gradually increased in number and size.", "Physical examination revealed extensive, dry scaly patches on the trunk, arms, and legs."], "Examination and Results": ["Several 0.5- to 1-cm, dome-shaped, red papules and nodules were found on the upper back (Figure, A and B).", "Mildly enlarged lymph nodes were observed on the cervical, axillary, and inguinal regions.", "Results of routine blood tests, biochemistry analyses, and peripheral blood flow cytometry tests were within normal limits.", "No atypical cells were found in the peripheral blood.", "A biopsy specimen was obtained from the nodules on the patient\u2019s back (Figure, C and D).Clinical images show multiple dome-shaped nodules on the back (A) and extensive, dry scaly patches on the leg (B).", "Lesional histopathologic images show small to medium-sized atypical cells, and focal areas of epidermotropism (C, hematoxylin-eosin) and CD4 on immunohistochemical analysis (D) (original magnification \u00d7200)."]}
{"Patient Symptoms": ["Although the patient\u2019s surgical course was uncomplicated, several months postoperatively she noted persistent asymptomatic rough areas that she assumed were scars."], "Examination and Results": ["Seven years after the second surgery, she was referred to dermatology for improvement of the areas for cosmetic reasons.On physical examination, the patient had well-healed, barely identifiable scars on the inframammary creases and lower breast areas.", "Separate from the scars and located on the inferior medial bilateral breasts were 1- to 2-cm slightly erythematous annular atrophic plaques with more involvement of the left breast than the right.", "The rims of the lesions were raised with slight white scale and the centers slightly depressed and wrinkled in appearance (Figure 1).Clinical images of the inferior medial bilateral breasts with 1- to 2-cm erythematous annular atrophic plaques with more involvement of the left breast (A) than the right (B)."], "Treatment": ["Five years later, she underwent a bilateral augmentation mammoplasty with removal and replacement of silicone gel implants and major mastopexy with capsulotomy."]}
{"Patient Personal Background": ["In the weeks prior to onset, she traveled to Yosemite National Park but denied any particular infectious exposures or symptoms including rash.", "She reported no personal or family medical history.", "Although she did consume a variety of nutraceuticals, she denied medication and recreational drug use.On examination, mental status, cranial nerves, and upper extremities were normal."], "Patient Symptoms": ["Lower extremities were significant for her right side having greater pyramidal weakness than the left, with brisk reflexes and right ankle clonus, as well as a sensory level to pinprick at T6."], "Examination and Results": ["Although she did consume a variety of nutraceuticals, she denied medication and recreational drug use.On examination, mental status, cranial nerves, and upper extremities were normal.", "Magnetic resonance imaging (MRI) of the total spine with and without gadolinium is seen in Figure 1.", "Initial investigations were notable for normal complete blood cell count, electrolytes, kidney and liver function, B12, and thyrotropin as well as an unremarkable MRI of the brain.", "Three lumbar punctures were performed over the course of the patient\u2019s hospitalization, each with a white blood cell count less than 5 /\u00b5L (to convert to \u00d7109/L, multiply by 0.001), normal IgG index, absent oligoclonal bands, normal protein and glucose levels, and benign cytology.", "A comprehensive infectious and inflammatory workup including HIV, herpes simplex virus, varicella-zoster virus, Lyme disease, antinuclear antibodies, astrocyte aquaporin-4 autoantibody, myelin oligodendrocyte glycoprotein autoantibody, and serum and cerebrospinal fluid autoimmune panels were negative.", "Whole-body positron emission tomography demonstrated hypermetabolism of the midthoracic cord.A, Long-segment, expansile T2 hyperintense lesion spanning C5 through T12 and involving greater than two-thirds of the cord diameter.", "The spinal cord is mildly diffusely swollen without an appreciated focal mass.", "B, Associated extensive ill-defined enhancement of the spinal cord spanning T3 through T9."]}
{"Examination and Results": ["Examination of the jugular venous contour with the patient sitting upright at 90\u00b0 is shown in Video 1.", "Auscultatory findings at the left lower sternal border showed normal S1 and S2 heart sounds with a diastolic sound and no murmurs (Figure 1; Video 2).", "Abdominal examination revealed an enlarged, pulsatile liver with smooth edges palpable 4 cm below the costal margin.", "Electrocardiography showed resting abnormalities (rightward axis and inferolateral T-wave inversions).", "Posteroanterior chest radiography showed normal heart size and clear lungs (Figure 1).", "Transthoracic echocardiography was performed, which showed normal left ventricular size and function without valvular abnormalities.A, Phonocardiography from the left sternal border."], "Others": ["Asterisks indicate diastolic sound.", "B, Upright chest radiography with posteroanterior projection."]}
{"Patient Personal Background": ["He had hypertension, diabetes, hyperlipidemia, and obesity and was a current smoker.", "His medications included carvedilol, furosemide, lisinopril, metformin, and aspirin but no testosterone or herbal supplements.", "Family history was significant for a sister with brain cancer, diagnosed in her 40s."], "Patient Symptoms": ["His left nipple was retracted."], "Examination and Results": ["On physical examination, his vital signs were within normal limits; his body mass index, calculated as weight in kilograms divided by height in meters squared, was 53.", "At the 2-o\u2019clock position of the left breast, 3 cm from the nipple, there was a 3.5\u2009\u00d7\u20093.0\u2013cm firm mass.", "The right breast was normal without masses, and there was no palpable axillary lymphadenopathy.", "He underwent a bilateral diagnostic mammogram, which showed a partially obscured mass in the left upper outer quadrant with linear extension to the nipple (Figure, left panel).", "Targeted ultrasound showed a 2.0\u2009\u00d7\u20091.6\u2009\u00d7\u20091.6\u2013cm irregular hypoechoic mass (Figure, right panel).Left, Mediolateral view of the diagnostic mammogram of the left breast.", "Right, Targeted ultrasound of the left breast."]}
{"Patient Personal Background": ["He did not take medication over the past 3 months.", "There was no relevant family medical history.", "At that time, no diagnosis was found and the lesions disappeared following treatment with corticosteroids."], "Patient Symptoms": ["The patient reported fever and rhinorrhea in the few days preceding the emergency consultation.", "At the clinical examination, the patient had several macules and desquamatory lesions on the mucosa of the oral cavity, lips, and penis, and he had hemorrhage lesions of the eye sclera (Figure)."], "Examination and Results": ["The skin of the patient was unremarkable.", "The nasofibroscopy results showed generalized desquamatory lesions of the upper aerodigestive tract mucosa affecting the laryngeal and vocal fold mucosa (Figure).", "There was no dyspnea and the airway was clear.", "Desquamatory injuries were found on vocal folds and ventricular bands (A); iris (B); lips and oral mucosa (C); and epiglottis (D).", "There was a moderate laryngeal mucosa hypertrophy related to the inflammatory reaction."], "Treatment": ["Dermatopathologic analysis, biology, serology, and biopsy were performed.Lesions of eye, oral, and upper aerodigestive tract mucosa."], "Others": ["The patient revealed that he had a similar but less severe clinical event 5 years previously."]}
{"Patient Personal Background": ["He had no notable medical history except stable asthma."], "Patient Symptoms": ["He also complained of recurrent epistaxis."], "Examination and Results": ["On physical examination, nasopharyngoscopy showed a pedunculated mass with a smooth mucosal surface arising from the roof of the nasopharynx.", "Computed tomographic (CT) imaging (Figure, A and B) revealed a midline, well-defined, pedunculated polypoid lesion with areas of calcifications in the nasopharynx, measuring approximately 1.2\u2009\u00d7\u20091.5\u2009\u00d7\u20092.0 cm.", "Results of other investigations after surgery were negative for cancer, including magnetic resonance imaging (MRI) of the neck and thyroid ultrasonography.", "In addition, no residual tumor or systemic metastasis was observed on positron emission tomography (PET)-CT results.", "There was no evidence of recurrence at 12-month postoperative follow-up.A and B, Computed tomography images with contrast enhancement reveal a 1.2\u2009\u00d7\u20091.5\u2009\u00d7\u20092.0-cm soft-tissue\u2013density mass (white arrowheads) with multiple nodular calcifications (red arrowhead) in the nasopharynx.", "C and D, Lesional histopathologic images (hematoxylin-eosin) show tumor cells arranged in papillary structures with fibrovascular cores (asterisk)."], "Treatment": ["An endoscopic resection via retrovelar approach using a 70-degree endoscope combined with transnasal approach was performed under general anesthesia.", "The mass was completely resected with its stalk and with adequate surgical margin."], "Others": ["Histopathological results (Figure, C and D) showed that the tumor cells were arranged in papillary structures with fibrovascular cores and these cells also had nuclear grooves.", "Nuclear grooves (black arrowheads) in these cells were also identified."]}
{"Patient Personal Background": ["His medical history included hypertension treated with captopril and a remote history of psoriasis."], "Patient Symptoms": ["The lesions initially only involved his lips and nasal bridge, and appeared 5 months prior while he was living on a ranch in Mexico.", "Physical examination demonstrated several dry, crusted skin lesions with blistering and ulceration, and shallow erythematous ulcerations of his oral mucosa."], "Examination and Results": ["Results of flexible fiberoptic laryngoscopy demonstrated erythematous and ulcerative lesions with surrounding leukoplakia involving the base of tongue, glossoepiglottic fold, lingual and laryngeal surfaces of the epiglottis, and aryepiglottic folds (Figure, C and D).", "Serum antigen testing for blastomyces, histoplasmosis, syphilis, HIV, hepatitis B virus, hepatitis C virus, human herpesvirus 6, cytomegalovirus, Epstein-Barr virus, varicella zoster virus, human polyomavirus 2, and West Nile virus were performed, and all results were found to be negative.", "Enzyme-linked immunosorbent assay serological testing was subsequently performed, and results demonstrated elevated levels of antidesmoglein 1 immunoglobulin G (IgG) and antidesmoglein 3 IgG.A, Lesions involving the patient\u2019s nose and lower lip.", "B, Direct immunofluorescence staining for immunoglobin G of an intralesional biopsy at magnification \u00d734 demonstrating autoantibody deposition in a lacelike pattern localized to the intracellular matrix of the stratified squamous epithelium.", "C, Bullous lesion involving the epiglottis (black arrowhead).", "D, Bullous lesions involving the left posterior true vocal fold, left false vocal fold, and right vestibule (black arrowheads)."], "Treatment": ["The lesions did not respond to treatment with an unknown oral antibiotic."], "Others": ["Internal medicine, otolaryngology, and dermatology departments were consulted.", "A QuantiFERON-TB Gold test was obtained, and results were found to be positive.", "A biopsy of the skin lesion was obtained from the edge of the lesion found on the patient\u2019s back (Figure, B)."]}
{"Patient Personal Background": ["Her medical history was unremarkable except for allergic rhinitis."], "Patient Symptoms": ["She reported no associated fevers, chills, dryness of mouth, nausea, vomiting, dysphagia or odynophagia."], "Examination and Results": ["On physical examination, she had slight enlargement of the left submandibular gland, which was not tender on palpation.", "Ultrasonography results revealed normal submandibular and parotid glands bilaterally without any mass or calcifications.", "Blood examinations and basic metabolic panel results were all within normal limits.", "The areas of webbing were broken up with irrigation, and at the end of the procedure steroid instillation and irrigation were performed."], "Treatment": ["Sialoendoscopy of the left submandibular duct was performed under general anesthesia.", "The patient was found to have a cast at the opening of the Wharton duct, which was removed and sent for pathological evaluation (Figure).", "Using sialoendoscopy with saline irrigation, the entire duct was examined up to the hilum of the gland.", "There were areas of mild partial webbing without complete obstruction.", "There were no complications during or after the procedure.Hematoxylin-eosin\u2013stained histological slide of the cast showing numerous eosinophils."], "Others": ["No stones were noted."]}
{"Patient Personal Background": ["She had undergone an uncomplicated Descemet stripping automated endothelial keratoplasty (DSAEK) for Fuchs endothelial dystrophy in the right eye 5 months before, which improved her corrected-distance visual acuity to 20/20 OD.", "She denied any history of ocular trauma or cold sores, and she was taking dexamethasone, 0.1% drops 4 times a day.At presentation, her corrected-distance visual acuity was 20/60 OD."], "Patient Symptoms": ["Slitlamp examination revealed a right inflamed conjunctiva with circumcorneal hyperemia, 2 mm\u2009\u00d7\u20092 mm epithelial defect with a small infiltrate at the temporal cornea, 2+ cells in the anterior chamber with a 1-mm hypopyon, and a peculiar graft-host interface haze with crisscross pattern (Figure, A)."], "Examination and Results": ["Slitlamp examination revealed a right inflamed conjunctiva with circumcorneal hyperemia, 2 mm\u2009\u00d7\u20092 mm epithelial defect with a small infiltrate at the temporal cornea, 2+ cells in the anterior chamber with a 1-mm hypopyon, and a peculiar graft-host interface haze with crisscross pattern (Figure, A).", "Corneal scrapes were performed and samples were sent for microscopy with Gram staining, culture, and sensitivity testing.", "One day later, there was no improvement in the graft-host interface haze, and results of microbiological investigations, including donor rim culture, were all negative.", "Slitlamp photography demonstrating an inflamed right eye with diffused stromal haze in crisscross pattern at the graft-host interface and a mild opacity at the temporal host cornea.", "B, In vivo confocal micrograph demonstrating diffuse hyperreflective crisscross changes at the graft-host interface (at the depth of 598 \u03bcm)."], "Treatment": ["The patient was admitted on that day and commenced taking topical cefuroxime, 5%, and gentamicin, 1.5%, drops every hour around the clock, and topical steroid was discontinued."], "Others": ["In view of the clinical dilemma, an in vivo confocal microscopy was performed to aid the diagnosis (Figure, B).A, Right eye after Descemet stripping automated endothelial keratoplasty."]}
{"Patient Personal Background": ["He was born and raised in Mexico prior to his immigration to the United States 5 years before presentation.", "He worked as a farmer and denied recent illnesses, contacts with illnesses, alcohol or tobacco use, and having pets."], "Patient Symptoms": ["He complained of a gradual decline in his vision bilaterally over the past 2 years.", "He denied flashes, floaters, or eye pain but endorsed a chronic cough."], "Examination and Results": ["His visual acuity was 20/60 OD and 20/40 OS with normal intraocular pressures.", "His slitlamp examination results were notable for mild nuclear sclerosis in both eyes and were negative for conjunctival or corneal lesions.", "He had round, reactive pupils and no anterior chamber inflammation in either eye.", "Dilated fundus examination results revealed a few pigmented anterior vitreous cells, a normal optic disc, and flat and large yellowish chorioretinal lesions with overlying pigment scattered throughout the macula and periphery in the right eye (Figure)."], "Others": ["He had no known ocular or medical history and took no systemic medications."]}
{"Patient Personal Background": ["The patient\u2019s medical history was remarkable for hypertension and asthma.", "He denied smoking, drinking alcohol, and using recreational drugs.", "His medications included losartan, albuterol, and fluticasone."], "Patient Symptoms": ["He had woken up earlier that morning with normal visual acuity, but his visual acuity had progressively worsened to the point that he was unable to work.", "He denied additional symptoms, other than mild tearing."], "Examination and Results": ["Per his ophthalmologist, his visual acuity improved with a \u221210 diopter lens, but his intraocular pressure was elevated to between 30 and 40 mm Hg OU.", "On examination, his visual acuity was 20/400 OU (while wearing prescription lenses, \u22122.75\u2009+\u20091.00\u2009\u00d7\u2009090 OD and \u22122.50\u2009+\u20091.00\u2009\u00d7\u2009081 OS).", "His best-corrected visual acuity was 20/25 OU (manifest refraction, \u221212.00\u2009+\u20091.75\u2009\u00d7\u2009097 OD and \u221210.75\u2009+\u20090.25\u2009\u00d7\u2009050 OS).", "His intraocular pressure was 19 OU.", "Sensorimotor and external examination results were normal.", "A slitlamp examination revealed mild diffuse vasodilation and temporal chemosis, clear corneas, shallow anterior chambers, and clear lenses in both eyes.", "A gonioscopic examination showed no angle structures in either eye.", "Results of an undilated fundus examination was unremarkable.", "A, B-scan on initial presentation showed no masses and shallow choroidal effusion."], "Others": ["The patient was sent to the emergency department, where the authors\u2019 consultation team evaluated him.", "A review of symptoms was otherwise negative.", "Figure 1 shows ultrasonographic images of his eyes.Images on initial presentation."]}
{"Patient Personal Background": ["He had a distant history of right temple melanoma that was excised with clean margins and accompanied by a negative sentinel lymph node biopsy result.On examination, he was found to have a best-corrected visual acuity of 20/20 OD and 20/40 OS, with a normal pupillary response and intact color vision bilaterally."], "Patient Symptoms": ["He reported several eyeglass prescription changes in the left eye over the past 2 years and frequent ipsilateral tearing."], "Examination and Results": ["He had a mild limitation of left abduction and supraduction.", "He had 5 mm of relative left proptosis, with moderate resistance to retropulsion of the left globe.", "No change in globe position was appreciated with systolic pulsations or the Valsalva maneuver.", "Anterior segment examination results were normal bilaterally.", "Dilated fundus examination results of the left eye revealed an abnormality of the posterior pole (Figure 1A), which was confirmed on fluorescein angiography (Figure 1B).Color fundus photograph (A) and fluorescein angiography (B)."], "Others": ["He denied ocular discomfort, headaches, or double vision."]}
{"Patient Symptoms": ["Physical examination revealed ptosis, modest restriction of ocular motility in all directions bilaterally, and esotropia with left hypertropia in the primary gaze."], "Examination and Results": ["Muscle strength was 5/5 on hip flexion and extension bilaterally.", "There was no weakness with repetitive and sustained testing of power.", "Workup revealed elevated creatine kinase (1222 U/L; reference range, 24-195 U/L [to convert to \u03bckat/L, multiply by 0.0167]), aldolase (24.5 U/L; reference range, <8.1 U/L [to convert to \u03bckat/L, multiply by 0.0167]), and C-reactive protein levels (106 mg/L; reference range, <5 mg/L [to convert to nmol/L, multiply by 9.524]).Acetylcholine receptor binding and modulating antibody levels were elevated (0.69 nmol/L [reference range, <0.3 nmol/L] and 48% [reference range, 0%-20%], respectively).", "Results of the striated muscle antibody titer were also abnormal (1:160; reference range, <1:40).", "Blood test results were negative for acetylcholine receptor blocking and muscle-specific receptor tyrosine kinase antibodies.", "Nerve conduction studies showed a normal response to repetitive nerve stimulation.", "Single-fiber electromyography was pathologic and revealed an abnormal mean consecutive difference in more than 50% of the tested pairs (Figure, B), and no blocking was seen."], "Treatment": ["He enrolled in a phase 1 clinical trial (NCT03299946) using neoadjuvant cabozantinib plus nivolumab followed by definitive resection for patients with locally advanced disease.A, Magnetic resonance image of the abdomen shows a liver mass."], "Diagnosis": ["A biopsy was performed, and pathology results were consistent with a well-differentiated hepatocellular carcinoma."], "Others": ["B, On single-fiber electromyography, the mean consecutive difference of the tested pairs was abnormal, and there was no blocking.Five weeks after the first dose of nivolumab, he developed diplopia and myalgia that mostly affected proximal muscle groups.", "Myopathic action potentials were not present."]}
{"Patient Personal Background": ["Her breast cancer was diagnosed in 2007 as stage IA estrogen-receptor positive, progesterone-receptor negative (ER+, PR\u2212), and human epidermal growth factor 2 (ERBB2; formerly HER2) negative, initially treated with lumpectomy plus left breast radiotherapy followed by doxorubicin, cyclophosphamide, paclitaxel, and anastrazole."], "Patient Symptoms": ["Later, progressive liver metastasis and repeat biopsy with equivocal ERBB2 testing led to treatment with capecitabine plus trastuzumab.On presentation to the ophthalmologist, her visual acuity was reduced to only being able to count fingers (worse than 20/400) OD and 20/40 in the left eye (OS).", "She reported not experiencing any headache, photophobia, diplopia, or eye pain."], "Examination and Results": ["Visual acuity was 20/25 bilaterally at her last eye examination, 1 year prior.", "Ocular motility, pupillary response, and intraocular pressure were normal for each eye.", "On slit lamp examination, the anterior segment of each eye was normal, without inflammation or blood."], "Treatment": ["In 2017, metastases were found in the lumbar spine and lung and treated with fulvestrant and palbociclib plus left brachial plexus radiotherapy.", "Later, progressive liver metastasis and repeat biopsy with equivocal ERBB2 testing led to treatment with capecitabine plus trastuzumab.On presentation to the ophthalmologist, her visual acuity was reduced to only being able to count fingers (worse than 20/400) OD and 20/40 in the left eye (OS)."]}
{"Patient Personal Background": ["She lost 50.8 kg from the time of the procedure to presentation, her body mass index at presentation was 23, and her preoperative comorbidities were in remission.", "She was under some financial stress after recently losing her job, and reported drinking 2 to 6 beers within a 2-hour period on the weekends.", "She took a gummy multivitamin sporadically and self-reported a daily total calorie intake of less than 500 kcal and less than 20 g of protein."], "Patient Symptoms": ["She did not have any nausea, abdominal pain, or change in bowel habits, but her periods had been more irregular over the past 2 to 3 months and, when present, lasted for 7 to 10 days.", "She also noted a tingling sensation in her hands and feet."], "Examination and Results": ["On physical examination, although she reported having paresthesias in her fingertips and toes, her neurological examination findings were nonfocal.", "She exhibited bilateral flattening of the temporalis muscle and thenar eminence.", "Her vital signs were normal, and serum tests were ordered (Table).This patient has iron deficiency anemia in the setting of polycystic ovarian syndrome.The patient has both iron and vitamin B12 deficiencies."], "Diagnosis": ["Her vital signs were normal, and serum tests were ordered (Table).This patient has iron deficiency anemia in the setting of polycystic ovarian syndrome.The patient has both iron and vitamin B12 deficiencies."]}
{"Patient Personal Background": ["The patient had a history of rectal carcinoma with lymph node metastasis and 2 years prior had received low anterior resection plus postoperative chemotherapy (6 cycles of oxaliplatin, calcium folinate, and tegafur)."], "Examination and Results": ["A physical examination revealed well-defined, firm, indurated plaques on the vulva with nodules on the surface (Figure 1A).", "A biopsy of the left vulva was performed (Figure 1B and C).A, Well-defined, firm, indurated plaques on the vulva.", "B and C, A biopsy of the left vulva was performed for evaluation (hematoxylin-eosin)."]}
{"Patient Symptoms": ["The lesions were never ulcerated or inflamed, but hemorrhage occurred occasionally after rubbing.", "At 3 years of age, scarlike macules appeared on the occipital scalp and coalesced to form a larger plaque with sparse hair.", "Simultaneously, multiple brown-red, dome-shaped papules developed on the nose and gradually evolved to involve the cheeks.", "Rubbery plaques also developed on the sacrococcygeal area, along with hypopigmented patches on the right buttock."], "Examination and Results": ["The patient has no systemic symptoms or mental impairment and denied a family history of genetic disease.Physical examination revealed a group of unevenly distributed skin\u2013colored-to-pink, discrete, coalescing papules superimposed on a firm plaque on the occipital scalp (Figure, A).", "A biopsy specimen was obtained from one of these papules (Figure, B, C, and D).", "Another biopsy from a facial papule demonstrated features of angiofibroma.A, Clinical photograph shows a firm plaque with superimposed papules and decreased hair density."]}
{"Patient Personal Background": ["His medical history was significant for adenosine deaminase\u2013deficient severe combined immunodeficiency (ADA-SCID), which had been managed since childhood with twice weekly intramuscular injections of pegademase bovine enzyme replacement, thrice weekly trimethoprim-sulfamethoxazole for Pneumocystis prophylaxis, and monthly infusions of intravenous immunoglobulin."], "Patient Symptoms": ["Although most were asymptomatic, the patient was concerned about the ongoing appearance of new lesions and the associated pain that some lesions were causing."], "Examination and Results": ["Physical examination revealed 9 smooth-surfaced, skin-colored to hyperpigmented, 0.5- to 1.5-cm atrophic papules and plaques that exhibited the buttonhole sign on palpation (Figure, A).", "The multicentric lesions were located on the left knee, left thigh, bilateral chest, and back.", "Punch biopsies of lesions on his trunk and extremities were sent for histopathological examination with hematoxylin-eosin (H&E) staining (Figure, B and C), immunohistochemical (IHC) studies, and molecular evaluation with reverse transcription polymerase chain reaction.A, The patient presented with 2 distinct, smooth-surfaced, 0.5- to 1.0-cm atrophic plaques with overlying hyperpigmentation on the left thigh.", "Both lesions exhibited the buttonhole sign on palpation.", "B and C, Histopathology shows poorly circumscribed hypercellular proliferation of spindle cells occupying the lower reticular dermis with lacelike infiltration of the subcutaneous fat (hematoxylin-eosin).", "The somewhat whorled, uniform appearing spindle cells with mildly hyperchromatic, elongated, wavy nuclei surrounded by pale cytoplasm.", "Mitotic figures and nuclear pleomorphism are uncommon."]}
{"Patient Personal Background": ["He had psoriasis for 30 years, for which he was taking steroids intermittently, and hypothyroidism for 4 years, for which he was taking levothyroxine."], "Patient Symptoms": ["The patient denied confusion, memory problems, hallucinations, and sleep disturbance."], "Examination and Results": ["His examination results were significant for psoriatic skin lesions and purple stria in the abdomen and both calves.", "Undulating wavelike movements were visible on the muscle surface of the abdomen and calves (Video).", "The remaining general and neurological examination results were normal.", "Laboratory test results, including creatine kinase, thyrotropin, antinuclear antibodies, paraneoplastic antibodies (includes Hu, Yo, Ri, CV2, Ma2, and amphiphysin antibodies), were normal.", "Chest computed tomography results were normal."], "Others": ["His family history was unremarkable."]}
{"Patient Personal Background": ["The patient was diagnosed as having vasospastic angina (VA); diltiazem and glyceryl trinitrate were prescribed, and an implantable cardioverter-defibrillator (ICD) was implanted.Two months later, she presented with similar symptoms to another hospital; her ICD had not delivered a shock."], "Patient Symptoms": ["The patient was diagnosed as having vasospastic angina (VA); diltiazem and glyceryl trinitrate were prescribed, and an implantable cardioverter-defibrillator (ICD) was implanted.Two months later, she presented with similar symptoms to another hospital; her ICD had not delivered a shock.", "The electrocardiogram showed asystole with pacemaker spikes not followed by QRS complexes.", "Given her history of VA, we started nitroglycerin infusion, which resulted in return to normal sinus rhythm after 5 minutes with a palpable peripheral pulse.Despite the intensification of therapy with isosorbide mononitrate and concomitant use of amlodipine, diltiazem, and benzodiazepine, the patient experienced another episode of asystole and multiple episodes of asymptomatic ST-T changes in the coronary care unit."], "Examination and Results": ["Cardiopulmonary resuscitation was initiated and was followed with coronary angiography, which showed significant 3-vessel stenosis that completely resolved after nitroglycerin injection.", "Angiography was again performed and showed severe spasm of all coronary vessels that resolved after nitroglycerin administration (Figure).", "Medical treatment was intensified by adding verapamil and a statin to the regimen.Total occlusion of all coronary arteries during cardiac arrest (A) that was completely resolved after nitroglycerin administration (B).Four months later, the patient was admitted to our center in an unconscious state.", "The electrocardiogram showed asystole with pacemaker spikes not followed by QRS complexes.", "Her ejection fraction declined to 30%."], "Treatment": ["Cardiopulmonary resuscitation was initiated and was followed with coronary angiography, which showed significant 3-vessel stenosis that completely resolved after nitroglycerin injection.", "The patient was diagnosed as having vasospastic angina (VA); diltiazem and glyceryl trinitrate were prescribed, and an implantable cardioverter-defibrillator (ICD) was implanted.Two months later, she presented with similar symptoms to another hospital; her ICD had not delivered a shock.", "Medical treatment was intensified by adding verapamil and a statin to the regimen.Total occlusion of all coronary arteries during cardiac arrest (A) that was completely resolved after nitroglycerin administration (B).Four months later, the patient was admitted to our center in an unconscious state.", "Given her history of VA, we started nitroglycerin infusion, which resulted in return to normal sinus rhythm after 5 minutes with a palpable peripheral pulse.Despite the intensification of therapy with isosorbide mononitrate and concomitant use of amlodipine, diltiazem, and benzodiazepine, the patient experienced another episode of asystole and multiple episodes of asymptomatic ST-T changes in the coronary care unit."], "Diagnosis": ["The patient was diagnosed as having vasospastic angina (VA); diltiazem and glyceryl trinitrate were prescribed, and an implantable cardioverter-defibrillator (ICD) was implanted.Two months later, she presented with similar symptoms to another hospital; her ICD had not delivered a shock."], "Others": ["Because she was not carrying her medical records, she was immediately transferred to the catheterization laboratory.", "Cardiopulmonary resuscitation was started, but after 10 minutes of resuscitation there was no response."]}
{"Patient Symptoms": ["Physical examination was notable for tenderness over the nasal bones."], "Examination and Results": ["No neurologic deficits were noted.", "Computed tomography (CT) scan of the head without contrast revealed nasal bone fractures and an incidental 7-mm tissue density within the posterior aspect of the left sphenoid sinus (Figure 1A) with an apparent dehiscence of the posterior wall and possible communication with the intracranial extra-axial spaces and brain parenchyma.", "A magnetic resonance imaging scan with contrast was recommended to further characterize the lesion which showed a transosseous T1 dark, T2 bright multilobulated mass measuring 2.1\u2009\u00d7\u20091.4\u2009\u00d7\u20091.3 cm with heterogeneous enhancement on postcontrast imaging extending into the sphenoid sinus.", "Pathological analysis revealed sheets of neoplastic, vacuolated, \u201csoap bubble\u2013like\u201d cells with a myxoid background (Figure 1B).A, Sagittal computed tomography (CT) scan showing 7 mm tissue density within the posterior aspect of the left sphenoid sinus.", "B, Sheets of neoplastic, vacuolated, physaliphorous cells with a myxoid background (original magnification \u00d740)."], "Treatment": ["An endoscopic transnasal approach was used to obtain a tissue biopsy specimen."]}
{"Examination and Results": ["A polypoid lesion was identified at the left lateral nasal wall.", "Noncontrasted computed tomography showed a hyperdense mass involving the left medial canthus extending through the nasolacrimal duct into the left nasal cavity.", "On examination, there was a palpable subcutaneous nodule 1 cm inferior to the left medial canthus with normal overlying skin.", "On nasal endoscopy, residual tumor was visible at the anterior aspect of the lateral nasal wall.", "Computed tomography showed postoperative changes with enhancement of left medial canthus extending into nasolacrimal duct and along the lateral nasal sidewall (Figure, A).A, Coronal view of contrast-enhanced maxillofacial computed tomography obtained after initial biopsy and before resection showing tumor involvement of lateral nasal sidewall and nasolacrimal duct.", "Microscopic examination showed sheets of monomorphic undifferentiated tumor cells with interspersed areas of abrupt squamous differentiation and keratinization (Figure, B and C)."], "Treatment": ["The patient underwent endoscopic left maxillary antrostomy, ethmoidectomy, and biopsy of mass, with results of pathology analysis showing poorly differentiated squamous cell carcinoma.", "The tumor appeared to originate from left lateral nasal wall, with involvement of nasal floor and extension into the orbit and periorbita.Histologically, the tumor extensively eroded maxillary bone, with abundant necrosis and widespread involvement of surgical margins."], "Diagnosis": ["The patient underwent endoscopic left maxillary antrostomy, ethmoidectomy, and biopsy of mass, with results of pathology analysis showing poorly differentiated squamous cell carcinoma."], "Others": ["Immunohistochemical (IHC) staining was positive for cytokeratin 5/6 and p63, and negative for Epstein-Barr virus, p16, CD45 (leukocyte common antigen), and synaptophysin.", "The patient was referred to a tertiary care facility for further treatment.", "B and C, Hematoxylin eosin\u2013stained histologic sections of tumor after resection showing bony invasion by sheets of undifferentiated cells (B) and focal areas of abrupt keratinization (C).The patient subsequently underwent left medial maxillectomy via lateral rhinotomy approach, with resection of residual tumor."]}
{"Patient Personal Background": ["Medical history included corrective lens replacement surgery in early childhood and a family history of childhood hearing loss in the patient\u2019s maternal grandfather."], "Patient Symptoms": ["The patient failed a school-administered hearing screening as well as a subsequent hearing screening performed by his pediatrician.", "According to his mother, the patient had struggled with his hearing, often failing to respond to vocalizations and requiring statements to be frequently repeated."], "Examination and Results": ["Physical examination revealed no effusions, while formal audiological testing revealed restricted middle ear mobility and bilateral moderately severe mixed hearing loss rising to normal hearing sensitivity in both ears (Figure, A).", "A noncontrast computed tomography (CT) scan of the temporal bones revealed bilateral enlargement of the vestibular aqueducts (Figure, B), fistulous communication between the internal auditory canal (IAC) and the basal turn of the cochlea (Figure, C), and a bulbous dilation of the IAC (Figure, D)."], "Others": ["He reportedly passed his newborn hearing screening and his mother had no serious hearing concerns prior to his failed school screening.", "Given the family history of childhood-onset hearing loss, genetic testing was performed and revealed genetic mutation of the POU3F4 gene."]}
{"Patient Symptoms": ["She reported the sensation of eye fullness and denied pain."], "Examination and Results": ["Brain magnetic resonance imaging (MRI) results revealed a thickening and enhancement of the pituitary gland, stalk, and hypothalamus.", "The abnormal imaging findings improved on subsequent MRIs without treatment.", "Surveillance pituitary MRIs remained stable.", "Four years later, MRI results (Figure) revealed bilateral T1 and T2 low-intensity intraconal soft tissue masses with avid enhancement on postcontrast images.", "The optic nerves were encased with no evidence of infiltration of the nerves, vascular structures, or extraocular muscles.", "Her best-corrected visual acuity was 20/20 OU.", "Her pupils were symmetric and responded to light and near effort; there was no relative afferent pupillary defect.", "The results of testing with an Amsler grid and Ishihara color plates were normal.", "Her visual fields were full to confrontation.", "The optic nerves and retina were normal bilaterally.", "There was bilateral periorbital swelling and proptosis.", "Exophthalmometry measurements on a base of 92 were 17 mm on the right and 19 mm on the left.", "Applanation tonometry results were 12 mm Hg on the right and 15 mm Hg on the left.", "Extraocular motility examination results revealed substantial (\u22123) deficits in both eyes."]}
{"Patient Personal Background": ["He had no history of hearing loss or pigmented skin lesions.", "He had no past ocular history or prior ophthalmic examinations."], "Examination and Results": ["Color vision was severely diminished in the right eye, as determined by Ishihara color plates, and he had no detectable stereoacuity, as determined by Titmus testing.", "Intraocular pressure and extraocular movements were normal.", "He had a mild relative afferent pupillary defect in the right eye but no strabismus or nystagmus.", "The cycloplegic refraction was +2.50\u2009+\u20090.50\u2009\u00d7\u2009100 OD and +2.00 sphere OS.", "Results of an anterior segment slitlamp biomicroscopy examination showed no abnormalities.", "Results of a dilated retinal examination showed a large, elevated, homogenous, gray mass in the macula of the right eye with temporal pallor of the optic disc (Figure, A)."]}
{"Patient Personal Background": ["He took no medications and denied prior surgery, eye trauma, or pain."], "Patient Symptoms": ["He experienced left temporal field loss when lifting heavy objects."], "Examination and Results": ["His best-corrected visual acuity was 20/25 OD and 20/30 OS.", "The only abnormalities on bilateral eye examination were 1+ levels of anterior vitreous cells and trace levels of posterior vitreous cells in the left eye, without vitreous haze, and a left retinal detachment extending from 1:30 to 10:00 o\u2019clock, with macular involvement and without visible retinal tears.", "There were 360\u00b0 left choroidal detachments.Optical coherence tomography showed choroidal thickening in both maculae.", "Fluorescein angiography (FA) of the right eye gave normal results.", "On B-scan ultrasonography, there was a subclinical choroidal detachment superonasally in the right eye.", "An ultrasonographic image confirmed the detachments in the left eye (Figure 1B).", "The findings of a prior magnetic resonance image of the brain, chest radiographic image, and computed tomographic image of the chest were unremarkable.", "Test results for syphilis, tuberculosis, bartonella, and toxoplasma were negative, as were test results for inflammatory markers, quantitative serum proteins, and immunoglobulins.Images of the left eye at baseline.", "A, Midphase fluorescein angiography of the left eye.", "There are multiple peripheral areas of punctate hyperfluorescence.", "Leakage is more pronounced posteriorly around the nerve.", "There is scattered blockage of background fluorescence owing to retinal pigment epithelium mottling, which creates a leopard-spot pattern.", "A retinal detachment is seen inferiorly with tortuous vessels and nonfluorescent subretinal fluid.", "B, A B-scan ultrasonographic image of the left eye in the longitudinal 6 o\u2019clock meridian demonstrates retinal detachment and a nonserous choroidal detachment superiorly.", "The optic nerve shadow is seen inferiorly.", "There is no fluid in the Tenon capsule.", "The detachment was mapped to extend from 1:30 to 10:00 o\u2019clock and involve the macula."], "Treatment": ["The maximum height of the choroidal detachment was 3.4 mm.", "Three weeks later, his best-corrected visual acuity worsened to 20/50 OS.", "A posterior sub-Tenon injection of 40 mg of triamcinolone acetonide was given, along with tapering doses of oral prednisone for 6 more weeks."], "Others": ["Figure 1A depicts the FA image of the left eye.", "No retinal tear was visualized.The patient started receiving 60 mg of oral prednisone  daily."]}
{"Patient Personal Background": ["He had been diagnosed with type 1 diabetes 5 years prior and had never been examined for diabetic retinopathy."], "Examination and Results": ["At the initial examination, his hemoglobin A1c level was 11.0% (to convert to the proportion of total hemoglobin, multiply by 0.01), suggesting a lack of compliance with his diabetic treatment regimen.", "His best-corrected visual acuity (BCVA) was 20/100 OS and 20/60 OD.", "On examination of the left eye, the anterior segments were unremarkable, with no neovascularization of the angle or iris.", "However, there was considerable retinal thickening, substantial capillary nonperfusion in the macular area, and a large area of disc neovascularization (in more than one-third of the disc area), with leakage on the disc associated with prepapillary neovascularization, as confirmed by fluorescein angiography (Figure 1A).", "Optical coherence tomography confirmed retinal thickening in the macular area (central subfield thickness [CST], 805 \u03bcm), with cystoid abnormalities throughout the retinal layers as well as subretinal fluid (Figure 1B).A, Large prepapillary neovascular complex, nonperfusion in the macula and the periphery, and central subfield involvement of the macular edema is visible.", "Arrowheads indicate neovascularization of the disc (pink) and nonperfusion (blue)."]}
{"Patient Symptoms": ["At the moment of impact, she was wearing her seat belt, the airbag deployed, and an intense flexion-extension head movement occurred.Best-corrected visual acuity was 20/125 OD and 20/63 OS."], "Examination and Results": ["Intraocular pressure was 19 mm Hg OD and 20 mm Hg OS.", "Slitlamp examination revealed no palpebral hematoma, and the anterior segment was found to be normal.", "On the fundus bilaterally, we only noted an alteration of the foveal reflection, with neither retinae commotio nor hemorrhages.", "Macular optical coherence tomography (OCT) showed bilateral macular edema with cystoid abnormalities (Figure 1).", "An epiretinal membrane also was noted in the left eye (Figure 1B).Optical coherence tomography showed bilateral macular edema with cystoid abnormalities.", "Central subfield thickness was 696 \u03bcm in the right eye and 392 \u03bcm in the left eye."]}
{"Patient Symptoms": ["The patient first noticed a rapidly expanding, itchy, painful nodule, which measured 3 cm in diameter, 5 months prior to presentation (Figure, B).Lesion appearance at the first visit (A) and 5 months earlier (B).", "C, Hematoxylin-eosin stain, magnification \u00d720.The patient reported decreased appetite with weight loss of 7 kg over 5 months and denied fever, itching aside from the lesion, vomiting, or bowel alterations."], "Examination and Results": ["On physical examination, there were no other cutaneous lesions though multiple ipsilateral axillary lymph nodes, and enlarged supraclavicular and cervical lymph nodes were present.", "All other physical and laboratory findings were unremarkable."], "Treatment": ["Owing to intense and continuous pain from the lesion, she began opioid treatment with oxycodone/naloxone association at an initial dose of 5 mg/2.5 mg twice a day and titrated to 10 mg/5 mg twice a day after a week to achieve pain control.Abdominal ultrasonography revealed only a left adrenal gland mass, consistent with adenoma."], "Others": ["A skin punch biopsy of the lesion was obtained (Figure, C)."]}
{"Patient Symptoms": ["He did not have chest pain or any other symptoms."]}
{"Patient Personal Background": ["She had no history of neonatal respiratory distress, nasal congestion, persistent urticaria, joint laxity, or illicit drug use.", "She denied a family history of liver cirrhosis, chronic obstructive pulmonary disease (COPD), or cystic fibrosis."], "Patient Symptoms": ["Her cough was productive of yellow-green sputum and treated with antibiotics on multiple occasions, which provided some alleviation of her symptoms."], "Examination and Results": ["Examination revealed scattered wheezes and rhonchi on auscultation.", "Pulmonary function testing demonstrated a severe obstruction with a forced expiratory volume at 1 second (FEV1) of 0.79 L (28% of predicted), forced vital capacity (FVC) of 1.64 L (47% of predicted), FEV1:FVC ratio of 48%, and a reduced diffusing capacity for carbon monoxide of 8.74 mL/min per mm Hg (23.75% of predicted), which was consistent with emphysema.", "Chest radiography followed by computed tomography (CT) of the chest showed lower lobe predominant emphysema and bronchiectasis (Figure).Computed tomography of the chest."], "Treatment": ["Her cough was productive of yellow-green sputum and treated with antibiotics on multiple occasions, which provided some alleviation of her symptoms."], "Diagnosis": ["Pulmonary function testing demonstrated a severe obstruction with a forced expiratory volume at 1 second (FEV1) of 0.79 L (28% of predicted), forced vital capacity (FVC) of 1.64 L (47% of predicted), FEV1:FVC ratio of 48%, and a reduced diffusing capacity for carbon monoxide of 8.74 mL/min per mm Hg (23.75% of predicted), which was consistent with emphysema.", "Chest radiography followed by computed tomography (CT) of the chest showed lower lobe predominant emphysema and bronchiectasis (Figure).Computed tomography of the chest."], "Others": ["Left, Transverse view."]}
{"Patient Personal Background": ["He had not received any prior treatment for the lesions."], "Patient Symptoms": ["On examination, there were hypopigmented and hyperpigmented reticulated patches and thin, atrophic plaques covering more than 10% of the total body surface area involving the axilla, groin, and flanks bilaterally (Figure, A)."], "Examination and Results": ["No cervical, axillary, or inguinal lymphadenopathy was noted.", "Results from a comprehensive review of systems was unremarkable.", "Results from a complete blood cell count, erythrocyte sedimentation rate, and blood chemistry analyses were normal.", "A 6-mm punch biopsy specimen from the right flank was obtained for histopathological examination (Figure, B).", "Immunohistochemical analysis was also performed (Figure, C and D).A, Hyperpigmented reticulated patches with central hypopigmentation on the right axilla."], "Others": ["B, Lesional punch biopsy specimen obtained from the right flank (hematoxylin-eosin stain).", "C and D, Immunohistochemical analysis (positivity stain, original magnification \u00d7100)."]}
{"Patient Personal Background": ["He was taking finasteride, montelukast, enalapril, and metoprolol.", "His medical history was significant for right total reverse shoulder replacement 5 years prior."], "Patient Symptoms": ["There was no warmth, thrills, or pulsations across the affected area.", "The patient complained about a mild tingling sensation within the lesion.", "The patient could not think of any triggers or causes for his condition and denied any aggravating or alleviating factors as well as any treatment attempts."], "Examination and Results": ["Complete review of systems yielded negative results except for easy bruising.", "Apart from the previously described lesion, his physical examination was unremarkable, and he had full range of motion of his right shoulder.", "A punch biopsy of the slightly indurated papule from the involved area on the right biceps was completed (Figure, C and D).A and B, An irregularly linear, rusty-brown, atrophic, streaklike plaque extends from the tip of the right shoulder to the right biceps, where it ends in arborizing purple plaque with scattered, slightly indurated, irregular papules within it.", "C, Hematoxylin-eosin staining demonstrates a dermal infiltrate arranged in nodules with clefting between nodules; some inflammatory aggregates are also seen within dilated vessels.", "D, Immunohistochemical staining for CD68 antigen reveals that the infiltrate is composed mostly of histiocytes."]}
{"Patient Personal Background": ["The patient was an active smoker (1 pack per day) with an unremarkable family history."], "Patient Symptoms": ["He began pembrolizumab therapy.After starting treatment, the patient began to notice slowly worsening painless, nonpruritic, diffuse dark gray skin, nail beds, and eye discoloration (Figure)."], "Examination and Results": ["Physical examination revealed palpable right axillary lymphadenopathy.", "A positron emission tomography scan showed a hypermetabolic right axillary lymph node that measured 5\u2009\u00d7\u20095 cm as well as multiple liver lesions, the largest of which measured 8 cm.", "The results of a core needle biopsy specimen from the right axillary lymph node were consistent with malignant neoplasm, with immunohistochemistry staining positive for S100, HMB-45, and MART-1.", "The results of laboratory studies revealed normal electrolytes, normal kidney function, mild elevation of liver function, and mild anemia with a hemoglobin level of 12 g/dL (for SI unit conversion, multiply by 10.0 to convert to liters).", "Computed tomography of the chest, abdomen, and pelvis showed worsening hepatic metastases and right axillary adenopathy."], "Treatment": ["He began pembrolizumab therapy.After starting treatment, the patient began to notice slowly worsening painless, nonpruritic, diffuse dark gray skin, nail beds, and eye discoloration (Figure)."]}
{"Patient Symptoms": ["Two weeks later, she presented to the emergency department (ED) after receiving several shocks from the device during the early morning, waking her up from sleeping."], "Examination and Results": ["Postprocedure chest radiography results showed appropriate device placement.", "Postimplant interrogation results showed appropriate device function.", "Physical examination results revealed no signs of decompensated heart failure.", "Device interrogation results showed shock therapies delivered postimplant on days 3, 5, 6, and 10.", "Repeated chest radiography at the ED showed appropriate device location, lead pin, and an absence of subcutaneous air trapping at the proximal and distal sense electrodes.Surface electrogram recorded by subcutaneous implantable cardioverter defibrillator from one of the events."], "Treatment": ["The device was programmed with a conditional shock zone of 200 beats per minute and a shock zone of 230 beats per minute."], "Others": ["The patient was discharged the day after implant.", "There were no reported symptoms associated with shortness of breath, chest pain, or syncope.", "The surface electrogram from the events, recorded at a paper speed of 25 millimeters per second and an amplitude of 2.5 mm/mvV) is shown in Figure 1.", "Recorded at a paper speed of 25 millimeters per second and an amplitude of 25 mm/mV."]}
{"Patient Personal Background": ["She reported no constitutional symptoms or any history of tobacco or alcohol use."], "Patient Symptoms": ["The lesion waxed and waned but never completely healed; however, it greatly increased in size over 3 weeks before presentation.", "She reported constant, severe stabbing pain, right otalgia, and occasional swelling that caused oral dysphagia."], "Examination and Results": ["On examination, the mass was a 3\u2009\u00d7\u20092-cm, exophytic and raised, plateaulike lesion on the right dorsolateral tongue with approximately 1 to 2 cm of surrounding induration (Figure, A).A, Right lateral tongue lesion at presentation.", "B, Spindled-cell proliferation with palisaded areas (Verocay bodies) and an associated inflammatory infiltrate with abundant eosinophils (hematoxylin-eosin, original magnification \u00d720).A biopsy was obtained that demonstrated ulceration, pseudoepitheliomatous hyperplasia, and abundant acute and chronic inflammation replete with eosinophils."], "Diagnosis": ["The differential based on the biopsy included traumatic ulcerative granuloma with stromal eosinophilia and ulceration due to drug- or infection-related sources.", "In addition, the possibility of an unsampled submucosal mass with overlying ulceration was suggested by the pathologist who interpreted the biopsy findings."]}
{"Patient Personal Background": ["He had been diagnosed a year earlier with HIV infection and hepatic tuberculosis.", "Baseline CD4 count was 7 cells/\u03bcL, and following treatment with HAART (highly active antiretroviral therapy) consisting of dolutegravir, emtricitabine, and tenofovir-disoproxil-fumarate, he achieved full virological suppression; however, CD4 counts remained low at 31 cells/\u03bcL.", "He had completed 12 months of directly observed therapy with ethambutol, moxifloxacin, and rifabutin\u2014a liver-sparing regimen\u2014owing to toxic effects from the first-line regimen 1 month prior to admission."], "Patient Symptoms": ["Physical examination revealed evidence of perforation of the hard palate (Figure, A)."], "Examination and Results": ["Physical examination revealed evidence of perforation of the hard palate (Figure, A).", "A computed tomographic scan of the chest revealed necrotic lymph nodes, and a palatine biopsy was performed (Figure, B and C).A, Clinical view of the perforation of the hard palate."], "Treatment": ["Baseline CD4 count was 7 cells/\u03bcL, and following treatment with HAART (highly active antiretroviral therapy) consisting of dolutegravir, emtricitabine, and tenofovir-disoproxil-fumarate, he achieved full virological suppression; however, CD4 counts remained low at 31 cells/\u03bcL.", "He had completed 12 months of directly observed therapy with ethambutol, moxifloxacin, and rifabutin\u2014a liver-sparing regimen\u2014owing to toxic effects from the first-line regimen 1 month prior to admission."], "Diagnosis": ["He had been diagnosed a year earlier with HIV infection and hepatic tuberculosis."], "Others": ["B, Low-power microscopic view of a biopsy specimen from the hard palate (hematoxylin-eosin).", "C, Oil immersion image of the same tissue shown panel B stained with Grocott methenamine silver."]}
{"Patient Personal Background": ["His ocular history included nonclearing vitreous hemorrhage in the right eye requiring pars plana vitrectomy, panretinal photocoagulation, multiple treatments with intravitreous bevacizumab, and cataract extraction with placement of an intraocular lens (IOL) into the capsular bag approximately 4 years ago."], "Patient Symptoms": ["Examination of the anterior segment at that time was unremarkable.At his current visit, visual acuity with the previous correction had been reduced to 20/150."], "Examination and Results": ["At his routine follow-up visit 2 weeks prior, the proliferative diabetic retinopathy was quiescent, and his Snellen visual acuity was 20/20 OD with manifest refraction of \u22121.50\u2009+\u20090.25\u2009\u00d7\u2009180.", "Repeated manifest refraction of the right eye was \u22124.00\u2009+\u20091.50\u2009\u00d7\u2009166, resulting in a visual acuity of 20/25.", "Intraocular pressure of the right eye was 10 mm Hg by Goldmann applanation tonometry.", "Evaluation of the posterior segment, including dilated fundus examination and optical coherence tomography (OCT) of the macula, showed stability compared with previous results."], "Others": ["Imaging of the anterior segment with OCT is shown in Figure 1."]}
{"Patient Personal Background": ["Medical history was significant for Sj\u00f6gren syndrome, for which she was taking hydroxychloroquine sulfate."], "Examination and Results": ["Family history was negative for corneal disease.On initial presentation to the clinic, the best-corrected visual acuity of the patient was 20/150 OD and 20/40 OS.", "She was found to have bilateral, gray-white, irregular, poorly circumscribed, linear and nummular central and peripheral corneal opacities, confined primarily to the subepithelium and focally to the underlying anterior stroma (Figure 1A).", "The epithelium itself and deeper corneal stroma were spared, and the remainder of her anterior segment and fundus examination results were within normal limits.", "Anterior segment optical coherence tomography documented deposition of hyperreflective material in the subepithelium with trace deposition in the anterior stroma (Figure 1B).", "Evaluation of the patient's children showed no evidence of corneal disease.A, Right eye gray-white, irregular, linear and nummular central and peripheral corneal opacities.", "The left eye had similar findings.", "B, Hyperreflective deposits in the subepithelium (black arrowhead) with trace deposit in the anterior stroma (white arrowhead)."], "Others": ["Ocular history was notable for neovascular age-related macular degeneration under good control with intravitreal injections in the right eye and intermediate dry age-related macular degeneration in the left eye."]}
{"Patient Symptoms": ["One month after presentation, the patient developed worsening photophobia, and his visual acuity declined to 20/50 OS."], "Examination and Results": ["On ophthalmic evaluation, visual acuity was 20/20 OS, intraocular pressure was 13 mm Hg OS, and slitlamp examination of the left eye demonstrated a clear, intrinsically vascularized, cystic lesion extending into the anterior chamber from the peripheral superonasal iris (Figure 1A).", "The base of the lesion was surrounded by iris atrophy and corectopia was noted.", "The remainder of the ocular examination was unremarkable.", "Examination of the right eye was also unremarkable.", "Ultrasonographic biomicroscopy of the anterior segment demonstrated a large, cystic lesion incorporated in the iris of the left eye with a thickness of 2.2 mm and a maximum radial extent of 6.1 mm (Figure 1B).A, Slitlamp photograph of the iris cyst in the superonasal periphery of the left eye.", "B, Ultrasonographic biomicroscopy of the anterior segment in the left eye with longitudinal orientation at the 10-o\u2019clock position.Given the patient\u2019s excellent visual acuity and no documented evidence of growth, the lesion was initially monitored closely.", "The iris lesion was noted to have grown, with maximum thickness measuring 3.5 mm and with radial extension now involving the visual axis."], "Diagnosis": ["The referring clinician initially suspected traumatic iridodialysis and vitreous prolapse."]}
{"Patient Personal Background": ["The patient had a history of congestive heart failure, cleft lip surgery as an infant, and right eye amblyopia."], "Patient Symptoms": ["She reported occasional floaters and flashes in the right eye but denied any ocular complaints in the left eye."], "Examination and Results": ["On examination, her visual acuity measured 3/200 OD and 20/30 OS, stable compared with her baseline.", "Her intraocular pressure was 18 mm Hg OD and 14 mm Hg OS.", "Right eye slitlamp biomicroscopy showed an irregular pupil, aphakia, and a pigmented mass behind the temporal iris (Figure 1A).", "Ophthalmoscopic examination results revealed a subluxed white cataractous lens in the inferior vitreous base (Figure 1B).", "An evaluation of the left eye yielded normal results aside for a moderate cataract.", "B-scan ultrasonography results showed the 2 masses described previously; both were moderately reflective, oval, and separate from the wall of the eye.", "Ultrasonography biomicroscopy (UBM) confirmed that the temporal mass and the inferiorly subluxed lens were separate from the iris and ciliary body and were similar to each other in size, shape, and density.A, Anterior fundus photograph of the right eye shows a dark mass behind the pupil temporally."]}
{"Patient Personal Background": ["She had a medical history significant for a renal transplant performed 4 years prior.", "She received induction with alemtuzumab and maintenance immunosuppression with tacrolimus and mycophenolate."], "Patient Symptoms": ["On admission, the patient developed left eye pain and slurred speech."], "Examination and Results": ["Physical examination revealed expressive aphasia, partial left abducens nerve palsy, decreased motor strength in her right upper and lower extremities, and right-sided pronator drift.", "Laboratory evaluation showed a white blood cell count of 9.6 K/\u03bcL (reference range, 4.5-11.0 K/\u03bcL), and a lactic acid dehydrogenase level of 547 U/L (reference range, 160-450 U/L).", "Cerebrospinal fluid analysis revealed a white blood cell count of 51 cells/\u03bcL (reference range, 0-5 cells/\u03bcL) with 92% lymphocytes, a glucose level of 76 mg/dL (reference range, 40-70 mg/dL), and a protein level of 136 mg/dL (reference range, 12-60 mg/dL).", "A computed tomography (CT) scan of the brain showed multifocal vasogenic edema around the left lentiform nuclei, left temporal occipital white matter, and right parietal white matter, with mass effect causing near complete effacement of the third ventricle and subsequent rightward midline shift.", "Magnetic resonance imaging of the brain revealed multiple ring-enhancing lesions (Figure, A).", "A fluorine 18 fluorodeoxyglucose positron emission tomography/CT demonstrated increased focal fluorodeoxyglucose activity throughout the brain only."], "Others": ["She was not on any antiviral therapies prior to presentation.", "The patient underwent a biopsy of the right posterior temporal lobe (Figure, B and C).A, Ring-enhancing lesions are visible.", "B, A lesional biopsy specimen of the brain was obtained (hematoxylin-eosin, original magnification \u00d7400).", "C, Immunohistochemical stain of CD20 (original magnification \u00d7400)."]}
{"Patient Personal Background": ["He had no other medical conditions, took no medications, and was sexually monogamous with his wife, who was asymptomatic.The patient was hemodynamically stable and had a normal respiratory examination."], "Patient Symptoms": ["Two days later, he returned with worsening oral lesions, painful phonation, poor oral intake, odynophagia, and new painful penile lesions.", "He denied any abdominal pain, diarrhea, rectal bleeding, weight loss, arthralgia, fatigue, vision changes, or skin rashes.", "He reported a similar episode of widespread oral lesions 18 months earlier that was less severe and self-resolving.", "He had a fever (39.4\u00b0C) on presentation, but his temperature abated overnight and he remained afebrile for the rest of the admission."], "Examination and Results": ["His superior and inferior lips had extensive well-circumscribed erosions and ulcerations with erythematous edges, crusting, and a gray-white base (Figure, left).", "Lesions extended into the buccal mucosa and soft palate.", "His tongue was enlarged with fissures.", "A genital examination showed similar lesions on the penis, with scalloped borders (Figure, right).", "There were no skin lesions, lymphadenopathy, or hepatosplenomegaly.Left, Extensive well-circumscribed oral lesions limited to the mucosa in a 28-year-old man.", "Right, Similar lesions with scalloped borders on the distal shaft and glans of the penis in the same patient.Results of laboratory tests from the emergency department were normal, and a chest radiograph showed no evidence of pneumonia.", "Results of further testing for antinuclear antibodies, erythrocyte sedimentation rate, C-reactive protein level, HIV, HSV serology, syphilis, chlamydia, and gonorrhea were negative.", "Bacterial and viral cultures of the oral and penile lesions were also negative.", "Serum enzyme immunoassay for Mycoplasma pneumoniae IgM was positive at 1280 U/mL."], "Treatment": ["He was diagnosed with herpes simplex virus (HSV) and discharged home with acyclovir."], "Diagnosis": ["He was diagnosed with herpes simplex virus (HSV) and discharged home with acyclovir."]}
{"Patient Personal Background": ["She had a medical history of hypertension and palmar and axillary hyperhidrosis."], "Patient Symptoms": ["She denied double vision, ptosis, headache, and weakness."], "Examination and Results": ["On examination, she appeared well and her blood pressure was 128/78 mm Hg; heart rate, 76/min; and respiratory rate, 13/min.", "Visual acuity was 20/20 in both eyes, there was no ptosis, and extraocular movements were full.", "Pupillary examination revealed anisocoria that was more pronounced in bright lighting conditions (Figure).", "The right pupil measured 6 mm in the dark and 3 mm in the light, whereas the left pupil measured 9 mm in the dark and 8 mm in the light.", "The left pupil was poorly reactive to light and to a near target.", "Slitlamp examination revealed normal-appearing anterior chambers without any signs of intraocular inflammation.", "Cranial nerve function was otherwise normal."]}
{"Patient Personal Background": ["He immigrated to the United States as an adult more than 20 years before presentation."], "Patient Symptoms": ["He reported a 4-month history of nonproductive cough, 5-kg weight loss, and fatigue."], "Examination and Results": ["His temperature was 37\u00b0C, heart rate was 78/min, respiratory rate was 17/min, and blood pressure was 158/95 mm Hg.", "A chest radiographic image suggested cardiomegaly and a computed tomographic scan demonstrated a moderate to large pericardial effusion.", "A pericardial drain was placed and pericardial fluid was sent to the laboratory for evaluation.", "Initial pericardial fluid study results are presented in the Table."], "Treatment": ["Empirical treatment for tuberculosis was initiated."]}
{"Patient Personal Background": ["He had no history of chronic abdominal pain.", "Past surgical history was noteworthy for emergency exploratory laparotomy and splenectomy for blunt trauma 14 years prior."], "Patient Symptoms": ["He stated that \u201cI think I have a kidney stone blocking my kidney\u201d but denied nausea, vomiting, fever, dysuria, hematuria, or weight loss."], "Examination and Results": ["Physical examination revealed a comfortable-appearing patient in no acute distress.", "His temperature was 36.8\u00b0C; pulse, 77/min; and blood pressure, 125/86 mm Hg.", "Abdominal palpation elicited only mild epigastric tenderness without masses or rebound.", "There was no costovertebral angle tenderness.Laboratory data revealed normal levels of serum urea nitrogen and creatinine and normal liver function.", "A complete blood cell count showed leukocytosis (15\u202f300/\u03bcL with 54% neutrophils, 38% lymphocytes, 8% monocytes); hemoglobin level, 15.5 g/dL; and hematocrit, 45.2%.", "Urinalysis revealed no red or white blood cells and was negative for leukocyte esterase and nitrate."]}
{"Patient Symptoms": ["She subsequently developed multiple asymptomatic pink papules on the trunk and extremities."], "Examination and Results": ["Clinical examination revealed scattered pink papules with a white firm center and dark brown core scattered throughout the chest, abdomen (Figure, A and B), back, groin, and upper and lower extremities.", "Laboratory workup was significant for leukopenia with neutropenia, anemia, and thrombocytopenia.", "Creatinine and transaminase levels were within normal limits.", "Blood cultures were negative."], "Treatment": ["The patient was afebrile and was receiving broad-spectrum antibiotic, antifungal, and antiviral treatment for a prior episode of neutropenic fever."], "Others": ["A punch biopsy from the left flank was obtained for hematoxylin-eosin staining, and a punch biopsy from the left leg was sent for tissue and fungal culture.", "Histopathological analysis was subsequently performed (Figure, C and D).A, Multiple papules on the abdomen.", "B, Closer view of a single papule.", "C and D, Hematoxylin-eosin\u2013stained lesional specimens."]}
{"Patient Symptoms": ["The patient had experienced a weight loss of 6 kg during the last 3 months.", "Within the last month, the patient\u2019s thyroid became enlarged, and she developed anorexia and abdominal discomfort."], "Examination and Results": ["The verrucous plaques also involved the conjunctiva, lips, and gingiva (Figure 1B).", "Laboratory test results revealed remarkably elevated levels of carcinoembryonic antigen, carbohydrate antigen 19-9, carbohydrate antigen 125, tissue polypeptide antigen and carbohydrate antigen 242.", "Biopsy specimens of lesions on the axillae and lips both revealed a papillary structure with hyperkeratosis.", "An endoscopic examination and computed tomographic scan of the abdomen were performed.Axilla with velvety, hyperpigmented skin (A) and verrucous plaques on the lips and gingiva (B)."]}
{"Patient Personal Background": ["Social history was significant for 25 pack-years of smoking."], "Patient Symptoms": ["The onset was gradual and started on the lower extremities and gradually extended to involve the lower trunk.", "The rash was associated with mild discomfort.", "The patient denied itching, weeping, or bleeding from the rash.", "She denied any constitutional symptoms (weight loss, fever, night sweats), joint pains, history of blood in urine, periorbital edema, and recent intake of medications or herbal medications."], "Examination and Results": ["Physical examination revealed multiple well-defined, coalescent, erythematous, palpable, purpuralike lesions that were predominantly present over the trunk and lower extremities (Figure, A and B).", "Laboratory test results at presentation included a hemoglobin level of 11.2 g/dL (to convert to g/L, multiply by 10), mean corpuscular volume of 84 fL, erythrocyte sedimentation rate of 72 mm/h, and a lactate dehydrogenase level of 412 IU/L.", "Hepatic and renal function levels were within normal limits.", "Complement levels were normal.", "Hepatitis B and C and HIV profiles were negative.", "A chest radiograph showed a 2-cm lesion in the upper lobe of the left lung.", "A computed tomographic scan of the chest showed a spiculated mass in the same region along with mediastinal lymphadenopathy.", "An ultrasound of the abdomen showed bilateral adrenal masses."], "Others": ["A lesional skin biopsy specimen was obtained (Figure, C).Coalescent, erythematous, palpable lesions on the lower extremity (A) and trunk (B)."]}
{"Patient Personal Background": ["Her family history was notable for hypertension, and no other systemic diseases were reported."], "Patient Symptoms": ["The pain started at rest, was 10 of 10 in severity, and was not alleviated by changing position.", "She also experienced concomitant nausea and diaphoresis."], "Examination and Results": ["On physical examination, her blood pressure was 115/76 mm Hg, heart rate was regular at 72 beats per minute, respiratory rate was 20 breaths per minute, and oxygen saturation level was 98% on room air.", "The patient was afebrile.", "Physical examination also revealed mild bibasilar crackles and jugular venous distention, and no murmurs or lower extremity edema.", "Laboratory test results demonstrated an elevated troponin, and the 12-lead electrocardiogram showed marked ST-segment elevations in leads V2 to V5 (Figure, A)."], "Treatment": ["The ST-segment elevation myocardial infarction (STEMI) pager was activated, and the patient was transferred urgently to the catheterization laboratory.", "Coronary angiography of the patient\u2019s left anterior descending coronary artery was performed, and the findings are depicted in the Figure, B.A, Twelve-lead electrocardiogram."], "Diagnosis": ["Laboratory test results demonstrated an elevated troponin, and the 12-lead electrocardiogram showed marked ST-segment elevations in leads V2 to V5 (Figure, A)."]}
{"Patient Personal Background": ["She had developed a recurrence for which she had just completed 3 cycles of treatment with carboplatin.", "She also had a history of anxiety, hypertension, and pterygium, and she was taking gabapentin, lorazepam, prochlorperazine, metoprolol succinate, bromfenac and ketorolac ophthalmic solution, and aprepitant."], "Patient Symptoms": ["Her local dentist had prescribed an antibiotic and performed a tooth extraction in the area 6 months prior with no improvement in symptoms.", "Ultimately, her pain became persistent and radiated to the right lower lip."], "Examination and Results": ["Intraoral examination revealed a 1.5\u2009\u00d7\u20091.0-cm firm, erythematous gingival mass in the area of missing right mandibular second bicuspid and first molar with buccal and lingual expansion (Figure 1A).", "The right mandibular first bicuspid was grade 3 mobile.", "A periapical radiograph was obtained, and results showed a diffuse, poorly demarcated radiolucency measuring approximately 1.2\u2009\u00d7\u20090.8 cm (Figure 1B).", "Findings from an incisional biopsy of the mass showed an infiltrative tumor (Figure 1C).", "Tumor cells were positive for CK7, PAX8, and WT-1, and negative for CK20 and TTF-1 (Figure 1C, inset).A, A 1.5\u2009\u00d7\u20091-cm gingival mass is distal to the right mandibular first bicuspid.", "B, Diffuse, poorly demarcated radiolucency is seen in the area of the missing right mandibular second bicuspid and first molar (arrowheads).", "C, Multiple nests of round to ovoid epithelial cells form ducts (hematoxylin-eosin stain, original magnification \u00d7100)."]}
{"Patient Personal Background": ["He had been taking prophylactic emtricitabine-tenofovir daily and had received his last diphtheria booster 2 years prior to presentation."], "Patient Symptoms": ["Owing to the odynophagia, he had presented to the emergency department for dehydration.", "At that time, he was febrile to 101\u00b0F and denied any dysphonia or dyspnea."], "Examination and Results": ["The results of a rapid Streptococcus test, recent HIV screen, and a rapid plasma reagin test were all negative.", "He denied any genital lesions or symptoms at that time.", "On physical examination, there was no cervical lymphadenopathy, and there were no genital lesions.", "Flexible fiber-optic nasopharyngoscopy showed ulcerative lesions with exudate and erythema extending diffusely along the base of tongue, oropharynx, nasopharynx, hypopharynx, and epiglottis (Figure 1)."], "Treatment": ["Treatment with amoxicillin clavulanate over several days had not prevented a worsening of his symptoms."]}
{"Patient Personal Background": ["Her history also included chronic gastroesophageal reflux disease and a 14-pack-year smoking history."], "Patient Symptoms": ["She initially presented 3 months prior with upper respiratory symptoms, which continued to worsen despite oral antibiotic therapy.", "Her cough became productive with white, frothy phlegm that was accompanied by fever, wheezing, hoarseness, and fatigue.", "Her dyspnea worsened in the supine position.Flexible laryngotracheoscopy results revealed diffuse, white-to-yellow pseudomembranous changes involving the glottis and supraglottis (Figure, A), posterior tracheal wall, and left mainstem bronchus with skip lesions in the subglottis and distal 1 cm of the trachea (Figure, B)."], "Examination and Results": ["Glottic mobility was limited in both abduction and adduction with substantial airway obstruction.", "Computed tomographic findings revealed posterior tracheal wall thickening with the loss of the fat plane between the trachea and esophagus, and a moderate to severe obstruction within the distal left mainstem bronchus.", "Biopsy results are shown in Figure, C.Laryngoscopic images demonstrate pseudomembranous plaques lining supraglottis and glottis (A) and posterior wall of the trachea (B).", "Supraglottic biopsy demonstrates branching organisms superficial to squamous epithelium (original magnification \u00d7400) (C)."]}
{"Patient Symptoms": ["The patient did not have any noteworthy rhinological symptoms on review."], "Examination and Results": ["Preoperative magnetic resonance imaging examination of the sella revealed a left-sided pituitary microadenoma (Figure, A) and lobulated polypoid soft tissue masses in the superior nasal cavities arising from the olfactory clefts.", "These lesions demonstrated avid post\u2013contrast enhancement with small areas of cystic change and heterogeneously hyperintense T2 signal.", "There was mild widening of the olfactory clefts, particularly on the left side (Figure, B).", "The intervening nasal septum was intact, and there was no intracranial extension.", "He later underwent nasal endoscopy, and results showed tan-colored polypoid lesions emanating from the olfactory clefts of both nasal cavities (Figure, C).", "Biopsy findings revealed submucosal proliferation of seromucinous and respiratory epithelial glands (Figure, D).A, An incidental polypoid-enhancing mass in the nasal cavity demonstrating avid post\u2013contrast enhancement (yellow arrowheads) was observed on the magnetic resonance imaging examination.", "The white arrowhead points to the pituitary adenoma.", "B, Widening and remodeling of the olfactory clefts (yellow arrowheads) was also observed on the magnetic resonance imaging examination.", "C, The incidental polypoid-enhancing mass in the nasal cavity (yellow arrowheads) as seen on nasal endoscopic analysis.", "D, Results of the nasal cavity mass biopsy (original magnification \u00d7100) revealed submucosal proliferation of bland-appearing seromucinous and respiratory epithelial glands."]}
{"Patient Personal Background": ["Her medical history was notable for a growth hormone\u2013producing pituitary macroadenoma for which she underwent surgical resection 2.5 years prior to presentation, followed by \u03b3-knife radiosurgery (50 Gy) 6 months after the initial surgical procedure.", "She also had a history of congenital hip dysplasia.", "Medications included cabergoline, levothyroxine, ethinyl estradiol/drospirenone, and pasireotide.Her visual acuity was 20/20 OU."], "Patient Symptoms": ["The double vision occurred every day, multiple times throughout the day, and was provoked after looking to the right."], "Examination and Results": ["Her pupils were equal in size with no relative afferent pupillary defect.", "Automated perimetry was full in both eyes.", "The anterior and posterior segments were normal in both eyes.", "There was no proptosis or ptosis.", "On initial examination, the eye movements were full, with no ocular deviation in primary, right, or lateral gazes.", "However, on returning to a primary gaze from a sustained right-gaze position, a large angle exotropia was present, and on attempted left gaze, there was a limitation of adduction of the right eye (Figure).", "After 10 to 15 seconds, the exotropia resolved, and eye movements returned to normal.A, Eye positions in right gaze, and B, eye positions in primary gaze.", "After sustaining a right gaze position for 10 to 15 seconds (A) and then returning to primary gaze (B), there is a large-angle right exotropia."]}
{"Patient Personal Background": ["He had an unremarkable medical and ocular history and had not sustained any ocular trauma."], "Patient Symptoms": ["He described a painless, reddish mass in his lateral conjunctiva, which had been present since birth.", "He was asymptomatic aside from rare episodes of pink tears in his right eye, and the lesion did not bother him cosmetically.", "He noted no blurry vision, diplopia, or pain with eye movements."], "Examination and Results": ["His visual acuity was 20/20 OU, and there was no proptosis, ptosis, or afferent pupillary defect.", "Extraocular muscle movements were intact, and his intraocular pressure was 15 mm Hg OU.", "There was no change in lesion size observed with the Valsalva maneuver.", "A slitlamp examination revealed an 8-mm, round, fluctuant, vascular, multifocal mass involving the bulbar and palpebral conjunctiva near the lateral canthus (Figure)."]}
{"Patient Symptoms": ["The lesion was followed closely and throughout a series of visits, the lesion and fluid continued to progress, the visual acuity worsened to 20/200, and the tumor mass extended closer to the fovea (Figure 1)."], "Examination and Results": ["Visual acutiy was 20/60 OD and 20/20 OS.", "Intraocular pressures and anterior segment examination findings were normal.", "Fundus examination revealed orange, subretinal mass with associated subretinal fluid in the posterior pole.", "The mass measured 15 mm in basal diameter with a thickness of 6.4 mm on B-scan ultrasonography.Large choroidal vascular mass of inferotemporal right choroid.", "Note large choroidal mass on B-scan ultrasonography."]}
{"Patient Personal Background": ["His medical history was significant for pyruvate dehydrogenase deficiency, and his family history was notable for glaucoma in his grandmother.", "He was being treated by the neurology department for his pyruvate dehydrogenase deficiency with thiamine, vitamin C, and oxaloacetate."], "Patient Symptoms": ["He had exotropia and amblyopia of the left eye.", "His systemic symptoms included hyperhidrosis and episodes of hand tremors, ataxia, and dysarthria that occur every 2 to 3 years.Best-corrected visual acuity was 20/40\u2009\u22122 OD and 20/100\u2009+2 OS, with a relative afferent pupillary defect in the left eye."], "Examination and Results": ["Intraocular pressure (IOP) was 16 mm Hg OU, and pachymetry was 611 \u03bcM OD and 592 \u03bcM OS (normal mean [SD], 542.4  [33.5] \u03bcM).", "He identified 8/8 OD and 3/8 OS Ishihara color plates.", "His nuclear sclerotic cataracts were not consistent with visual acuity in both eyes; his anterior segment examination was otherwise within normal limits.", "His dilated examination was normal except for cupping and pallor in both eyes with a supratemporal optic nerve pit in the right eye.", "The optic discs and automated perimetry are shown  in the Figure.", "Optical coherence tomography (OCT) of the retinal nerve fiber layer showed a mean thickness of 64 \u03bcM OD and 47 \u03bcM OS (normal mean [SD], 97.3 [9.6] \u03bcM), and OCT of the macula showed perifoveal thinning with normal foveal thickness in both eyes.A and B, Fundus photographs show cupping with optic nerve pallor in both eyes and a supratemporal optic nerve pit in the right eye (arrowhead)."], "Treatment": ["He was diagnosed as having glaucoma 6 months prior to presentation owing to optic nerve cupping and visual field deficits on automated perimetry and was taking latanoprost."], "Diagnosis": ["He was diagnosed as having glaucoma 6 months prior to presentation owing to optic nerve cupping and visual field deficits on automated perimetry and was taking latanoprost."], "Others": ["He had an exotropia with full range of motion in both eyes."]}
{"Patient Symptoms": ["He was diaphoretic and had poor dentition."], "Examination and Results": ["His vital signs were temperature, 38.4\u00b0C (101.1\u00b0F); blood pressure, 94/40 mm Hg; heart rate, 116/min; and respiratory rate, 26/min.", "A soft S1 was present on cardiac examination, and crackles were auscultated in basilar lung fields bilaterally.", "A bedside transthoracic echocardiogram was performed, the patient was transferred to the intensive care unit, and a transesophageal echocardiogram was obtained (Figure 1).Transesophageal echocardiogram obtained from the patient in diastole on the midesophageal long-axis view."], "Treatment": ["Three sets of blood cultures from different sites were obtained.", "Cardiology, cardiac surgery, and infectious disease physicians were consulted."]}
{"Patient Symptoms": ["The patient first noticed papules on his forehead 1 year prior to presentation that spread to his face, trunk, and extremities.", "He had mild dysphagia and severe joint pain in his hands and wrists, with carpal tunnel of his right wrist.", "Additionally, his daily activities were impaired owing to decreased mobility."], "Examination and Results": ["During clinical evaluation, he denied cough, shortness of breath, chest pain, Raynaud phenomenon, fevers, night sweats, weight loss, seizures, or confusion.Physical examination revealed diffuse skin-colored to pink papules coalescing into plaques on the entire face, with exaggerated skin folds of the forehead (Figure, A), glabella, periocular regions, and superior cutaneous lip.", "This was accompanied by swelling and erythema of both ears.", "On his extremities and trunk, he had diffuse infiltration of the skin, with exaggerated skin folds (Figure, B), decreased finger flexion, and four-fifths grip strength.", "His nailfold capillaries were normal.", "C, Hematoxylin-eosin stain image from the punch biopsy featuring fibroblastic proliferation from the papillary to the reticular dermis (original magnification \u00d740).", "D, Hematoxylin-eosin and Alcian blue stain image featuring mucin deposition in the reticular dermis.Notable laboratory results included a normal level of thyroid-stimulating hormone, macrocytic anemia, normal creatinine and calcium levels, and a monoclonal spike on a serum protein electrophoresis test.", "Serum free light chains revealed normal \u03ba free light chains, \u03bb free light chains, and a normal \u03ba/\u03bb ratio.", "Immunofixation results revealed IgG \u03bb monoclonal gammopathy."], "Others": ["Skin sensation was intact.A, Clinical image of the exaggerated skin folds of the forehead and glabella.", "B, Clinical image of the wrist and hand depicting the exaggerated skin folds and decreased finger flexion."]}
{"Patient Personal Background": ["He had a 16-year history of diabetes mellitus that was being treated with metformin."], "Patient Symptoms": ["Physical examination revealed reddish brown hyperkeratotic papules 1 to 10 mm wide on the front and back of the left leg from knee to ankle.", "Removal of the scales caused slight bleeding."], "Examination and Results": ["Hematological and biochemical test results were unremarkable.", "The rest of the physical examination findings were unremarkable.", "A lesional skin biopsy was performed (Figure 1B and C).A, Clinical image of the reddish brown hyperkeratotic papules on the front of the left leg.", "B and C, Hematoxylin-eosin\u2013stained lesional skin biopsy specimens revealing compact hyperkeratosis, epidermal atrophy, and bandlike lymphocyte infiltrate in the superficial dermis."], "Others": ["There was no history of another endocrine disorder or malignant neoplasm.", "There was no family history of similar cutaneous findings."]}
{"Patient Symptoms": ["He described transient episodes of expressive speech difficulties, paroxysmal dizziness, and involuntary nonsuppressible jerks of the right arm, which occurred without warning and were associated with mild disorientation."], "Examination and Results": ["Video electroencephalography (EEG) captured the movements (Figure, A).", "They consisted of involuntary, synchronous contractions of the right face, arm, and leg that were sustained for a few seconds before muscle relaxation occurred (Figure, B and C; Video).", "There was no epileptic abnormality that correlated with the movements on EEG, and head magnetic resonance imaging was unremarkable.A, Electroencephalogram (EEG) during the event (bipolar montage, 60-Hz filter, 7-uV/mm sensitivity).", "B, Patient position prior to the event.", "C, Patient position while experiencing an involuntary, sustained contraction of the right lower face, arm, and leg lasting almost 2 seconds before spontaneous resolution.", "The event took place during the time span marked with red vertical lines on the EEG and did not show a clear change from baseline rhythm.", "Muscle artifacts are seen prior to and during the event."], "Others": ["The movements were not elicited by action or exertion."]}
{"Patient Personal Background": ["She previously received a diagnosis of viral conjunctivitis at an outside institution and was treated with topical prednisolone acetate without improvement before presenting to our institution."], "Examination and Results": ["On examination, visual acuity was 20/25 OD and hand motions OS.", "A relative afferent pupillary defect was present on the left in the setting of left optic atrophy from the patient\u2019s locally invasive meningioma.", "Confrontational visual fields were otherwise full in the right eye.", "Intraocular pressures were within normal limits in both eyes.", "Hertel exophthalmometry was notable for 3 mm of proptosis on the right.", "Slitlamp examination demonstrated 3 to 4+ meibomian gland dysfunction in both eyes, but with prominent conjunctival injection in the right eye only.", "Dilated funduscopy revealed scattered intraretinal hemorrhages (IRHs) and cystoid macular edema (CME) in the right eye, which was also seen on optical coherence tomography (Figure 1).", "Vital signs, complete blood cell count, and the results of thyroid function tests were within reference ranges.", "Magnetic resonance imaging and magnetic resonance angiography of the brain and orbits with and without contrast showed a stable size of the meningioma and were otherwise normal.A, Color fundus photograph of the right eye showing scattered intraretinal hemorrhages and a blunted foveal light reflex."]}
{"Patient Personal Background": ["Her medical history was notable for hypertension and type 2 diabetes.", "Family history was positive for hypertension in her mother, prostate cancer in her father, and ductal carcinoma in situ in her daughter.", "She was a current daily smoker at presentation."], "Patient Symptoms": ["Over the previous 5 months, the patient had experienced gradual onset of binocular, horizontal diplopia and ptosis of the left upper eyelid.", "Her symptoms were constant, without fluctuation during the day."], "Examination and Results": ["An ophthalmologic examination revealed a visual acuity of 20/25 OD and 20/30 OS.", "Pupillary, intraocular pressure, and dilated fundus examinations were unremarkable.", "Abduction was severely restricted in the left eye, but it did not elicit pain, and extraocular muscle movements were otherwise full.", "There was substantial resistance to retropulsion of the left eye.", "Bilateral blepharoptosis, with more severity on the left side, was noted.", "The margin-to-reflex distance 1 was 2 mm on the right and 0 mm on the left.", "A 3.5-mm left enophthalmos was noted compared with the right side, and there was hollowing of the left superior sulcus."], "Others": ["There were no neurological deficits and no pain.", "There was no history of trauma or prior surgery of the eye."]}
{"Patient Personal Background": ["He had a history of herpetic keratitis and cataract surgery 2 years prior, both in the right eye, complicated by postoperative bullous keratopathy without treatment.", "The patient noted a corneal scar after the cataract surgery that gradually thickened over the ensuing 6 months."], "Patient Symptoms": ["The patient noted a corneal scar after the cataract surgery that gradually thickened over the ensuing 6 months.", "In our office, his examination in the right eye was notable for hand motion visual acuity and a pearly white, raised, 10\u2009\u00d7\u200910-mm, gelatinous, corneal lesion with both intrinsic and feeder vessels (Figure 1A)."], "Examination and Results": ["In our office, his examination in the right eye was notable for hand motion visual acuity and a pearly white, raised, 10\u2009\u00d7\u200910-mm, gelatinous, corneal lesion with both intrinsic and feeder vessels (Figure 1A).", "There was no view of the anterior segment.", "Ultrasound biomicroscopy showed a hyperechoic opacity on the surface of the cornea, with maximal thickness of 1.5 mm.", "A cleft was noted between the lesion and the cornea (Figure 1B).", "There was no extension posteriorly into the anterior chamber, iris, or ciliary body.A, Slitlamp external photograph of right-eye corneal lesion showing prominent elevation and both intrinsic and feeder vessels.", "B, Ultrasound biomicroscopy showing hyperechoic anterior corneal lesion with hypoechoic cleft labeled centrally.", "The lesion did not involve any other adjacent structures."]}
{"Patient Personal Background": ["She was diagnosed with Hodgkin lymphoma at 35 weeks\u2019 gestation, and 1 week later she underwent cesarean delivery.", "Laboratory test results revealed a white blood cell count of 1.6 \u00d7103 cells/mm3, with an absolute neutrophil count of 500 cells/mm3 and a total bilirubin of 0.3 mg/dL (to convert to \u03bcmol/L, multiply by 17.104), which was unchanged from the baseline total bilirubin.Clinical photograph of the patient\u2019s back shows scratch marks that appeared after diffuse pruritus.Prior to the diagnosis of Hodgkin lymphoma, she was receiving routine prenatal care, and the only complication was pruritus without a rash that developed during the first trimester.", "She was evaluated for right supraclavicular adenopathy that was unresponsive to antibiotics during the third trimester."], "Patient Symptoms": ["On day 15 of cycle 1, she presented with linear, hyperpigmented streaks and welts on her arms, back, and legs.", "Intense, diffuse pruritus had developed within 24 hours of the patient\u2019s first day of treatment, and her symptoms were poorly responsive to antihistamines and topical steroids.", "Pruritus was followed by the appearance of dark scratch marks as demonstrated in the Figure.", "Laboratory test results revealed a white blood cell count of 1.6 \u00d7103 cells/mm3, with an absolute neutrophil count of 500 cells/mm3 and a total bilirubin of 0.3 mg/dL (to convert to \u03bcmol/L, multiply by 17.104), which was unchanged from the baseline total bilirubin.Clinical photograph of the patient\u2019s back shows scratch marks that appeared after diffuse pruritus.Prior to the diagnosis of Hodgkin lymphoma, she was receiving routine prenatal care, and the only complication was pruritus without a rash that developed during the first trimester."], "Examination and Results": ["Laboratory test results revealed a white blood cell count of 1.6 \u00d7103 cells/mm3, with an absolute neutrophil count of 500 cells/mm3 and a total bilirubin of 0.3 mg/dL (to convert to \u03bcmol/L, multiply by 17.104), which was unchanged from the baseline total bilirubin.Clinical photograph of the patient\u2019s back shows scratch marks that appeared after diffuse pruritus.Prior to the diagnosis of Hodgkin lymphoma, she was receiving routine prenatal care, and the only complication was pruritus without a rash that developed during the first trimester.", "Findings from a lymph node biopsy were consistent with classic Hodgkin lymphoma, nodular sclerosis subtype.", "Staging imaging revealed bilateral supraclavicular jugular chain, paratracheal and mediastinal lymphadenopathy, and the erythrocyte sedimentation rate was 67 mm/h."], "Treatment": ["At 3 weeks\u2019 postpartum, she began chemotherapy (cycle 1, day 1) with adriamycin, bleomycin, vinblastine, and dacarbazine (ABVD)."], "Diagnosis": ["She was diagnosed with Hodgkin lymphoma at 35 weeks\u2019 gestation, and 1 week later she underwent cesarean delivery.", "Findings from a lymph node biopsy were consistent with classic Hodgkin lymphoma, nodular sclerosis subtype.", "She was diagnosed with stage II, unfavorable-risk Hodgkin lymphoma."]}
{"Patient Symptoms": ["The lesions had started a month previously as red nodules on the left axilla, ipsilateral chest, and back.", "Twenty days later, he developed edema in the left upper limb.", "There was diffuse erythema and edema on the left upper limb, leading to difficulty in limb movement (Figure, A)."], "Examination and Results": ["While being evaluated for the cutaneous lesions, the patient was diagnosed with AIDS and began antiretroviral therapy.On examination, 6 erythematous, firm, subcutaneous nodules were present on the left side of the chest, abdomen, and left upper limb, varying in size from 2\u2009\u00d7\u20092 cm to 4\u2009\u00d7\u20094 cm (Figure, A).", "Multiple dilated superficial vessels were present on the posterior aspect of the left arm and ipsilateral chest wall.", "Left axillary lymph nodes were grossly enlarged, firm, nontender, and nonmatted, with the largest lymph node measuring 6\u2009\u00d7\u20094 cm.", "The patient\u2019s CD4 cell count was 141/\u03bcL (to convert to \u00d7109/L, multiply by 0.001), and his HIV load was 504\u202f473 copies/mL.", "B, Skin biopsy sample showing infiltration with lymphoid cells and few histiocytes in the subcutaneous tissue (hematoxylin-eosin, original magnification \u00d7400).", "C, On immunohistochemical analysis, these cells showed nuclear positivity for c-Myc (c-Myc, original magnification \u00d7400)."], "Treatment": ["While being evaluated for the cutaneous lesions, the patient was diagnosed with AIDS and began antiretroviral therapy.On examination, 6 erythematous, firm, subcutaneous nodules were present on the left side of the chest, abdomen, and left upper limb, varying in size from 2\u2009\u00d7\u20092 cm to 4\u2009\u00d7\u20094 cm (Figure, A)."], "Diagnosis": ["While being evaluated for the cutaneous lesions, the patient was diagnosed with AIDS and began antiretroviral therapy.On examination, 6 erythematous, firm, subcutaneous nodules were present on the left side of the chest, abdomen, and left upper limb, varying in size from 2\u2009\u00d7\u20092 cm to 4\u2009\u00d7\u20094 cm (Figure, A)."], "Others": ["A skin biopsy sample was obtained from the plaque and sent for histopathologic examination (Figure, B and C).A, Multiple erythematous indurated plaques and nodules confined to the left side of the chest and abdomen with axillary lymphadenopathy and upper limb edema."]}
{"Patient Personal Background": ["He had no history of drug use or cardiac events."], "Patient Symptoms": ["The heart sounds were normal, and bilateral ankle edema was present."], "Examination and Results": ["On physical examination, he had warm extremities.", "His body temperature was 36.8\u00b0C.", "His blood pressure was 100/60 mm Hg, heart rate was 130 beats/min, respiratory rate was 24 breaths/min, and pulse oximetry was 98% on ambient air.", "There were bibasilar rales on lung auscultation.", "Laboratory tests revealed hyponatremia (sodium, 124 mEq/L [to convert to millimoles per liter, multiply by 1]), a compensated metabolic acidosis with a bicarbonate concentration of 14 mEq/L (to convert to millimoles per liter, multiply by 1), and a lactate concentration of 82.0 mg/dL (to convert to millimoles per liter, multiply by 0.111).", "The D-dimer level was 0.0003 \u03bcg/mL (to convert to nanomoles per liter, multiply by 5.476), and the pro\u2013brain-type natriuretic peptide level was 6062 pg/mL (to convert to nanograms per liter, multiply by 1).", "Echocardiography (Video 1 and Video 2) revealed a left ventricular ejection fraction of 50%."], "Others": ["The electrocardiogram on presentation is shown in the Figure."]}
{"Patient Symptoms": ["The mass was soft, mobile, and compressible in midline level IA, measuring 7 cm and posterior-superiorly displacing the tongue.", "The mass was visible as a clear blue lesion in the floor of the mouth and was nontender."], "Examination and Results": ["Computed tomographic (CT) scan of the neck with IV contrast was performed (Figure).", "A, Coronal view of midline neck mass.", "B, Sagittal view of midline neck mass."], "Treatment": ["The patient was taken to the operating room for a successful combined intraoral and transcervical approach to excision.Computed tomographic images."]}
{"Patient Personal Background": ["Social history included routine cocaine use 10 years ago."], "Patient Symptoms": ["Associated symptoms included epistaxis and left-sided epiphora."], "Examination and Results": ["Physical examination demonstrated substantial erythema and edema of the left infraorbital region and left nasal sidewall and purulent nasal secretions (Figure 1A).", "Endoscopic nasal examination revealed substantial swelling of the left nasal vestibule completely obstructing the left naris, swelling of the left nasolacrimal duct orifice, nearly total septal perforation with areas of necrotic bone, and no identifiable intranasal landmarks except for a remnant of the left middle turbinate (Figure 1B).", "There was no cervical lymphadenopathy.", "Laboratory evaluation revealed a white blood cell count of 12\u202f300/\u03bcL with normal neutrophil count; erythrocyte sedimentation rate of 83 mm/h; and a C-reactive protein level of 134 mg/L.", "A maxillofacial computed tomographic (CT) scan demonstrated cartilaginous and anterior osseous nasal septal perforation and left nasal and preseptal soft-tissue thickening with associated periosteal reaction of the nasal process of the maxilla.A, Periorbital and nasal cellulitis."], "Treatment": ["Prior to presentation, she had been treated as an outpatient with multiple rounds of oral antibiotics and steroids for presumed sinusitis without improvement."], "Others": ["(To convert white blood cells to \u00d7109/L, multiply by 0.001; C-reactive protein to nanomoles per liter, multiply by 9.524.)"]}
{"Patient Symptoms": ["One week after symptom onset, she remained febrile (maximum temperature, 39.6\u00b0C [103.2\u00b0F]) and the rash spread to her palms and soles, with some progression to pustules (Figure, left panel).", "She developed right knee pain, followed by pain in other joints.", "Two weeks after symptom onset, she presented to a local emergency department, reporting inability to stand due to severe joint pain.", "Approximately 3 weeks after symptom onset, she presented to the emergency department again with persistent fever, worsening arthralgia, back pain, and progressive purpuric and pustular rash."], "Examination and Results": ["Her vital signs were unremarkable.", "White blood cell count was 12\u202f100/\u03bcL (reference range, 4000/\u03bcL-10\u202f000/\u03bcL), with 84% neutrophils.", "Urinalysis results and levels of serum electrolytes and liver enzymes were within normal limits."], "Treatment": ["She was presumptively diagnosed with a viral illness and discharged home with supportive care."], "Diagnosis": ["She was presumptively diagnosed with a viral illness and discharged home with supportive care."], "Others": ["Results of tests for sexually transmitted infections and respiratory viruses were negative."]}
{"Patient Symptoms": ["She had no other associated symptoms."], "Examination and Results": ["On examination, she had a large, palpable, nontender right gluteal mass.", "She had no neurovascular deficits.", "Results of laboratory studies were within normal limits.", "Computed tomography (CT) revealed an 11-cm heterogeneous lipomatous tumor involving the right gluteal musculature (Figure).Axial (left) and coronal (right) computed tomography images of patient\u2019s right gluteal mass."]}
{"Patient Personal Background": ["Prior to presentation, he had been treated for herpes zoster with famciclovir for 1 week, during which the lesions kept developing and were accompanied with irregular fever (maximum temperature, 39\u00b0C)."], "Patient Symptoms": ["Prior to presentation, he had been treated for herpes zoster with famciclovir for 1 week, during which the lesions kept developing and were accompanied with irregular fever (maximum temperature, 39\u00b0C).", "Physical examination revealed edema on both eyelids; multiple papules, blisters, and crusted erosions with thin exudation on his right cheek and neck; and erythematous plaques and tense blisters and bullae on his back and on the dorsal surface of both hands (Figure 1B)."], "Examination and Results": ["Physical examination revealed edema on both eyelids; multiple papules, blisters, and crusted erosions with thin exudation on his right cheek and neck; and erythematous plaques and tense blisters and bullae on his back and on the dorsal surface of both hands (Figure 1B).", "A full laboratory workup was performed for autoantibodies for systemic lupus erythematosus (SLE), pemphigus, and bullous pemphigoid; skin and bone-marrow biopsies and direct immunofluorescence were performed; and immunohistochemichal analysis, a swab of exudation, and bacterial, fungal, and atypical mycobacterial cultures from blood and tissue were also examined.A, Edema on both eyelids; multiple papules, blisters, and crusted erosions with thin exudation on right cheek and neck."], "Treatment": ["Prior to presentation, he had been treated for herpes zoster with famciclovir for 1 week, during which the lesions kept developing and were accompanied with irregular fever (maximum temperature, 39\u00b0C)."]}
{"Patient Personal Background": ["Eleven years earlier, she had been diagnosed with left breast carcinoma and had undergone a mastectomy with subsequent radiotherapy and chemotherapy.", "Seven years later, she had been found to have left supraclavicular lymph nodes metastasis and had undergone a surgical excision."], "Patient Symptoms": ["On presentation for the current problem, the patient experienced pain on palpation, but denied fever, chills, or other symptoms."], "Examination and Results": ["A physical examination revealed violaceous swelling with telangiectasia and necrosis on the forehead, eyelids, nose, and cheek, predominantly involving the left side of the face (Figure 1)."], "Others": ["A biopsy of the lesion was performed for histopathological analysis (Figure 2).A, A full image and B, a three-quarters image of the face, showing telangiectatic, swelling erythema mainly involving the left side of the forehead, eyelids, nose, and cheek."]}
{"Patient Personal Background": ["His medical history included hepatitis C, cirrhosis, and an orthotopic liver transplant (OLT) 3 years prior that was subsequently treated with tacrolimus, 5 mg, and mycophenolate, 750 mg, twice daily."], "Patient Symptoms": ["Five weeks after treatment with CHOP chemotherapy, the patient presented with an acute-onset abdominal skin eruption without fever or pain."], "Examination and Results": ["Physical examination revealed confluent indurated violaceous papules and plaques coalescing into an annular pattern encircling the healed OLT incisional scar with central sparing (Figure 1A).", "A 4-mm punch biopsy specimen was obtained for histopathological evaluation (Figure 1B and C) and bacterial and fungal cultures.A, Confluent, indurated, violaceous papules and plaques coalescing into an annular pattern encircling the well-healed orthotopic liver transplant incisional scar.", "B, Hematoxylin-eosin staining of the punch biopsy shows an atypical, hyperchromatic infiltrate present throughout the superficial and deep dermis.", "C, High magnification reveals crushed but markedly atypical-appearing lymphoid cells with nuclear hyperchromasia and scant amounts of cytoplasm.", "Multiple mitotic and apoptotic figures are easily identified."], "Treatment": ["He was subsequently instructed to stop use of mycophenolate and decrease use of tacrolimus to 0.25 mg daily, then treated with 1 cycle of CHOP chemotherapy (cyclophosphamide, doxorubicin hydrochloride, vincristine sulfate, and prednisone) and lenalidomide, resulting in symptomatic and radiologic improvement.", "A computed tomographic scan of the abdomen and pelvis showed possible abdominal wall cellulitis, so treatment with piperacillin-tazobactam and vancomycin was empirically started."], "Diagnosis": ["The gastric wall mass was found to be associated with plasmablastic posttransplantation lymphoproliferative disorder (pPTLD)."], "Others": ["Approximately 2\u00bd years after the transplant, the patient developed gastric outlet obstruction secondary to an infiltrative gastric wall mass."]}
{"Patient Personal Background": ["The patient had reportedly always walked on the outside of his feet and had been considered clumsy when compared with other children but had no history of motor delays.", "Family history revealed a mother with diminished reflexes, hand tremor, and balance issues with a prior inconclusive electromyogram  and nerve conduction study.", "A younger brother with attention-deficit/hyperactivity disorder also had similar gait abnormalities."], "Patient Symptoms": ["Symptoms lasted approximately 60 minutes each before completely resolving; prior to the day of the events, he had never experienced similar phenomena."], "Examination and Results": ["Initial examination following the second event revealed mild-to-moderate dysarthria, pes planovalgus and tight achilles tendons bilaterally, and decreased vibratory and fine touch sensation from the great toe up to the mid shin bilaterally.", "Reflexes were absent at the patella and achilles bilaterally.", "Bilateral dorsiflexion weakness was present (4 of 5).", "There were otherwise no motor deficits, muscle atrophy, or lateralizing neurologic abnormalities.On arrival, the patient underwent a stroke/transient ischemic attack workup.", "Results of a comprehensive metabolic panel, complete blood cell count, erythrocyte sedimentation rate, C-reactive protein, and a coagulation panel were within normal limits.", "Computed tomography angiogram demonstrated no evidence of extra or intracranial dissection.", "Magnetic resonance imaging of the brain with and without contrast (Figure) demonstrated symmetric, bilateral, restricted diffusion, with T2 hyperintensities in the supratentorial white matter and corpus callosum.", "Lumbar puncture was obtained and revealed normal cell counts and no oligoclonal bands or evidence of infection.A, Diffusion-weighted imaging sequence demonstrating bilateral, symmetric, restricted diffusion of the supratentorial white matter (corresponding hypointensity noted on apparent diffusion coefficient sequences).", "B, T2 sequence demonstrating bilateral and symmetric increased signal in the supratenorial white matter\u2013sparing U-fibers."]}
{"Patient Symptoms": ["His right eye had experienced an episode of blurry vision 4 months previously that had spontaneously improved over a few weeks.", "Two weeks before presentation, he experienced blurry vision in his left eye and received a diagnosis of vasculitis based on fluorescein angiography (FA) findings.", "Over the next 2 weeks, he experienced a rapid worsening of vision in both eyes and presented to the Illinois Eye and Ear Infirmary."], "Examination and Results": ["In the absence of other signs or symptoms of syphilis, he was scheduled to undergo a lumbar puncture later that day.On presentation, his visual acuity was counting fingers OD and 20/300 OS, with manifest refraction to 20/60 OS only.", "He had no afferent pupillary defect and his intraocular pressures were healthy.", "The anterior segment examination yielded normal results without evidence of anterior chamber inflammation.", "A dilated fundus examination was notable for mild vitritis of both eyes, mild hyperemia of the right optic nerve, and a large white lesion that encompassed the nerve and macula of both eyes.", "Fluorescein angiography results revealed multiple hyperfluorescent lesions in late frames (Figure 1).A, Color fundus photograph of the left eye shows  a large placoid lesion in the macula.", "B, Late fluorescein angiography."], "Treatment": ["He was referred to a rheumatologist and received high-dose oral prednisone therapy for presumed autoimmune vasculitis."], "Diagnosis": ["Two weeks before presentation, he experienced blurry vision in his left eye and received a diagnosis of vasculitis based on fluorescein angiography (FA) findings."], "Others": ["During an interview, he noted that the laboratory workup results had recently come back as notable for a mildly reactive fluorescent treponemal antibody absorption test.", "showing multiple areas of hyperfluorescence in the macula and periphery with peripheral vascular leakage."]}
{"Patient Personal Background": ["She had a 4-year history of Beh\u00e7et disease (BD), and her condition had been stabilized with thalidomide."], "Patient Symptoms": ["She denied any other neurologic symptoms, such as headache, nausea, vomiting, seizures, and paresis.", "Humphrey visual fields showed complete visual field loss in the right eye and peripheral visual field defects in the left eye."], "Examination and Results": ["Intraocular pressure was 21 mm Hg OD and 19 mm Hg OS.", "Fundus examination revealed papilledema in both eyes (Figure 1A).", "No obvious sign of optic disc ischemia or active uveitis was observed by fundus fluorescein angiography bilaterally.", "Humphrey visual fields showed complete visual field loss in the right eye and peripheral visual field defects in the left eye.", "Her anterior segment was normal in both eyes except for relative afferent pupillary defect in the right eye.", "Cranial nerve examination was otherwise unremarkable.", "Magnetic resonance imaging of the brain showed no remarkable abnormalities except for partially empty sella (Figure 1B).", "She had normal blood pressure levels.", "Results of laboratory testing regarding systemic infection were negative, and her serum D-dimer level was normal.A, Fundus photograph of the right eye indicated papilledema, disc congestion, venous distension, and macular exudates."], "Treatment": ["Her optic neuropathy of BD had been treated with high-dose intravenous methylprednisolone for 4 days followed by oral prednisone for a month without improvement.Her best-corrected visual acuity was no light perception OD and 20/20 OS."]}
{"Patient Personal Background": ["Bilateral lateral rectus muscle recession for exotropia was performed 4 years before this presentation.", "Medical history was otherwise unremarkable.", "The patient was born full term after a normal pregnancy and delivery, with normal growth assessments.", "The patient was performing well in school.On examination, her best-corrected visual acuity was 20/40 OD and 20/40 OS, which was stable from previous visits."], "Examination and Results": ["Her pupils were round and reactive.", "There was a residual intermittent exotropia of 4 prism diopters bilaterally.", "Findings on slitlamp examination of the anterior segment were unremarkable.", "A single, 1-cm, oval, lightly pigmented macule with irregular borders was noted on her right upper arm.", "Dilated fundus examination revealed eccentric, yellow-clear, preretinal lesions in the maculas of both eyes.", "Optical coherence tomography revealed hyperreflective areas on the surface of the macula with a spiculated appearance, projecting anteriorly into the vitreous."]}
{"Patient Personal Background": ["The patient had an ocular history of bilateral cataract surgery in 2016, a medical history of thyroid cancer with thyroidectomy in 1990, and stage IIIc lobular carcinoma of the right breast with mastectomy of the right breast in 2008.On examination, her visual acuity was 20/80 OD and 20/30 OS."], "Patient Symptoms": ["The ptosis was first noticed 3 weeks prior to presentation and had gradually worsened."], "Examination and Results": ["Pupils were equal in size and reactive without an afferent pupillary defect.", "Intraocular pressures were 21 mm Hg OD and 16 mm Hg OS.", "Assessment of the extraocular motility demonstrated moderate limitation to up gaze of the right eye and full ductions of the left eye.", "External examination confirmed right upper eyelid ptosis without substantial proptosis.", "On slitlamp examination, eversion of the right upper eyelid revealed a solid, superior bulbar conjunctival mass measuring 10 mm in diameter (Figure 1A).", "B-scan ultrasonography demonstrated an extraconal, noncompressible lesion of orbital tissue (Figure 1B).", "A computed tomographic scan showed nonspecific, increased soft-tissue density in the superior and anterior orbit.A, External photograph of the right eye demonstrating an elevated conjunctival lesion."], "Others": ["She denied any acute changes in her health and review of her systems was unremarkable."]}
{"Patient Personal Background": ["He had not received medical care in 20 years and had no known medical diagnoses, but his social history was notable for consumption of approximately 12 alcoholic beverages per day.", "His ocular history was notable for left-eye enucleation from recent trauma."], "Patient Symptoms": ["He initially presented to his local ophthalmologist with right eye redness, pain, and photophobia for 1 week."], "Examination and Results": ["On referral, his visual acuity was 20/100 OD, and his intraocular pressure was 16 mm Hg.", "Anterior examination revealed a diffusely hazy cornea with a blunted light reflex.", "A large, well-demarcated epithelial defect with substantial underlying stromal loss was seen in the inferonasal periphery (Figure).", "The stroma was 40% thinned without infiltrate.", "The epithelium was heaped up along the lesion borders.", "Corneal sensation was diminished.", "The conjunctiva demonstrated hyperemia, which was more prominent around the corneal lesion, although there was no discharge.", "A dilated ophthalmoscopic examination was unremarkable."], "Treatment": ["Bacterial (aerobic and anaerobic) and fungal cultures were obtained, and the patient started receiving topical moxifloxacin."], "Diagnosis": ["He was diagnosed with a corneal ulcer."], "Others": ["The cultures were negative after 1 week, but the patient did not demonstrate signs of clinical improvement.", "A complete blood cell count, metabolic panel, and serum test results (for antinuclear antibodies, peripheral antineutrophil cytoplasmic antibodies, cytoplasmic antineutrophil cytoplasmic antibodies,  rheumatoid factor, and anti\u2013cyclic citrullinated peptide) were unremarkable."]}
{"Patient Personal Background": ["Medical history included medulloblastoma treated with irradiation of the brain and spine at age 2 years."], "Examination and Results": ["He was also treated for several seemingly similar lesions on the face and scalp and had a family history of similar cutaneous lesions reported in 2 brothers and 1 niece.Figures show crusted erythematous papules and plaques adjacent to the surgical excision scar within a prior irradiation field on the head and neck (A) and erythematous and hyperpigmented papules and plaques overlying diffuse postsurgical scarring within a prior irradiation field on the back (B)."], "Treatment": ["He also received radiation therapy for a meningioma of the posterior fossa in adulthood."]}
{"Patient Symptoms": ["However, after 11 cycles of nivolumab, the patient presented with progressive painful reddening and swelling of the left thigh.", "There was no deterioration of the general condition, no fever, no change in current medication, and no recent cold exposure."], "Examination and Results": ["Clinical examination revealed diffuse erythematous induration of the upper thigh expanding to the lower left abdominal area, as well as multiple small palpable subcutaneous nonindurated nodules on the ipsilateral gluteal region and leg (Figure, A).", "Fluorine 18 (18F) fluorodeoxyglucose (FDG) positron emission tomography\u2013computed tomography (PET-CT) detected multiple FDG-active lesions in both lower extremities and the lumbar region; a previously described left iliac lymphadenopathy was partially regressed (Figure, B).", "A diagnostic biopsy specimen of the left thigh revealed a lobular lymphocytic panniculitis with dense infiltrate of mainly lymphocytes and plasma cells with no signs of vasculitis (Figure, C and D).", "Direct immunofluorescence and blood analysis showed an absence of specific autoimmune antigens (test results for \u03b1-1 antitrypsin, antinuclear antibody, anti-Sj\u00f6gren syndrome\u2013related antigen, and anti-Sj\u00f6gren syndrome\u2013related antigen B were all unremarkable).A, Localized erythematous brownish induration seen on the upper thigh."], "Treatment": ["One year later she underwent inguinal lymphadenectomy for macrometastasis followed by adjuvant immunotherapy with ipilimumab, a monoclonal antibody that targets cytotoxic T-lymphocyte antigen 4.", "Owing to local disease progression, treatment escalation with combined immunotherapy (ipilimumab and nivolumab, an anti\u2013PD-1 [programmed cell death 1]) antibody was initiated."], "Others": ["Apart from immunotherapy-induced thyroiditis, the treatment was well tolerated.", "Arrowheads correlate with the most prominent clinical findings.", "B, Radioactive fluorine 18 (18F) fluorodeoxyglucose (FDG) positron emission tomography\u2013computed tomography (PET-CT) reveals multiple subcutaneous lesions in both lower extremities, the lumbar region, and on the ipsilateral lower leg with high FDG uptake highly suggestive of (in transit) metastasis.", "C and D, Lesional skin biopsy samples obtained from the proximal left thigh show normal epidermis and dermis with patchy infiltrate of the deep subcutaneous fat (hematoxylin-eosin stain).", "Green arrows indicate the plasma cells, and blue arrows indicate the lymphocytes."]}
{"Patient Personal Background": ["She had undergone mechanical mitral valve replacement and aortic dissection repair 2 months prior to presentation."], "Patient Symptoms": ["On physical examination, she was found to have elevated jugular venous pressure, bilateral rales in her lungs, and reduced intensity of the mitral valve closure sound, and her international normalized ratio was subtherapeutic (1.5)."], "Examination and Results": ["On physical examination, she was found to have elevated jugular venous pressure, bilateral rales in her lungs, and reduced intensity of the mitral valve closure sound, and her international normalized ratio was subtherapeutic (1.5).", "An echocardiographic image showed a mean gradient of 12 mm Hg across the mitral valve, suggesting valve stenosis.", "Fluoroscopy showed restricted mobility of the leaflets (Video 1).", "Transesophageal echocardiography showed a large thrombus on the mechanical mitral valve, along with a small new dissection flap in the aortic root (Figure and Video 2)."]}
{"Patient Personal Background": ["His comorbidities included congestive heart failure, atrial fibrillation, coronary artery disease, chronic obstructive pulmonary disease, hypertension, and a 50-pack-year history of tobacco abuse."], "Patient Symptoms": ["The mass covered the globe completely, resulting in total vision obstruction (Figure, A).", "However, the patient\u2019s vision remained intact when the mass was elevated off the eye with great effort."], "Examination and Results": ["Physical examination revealed a firm, nonmobile, nontender, bulging mass situated over the right frontal sinus, which expanded to the upper right eyelid.", "His right pupil was round and reactive to light without afferent pupillary defect.", "No palpable lymphadenopathy was noted.", "A non\u2013contrast-enhanced computed tomography (CT) scan demonstrated a large, right supraorbital mass with bony destruction of the anterior table of the right frontal sinus (Figure, B).", "It extended into the superior aspect of the orbit, displacing the right globe inferiorly.", "Air was seen within the mass (Figure, C).", "After medical clearance, the patient was taken to the operating room for a wedge excisional biopsy with decompression of the right supraorbital mass under monitored anesthesia care.", "Histopathological investigation revealed large nests of neoplastic epithelioid cells surrounded by fibrotic tissue and necroinflammatory debris.", "The neoplastic cells contained round nuclei with single prominent nucleoli and abundant clear to vacuolated cytoplasm (Figure, D).A, Enlarged right supraorbital mass.", "B, Computed tomography (CT) scan of destruction of the anterior table of right frontal sinus.", "C, Air pocket within the mass."], "Treatment": ["A fine-needle aspiration biopsy yielded inconclusive results."]}
{"Patient Personal Background": ["The patient had spent his childhood in eastern Africa, where he swam in Lake Tanganyika."], "Patient Symptoms": ["He also reported asthenia, sleep disorders, and urinary frequency.", "The urinary frequency has been treated for 2 years with many drugs (tamsulosin, desmopressin, and solifenacin) without improvement.", "He could not walk properly owing to his vertigo."], "Examination and Results": ["The ear, nose, and throat examination revealed a right horizontal nystagmus and a poorly delineated hypoesthesia of the left pinna.", "The rest of the clinical examination findings were unremarkable.", "Additional examinations (ie, pure-tone audiometry, video nystagmography, tympanometry) revealed left profound hearing loss with an air-bone gap of 40 dB and central vertigo.", "Otoacoustic emissions were absent on the left side.", "There was no left acoustic reflex.", "Auditory brainstem responses showed asymmetric interpeak latencies of waves I through V and III through V, suggesting slower conduction on the left side.", "Computed tomography and cerebral magnetic resonance imaging (MRI) revealed a 24\u2009\u00d7\u200920-mm hemorrhagic lesion in the left middle cerebellar peduncle associated with a thickening of the cochleovestibular nerve (Figure).", "The patient was referred to urology, where a 13\u2009\u00d7\u20098-mm mass was discovered in the lateral wall of the prostate gland.", "Biopsies of prostate and brain lesions, blood tests, and urinalysis were performed.Computed tomography (CT) scan and magnetic resonance images (MRIs) of the left middle cerebellopontine angle and prostate gland.", "A, Axial CT scan showed a hyperdense lesion suggesting hemorrhage in the left middle cerebellar peduncle.", "B, The lesion extended to the base of the vestibulocochlear nerve that was thickened (arrowheads) on the Fast Imaging Employing Steady-State Acquisition (FIESTA) MRI (axial plane).", "C, Coronal postcontrast MRI demonstrated a T1 hyperintense lesion that was consistent with hemorrhagic lesion with no true enhancement."], "Treatment": ["The urinary frequency has been treated for 2 years with many drugs (tamsulosin, desmopressin, and solifenacin) without improvement."], "Others": ["His history did not reveal trauma, infection, or any other associated conditions at the onset of the complaints."]}
{"Patient Personal Background": ["His medical history was unremarkable, as were the rest of the mucocutaneous and systemic examination findings."], "Patient Symptoms": ["On examination, there were multiple, erythematous papules coalescing to form a plaque with areas of scarring over the posterior aspect of right ear, along with firm, nontender posterior cervical lymphadenopathy (Figure, A).", "There was no history of trauma or intervention prior to the onset of lesions."], "Examination and Results": ["On examination, there were multiple, erythematous papules coalescing to form a plaque with areas of scarring over the posterior aspect of right ear, along with firm, nontender posterior cervical lymphadenopathy (Figure, A).", "A skin biopsy from the plaque was submitted for histopathological examination (Figure, C and D).A, Erythematous papules coalescing to form a plaque with areas of scarring, along with ipsilateral posterior cervical lymphadenopathy.", "C, Microphotograph showing unremarkable epidermis with evidence of granulomatous inflammation and central caseous necrosis in the dermis (original magnification \u00d7100).", "D, Ziehl-Neelsen stain shows acid-fast bacilli (oil immersion; original magnification \u00d71000)."], "Treatment": ["B, The lesions have healed with atrophic scarring after 6 weeks of treatment."]}
{"Patient Personal Background": ["He had a history of pseudogout and kidney transplant 13 years ago.", "He was taking sirolimus and prednisone, with excellent graft function."], "Patient Symptoms": ["He also reported 3 days of right knee pain and swelling.", "He had nuchal rigidity and positive Kernig sign."], "Examination and Results": ["His temperature on presentation was 102\u00b0F (38.9\u00b0C).", "There were no focal neurologic deficits and no spinal tenderness.", "He had a right knee effusion without erythema and with full range of motion.", "Laboratory workup of serum showed a white blood cell (WBC) count of 10\u202f200/\u03bcL (neutrophils, 63.8%; lymphocytes, 19.6%; monocytes, 15.1%) and erythrocyte sedimentation rate, 63 mm/h; workup of cerebrospinal fluid showed a WBC count of 0/\u03bcL; red blood cell count, 32/\u03bcL; total protein level, 109 mg/dL; and glucose level, 59 mg/dL (3.3 mmol/L).", "Magnetic resonance imaging (MRI) of the spine showed cervical degenerative changes with reactive marrow (Figure 1).", "Blood and cerebrospinal fluid (CSF) cultures were negative."], "Treatment": ["He was prescribed intravenous vancomycin and cefepime."]}
{"Patient Symptoms": ["Given her erythrocyte sedimentation rate (ESR) of 110 mm/h and symptoms concerning for giant cell arteritis (GCA), a temporal artery biopsy was obtained."], "Examination and Results": ["Laboratory results are shown in the Table.", "Given her erythrocyte sedimentation rate (ESR) of 110 mm/h and symptoms concerning for giant cell arteritis (GCA), a temporal artery biopsy was obtained.", "Results showed a normal caliber lumen without infiltrating inflammatory cells."]}
{"Patient Symptoms": ["The patient denied fevers, chills, weight loss, night sweats, cough, lymphadenopathy, abdominal pain, change in bowel habits, or other systemic symptoms."], "Examination and Results": ["Skin examination was significant for multiple erythematous and flesh-colored papules and nodules symmetrically affecting the upper and lower lips with extension onto the vermilion border (Figure 1A).", "There were no intraoral lesions, and all other findings of his examination were within normal limits.", "A biopsy was obtained of the vermilion lip (Figure 1B).A, Symmetric lip enlargement with infiltrative erythematous and skin-colored papules and nodules extending onto the vermilion border.", "B, Hematoxylin-eosin stain (original magnification \u00d740)."]}
{"Patient Symptoms": ["Then, owing to knee pain, a plain radiograph was obtained which demonstrated osteosclerosis of the distal femur."], "Examination and Results": ["Computed tomographic (CT) scan of the chest, abdomen, and pelvis demonstrated extensive infiltrative stranding from the thorax through the retroperitoneal space.", "Sclerotic changes in multiple osseous structures were noted.", "Biopsy of the lower-eyelid yellow plaque returned xanthelasma (Figure, A).", "A second retroperitoneal biopsy exhibited fibroadipose tissue, foamy macrophages, and chronic inflammation with fibrosis.", "Then, owing to knee pain, a plain radiograph was obtained which demonstrated osteosclerosis of the distal femur.", "The clinicopathologic presentation was confirmed with a molecular test.A, Clinical image of a soft, nonscaly yellow-tan plaque on the medial canthus.", "B, Hematoxylin-eosin stain image demonstrating foamy histiocytes with Touton giant cells (original magnification \u00d7100).", "C, CD68 immunohistochemical stain diffusely positive in the histiocytic infiltrate (original magnification \u00d7100).", "D, Computed tomographic image with contrast demonstrating retroperitoneal stranding and fibrosis with hydronephrosis (arrowheads indicate hairy kidney appearance of fibrosis)."], "Treatment": ["Prednisone and azathioprine were started.", "Azathioprine was stopped after 1 year.", "Azathioprine and prednisone were restarted."], "Diagnosis": ["Idiopathic retroperitoneal fibrosis was diagnosed following biopsies."], "Others": ["Ureteral obstruction, chronic kidney disease, and lymphedema complicated her course.", "Prednisone was slowly tapered but she relapsed 3 years later.", "She required multiple surgeries for spinal stenosis and ureteral obstruction.", "Her kidney function continued declining.", "Consequently, the previous eyelid and retroperitoneal biopsies were reviewed."]}
{"Patient Personal Background": ["He had emigrated from Japan more than 10 years earlier but had no history of recent travel.", "He took no medications, had no significant medical or surgical history, and denied personal and family history of atopy.", "While he worked as a biomedical researcher, he denied any caustic exposures."], "Examination and Results": ["On physical examination, his face, trunk, upper extremities, palms, and soles were marked by 1- to 2-mm erythematous papules and pustules coalescing into large, partially indurated and polycyclic plaques with centrifugal extension and occasional central clearing (Figure, A and B).", "Punch biopsies of lesions on the shoulder (Figure, C) and foot (Figure, D) were performed.A, Annular erythematous plaque studded with papules and pustules on the cheek and temple.", "B, Erythematous plaques studded with papules and pustules on the shoulder.", "C and D, Lesional specimens under hematoxylin-eosin stain taken from the shoulder (C, original magnification \u00d7400) and plantar foot (D, original magnification \u00d740)."], "Treatment": ["Treatment with potent topical corticosteroids was ineffective."]}
{"Patient Symptoms": ["She admitted to having developed new intermittent vertigo and more frequent and severe throbbing migraine with transient blurry vision and nonpulsatile tinnitus several months prior.", "She had recently developed hearing loss with a robotic quality of auditory perception."], "Examination and Results": ["A neurologic examination revealed diminished hearing to a finger rub on the right side.", "Fundoscopy showed several segmental retinal arterial plaques, with the right side worse than the left.", "A brain magnetic resonance image (MRI) with gadolinium revealed multiple white-matter lesions that were hyperintense on diffusion-weighted imaging (DWI), including some with enhancement, as well as a small DWI-negative lesion in the left thalamus and corpus callosum that was hyperintense on T2/fluid-attenuated inversion recovery magnetic resonance imaging (FLAIR; Figure 1).", "An MRI of the spine with gadolinium did not reveal a signal abnormality in the spinal cord.", "A lumbar puncture revealed a white blood cell count of 8 cells/\u03bcL (normal range, 0-5 cells/\u03bcL; to convert to cells\u2009\u00d7\u2009109/L, multiply by 0.001) with 78% lymphocytes and 22% monocytes (to calculate these as proportions of 1.0, multiply by 0.01), and a protein level of 0.067 g/dL (normal range, 0.015-0.045 g/dL; to convert to grams per liter, multiply by 10).", "Cerebrospinal fluid (CSF) glucose and IgG index test results were normal, with culture and oligoclonal bands negative.", "An audiogram revealed bilateral sensorineural hearing loss, with the right side worse than the left."], "Others": ["She denied mouth or genital ulcers.", "Infectious, rheumatologic, and hypercoaguable test results were negative.", "Retinal fluorescein angiography was obtained.A, Pink arrowheads indicate hyperintensities in the right centrum semiovale."]}
{"Patient Personal Background": ["Her medical history included migraine and polycystic ovaries.", "The patient was taking oral contraceptives and denied the use of recreational drugs."], "Patient Symptoms": ["She reported a sudden onset of photopsia and visual disturbances described as \u201cfixed swirl circles\u201d in the central vision of both eyes noticed on awakening 5 days prior and persisting since that time.", "Ocular movements were full but the patient reported pain and discomfort during movements of the right eye."], "Examination and Results": ["Pupils were equal and reactive to light and there was no afferent pupillary defect.", "Best-corrected visual acuity was 20/20 OU; color vision was 17/17 OU on Ishishara plates.", "The anterior segment was unremarkable and intraocular pressure was 14 mm Hg in both eyes.", "Dilated fundus examination revealed a healthy optic disc and no obvious abnormalities at the macula of both eyes.", "Near-infrared reflectance imaging and spectral-domain optical coherence tomography (OCT) scans of the right eye are shown in the Figure.A, Near-infrared reflectance imaging of acute macular neuroretinopathy in the right eye at presentation reveals hyporeflective teardrop-shaped lesions (black arrowheads).", "B, Simultaneous spectral-domain optical coherence tomography scan passing through the acute macular neuroretinopathy lesions in the right eye reveals increased reflectivity of the outer plexiform layer (yellow arrowheads) and attenuation of the ellipsoid zone (white arrowheads)."], "Others": ["She had a flulike episode 1 week prior to the onset of symptoms."]}
{"Patient Personal Background": ["He had no relevant medical, ocular, or family history, and he denied use of illicit drugs or anticoagulants.Uncorrected visual acuity was 20/30 OD and 20/400 OS."], "Patient Symptoms": ["His ocular symptoms began 2 days prior when he noticed dark scotomas in his central field and decreased visual acuity."], "Examination and Results": ["Extraocular motility and intraocular pressures were normal.", "Results of an anterior examination was unremarkable.", "Dilated funduscopic examination of the left eye revealed a pink optic nerve with sharp margins, diffuse intraretinal hemorrhages and Roth spots extending from the posterior pole to the far periphery, and preretinal hemorrhage overlying the central macula (Figure, A).", "Spectral-domain optical coherence tomography through the preretinal macular hemorrhage demonstrated layered blood in the sub\u2013internal limiting membrane space (Figure, B).", "The right fundus exhibited a similar appearance aside from the preretinal hemorrhage.A, Bedside indirect ophthalmoscopy (slightly out of focus) of the left eye with a 20-diopter lens reveals diffuse retinal hemorrhages; the white arrowhead indicates hemorrhage corresponding to Figure, B and the blue arrowheads, Roth spots in the posterior pole with a normal-appearing optic nerve."], "Others": ["There was no recent trauma or strenuous physical activity.", "Findings extended to the far periphery."]}
{"Patient Personal Background": ["His ocular history was notable for occupational exposure to sunlight and occasional smoking.", "There was no personal or family history of cancer, and he denied ocular surgery or trauma."], "Examination and Results": ["On examination, his best-corrected visual acuity was 20/20 OD/OS, and intraocular pressures were 15 mm Hg OD and 18 mm Hg OS.", "A slitlamp examination of the right eye showed no conjunctival pigmentation.", "Examination of the left eye revealed a pigmented lesion at the temporal limbus from 3 to 4 o\u2019clock with a 2-mm extension into the cornea (Figure 1A).", "Some opalescence underlied the pigment on the cornea.", "In addition, there was an adjacent small area of flat, superficial, mobile bulbar conjunctival pigmentation.", "The anterior segment high-resolution optical coherence tomography (HR-OCT) of the 4-o\u2019clock corneolimbal lesion of the left eye demonstrated thickened hyperreflective corneal epithelium with an abrupt transition from normal to abnormal (Figure 1B).A, Slitlamp photography of the left eye shows a pigmented limbal lesion at 3 to 4 o\u2019clock; another small area of bulbar conjunctival pigmentation is noted (arrowhead).", "B, High-resolution optical coherence tomography of the left eye through the area of the pigmented conjunctival lesion (inset with red line in area of scan), showing epithelial hyperreflectivity and thickening with an abrupt change from normal to mildly thickened epithelium (arrowhead)."], "Diagnosis": ["The referring physician suspected primary acquired melanosis (PAM)."]}
{"Patient Personal Background": ["He had endorsed proper contact lens care and hygiene.", "He also noted an upper respiratory tract illness 4 weeks before presentation."], "Patient Symptoms": ["He did not report any redness or discharge but did note mildly increased irritation mainly from soft contact lens wear."], "Examination and Results": ["Visual acuity was 20/20 OU with normal intraocular pressure.", "Several giant follicles were noted on the right inferior palpebral conjunctiva, and a few smaller follicles were noted in the left inferior fornix.", "Papillae were also noted bilaterally on the superior palpebral conjunctiva.", "Because of the papillary reaction, prednisolone acetate, 1%, twice a day for 2 weeks was prescribed.After 3 months, the symptoms had improved in the left eye, but conjunctival follicles were still present in the right inferior palpebral conjunctiva (Figure 1).", "During this follow-up, Lyme disease and Epstein-Barr virus serologic tests were performed in addition to repeated chlamydia testing."], "Treatment": ["Initially, he received a giant papillary conjunctivitis diagnosis because of soft contact lens intolerance and a recommendation to take a contact lens break.", "The patient subsequently underwent testing for chlamydia and gonorrhea, and the result was negative."], "Diagnosis": ["Initially, he received a giant papillary conjunctivitis diagnosis because of soft contact lens intolerance and a recommendation to take a contact lens break."], "Others": ["At the 1-year follow-up, the examination findings were unchanged."]}
{"Patient Personal Background": ["He had no history of ocular trauma, drug use, or familial ocular diseases.The anterior segment of both eyes was normal on slitlamp examination, but the fundus examination of the right eye showed multiple refractile small crystals scattered on the posterior pole (Figure 1A)."], "Patient Symptoms": ["He denied photopsia or floaters and did not note any visual field defects."], "Examination and Results": ["His best-corrected visual acuity was 20/25 OD and 20/20 OS.", "Isolated crystals were also present in the vitreous core.", "Optical coherence tomography of the macula revealed the crystals to be located preretinally on the surface of the inner limiting membrane with sporadic crystals within the cortical vitreous (Figure 1B).A, Fundus photography at presentation shows multiple refractile crystals at the posterior pole (black arrowheads).", "B, The corresponding optic coherence tomography at presentation shows these crystals adhering to the internal limiting membrane and floating in the vitreous (white arrowheads).Apart from this, biomicroscopy, fluorescein angiography, and optical coherence tomography of the posterior pole showed no abnormalities."]}
{"Patient Personal Background": ["He reported owning cats.On presentation, the patient\u2019s blood pressure was 210/150 mm Hg, and he had a history of acute kidney failure and non\u2013ST-elevation myocardial infarction."], "Patient Symptoms": ["Two weeks prior to presentation, he started noticing black spots in his peripheral vision and progressive blurring of vision in both eyes."], "Examination and Results": ["The patient denied recent travel, cough, gastrointestinal or genitourinary tract symptoms, ulcers, aching joints, tinnitus, or transient visual obscurations.", "On ophthalmic examination, his uncorrected near visual acuity was 20/25 OD and 20/30 OS.", "Extraocular motility, Ishihara color plates, intraocular pressure, pupils, and results of slitlamp examination were within normal limits.", "Ophthalmoscopy showed Frisen grade 5 optic nerve head swelling in both eyes with extensive flame hemorrhages and nerve fiber layer infarcts surrounding both nerves and retinal exudates extending from the nerves temporally into both fovea\u2019s (Figure 1).", "The vessels were of normal course and caliber.", "There were scattered peripheral dot-and-blot hemorrhages.", "Results of Humphrey visual field testing were reliable and showed bilateral concentric constriction and enlarged blind spots.Grade 5 optic nerve head edema.", "A, Fundus photograph of the right eye shows Frisen grade 5 optic disc edema, flame hemorrhages, and peripapillary exudation into the macula."]}
{"Patient Symptoms": ["On examination, she had a florid, erythematous macular eruption over the trunk and limbs (Figure, A) but no hepatosplenomegaly or lymphadenopathy."], "Examination and Results": ["In addition to the high hemoglobin level, mild lymphocytosis (absolute lymphocyte count, 6.2\u2009\u00d7\u2009109/L, range 1.5-4.0\u2009\u00d7\u2009109/L) was noted with the lymphocyte morphology, suggesting reactive changes.", "Skin biopsy specimen (Figure, B) showed a normal epidermis with a pericapillary infiltrate of small lymphocytes restricted to the dermis and no leukocytoclastic vasculitis, fungal organisms, or dermal mucin.", "The absence of cellular atypia and epidermal involvement suggested a diagnosis of lupus, or gyrate or annular erythema, and the need for clinicopathological correlation.A, Photograph shows erythroderma.", "Skin biopsy was repeated 2 months after the original procedure owing to a suboptimal clinical response, but the histological appearances were unchanged.", "The hemoglobin level remained high, and the lymphocyte count had increased to 9.0\u2009\u00d7\u2009109/L (Figure, C)."], "Treatment": ["C, Blood smear shows a typical lymphocyte (May-Gr\u00fcnwald Giemsa stain, original magnification \u00d7400).Treatment began with a topical emollient, steroid creams, and oral antihistamines."], "Diagnosis": ["The absence of cellular atypia and epidermal involvement suggested a diagnosis of lupus, or gyrate or annular erythema, and the need for clinicopathological correlation.A, Photograph shows erythroderma."], "Others": ["B, Skin biopsy specimen shows a pericapillary infiltrate of small lymphoid cells restricted to the dermis (hematoxylin-eosin, original magnification \u00d7200)."]}
{"Examination and Results": ["Laboratory test results were notable for high serum concentrations of IgG4 (5650 mg/dL; to convert to grams per liter, multiply by 0.01) and C-reactive protein (78.1 mg/L; to convert to nanomoles per liter, multiply by 9.524).", "Coronary computed tomographic angiography was performed (Figure, A and B).", "It revealed a large aneurysm (90 mm\u2009\u00d7\u200948 mm) with a thrombosis in the left anterior descending artery (LAD) and a perivascular soft-tissue mass involving the patent proximal right coronary artery (RCA) and left circumflex artery, which showed homogeneous moderate enhancement on contrast-enhanced images.", "Coronary computed tomographic angiography with cinematic rendering (Figure, C) showed multiple mass lesions around the RCA and LAD.", "Invasive coronary angiography results were unable to visualize the LAD but did identify a hypervascular mass in the proximal RCA.A, Contrast-enhanced axial computed tomographic image revealing perivascular soft-tissue masses involving the left circumflex and right coronary arteries (arrowheads).", "B, Maximum intensity projection reformatted image of coronary computed tomographic angiography revealing perivascular soft-tissue masses involving the left circumflex and right coronary arteries (arrowheads) and a large aneurysm with a thrombus involving the left anterior descending artery (asterisk).", "C, A 3-dimensional rendering demonstrated mass lesions involving the left anterior descending and right coronary arteries (arrowheads)."]}
{"Patient Symptoms": ["He denied recent injury, fever, chills, odynophagia, or difficulty breathing."], "Examination and Results": ["Laboratory examination was significant for leukocytosis (white blood cell count, 15\u202f700/\u03bcL) and hypercalcemia (total calcium level, 13.1 mg/dL) (to convert white blood cells to \u00d7109 per liter, multiply by 0.001; to convert calcium to millimoles per liter, multiply by 0.25).", "Physical examination was notable for a 4- to 5-cm pedunculated, ulcerative mass on the dorsal oral aspect of the tongue near midline, anterior to the foramen cecum, without palpable cervical lymphadenopathy.", "Contrast-enhanced computed tomography (CT) demonstrated a rim-enhancing, centrally hypodense lesion in the right dorsal tongue abutting the lingual septum with a somewhat ill-defined border (Figure 1); there was no associated osseous erosion of the mandible or hard palate, no tongue prolapse to suggest hypoglossal nerve palsy, no involvement of the soft palate, and no cervical lymphadenopathy by radiological size criteria.", "An excisional biopsy of the anterior aspect of the mass was performed at bedside, and the patient was discharged home with instructions to follow up in the otolaryngology clinic.A, Sagittal contrast-enhanced computed tomography (CT) demonstrates an exophytic mass on the dorsal aspect of the tongue.", "B, Axial contrast-enhanced CT demonstrates a peripherally enhancing mass of the oral tongue, to the right of midline."], "Treatment": ["An excisional biopsy of the anterior aspect of the mass was performed at bedside, and the patient was discharged home with instructions to follow up in the otolaryngology clinic.A, Sagittal contrast-enhanced computed tomography (CT) demonstrates an exophytic mass on the dorsal aspect of the tongue."]}
{"Patient Personal Background": ["She had previously been treated with antibiotics and mupirocin nasal irrigation, with temporary improvement.", "The patient and her identical twin sister had required multiple surgical procedures in the past for osseous lesions in the upper and lower jaws, including an aggressive resection via bilateral Caldwell-Luc approach 2 years previously; a computed tomographic scan from that initial presentation is shown in the Figure, A."], "Examination and Results": ["At the current presentation, examination using flexible nasal endoscopy revealed bulging of the left lateral nasal wall; imaging revealed a 14-mm, dense, expansile, sclerotic mass with moderate calcifications obstructing the left nasolacrimal duct; a similar 2.3\u2009\u00d7\u20091.8\u2013cm lesion of the right mandibular body; and evidence of previous sinus surgery (Figure, B).", "Histologic findings are shown in the Figure, C and D.A, Contrast-enhanced computed tomographic image at initial presentation.", "B, Non\u2013contrast-enhanced computed tomographic image at 2 years after bilateral Caldwell-Luc resection showing mass in left nasolacrimal duct.", "C, Photomicrograph depicting a proliferation of highly cellular, fibrous connective tissue (arrow) and cementum-like hard tissue (arrowhead) (hematoxylin-eosin, original magnification \u00d7100).", "D, Photomicrograph showing whorls of spindle cells (arrow) with relatively acellular calcified masses of cemento-osseous material (arrowhead) (hematoxylin-eosin, original magnification \u00d7200)."], "Treatment": ["Because of these findings, left-sided endoscopic dacryocystorhinostomy and sinus surgery was performed."]}
{"Patient Personal Background": ["Her social history was significant for a 45\u2013pack-year smoking history and social drinking."], "Patient Symptoms": ["She denied associated pain, bleeding, or recent trauma to the lip.", "She also denied any other constitutional symptoms."], "Examination and Results": ["On physical examination, the patient had right upper lip submucosal masses without any tenderness or mucosal abnormality.", "The remainder of the otolaryngic examination was unremarkable.", "A computed tomographic scan of the neck with contrast demonstrated multiple hyperenhancing nodules; the largest was 3\u2009\u00d7\u20097\u2009\u00d7\u20096 mm, with no local bony erosion or cervical lymphadenopathy (Figure 1).Computed tomographic (CT) scans of hyperenhancing nodules of the upper lip (red arrows)."]}
{"Patient Personal Background": ["The patient, a construction demolition worker, was otherwise healthy and took no medications.", "He had 1 lifetime female sexual partner with whom he used barrier contraception."], "Patient Symptoms": ["The number of lesions and degree of pain had alternately increased and decreased over the years.", "Occasionally the lesions would rupture and leak clear fluid."], "Examination and Results": ["Physical examination revealed an asymmetric cluster of lesions on the right flank measuring 14\u2009\u00d7\u200912 cm at the widest margins (Figure 1).", "The cluster contained verrucous papules and plaques in the center and vesicles filled with clear and milky-white fluid in the periphery.", "Crust was partially covering some of the lesions.", "The surrounding skin was erythematous without warmth or induration.", "The remainder of the physical examination was normal except for stretch marks on the lateral abdomen.Left, Vesicular and verrucous skin lesions on patient\u2019s right flank."], "Treatment": ["One year prior, he was hospitalized for a \u201cskin infection\u201d on his right flank and treated with intravenous antibiotics."], "Others": ["Right, Close-up view of lesions."]}
{"Patient Symptoms": ["She awakened with severe lower back pain, abdominal pain, nausea, and vomiting.", "She came to the emergency department with 10/10 abdominal pain but no fever, chills, vaginal bleeding, or rupture of membranes.", "Thirty-six hours after her initial presentation, she still had rebound tenderness in the left side of the abdomen."], "Examination and Results": ["Her abdominal examination revealed diffuse tenderness and guarding.", "She was afebrile, blood pressure was 104/77 mm Hg, and heart rate was 152/min.", "White blood cell count was 10.7 \u00d7109/L; anion gap, 13 mEq/L; and lactate dehydrogenase level, 131.7 U/L (2.2 \u03bckat/L).", "A computed tomography (CT) scan of the abdomen and pelvis with oral and intravenous contrast revealed mesenteric vascular compromise (Figure 1); after the scan, the patient had hematemesis."], "Treatment": ["She was initially diagnosed as having preterm labor and was given antibiotics, steroids, an epidural catheter for pain management, and intravenous fentanyl as needed."], "Diagnosis": ["She was initially diagnosed as having preterm labor and was given antibiotics, steroids, an epidural catheter for pain management, and intravenous fentanyl as needed.", "A computed tomography (CT) scan of the abdomen and pelvis with oral and intravenous contrast revealed mesenteric vascular compromise (Figure 1); after the scan, the patient had hematemesis."], "Others": ["She delivered a healthy baby without complications, but her severe abdominal pain, nausea, and vomiting persisted."]}
{"Patient Personal Background": ["He had a distant history of viral myocarditis and was taking lisinopril, carvedilol, furosemide, aspirin, and a multivitamin.", "Twelve years prior, he underwent uncomplicated Roux-en-Y gastric bypass (RYGB) surgery."], "Patient Symptoms": ["Review of systems was notable for fatigue and negative for fever, night sweats, weight loss, dyspnea, or abnormal bleeding."], "Examination and Results": ["Examination revealed temperature of 36.7\u00b0C; heart rate, 91/min; blood pressure, 120/70 mm Hg; and body mass index, 20.1 (calculated as weight in kilograms divided by height in meters squared).", "He was well-appearing with conjunctival pallor but no petechiae, no hepatosplenomegaly, and a normal neurologic examination.Laboratory evaluation showed a white blood cell count of 1.7\u2009\u00d7\u2009103/\u03bcL with an absolute neutrophil count of 0.17\u2009\u00d7\u2009103/\u03bcL; hemoglobin level, 7 g/dL with mean corpuscular volume of 103 fL (reticulocyte index, 0.94); and platelet count, 116\u2009\u00d7\u2009103/\u03bcL.", "Results of a complete blood cell count from 8 months prior were normal.", "Results of serum protein electrophoresis were normal, as were levels of lactate dehydrogenase, ferritin, folate, vitamin B12, and thyroid-stimulating hormone.", "A computed tomography (CT) scan of the abdomen showed no lymphadenopathy, masses, or hepatosplenomegaly.", "Peripheral blood smear showed occasional pseudo Pelger-Huet cells and rare teardrop cells.", "Histopathologic examination of bone marrow aspirate revealed a normocellular marrow and dyserythropoiesis with vacuolized and dysplastic erythroid precursors (Figure, panel A), left-shifted granulocytic maturation with vacuolized granulocytic precursors, ring sideroblasts (Figure, panel B), and no increase in blasts."], "Others": ["No new medications had been started in the past year."]}
{"Patient Personal Background": ["She reported being vaccinated against varicella zoster virus and was not immunocompromised.A, A clinical photograph shows an annular erythematous plaque with crusts, bullae, and central pallor."], "Patient Symptoms": ["Older lesions showed central crusts.", "According to the patient, the lesions recurrently appeared during the last 9 years, with a symptom-free period of 2 years (Figure, A).", "She could not identify or recall a specific cause for these skin lesions and denied self-inflicting them."], "Examination and Results": ["B, Histopathologic specimen shows normal stratum corneum, confluent necrosis of the upper epidermal layers, some multinucleated keratinocytes in the adjacent epidermis, and papillary edema with a subepidermal blister.", "A moderately dense perivascular lymphocytic infiltrate with eosinophilic and neutrophilic granulocytes is present in the upper dermis (hematoxylin-eosin, original magnification x200).A skin biopsy of the forearm (Figure, B), direct immunofluorescence, and blood samples were obtained."], "Treatment": ["She had been treated with antibiotics (cefuroxime) as well as with topical steroids (dexamethasone) but denied any lasting effect."], "Others": ["Her family history was without abnormalities."]}
{"Patient Symptoms": ["The lesions had started about 6 months previously as recurrent crops of pruritic erythematous papules that subsided leaving behind brownish-bluish black hyperpigmentation after each episode.On examination, there were multiple, brown, hyperpigmented patches symmetrically affecting her neck, axillae, antecubital fossa, and intermammary and inframammary areas (Figure, A)."], "Examination and Results": ["The patches showed a reticulate pattern at the peripheries.", "Intermammary patches had central erythema and a few subsiding papules.", "Additionally, there were dark brown to bluish-gray patches with reticulation on the lower back and dorsum of the neck (Figure, B).", "These patches also had a few resolving erythematous papules in the periphery.", "Her IgE levels and thyroid status were normal.", "Her fasting blood glucose and basal insulin levels were not raised.", "There was no family history of similar lesions.", "The rest of the skin, nails, and mucosae were all normal.", "Potassium hydroxide mount analysis from skin scrapings did not reveal fungal hyphae or spores.", "The patches show a reticulate pattern at the peripheries.", "The intermammary patches have central erythema and a few overlying edematous papules.", "B, Bluish-gray pigmented patches with prominent reticulation on lower back.", "C, Histopathologic lesional specimen shows mild epidermal hyperkeratosis, acanthosis, multiple foci of spongiosis, and an enhanced basal layer pigmentation.", "There is scant lichenoid and moderate perivascular lymphomononuclear and polymorphonuclear infiltrate, basal cell vacuolization, and melanin incontinence (hematoxylin-eosin)."], "Others": ["There was no history suggestive of allergic rhinitis or bronchial asthma.", "A skin biopsy was performed from lesions on the lower back, and the specimen was submitted for histopathologic analysis (Figure, C and D).A, Illustrated are multiple brown hyperpigmented patches symmetrically affecting the neck, axillae, antecubital fossa, and intermammary and inframammary areas."]}
{"Patient Symptoms": ["Each episode of joint pain and cutaneous eruption lasted 24 to 48 hours with episodes occurring anywhere from every other day to once weekly.", "The patient\u2019s joint pain and cutaneous symptoms resolved completely between each episode and were not associated with fever.", "Review of photos taken during the patient\u2019s flares revealed a variable eruption consisting of oval-shaped, salmon-pink macules on the trunk, urticarial-appearing papules on the dorsal hands, and flagellate arrays of petechial macules on the upper medial arms (Figure 1).", "Her joint pain recurred with each episode of cutaneous eruption and primarily affected the wrist, knee, and ankle joints bilaterally."], "Examination and Results": ["A complete blood cell count and comprehensive metabolic panel as well as C-reactive protein and erythrocyte sedimentation rate obtained during a flare were normal.", "Titers for parvovirus, Epstein\u2013Barr virus, and antistreptolysin O were also negative.A, Approximately 1-cm, oval-shaped, salmon-pink macules on the right lower abdomen and right lateral thigh."], "Treatment": ["She had been treated with naproxen during these flares, which improved her joint pain but not her cutaneous symptoms."], "Others": ["The patient\u2019s mother was unable to identify any possible triggers because the episodes occurred independent of pulmonary CF exacerbations or antibiotic use.", "This eruption was intermittently pruritic but otherwise was asymptomatic.", "B, 3- to 4-mm pink urticarial-appearing papules on the dorsal hand.", "C, Flagellate arrays of nonblanching 1- to 2-mm petechial macules on the upper medial arm."]}
{"Patient Personal Background": ["A review of his previous records indicated an admission to an outside facility 3 weeks beforehand with severe hyperglycemia and a hemoglobin A1c level of 14.1% (to convert to the proportion of total hemoglobin, multiply by 0.01)."], "Patient Symptoms": ["Neurological examination results were significant for choreiform and hemiballistic movements involving the left upper extremity.", "Despite an aggressive correction of blood glucose levels and metabolic correction, his choreiform movements had remained unresolved."], "Examination and Results": ["He was alert and oriented with healthy vital signs.", "No evidence of cognitive impairments was present on bedside testing results.", "On admission, a complete electrolyte and toxicology panel, including calcium, magnesium, and phosphorus, yielded normal results.", "The patient\u2019s serum glucose level was 159 mg/dL (to convert to millimoles per liter, multiply by 0.0555) and his hemoglobin A1c was 10.9% without ketoacidosis.", "Test results for antinuclear antibodies, lupus anticoagulants, and antiphospholipid antibodies were negative.", "Serum thyrotropin levels, liver function test results, and parathyroid hormone levels were healthy.", "Copper studies, a peripheral smear, and a routine electroencephalogram yielded normal results.", "A general screening for cancers yielded negative results.", "The patient underwent brain magnetic resonance imaging (MRI) (Figure), which showed a T1 hyperintensity in the right caudate head and a lentiform nucleus with no restricted diffusion."], "Treatment": ["Oral administration of olanzapine, 2.5 mg daily, in divided doses with careful monitoring of blood glucose levels resulted in the complete resolution of chorea.Magnetic resonance imaging shows T1 hyperintensity in the right caudate head (A) and a lentiform nucleus with no restricted diffusion (B)."], "Others": ["The patient denied any recent infections and risk for human immunodefiency virus (HIV) infection.", "His home medications were carefully reviewed to rule out any medications that could cause chorea."]}
{"Patient Personal Background": ["The patient had a history of asthma and had recently been hospitalized after radiologic findings of pulmonary infiltrates."], "Patient Symptoms": ["The patient denied rash, headache, and joint pain."], "Examination and Results": ["Serologic testing ruled out infectious causes of inflammation.On examination, best-corrected visual acuity was 20/25 OU.", "Intraocular pressure for the right eye was 16 mm Hg and for the left eye was 24 mm Hg.", "Slitlamp examination showed trace hyperemia of the right eye and 2+ diffuse scleral hyperemia of the left eye (Figure).", "Corneas were clear bilaterally, and sensitivity was symmetric and full.", "There was no cell or flare in the anterior chamber, and she had clear lenses with normal irises."], "Treatment": ["At hospital discharge, the patient\u2019s medications were changed to prednisone, 11 mg orally once daily, and azathioprine, 100 mg orally once daily.Although the severity of the ocular symptoms was variable, there was no improvement with the described medication regimen or with currently prescribed topical corticosteroids given 4 times daily in both eyes."], "Diagnosis": ["The patient was diagnosed with pneumonia, myocarditis, and hypereosinophilic syndrome and received high-dose intravenous corticosteroids."]}
{"Patient Personal Background": ["Her medical history was significant for a motor vehicle crash that occurred almost a year earlier, with no direct head trauma or eye injury."], "Examination and Results": ["On examination, her best-corrected visual acuity was 20/500 OD and 20/30 OS.", "Anterior segment examination was remarkable for pseudophakia on the right eye and mild cataract in the left.", "Fundus examination was remarkable for a slightly blunted foveal reflex in the right eye.", "Spectral-domain optical coherence tomography (SD-OCT) showed segmental atrophy of the inner retina (Figure 1A).", "Fluorescein angiography was unrevealing (Figure 1B).A, Spectral-domain optical coherence tomography of the right eye.", "B, Fluorescein angiogram of the right eye."]}
{"Patient Personal Background": ["His ocular history was significant for high myopia, a long-standing traumatic retinal detachment in his right eye, and laser-assisted in situ keratomileusis (LASIK) surgery of the left eye 8 months earlier.", "Three months earlier, the patient experienced an episode of elevated intraocular pressure (IOP) of the left eye, which was treated with travoprost ophthalmic solution, 0.004%, and oral acetazolamide and resolved."], "Patient Symptoms": ["The patient\u2019s presenting visual acuity was counting fingers OD (baseline) and 20/200 OS.", "Two days later, the patient returned to the clinic with decreased vision in his left eye, which showed an IOP measured by GAT of 6 mm Hg, visual acuity of 20/400, and a cornea that was edematous (Figure 1).A, Slitlamp photograph showing a prominent laser-assisted in situ keratomileusis (LASIK) flap in the patient\u2019s left eye."], "Examination and Results": ["His initial IOPs were right eye 16 mm Hg and left eye 46 mm Hg by TonoPen.", "Examination of the left eye indicated normal gonioscopy results and unremarkable anterior and posterior segment examination findings except for the presence of corneal edema without keratic precipitates.", "The patient started treatment with dorzolamide hydrochloride, timolol maleate, brimonidine tartrate, latanoprost, and oral acetazolamide.The next day, the left eye IOP improved to 28 mm Hg as measured by Goldmann applanation tonometry (GAT), with a clear cornea and return of visual acuity to 20/20."], "Treatment": ["Three months earlier, the patient experienced an episode of elevated intraocular pressure (IOP) of the left eye, which was treated with travoprost ophthalmic solution, 0.004%, and oral acetazolamide and resolved.", "The patient started treatment with dorzolamide hydrochloride, timolol maleate, brimonidine tartrate, latanoprost, and oral acetazolamide.The next day, the left eye IOP improved to 28 mm Hg as measured by Goldmann applanation tonometry (GAT), with a clear cornea and return of visual acuity to 20/20.", "Because of a concern for possible trabeculitis, he also started treatment with topical prednisolone acetate 4 times daily and oral valacyclovir hydrochloride."], "Others": ["Despite continuing maximum medical therapy for 1 week, the patient\u2019s examination findings remained unchanged."]}
{"Patient Personal Background": ["Medical and family history were otherwise unremarkable."], "Patient Symptoms": ["He had mild periorbital edema and low-grade eye pain in the left eye over 2 weeks prior to presentation.", "He had completed antibiotic treatment for presumed sinusitis with no improvement.", "A recent flulike illness over the past 1.5 weeks responded minimally to ibuprofen."], "Examination and Results": ["Magnetic resonance imaging of the orbits revealed an intraocular mass, suspicious for retinoblastoma.", "The patient was advised consultation by an ocular oncology service.On examination, visual acuity was fix and follow OU.", "The right eye showed normal findings anteriorly and posteriorly.", "The left eye revealed mild conjunctival chemosis with periorbital edema.", "There was trace eyelid edema and mild leukocoria.", "Dilated ophthalmoscopic examination of the left eye displayed a solid gray mass in the macular region, deep to the retina and with surrounding subretinal fluid (Figure 1A).A, Dilated ophthalmoscopic examination found a gray mass in the macular region of the left eye measuring 12 mm in diameter and 5.1 mm in thickness, with additional subretinal fluid inferiorly.", "B, B-scan ultrasonography confirmed the fundus mass, dependent subretinal fluid, and echolucency outside the posterior wall of the eye.Examination under anesthesia confirmed the solid mass, measuring 12 mm in diameter and 5.1 mm in thickness and demonstrating echodensity on ultrasonography (Figure 1B).", "There were no tumor-feeding vessels, and tumor margins were ill defined.", "Fluorescein angiography demonstrated slight hyperfluorescence of the disc and faint hyperfluorescence of the mass with overlying scattered pinpoint hyperfluorescent leakage.", "Optical coherence tomography revealed shallow subretinal fluid extending within 3.2 mm of the foveola."]}
{"Patient Symptoms": ["Bulging of the right eye was first noted 6 months earlier elsewhere when she reported progressive proptosis, worsening vision, and tearing in the right eye.", "She did not report any pain or diplopia.Visual acuity was 20/150 OD (no improvement with pinhole) and 20/20 OS."], "Examination and Results": ["Pupillary reaction and confrontational visual fields were normal.", "External examination was notable for proptosis of 7 mm, hypoglobus, and resistance to retropulsion.", "A firm, nontender mass was palpable in the right superotemporal orbit.", "The palpebral lobe of the right lacrimal gland was erythematous and prominent compared with the normal-appearing left lacrimal gland.", "Ocular motility showed \u22122 abduction deficit, right eye.", "Slitlamp examination revealed pseudophakia and posterior capsular opacification (right\u2009>\u2009left), but was otherwise normal.", "Sensation was normal in the V1, V2 distribution, and there was no preauricular, submandibular, or anterior cervical lymphadenopathy.", "Computed tomographic scan of the orbits without contrast from an outside facility revealed a spherical mass of unclear cause in the area of the right lacrimal gland.", "No lytic bone changes or bone remodeling could be seen (Figure 1).Computed tomographic imaging from outside facility revealed a 1.9\u2009\u00d7\u20092.3\u2009\u00d7\u20091.8-cm mass of an unclear cause within the anterolateral right orbit, exerting mass effect on the globe."]}
{"Patient Personal Background": ["She had no history of ocular disease or trauma, and her medical history was notable for resection of a benign thyroid mass 3 years prior.", "Family and social history were unremarkable."], "Patient Symptoms": ["Her new-onset acquired ptosis began 10 months prior."], "Examination and Results": ["Her vision was 20/30 OD and 20/25 OS.", "Intraocular pressures were normal.", "She had mild anisocoria with the right and left pupils reacting from 6 to 4 mm and from 5 to 3 mm, respectively.", "The pupils were equal in light and dark, with no reversal after apraclonidine hydrochloride treatment.", "No relative afferent pupillary defect was noted.", "Results of the Hertel testing at a base measurement of 100 mm were 20.5 mm OD and 21.0 mm OS.", "She had full ductions and versions, mild fullness of the left superior sulcus, and no sensory deficits in her facial cranial nerves.", "Her vertical palpebral fissure measured 10 mm OD and 7 mm OS.", "Her margin-to-reflex distance was 4 mm OD and 2 mm OS."], "Treatment": ["With phenylephrine hydrochloride, her margin-to-reflex distance became equal at 4 mm OS."], "Others": ["She had no lagophthalmos."]}
{"Patient Symptoms": ["Two months later, he presented to a hospital with complaint of shortness of breath, cough, and chest pain.", "On presentation to our multidisciplinary clinic, he reported constant, bothersome sweating of the left forehead."], "Examination and Results": ["A computed tomographic image of the chest (Figure 1) identified a large, 12-cm left upper lobe mass abutting the anterior chest wall pleura and extending into the mediastinum, with mediastinal lymphadenopathy as well as several liver lesions.", "On physical examination, a well-demarcated area of erythematous, perspiring skin on the left forehead was noted.A, Coronal computed tomographic image of the thorax with intravenous contrast at initial presentation, demonstrating a left upper lobe mass; asterisk depicts possible area of sympathetic nerve compression or invasion.", "B, Radiation planning computed tomographic image taken 2 weeks after initial presentation, demonstrating growth of the left upper lobe tumor."], "Diagnosis": ["A biopsy revealed poorly differentiated carcinoma, consistent with a primary tumor in the lung."], "Others": ["The red contour identifies the tumor; the orange contour, the area of sympathetic trunk compression; the yellow contour, the trachea; the teal contour, the left lung; the purple contour, the esophagus; the peach contour, the first rib."]}
{"Patient Symptoms": ["While in the emergency department, she developed monomorphic ventricular tachycardia (VT) with hemodynamic instability and was successfully cardioverted.", "She continued to have nonsustained monomorphic VT, so intravenous amiodarone and oral metoprolol were initiated."], "Examination and Results": ["Results of tests of electrolyte levels and coronary angiography were normal.", "Cardiac magnetic resonance imaging with gadolinium contrast revealed normal-sized cardiac chambers and normal biventricular function without delayed enhancement."], "Treatment": ["She continued to have nonsustained monomorphic VT, so intravenous amiodarone and oral metoprolol were initiated."], "Others": ["She was admitted for further evaluation."]}
{"Patient Personal Background": ["She was a nonsmoker and nondrinker.On examination, she appeared well."], "Patient Symptoms": ["At the time of presentation, it had begun to cause changes in her voice, globus sensation, and dysphagia.", "The patient reported a 20-pound weight loss over the prior 3 months and decreased appetite.", "She denied any associated difficulty breathing, pain, fever, chills, rash, or night sweats.", "Despite a muffled voice, she was not in respiratory distress."], "Examination and Results": ["Fiberoptic laryngoscopy revealed a large, partially obstructing mass in the right oropharynx protruding from the right tonsil.", "It descended inferiorly and was partially compressing the epiglottis.", "The true and false vocal cords, although partially obstructed, appeared normal and mobile.", "The lesion was without ulceration, exudate, or erythema.", "The contralateral tonsil was small and normal in appearance.", "The remainder of her physical examination findings were unremarkable, including no neck masses.The patient agreed to surgical excision of the mass, including tonsillectomy."], "Treatment": ["Her airway was secured via an awake transoral fiberoptic intubation without difficulty.", "The planned procedure occurred without difficulty or complication.", "The specimen excised was a 6\u2009\u00d7\u20093\u2009\u00d7\u20092-cm mass continuous with the right tonsil (Figure 1), without involvement of any surrounding structures.A, Intraoperative photograph of a large, irregularly shaped lesion protruding from the patient\u2019s right tonsil."], "Others": ["B, The excised specimen measured 6\u2009\u00d7\u20093\u2009\u00d7\u20092 cm and was continuous with the right tonsil."]}
{"Patient Personal Background": ["He had been born after an uncomplicated pregnancy, during which routine prenatal ultrasonography had not detected any anatomical abnormalities or lesions."], "Patient Symptoms": ["On physical examination, there were no abnormalities other than symmetrical submucosal swelling of the floor of the mouth and a midline external punctum present in the submental area (Figure, A).", "The tongue was displaced posteriorly and superiorly."], "Examination and Results": ["Contrast-enhanced magnetic resonance imaging of the neck and face performed shortly after presentation showed a midline sublingual lesion extending inferiorly through the mylohyoid muscle (Figure, B-D).", "The intrinsic muscles of the tongue appeared minimally displaced without obvious infiltration; however, the genioglossus muscle was difficult to locate relative to the mass.", "A thin-walled, multiloculated lesion was identified, measuring approximately 2.0\u2009\u00d7\u20092.5\u2009\u00d7\u20093.2 cm.", "The mass was bright on T2-weighted imaging and dark on T1-weighted imaging and did not enhance with intravenous gadolinium.", "There were no obvious fluid-fluid levels or calcifications.", "When in-phase and out-of-phase images were compared, there was no significant signal intensity drop, suggesting an absence of fat within the lesion.A, Appearance of the submental neck."], "Others": ["B, Coronal short tau inversion recovery (STIR) T2-weighted magnetic resonance image without contrast enhancement.", "C, Coronal T1-weighted, fat-saturated magnetic resonance image after contrast enhancement.", "D, Sagittal T1-weighted non\u2013fat-saturated magnetic resonance image after contrast enhancement."]}
{"Patient Personal Background": ["Family history included constipation in a sister and a great aunt with CF."], "Patient Symptoms": ["During her first week of life, she developed diarrhea and vomiting.", "With initiation of solid food, she developed laxative-dependent constipation."], "Examination and Results": ["She underwent newborn genetic screening before routine cystic fibrosis (CF) screening.", "Results were normal.", "Results of anorectal manometry, spinal magnetic resonance imaging, and thyroid studies were normal.", "Physical examination findings were unremarkable, including normal respiratory examination.", "Fecal elastase level was within reference range (>500 \u03bcg/g); abdominal computed tomographic image revealed a dilated, tortuous sigmoid colon; and full-thickness rectal biopsy was negative for Hirschsprung disease.", "She was referred for sweat chloride testing to assess for CF.", "Results of 3 separate sweat chloride tests were indeterminate (Table), prompting pulmonology referral.", "A 97-mutation CF transmembrane conductance regulator (CFTR) analysis panel was negative."], "Others": ["At the time of presentation to the gastroenterology clinic, she had no respiratory symptoms.", "Her body mass index (BMI) was below the third percentile (eFigureA in the Supplement)."]}
{"Patient Personal Background": ["He had no back or joint pain or skin rashes.", "Five years ago he had a black ink tattoo placed on his left arm, and 3 years ago a second tattoo was placed on his right arm."], "Patient Symptoms": ["Two years after the right arm tattoo was placed, he noticed tattoo elevation on the left arm and onset of decreased vision.", "He had recurrent episodes of ocular redness and blurred vision, coincident with inflammation of the skin surrounding both tattoos."], "Examination and Results": ["C, Hematoxylin-eosin stain of skin biopsy sample (original magnification \u00d7100).At presentation, best corrected visual acuity was 20/20 in the right eye and 20/40 in the left.", "Intraocular pressure was 34 mm Hg in the right eye (upper limit of normal, 21 mm Hg) and 11 mm Hg in the left.", "On anterior segment slitlamp examination, there were no visible inflammatory cells in the anterior chamber of the right eye, but there were more than 26 cells per 1-mm field in the left.", "Punch biopsy of the tattooed skin revealed epithelioid histiocytes with macrophages containing coarse black granular pigment (Figure, panel C)."], "Treatment": ["Two months before presentation, bilateral peripheral iridotomies (iris laser procedures) were performed because of inflammation-induced adhesions between the iris and the lens (Figure, panel A).A, Slitlamp photograph of left eye."], "Others": ["B, Tattooed skin on left arm.", "The left arm tattoo was elevated, with nodular elevation most prominent at the superior aspect of the tattoo (Figure, panel B).", "Results of testing for syphilis, tuberculosis, and sarcoidosis were negative."]}
{"Patient Personal Background": ["The infant was born to a 31-year-old mother by normal vaginal delivery.", "The mother had a benign prenatal course during pregnancy.", "On further questioning, the parents reported that the infant had had contact with a babysitter who reported pruritus, especially at night.", "The sitter had provided domestic care for the infant since birth until leaving that position 3 weeks earlier.On examination, the infant was afebrile with normal vital signs."], "Patient Symptoms": ["Since the rash developed, the infant had been fussy with increasing restlessness at night."], "Examination and Results": ["Multiple disseminated, edematous, pin-sized, papulopustulovesicles and 5- to 10-mm coalescing, crusted nodules were found all over the body; some with oval to elongated, serpiginous or J-shaped burrows (Figure 1).", "No excoriations were visible.", "A Tzanck smear showed no multinucleated giant cells in the pustular contents.", "A Gram stain and potassium hydroxide (KOH) preparation of the pustular contents showed no bacterial or fungal elements.", "Cultures of the pustular contents yielded no bacterial or fungal growth.", "The differential of a complete blood cell count showed 12% eosinophils."], "Others": ["The parents denied any personal or family history of rash."]}
{"Patient Symptoms": ["He reported that lesions began as pustules and developed into painful, itchy plaques.", "A complete review of systems was notable for the patient\u2019s difficulty with walking because of skin lesions."], "Examination and Results": ["On examination, pustules and hemorrhagic-crusted plaques were seen on the scalp, legs, arms, and trunk along with keloidal plaques on the face (Figure, A and B).", "A punch biopsy specimen from the arm was obtained for histopathologic study (Figure, C and D).Extensive vegetative plaques with bleeding and ulceration on extremities (A), and pustules and ulcerated plaques on extremities and trunk (B).", "Histopathologic examination of a biopsy specimen taken from the arm demonstrates pseudoepitheliomatous hyperplasia (hematoxylin-eosin stain, original magnification \u00d7100) (C) and dermal neutrophilia and microabscesses with eosinophilia (hematoxylin-eosin stain, original magnification \u00d7400) (D)."], "Treatment": ["Before evaluation at a referral hospital in Kenya, the patient was treated with prednisolone tablet 5 mg twice daily, clindamycin hydrochloride 300 mg daily, and fluconazole 200 mg daily, but he continued to develop new lesions."], "Others": ["Enzyme-linked immunosorbent assay testing for HIV was negative."]}
{"Patient Personal Background": ["He had no history of chicken pox or acne or traumatic lesions in those areas."], "Patient Symptoms": ["Before evaluation, his condition had been diagnosed as lupus and lipoatrophy and he tried several treatments with no success.The results of his physical examination showed several round atrophic lesions on his face, symmetric and bilateral, that were located especially on the malar and preauricular areas, with a diameter of 5 to 10 mm.", "The patient denied experiencing previous inflammation."], "Examination and Results": ["His skin lesions were not indurated and displayed no epidermal changes (Figure 1).", "New punch biopsy specimens were obtained for further evaluation.Atrophic lesions on the patient\u2019s left cheek (A) and with a cicatricial appearance on the preauricular right area (B)."], "Treatment": ["Before evaluation, his condition had been diagnosed as lupus and lipoatrophy and he tried several treatments with no success.The results of his physical examination showed several round atrophic lesions on his face, symmetric and bilateral, that were located especially on the malar and preauricular areas, with a diameter of 5 to 10 mm."], "Diagnosis": ["Before evaluation, his condition had been diagnosed as lupus and lipoatrophy and he tried several treatments with no success.The results of his physical examination showed several round atrophic lesions on his face, symmetric and bilateral, that were located especially on the malar and preauricular areas, with a diameter of 5 to 10 mm."]}
{"Patient Personal Background": ["He had been diagnosed with multiple myeloma 2 years earlier after discovery of osteolytic bone lesions of the skull and the findings of a bone marrow biopsy.", "He denied sexual risk behavior and reported no recent changes in medication."], "Patient Symptoms": ["At the time of the consultation, he was free of disease.The patient was referred for evaluation of an indolent, erythematous papule on his glans penis of 2 weeks\u2019 duration."], "Examination and Results": ["Careful physical examination revealed a shiny, tense, erythematous, hemispherical papule measuring 5 mm in diameter located on the lateral aspect of the glans (Figure 1A).", "There were no other skin lesions.", "The lymph nodes were not palpable, and there was no organomegaly.", "A punch biopsy was performed for histopathological evaluation (Figure 1B and C).A, Shiny, erythematous, hemispherical papule on the lateral aspect of the glans penis."], "Treatment": ["The patient had been treated with bortezomib and dexamethasone followed by autologous blood progenitor cell transplantation, which resulted in complete response."], "Others": ["B and C, Hematoxylin-eosin stain was performed for evaluation."]}
{"Examination and Results": ["On examination, he had a 5 cm \u00d7 3 cm palpable and partially reducible right groin mass that extended into the scrotum.", "He had a leukocytosis with a leukocyte count of 16\u202f400/\u03bcL (to convert to \u00d7109/L, multiply by 0.001), his creatinine level was 1.14 mg/dL (to convert to micromoles per liter, multiply by 88.4), and urinalysis showed leukocyturia with cultures that had positive results for Streptococcus viridians.", "Axial and sagittal (Figure) computed tomography scans with contrast are shown."]}
{"Patient Symptoms": ["The pain was located in the periumbilical region and intensified within a few hours.", "The physical examination was significant for diffuse abdominal tenderness."], "Examination and Results": ["The patient felt normal fetal movements during this time.", "Next, the patient was evaluated by an obstetrician-gynecologist, and although the gynecologic examination, ultrasonography, and monitoring were all normal, the patient was admitted for further supervision in the obstetrics department.", "The next day, when the abdominal pain and vomiting persisted and an elevated leukocyte blood count of 14\u202f200/mL was noted (to convert to \u00d7109 per liter, multiply by 0.001), a second surgical consultation was done.", "Although the patient was pregnant, and owing to nonavailability of magnetic resonance imaging at that time, a contrast-enhanced abdominopelvic computed tomography was performed (Figure 1).Coronal computed tomographic image showing an edematous small intestinal loop on the left abdomen, with uterus and head of fetus in the pelvis."], "Others": ["An initial surgical evaluation was done, and the cause for the abdominal pain was assumed to be not of surgical condition."]}
{"Patient Personal Background": ["The patient had his first liver transplant 12 years before presentation that failed despite immunosuppressive treatment with tacrolimus.", "He initiated mycophenolate mofetil treatment 2 months before his second transplant.", "In addition, the patient was positive for cytomegalovirus (CMV) IgG antibodies and had an undetectable CMV load 1 month before transplantation.On examination, visual acuities were hand motions OD and J1 OS."], "Patient Symptoms": ["He denied eye pain, floaters, and photopsias.", "The patient\u2019s right pupil was sluggishly reactive with a relative afferent pupillary defect."], "Examination and Results": ["Intraocular pressure was 16 mm Hg OD and 18 mm Hg OS.", "Extraocular movements were intact, and visual fields were full by confrontation.", "Anterior segment examination was within normal limits."], "Others": ["Fundus photographs of the right eye are shown in the Figure, A."]}
{"Patient Personal Background": ["Review of medical history revealed lumpectomy and radiotherapy for breast cancer 6 years prior."], "Examination and Results": ["Visual acuity was 20/160 OD (her baseline due to amblyopia) and 20/20 OS.", "Pupillary function was normal.", "The anterior chamber and vitreous were quiet.", "Fundus photographs showed optic nerve edema and a peripapillary choroidal infiltrate in the right eye.", "Swept-source optical coherence tomography (OCT) demonstrated retinal thickening with cystoid abnormalities, subretinal hyperreflective material consistent with fibrosis, and choroidal thickening in the right eye (Figure 1).", "Optical coherence tomography of the optic nerve head in the right eye demonstrated 360\u00b0 peripapillary nerve fiber thickening and diffuse nerve head elevation.", "Fluorescein angiography demonstrated staining with minimal leakage in the temporal peripapillary retina of the right eye.A, Fundus photography of the right eye revealed optic nerve edema and a peripapillary choroidal infiltrate.", "B, Swept-source OCT of the right eye demonstrated retinal thickening with cystoid abnormalities, subretinal fibrosis, and choroidal thickening in the area marked on the fundus photo.Testing results for an underlying neoplastic, inflammatory, or infectious process were unrevealing, including negative results of serology tests for tuberculosis, toxoplasmosis, syphilis, Lyme disease, and sarcoidosis.", "Results of complete blood cell count, serum protein electrophoresis, and bone marrow biopsy were not supportive of lymphoproliferative disease.", "Results of magnetic resonance imaging of the brain and orbits were normal.", "Computed tomographic scan of the chest, abdomen, and pelvis demonstrated no lymphadenopathy.Four months prior to presentation, routine electrocardiogram demonstrated a right bundle branch block."], "Treatment": ["Eight months later, complete heart block necessitated urgent pacemaker implantation."], "Others": ["The line marks the location of the cut through the retina represented by the optical coherence tomography (OCT)."]}
{"Patient Personal Background": ["He had no relevant ocular or other medical history."], "Patient Symptoms": ["The worsening vision was preceded by binocular diplopia, which was intermittent at first and then became constant.", "A review of systems was notable for a 2-month history of progressively worsening shortness of breath."], "Examination and Results": ["Visual acuity was found to be 20/200 OD and 20/25 OS.", "His pupils were round and equally reactive, and there was no relative afferent pupillary defect.", "The intraocular pressure was normal in both eyes.", "On external examination, bilateral proptosis and increased resistance to retropulsion was observed.", "There was very limited extraocular motility in all directions of gaze on the right side and moderately limited extraocular motility on the left side.", "In addition, the patient had an esotropia and right hypertropia.", "Anterior segment examination revealed bilateral chemosis.", "The fundus examination (Figure 1) showed chorioretinal folds in both eyes and intraretinal hemorrhages in the right eye.", "The optic discs had normal color and sharp margins bilaterally.A, Fundus photograph of the right eye showing prominent chorioretinal folds throughout the macula and 2 intraretinal hemorrhages near the vascular arcades."], "Others": ["He denied any fevers, night sweats, or unintentional weight loss."]}
{"Patient Personal Background": ["Her medical history was notable for hypertension, treated with clonidine hydrochloride, and opiate abuse, treated with methadone hydrochloride."], "Patient Symptoms": ["Examination revealed periorbital edema, proptosis, and limitation in supraduction, abduction, and adduction in the right eye.", "Two weeks later, new proptosis and periocular edema of the left eye developed, with no inciting trauma."], "Examination and Results": ["Her blood pressure was 138/87 mm Hg.", "The patient was afebrile with no leukocytosis.", "Her visual acuity was 20/20 OU with no afferent pupillary defect and normal intraocular pressures.", "There was no periorbital soft-tissue erythema, warmth, or tenderness to palpation.", "Computed tomography showed hyperattenuating soft tissue in the superior, medial, and inferior right orbit (Figure 1A, arrowheads).", "Magnetic resonance imaging showed no internal flow voids to suggest vascular malformation.", "Results of a laboratory workup revealed mildly elevated erythrocyte sedimentation rate (49 mm/h; reference range, 0-20 mm/h) and antinuclear antibody titer (1:80; reference range, <1:40) as well as positive results for anti-Ro and anti-La antibodies.", "Results of further autoimmune and infectious workup were negative.", "Her examination results were significant for proptosis, periorbital edema, and limitation in supraduction in the left eye.", "Computed tomography showed new hyperattenuating soft tissue in the left superior and lateral orbit (Figure 1B, arrowhead).A, Coronal contrast-enhanced computed tomographic scan shows hyperattenuating soft tissue in the superior, medial, and inferior subperiosteal space of the right orbit (arrowheads).", "B, Computed tomographic scan, not contrast enhanced, shows hyperattenuating orbital soft tissue in the left orbit (arrowhead)."]}
{"Patient Personal Background": ["She reported no history of diabetic retinopathy."], "Examination and Results": ["Visual acuity with correction was 20/80 OD and 20/30 OS.", "Dilated fundus examination results were notable for mild cataracts in both eyes and fine superficial retinal hemorrhages surrounded by a cluster of exudates in the right retina (Figure 1A).", "An examination of the left retina produced unremarkable results.Color fundus and optical coherence tomographic imaging of the right eye.", "A, A color fundus photograph of the right macula showing superficial retinal hemorrhages surrounded by a cluster of exudates; B, Optical coherence tomography of the right eye showing nasal intraretinal fluid and exudates as well as a distinct cystoid cavitary abnormality just temporal to the center of the macula.Optical coherence tomography of the right eye showed nasal intraretinal hyporeflective spaces that were likely consistent with intraretinal fluid and hyperreflective areas most likely consistent with transudates of lipid, as well as a distinct cystoid cavitary abnormality just temporal to the center of the macula (Figure 1B).", "A similar cystoid change was seen in the left eye (not shown).", "Fluorescein angiography showed an area of bright hyperfluorescence nasal to the fovea that progressively intensified with the leakage of dye, obscuring the borders of this area in the late phases, as well as mild leakage temporal to the fovea in both eyes (not shown).Recommend intravitreal anti\u2013vascular endothelial growth factor (anti-VEGF) injection.Recommend continued blood glucose control and consider intravitreal anti\u2013VEGF injection or focal laser treatment if the macular edema persists.Explain to the patient that these changes are medication-associated and recommend close observation.Recommend referral to the patient\u2019s primary care physician for stricter blood pressure control."], "Treatment": [], "Others": []}
{"Patient Symptoms": ["She also reported a 1-week history of left eye discomfort and left-sided tinnitus and a 1-day history of binocular horizontal diplopia.", "She denied any history of recent trauma."], "Examination and Results": ["Ophthalmologic examination at the time revealed visual acuities of 20/30 OD and 20/40 OS.", "Intraocular pressures were 15 mm Hg OD and 21 mm Hg OS, with a widened pulse pressure of the left eye.", "Extraocular motility revealed a left eye abduction deficit.", "Pupils and confrontational visual fields were unremarkable.", "Hertel measured 16 mm and 17 mm, respectively.", "Slitlamp examination of the right eye was unremarkable, but examination of the left eye revealed a large subconjunctival hemorrhage and engorged episcleral veins (Figure 1).", "Fundus examination of both eyes was unremarkable.Clinical photographs taken 3 weeks apart."], "Others": ["A, Dilated nasal episcleral vessels and conjunctival chemosis near the onset of the patient\u2019s symptoms.", "B, Photograph taken 3 weeks later revealing increased dilated episcleral vessels and subconjunctival hemorrhage.", "Orbital ecchymosis is also evident."]}
{"Patient Symptoms": ["He denied flashing lights, visual field defects, trauma, pain, redness, discharge, or other systemic symptoms.On examination, the patient\u2019s uncorrected visual acuity was 20/20 OD and 20/50 OS (no improvement on refraction), his pupils were equally round and reactive with no relative afferent pupillary defect, his intraocular pressures were normal, and extraocular motility and confrontational visual fields were full."], "Examination and Results": ["He denied flashing lights, visual field defects, trauma, pain, redness, discharge, or other systemic symptoms.On examination, the patient\u2019s uncorrected visual acuity was 20/20 OD and 20/50 OS (no improvement on refraction), his pupils were equally round and reactive with no relative afferent pupillary defect, his intraocular pressures were normal, and extraocular motility and confrontational visual fields were full.", "Results from slitlamp and dilated fundus examinations of the right eye were normal.", "Anterior segment examination of the left eye showed mild fine keratic precipitates and pigmented cell; dilated fundus examination showed significant vitritis but no obvious vascular sheathing or chorioretinal lesions (Figure 1A).", "Optical coherence tomography of the macula confirmed there was no intraretinal or subretinal fluid (Figure 1B), and fluorescein angiography did not show any vascular leakage or areas of nonperfusion.", "Results of further workup showed normal complete blood cell count and comprehensive metabolic panel laboratory testing, undetectable HIV viral load, and unremarkable chest radiography; laboratory results for tuberculosis (T-SPOT.TB testing), syphilis (rapid plasma reagin with reflex treponemal testing), cytoplasmic and perinuclear antineutrophil cytoplasmic antibodies, and blood cultures were all negative as well.A, On color fundus photography, significant vitreous haze obscuring most of the retinal vessels was observed in the left eye, but no apparent chorioretinal lesions were seen."]}
{"Patient Personal Background": ["Nine months before the current presentation, he was treated with intramuscular penicillin for syphilis.", "His medical history was also significant for HIV, for which he was receiving highly active antiretroviral therapy, and metastatic programmed cell death ligand 1\u2013positive squamous non\u2013small cell lung cancer.", "Four months before the current presentation, the patient had started pembrolizumab monotherapy as a first-line treatment for his cancer."], "Patient Symptoms": ["One month before this presentation, multiple ulcers developed on his buccal mucosa, as well as a nonpainful shallow penile ulcer and pruritic, mildly painful, hyperpigmented papules and plaques on the bilateral soles of his feet in a pattern identical to previous syphilitic eruption.", "The patient denied fever, chills, and weight loss."], "Examination and Results": ["Physical examination revealed multiple hyperpigmented papules and plaques with violaceous borders on his bilateral soles and lateral feet (Figure, A) and scattered, violaceous papules and nodules with overlying scale on his bilateral lower extremities.", "He was referred to the dermatology service, and a punch biopsy specimen was obtained from the right medial sole (Figure, B).A, Right foot with multiple hyperpigmented, lichenified papules, and plaques with violaceous borders.", "Lymphocytes, eosinophils, and plasma cells can be seen within the infiltrate (hematoxylin-eosin, original magnification \u00d740)."], "Others": ["B, A punch biopsy specimen from the right medial sole."]}
{"Examination and Results": ["A computed tomographic examination of the brain showed a right frontal lobe abscess with vasogenic edema (Figure 1)."], "Treatment": ["She underwent burrhole aspiration of the abscess, which grew mixed oral flora.", "Treatment involved a prolonged course of intravenous antibiotics, steroids, and medications for seizure prophylaxis."]}
{"Examination and Results": ["Nonenhanced computed tomography of the paranasal sinuses revealed a soft-tissue mass extending from the nasopharynx into the left sphenoid sinus with erosion of the sphenoid sinus floor and the clivus (Figure 1A).", "The sella was apparently normal with no disruption of its floor.", "The intracranial and orbital soft tissues were grossly normal, as were the remaining soft tissues under the skull base.A, Sagittal nonenhanced computed tomography images of the paranasal sinus depicting a soft-tissue mass involving the sphenoid sinus, the nasopharynx, and the clivus.", "B, Postcontrast sagittal T1-weighted magnetic resonance shows avid enhancement of the mass; involvement of the clivus is also depicted.A magnetic resonance imaging study was also performed (Figure 1B).", "There was a lobulated mass centered to the nasopharynx, measuring about 2.8\u2009\u00d7\u20092.6\u2009\u00d7\u20094.5 cm (anteroposterior\u2009\u00d7\u2009transverse\u2009\u00d7\u2009craniocaudal planes, respectively) in maximal diameters.", "The mass demonstrated intermediate T2 hyperintense signal and avid postcontrast enhancement.", "It extended inferiorly down to the oropharynx and superiorly along the floor of the left sphenoid sinus with extension into the sinus itself; posteriorly, there were erosions involving the sphenoid bone and the clivus.", "The floor of sella was intact, and a normal enhancing pituitary gland and infundibulum were seen within the sella.", "No sellar or suprasellar mass was evident.", "Both Meckel caves were normal, and the cavernous sinuses were also normal and without evidence of asymmetric mass or abnormal enhancement."], "Treatment": ["The patient underwent a total mass resection via endoscopic anterior cranial base approach, with extradural tumor resection, reconstruction of the skull base, and a nasoseptal flap."]}
{"Patient Symptoms": ["She reported diminished left-sided hearing that would temporarily improve with autoinsufflation.", "She denied facial numbness or weakness, and reported no dizziness or vertigo.", "The patient was initially observed but then experienced progressive hearing loss that no longer improved with the Valsalva maneuver, persistent ear fullness, and rare facial twitching."], "Examination and Results": ["Physical examination revealed a retrotympanic, nonpulsatile, tan-gray mass anterior to the malleus handle.", "A tuning fork examination revealed lateralization to the left ear and bone conduction louder than air conduction on the left side with a 512-Hz tuning fork.", "The remainder of the physical examination, including facial nerve function, was normal.", "An audiogram confirmed mild conductive hearing loss in the left ear.", "Computed tomography (CT) revealed a middle ear lesion lateral to the geniculate ganglion with possible extension into the peritubal space.", "Magnetic resonance imaging (MRI) demonstrated an enhancing lesion lateral to the geniculate ganglion (Figure, A-C).", "The middle ear mass appeared enlarged on repeated MRI and began to obstruct the eustachian tube.", "Transcanal endoscopy demonstrated a gray middle ear mass occupying the anterior mesotympanum and epitympanum and extending into the eustachian tube (Figure, D).", "The specimen revealed predominantly spindled stroma with a focus of tumor that was positive for antiepithelial membrane antigen and somatostatin receptor 2A.A, Noncontrast axial computed tomogram (CT) of the left temporal bone demonstrates an anterior mesotympanic mass lateral to the cochlea (yellow arrowhead) with blockage and extension into the supratubal recess (white arrowhead).", "A partial mastoid effusion (asterisk) is also visible.", "B, The coronal CT demonstrates an intact tegmen tympani with hyperostosis (arrowhead).", "C, Axial, fat-suppressed, postgadolinium, T1-weighted magnetic resonance image (MRI) reveals an enhancing mass of the left perigeniculate region (yellow arrowhead).", "The geniculate ganglion is marked (white arrowhead)."], "Others": ["The tegmen was intact."]}
{"Patient Personal Background": ["She was born at 36 weeks\u2019 gestation and spent 10 days in the neonatal intensive care unit."], "Patient Symptoms": ["Her parents noted that the lesion was present at birth and she always seemed congested on the left side.", "There was no report of clear drainage."], "Examination and Results": ["Physical examination showed an approximately 1-cm, firm, pedunculated polypoid mass in the anterior nasal cavity at the vestibule.", "The base was located just anterior to the septum and encompassed nearly the entire left nasal cavity.", "There was no fluid in the mass, and there was a negative Furstenberg sign.", "Nasal endoscopy was performed in the clinic, and there were no additional masses or mucosal abnormalities.", "The choana was patent.", "The patient was also noted to have left eye ptosis and left preauricular branchial remnants but no other significant abnormalities on examination.", "Magnetic resonance imaging was performed (Figure 1B) and showed a 0.8 \u00d7 0.5\u2013cm hyperintense mass on T1-weighted images, suggesting a fatty component and no intracranial tract.Photograph (A) and magnetic resonance imaging (MRI) (B) of the left anterior nasal cavity mass."]}
{"Patient Personal Background": ["He lived in a remote area in China.", "His parents were first cousins, but no similar cutaneous presentation was reported by other relatives.The physical examination revealed scaly skin with diffuse warty lesions on sun-exposed areas."], "Patient Symptoms": ["These lesions developed from local freckles beginning at 6 months of age and gradually spread with protruding growth.", "Over the past 2 years, tumors started to form and develop rapidly, becoming ulcerative and bleeding.", "The patient\u2019s face was severely disfigured, with numerous ulcerative, malodorous tumors (Figure 1A)."], "Examination and Results": ["The general examination findings, including neurological and ophthalmologic tests, were unremarkable.", "The lesional discharge culture revealed infection with Proteus vulgaris.", "Punch biopsy of a paranasal mass was performed (Figure 1B).", "Craniofacial computed tomography showed heterogenous soft tissue masses located superficially without bony invasion.", "No signs of cerebral atrophy were noticed."], "Diagnosis": ["B, Infiltrating basal cell carcinoma (original magnification \u00d740)."], "Others": ["The patient was intellectually standard and denied blurred vision, impaired hearing, or any other systemic symptoms.", "Genetic testing was advised but was declined.A, Preoperative clinical photography revealed a face severely disfigured by diffuse warty lesions and numerous tumors."]}
{"Patient Personal Background": ["She did not report a history of xerostomia, keratoconjunctivitis sicca, pleural effusions, pneumothoraces, seizure, cognitive impairment, recurrent sinopulmonary infections, or previous autoimmune disease diagnosis and had no relevant family history of lung disease."], "Patient Symptoms": ["She had slowly progressing dyspnea over the past year and general fatigue."], "Examination and Results": ["Her physical examination findings were unremarkable and there was no evidence of cutaneous lesions.", "A high-resolution computed tomographic (CT) scan of her chest revealed diffuse thin-walled pulmonary cysts without nodules, parenchymal changes, or lymphadenopathy (Figure).", "Imaging of her abdomen did not show kidney lesions or abdominal masses.", "The patient\u2019s serum vascular endothelial growth factor D (VEGF-D) level was elevated at 1300 pg/mL (reference range, <600 pg/mL).High-resolution computed tomography scan of the chest showing numerous, diffuse, thin-walled lung cysts surrounded by normal-appearing lung parenchyma."], "Others": ["There is no mediastinal or hilar adenopathy.The VEGF-D level is nonspecific and the patient should undergo further evaluation with a lung biopsy.The VEGF-D level is supportive of a diagnosis of pulmonary Langerhans cell histiocytosis.The VEGF-D level is supportive of a diagnosis of lymphangioleiomyomatosis.The VEGF-D level indicates that the patient should undergo folliculin gene test for Birt-Hogg-Dub\u00e9 syndrome."]}
{"Patient Symptoms": ["She noted pain and swelling in her right knee, which migrated to the right ankle and then affected the metacarpophalangeal (MCP) and proximal interphalangeal (PIP) joints of her fingers."], "Examination and Results": ["A malar rash was present (Figure), but there was no rash on the trunk or extremities.", "She had swelling and tenderness of the MCP and PIP joints and had difficulty making a fist and fully extending her fingers.", "Laboratory studies revealed a mild normochromic normocytic anemia with a hemoglobin level of 11.5 g/dL, normal white blood cell and platelet counts, and normal results for a comprehensive metabolic panel.", "She had a positive antinuclear antibody (ANA) result (1:160 [homogeneous pattern; negative <1:80 serum dilution])."], "Others": ["About 2 weeks before her symptoms began, her 5-year-old grandson had a febrile illness characterized by headaches, body aches, malaise, and rash on the cheeks, trunk, and extremities but no arthritis.", "Ten days later, her 10-month-old granddaughter developed a similar febrile illness.", "Eight days ago, her 25-year-old daughter developed headaches, malaise, and significant arthralgias affecting her wrists and knees but no rash or fever.", "Manifestations in all of the family members resolved spontaneously within 1 week.On examination, the patient was afebrile with normal vital signs."]}
{"Examination and Results": ["A computed tomography scan showed diffuse enlargement of the pancreas with peripheral hypoenhancement but no discrete mass.", "Soft tissue surrounded the infrarenal abdominal aorta, extended along the common iliac arteries, and obstructed the left ureter, causing hydronephrosis.", "Laboratory studies including immunoglobulin G subgroup 4 (IgG4) levels are shown in the Table.", "Fine-needle aspiration of the pancreas showed no malignancy.", "Colonoscopy results 8 months ago were normal.Test results indicate pancreatic cancer but the patient is a carbohydrate antigen (CA) 19-9 nonsecretor."], "Diagnosis": ["He was referred for evaluation of possible malignancy."]}
{"Patient Personal Background": ["His medical history was significant for Philadelphia chromosome-negative B-cell acute lymphocytic leukemia refractory to multiple treatments, including chimeric antigen receptor T-cell therapy, with transformation to acute myeloid leukemia (AML) status posttreatment.", "He was not receiving active cancer treatment."], "Patient Symptoms": ["At the time of evaluation, he had been hospitalized for 5 months with severe protein-calorie malnutrition, pancytopenia, and recurrent neutropenic fevers.", "He appeared cachectic and pale.", "Intraoral examination revealed poor oral hygiene.", "The left hard palate exhibited a large swelling with a 5\u00d73-cm indurated area of ulceration, central necrosis, and desquamation (Figure, A)."], "Examination and Results": ["The patient was febrile (38.3\u00b0C), with a white blood cell count of 0.5/\u03bcL (absolute neutrophil count 0.00; to convert to \u00d7109/L, multiply by 0.001), hemoglobin levels of 7.6g/dL (to convert to g/L, multiply by 10.0), hematocrit 21%, and platelet count 9/\u03bcL (to convert to \u00d7109/L, multiply by 1.0).", "A maxillofacial computed tomography (CT) scan completed the etiological investigation.A, The left hard palate shows enlargement with a large, focal, necrotic lesion.", "B, Hematoxylin-eosin stain of palatal tissue (original magnification \u00d71000).", "C, Grocott methenamine silver stain of palatal tissue (original magnification \u00d71000).", "D, Computed tomographic image of the maxillofacial complex shows tissue enlargement in the left hard palate and maxillary sinus."], "Treatment": ["The patient was treated palliatively with dexamethasone solution and nystatin rinse."], "Others": ["A biopsy was not recommended owing to medical instability.", "However, the patient retained a sloughed fragment of the affected tissue, which was submitted for histologic evaluation."]}
{"Patient Personal Background": ["There was no history of any systemic disorder and no family history of similar lesions."], "Examination and Results": ["Physical examination revealed multiple, well-demarcated, hypopigmented 1- to 5-mm macules on the lower abdomen and pubic area (Figure, A and B).", "Direct microscopic examination of scales soaked in potassium hydroxide did not reveal hyphae.", "Wood light examination revealed no accentuation.", "A punch biopsy specimen was obtained for further evaluation (Figure, C and D).A, Multiple discrete hypopigmented macules on the lower abdomen and pubic area.", "C, Histopathological examination revealed mild hyperkeratosis, acanthosis, and scattered clear cells in the epidermis (hematoxylin-eosin).", "D, The clear cells are larger than the neighboring keratinocytes and contain abundant pale cytoplasm (hematoxylin-eosin)."], "Others": ["B, Well-demarcated hypopigmented macules on the lower abdomen."]}
{"Patient Personal Background": ["He had no recent history of travel."], "Patient Symptoms": ["The plaque first appeared as a small inflammatory papule on the left nostril.", "One month before presentation at our facility, the patient began developing erythematous papules on his arms and legs.", "The papules enlarged and ulcerated.", "At admission, the patient was tachycardic and febrile to a temperature of 38.5\u00b0C."], "Examination and Results": ["Routine laboratory testing revealed normocytic anemia (hemoglobin, 7.7 g/dL [to convert to grams per liter, multiply by 10]).", "Shave biopsies of necrotic nodules on the left arm and left cheek (Figure, B-D) and, later, an excisional biopsy of a cervical lymph node were performed.", "Head computed tomography demonstrated a soft-tissue mass that encased the nasal bone and extended into the right maxillary sinus and left nasal cavity.", "Chest computed tomography showed bilateral pulmonary nodules.", "Physical examination revealed a necrotic plaque with surrounding erythema on the distal nose (Figure, A).", "A 1\u2009\u00d7\u20091-cm crateriform papule with central necrosis was present on the left malar cheek.", "Multiple nodules with central, dry necrosis and areas of poxlike scarring were scattered across the extremities.", "Slight contractures of his fingers were also noted.A, Clinical photograph."], "Treatment": ["Shortly thereafter, the patient was hospitalized at an outside facility for multifocal pneumonia.", "He was also treated for a methicillin-resistant Staphylococcus aureus infection of his nose."]}
{"Patient Personal Background": ["Four months earlier, he had presented to another hospital and received a diagnosis of adhesive small bowel obstruction, for which he underwent laparotomy and lysis of small adhesive bands that provided only temporary symptomatic improvement."], "Patient Symptoms": ["At his current presentation, he was unable to tolerate any oral intake and entirely dependent on total parenteral nutrition."], "Examination and Results": ["On examination, he was cachectic with a moderately distended, nontender abdomen.", "The result of a blood test (QuantiFERON-TB Gold; Qiagen) was positive for tuberculosis exposure.", "An abdominal computed tomography scan showed markedly dilated stomach and duodenum with decompressed, thickened distal small bowel without a clear transition point.Nonoperative management with persistently high nasogastric tube output failed, and the patient was subsequently taken to the operating room for exploratory laparotomy."], "Treatment": ["An abdominal computed tomography scan showed markedly dilated stomach and duodenum with decompressed, thickened distal small bowel without a clear transition point.Nonoperative management with persistently high nasogastric tube output failed, and the patient was subsequently taken to the operating room for exploratory laparotomy.", "Intraoperative findings are shown in Figure 1.Exploratory laparotomy showing the appearance of the small bowel."], "Others": []}
{"Patient Personal Background": ["His medical history was significant for hypertension, hyperlipidemia, and kidney stones."], "Examination and Results": ["Physical examination revealed poor dental hygiene and findings in the lower extremity suggestive of postthrombotic syndrome.", "The patient was afebrile with a heart rate of 108 beats per minute and a leukocyte level of 11\u202f600/cm (normal range, 4000-11\u202f000/cm), with 84% polymorphic neutrophils (normal, <75%); erythrocyte sedimentation rate was 57 mm/h (normal range, 0-10 mm/h), and C-reactive protein level was 15.9 mg/dL (normal, <0.6 mg/dL [to convert to nmol/L, multiply by 9.524])."], "Treatment": ["His surgical history was significant for a bilateral staged carotid endarterectomy in 1999 and 2000 and an open repair of a 7.4-cm transverse diameter juxtarenal abdominal aortic aneurysm with a knitted Dacron tube graft (18 mm) in 2014.", "Ligation of the left renal vein adjacent to the inferior vena cava was performed to gain proximal control of the aorta.", "The patient underwent extraction of a tooth secondary to an abscess 4 months earlier."], "Others": ["Computed tomography (CT) of the abdomen and pelvis was performed (Figure 1A and B).CT indicates computed tomography; WBC, white blood cell."]}
{"Patient Personal Background": ["Her medical and ocular histories were significant for pseudophakia of both eyes, obstructive sleep apnea, and hypertension treated with hydrochlorothiazide.On examination, visual acuity was 20/40 OD and 20/64 OS."], "Patient Symptoms": ["She described her vision as being blurred in the left eye, with areas of her vision being \u201cblocked.\u201d Her review of systems was unremarkable."], "Examination and Results": ["Intraocular pressure, pupillary reaction, and ocular motility were normal.", "Confrontation visual fields revealed a deficit in the inferotemporal quadrant of the left eye.", "External and slitlamp examinations were unremarkable.", "Dilated fundus examination revealed an epiretinal membrane, as well as extramacular, elevated, hypopigmented, yellow lesions with retinal pigment epithelium changes in both eyes, along with overlying subretinal fluid, subretinal hemorrhage, and exudates in the left eye (Figure, A).", "Optical coherence tomography showed an epiretinal membrane with cystoid macular edema and drusen in both eyes, along with subretinal fluid extending into the left macula, explaining her decreased vision.", "B-scan ultrasonography demonstrated hyperechoic, plaquelike, solid lesions with posterior acoustic shadowing corresponding anatomically to the lesions seen on clinical examination (Figure, B).", "Fluorescein and indocyanine angiography demonstrated leakage in the area of subretinal hemorrhage in the left eye (Figure, C).A, A yellowish lesion is located in the superonasal quadrant with nasal subretinal hemorrhage (asterisk)."]}
{"Patient Personal Background": ["His medical history included hypothyroidism and meningioma of the cervical spine.", "There was no history of trauma or surgery in the previous year."], "Patient Symptoms": ["The symptoms started in the right eye and progressed to the left eye 4 months later."], "Examination and Results": ["The patient had been evaluated elsewhere for suspected autoimmune retinopathy, with normal results for serum antibodies against recoverin and enolase, a complete blood cell count, antinuclear antibody, rheumatoid factor, anticitrullinated protein antibody, extractable nuclear antigens, and serologies for syphilis and Lyme disease.", "A previous neuro-ophthalmologic evaluation, including magnetic resonance imaging of the brain and orbits, had been unrevealing.His best-corrected visual acuity measured 20/400 OD and 20/100 OS.", "The results of a kinetic perimetry with a Goldmann perimeter demonstrated dense bilateral cecocentral scotomata.", "There was no afferent pupillary defect in either eye.", "A fundus examination showed trace temporal optic disc pallor in the right eye and a normal-appearing optic disc in the left eye (Figure 1A).", "Full-field electroretinography results were normal, but multifocal electroretinography (mfERG) showed reduced wave amplitudes nasal to the fovea in each eye (Figure 1B).", "Fundus autofluorescence and spectral-domain optical coherence tomography (SD-OCT) scans of the macula and optic nerve showed no abnormalities.A, Fundus photography shows a normal-appearing optic disc of the left eye.", "B, Multifocal electroretinography demonstrates reduced amplitudes of waveforms nasal to the fovea of the left eye."]}
{"Patient Personal Background": ["He received a diagnosis of type 1 diabetes at 10 years of age and has been taking insulin since the diagnosis."], "Patient Symptoms": ["He had consulted several physicians for hearing loss during the past 2 years.", "He had received multiple courses of antibiotics for frequent urinary tract infections."], "Examination and Results": ["The results of a systemic examination revealed hypochondroplasia, alopecia (Figure 1), and generalized hypotonia.", "His best-corrected visual acuity was 6/60 OU.", "Bjerrum tangent screen visual field analysis showed preservation of central 10 degrees of fields.", "His color vision was defective, and his pupils were slow reactive to light.", "The results of an optic nerve examination revealed bilateral pale optic discs with no evidence of edema and normal retinal vasculature.", "The results of the examination of the macula were normal in both eyes, with no diabetic retinopathy."]}
{"Patient Personal Background": ["Her medical history was remarkable for long-standing hypertension, diabetes, and mixed connective tissue disease."], "Examination and Results": ["On examination, the best-corrected visual acuity was 20/40 OD and 20/25 OS.", "Slitlamp examination showed prominent nuclear sclerosis and a posterior subcapsular cataract in the right eye and a well-positioned intraocular lens in the left eye.", "Ophthalmoscopic examination revealed bilateral pigment mottling with extensive peripheral depigmentation of the retinal pigment epithelium, sparing the central fovea bilaterally.", "Spectral-domain optical coherence tomography showed complete loss of photoreceptors outside the fovea, with retinal pigment epithelial atrophy, irregular proliferation, and some remodeling (Figure, A).", "Fundus autofluorescence showed a ring of parafoveal hypofluorescence and hyperfluorescence, with speckled hypofluorescence peripherally (Figure, B).", "Goldmann perimetry of both eyes (Figure, C) revealed significant constriction of the V-4-e isopter with an extensive ring scotoma between approximately 10\u00b0 and 30\u00b0 eccentricity.", "Central vision with the I-4-e isopter was constricted to 5\u00b0 to 7\u00b0.", "A multifocal electroretinogram (ERG) showed profound signal attenuation throughout the examined area.", "The full-field electroretinogram was nonrecordable under both scotopic and photopic conditions.A, Spectral-domain optical coherence tomography (SD-OCT) reveals extensive and diffuse retinal thinning (arrowhead) beyond the fovea, with loss of photoreceptors and pigment migration into the retina."]}
{"Patient Symptoms": ["He was initially seen locally for new-onset double vision in upgaze without other visual symptoms.", "During the subsequent 6 months, the patient experienced graying of vision on rightward gaze.", "The patient presented to our clinic 2 years after initial symptom onset with continued graying of vision on eccentric gaze."], "Examination and Results": ["The patient had a 3\u2013prism diopter left hypertropia in upgaze with full motility and was incidentally found to have optic disc edema in the right eye.", "His best-corrected visual acuity was 20/15 OU.", "Automated visual fields were normal, and there was no relative afferent pupillary defect.", "Magnetic resonance imaging (MRI) revealed no apparent abnormalities (Figure 1A).", "Results of an evaluation again demonstrated normal visual acuity and visual fields.", "His best-corrected visual acuity on examination was 20/25 OD and 20/20 OS.", "Relative afferent pupillary defect was noted in the right eye.", "There was prominent chronic-appearing optic disc edema in the right eye without abnormalities in the left eye (Figure 1B).", "Results of visual field testing showed superior greater than inferior peripheral field loss in the right eye and normal visual field in the left eye.A, T1-weighted magnetic resonance imaging scan of the orbit with contrast reveals trace enhancement at the orbital apex 2 years prior to presentation (arrowhead).", "B, Fundus photograph of the right eye demonstrates prominent chronic-appearing optic disc edema."], "Others": ["Results of a local workup were negative, including acetylcholine receptor antibody."]}
{"Patient Symptoms": ["According to the patient\u2019s report, he had experienced this vision abnormality in the left eye for 1 week.", "Two weeks later, he experienced acute worsening of visual acuity to 20/200 OU."], "Examination and Results": ["At presentation, visual acuity was 20/20 OD and 20/400 OS.", "Results of a dilated fundus examination were normal in the right eye and notable for a macular serous retinal detachment in the left eye (Figure 1A).", "Findings on optical coherence tomography (OCT) showed a dome-shaped collection of subretinal fluid in the macula (not shown).", "Late-phase fluorescein angiography revealed multifocal pinpoint areas of hyperfluorescence with mild leakage within the area of detachment (Figure 1B).Left eye.", "Examination and OCT showed resolution of subretinal fluid.", "Examination and OCT findings showed subretinal fluid in the macula bilaterally.", "Late-phase fluorescein angiography again revealed multifocal pinpoint areas of hyperfluorescence with mild leakage."], "Diagnosis": ["B, Late-phase fluorescein angiography shows multifocal pinpoint areas of hyperfluorescence with mild leakage.The patient was given a diagnosis of central serous chorioretinopathy (CSR) in the left eye."], "Others": ["A, A color fundus photograph shows serous macular detachment.", "After 3 weeks of observation, visual acuity in the patient\u2019s left eye improved to 20/40."]}
{"Patient Personal Background": ["Previous work-up had revealed minimal abdominal adenopathy, but the patient declined further workup."], "Patient Symptoms": ["The lesion was itchy but without generalized pruritus.", "The patient reported a weight loss of 10 pounds over the preceding 3 months.", "In addition, he reported a longer history of vague, nonspecific, intermittent abdominal pain without nausea, vomiting, or fever starting about 3 years prior to presentation."], "Examination and Results": ["On examination, he had no other cutaneous lesions, but he did have cervical lymphadenopathy.", "All other physical findings were within normal limits.", "Laboratory findings were unremarkable, save for a mild normochromic normocytic anemia and a mildly elevated levels of lactate dehydrogenase."], "Others": ["A biopsy specimen from the skin lesion is shown in Figure 1B.A, Clinical image of the patient at presentation.", "B, Biopsy specimen from the skin lesion is shown."]}
{"Patient Personal Background": ["His medical history was significant for remote percutaneous coronary intervention 19 years ago, with no available details at the time of the patient\u2019s presentation."], "Patient Symptoms": ["On arrival, the patient was hemodynamically unstable, with a blood pressure of 85/55 mm Hg.", "He was tachycardiac, with a heart rate of 105 beats per minute, and his oxygen saturation level was 91% on room air."], "Examination and Results": ["The patient was afebrile.", "Physical examination showed no jugular vein distension or peripheral edema, the presence of bibasilar rales, and no cardiac murmurs.", "A 12-lead electrocardiogram showed inferior ST-segment elevation in leads II, III, and aVF."], "Treatment": ["The patient was transferred urgently to the cardiac catheter laboratory."]}
{"Patient Symptoms": ["He reported no fevers, night sweats, abdominal pain, emesis, and diarrhea."], "Examination and Results": ["Physical examination revealed a thin habitus; no palmar erythema, spider angiomas, or gynecomastia were observed.", "Laboratory tests showed normal complete blood cell count and chemistry panel findings.", "Hepatic panel showed an elevated alkaline phosphatase level (209 U/L; upper limit of normal [ULN], 150 U/L [3.49 \u03bckat/L; ULN, 2.5 \u03bckat/L]), normal total bilirubin level (0.4 mg/dL [6.84 \u03bcmol/L]), elevated alanine aminotransferase level (41 U/L; ULN, 35 U/L [0.68 \u03bckat/L; ULN, 0.58 \u03bckat/L]), and normal aspartate aminotransferase level (27 U/L [0.45 \u03bckat/L]).", "A single-phase computed tomography (CT) scan of the abdomen revealed multiple hypoattenuating masses with rim enhancement throughout the liver, intussusception of the small bowel, and normal liver contour with no signs of portal hypertension (Figure 1, left).", "\u03b1-Fetoprotein (AFP) level was elevated (1252 ng/mL; ULN, 9 ng/mL); levels of carbohydrate antigen 19-9 (<2 U/mL) and carcinoembryonic antigen (2.8 ng/mL) were normal.", "A triple-phase CT scan was obtained to further evaluate the small bowel, which revealed no small bowel abnormalities but instead demonstrated a 3.3\u2009\u00d7\u20092.8-cm heterogeneously enhancing pancreatic tail mass not seen on the previous single-phase CT (Figure 1, right).Left, Axial view from single-phase computed tomography (CT) scan of the abdomen revealing bilobar liver masses."]}
{"Patient Symptoms": ["She presented with obvious biphasic stridor and a report of dyspnea on mild exertion.", "Vocal cord mobility was normal on fiberoptic laryngoscopy, and the patient verbally denied having dysphagia."], "Examination and Results": ["Noncontrast computed tomography of her chest showed a 1.1-cm nodular lesion in the upper trachea that appeared to be originating from the right lobe of the thyroid (Figure 1A).", "A CT of the chest showed a soft-tissue mass protruding into the trachea in the posterolateral aspect of the right side of the tracheal region that appeared to be contiguous with the thyroid gland.", "Ultrasound-guided fine-needle aspiration of the thyroid was performed; however, there was no nodule in the right thyroid lobe that correlated with the CT findings.", "The left thyroid lobe contained an 8-mm nodule.", "Examination of a biopsy specimen from this nodule showed medullary thyroid cancer (MTC).", "The patient\u2019s serum calcitonin level was 23 pg/mL.", "Magnetic resonance imaging (MRI) of the neck revealed a hyperintense tracheal mass on T2-weighted imaging (Figure 1B) that showed enhancement on administration of contrast medium (not shown).", "In addition, a 0.3-cm nonenhancing nodule at the lower pole of the right thyroid lobe, separate from the tracheal mass, was identified.", "Both ultrasonography and CT/magnetic resonance imaging failed to identify any suspicious adenopathy.A, Axial computed tomogram (CT) of the chest without contrast medium shows a 1.1-cm hypodense, exophytic right posterolateral intratracheal mass with apparent continuity with the right thyroid lobe.", "B, Axial, T2-weighted magnetic resonance image (MRI) with contrast medium revealed a hyperintense soft-tissue mass within the tracheal lumen.", "A T1-weighted image before the addition of contrast medium (not shown) showed a slightly hyperintense mass to the thyroid gland."], "Diagnosis": ["Examination of a biopsy specimen from this nodule showed medullary thyroid cancer (MTC)."], "Others": ["She was referred to our center for evaluation and management of what appeared to be an aggressive thyroid malignant neoplasm."]}
{"Patient Personal Background": ["She denied a medical history of sinonasal issues, immunodeficiency, autoimmune disease, malignant disease, or diabetes.On examination, she was afebrile with stable vital signs."], "Patient Symptoms": ["She described a 2-week medical history of diplopia and blurry vision as well as 4 months of nasal congestion and progressive headaches despite multiple antibiotic courses."], "Examination and Results": ["Ophthalmologic evaluation revealed a right afferent pupillary defect and cranial sixth-nerve palsy.", "Computed tomographic and magnetic resonance imaging of the sinuses revealed abnormal soft tissue throughout her sinuses with destruction of the sinus walls and skull base as well as extension of abnormal appearing tissue into the right orbital apex and posterior nasal septum.", "Laboratory evaluation demonstrated a normal white blood cell count and an elevated erythrocyte sedimentation rate and C-reactive protein level.", "Nasal endoscopy showed bloody mucus and crusting around the right middle turbinate and sphenoethmoidal recess.The acute nature of her vision loss amid concern for a destructive sinonasal process warranted operative intervention.", "A representative final pathology slide is shown in the Figure.Sinonasal mucosal biopsy results demonstrate numerous multinucleated giant cells (black arrowheads), necrosis (white arrowhead), and inflammatory cells invading vessel walls (blue arrowheads)."], "Treatment": ["Abnormal soft tissue with associated destruction throughout her sinonasal cavities and right orbital apex was identified.", "Frozen sections revealed negative results for fungal elements and cellular dysplasia but demonstrated widespread inflammation with giant cells."], "Others": ["Hematoxylin-eosin stain (original magnification \u00d710)."]}
{"Patient Symptoms": ["He had been hospitalized for this problem at an outside hospital and treated with antibiotics, without improvement.", "The swelling worsened and extended to his upper lip.", "He developed difficulty swallowing, headache, and nasal drainage."], "Examination and Results": ["On presentation, he was afebrile without leukocytosis.", "Physical examination demonstrated diffuse swelling and tenderness of the nose with honey-colored crusting that extended to above his upper lip.Axial and sagittal contrast-enhanced computed tomography (CT) (Figure, A and B) demonstrated marked soft tissue swelling and fullness with abnormal enhancement along the nasal cavity, including bilateral nasal ala, with areas of necrosis and emphysema.", "No significant bony erosion or associated calcification on bone windows was noted.", "After bedside debridement of the nasal soft tissue region, axial postcontrast T1-weighted fat-suppressed and sagittal T2-weighted fat-suppressed magnetic resonance imaging through the nasal cavity (Figure, C and D) demonstrated soft tissue fullness isointense to muscle on T1-weighted images, hyperintense on T2-weighted images, and with homogenous enhancement of the solid component on postcontrast T1-weighted images.", "No intracranial or intraorbital disease extension was noted.Contrast-enhanced computed tomography (CT) demonstrates marked soft tissue swelling and fullness with abnormal enhancement along the nasal cavity, including bilateral nasal ala, with areas of necrosis and emphysema."], "Treatment": ["After bedside debridement of the nasal soft tissue region, axial postcontrast T1-weighted fat-suppressed and sagittal T2-weighted fat-suppressed magnetic resonance imaging through the nasal cavity (Figure, C and D) demonstrated soft tissue fullness isointense to muscle on T1-weighted images, hyperintense on T2-weighted images, and with homogenous enhancement of the solid component on postcontrast T1-weighted images."]}
{"Patient Symptoms": ["On physical examination, the mass was firm, mobile, tender to palpation, and caused restricted range of motion."], "Examination and Results": ["Ultrasound imaging of the soft tissue of the neck was obtained, which demonstrated a neck mass with dense acoustic shadowing (Figure 1A).", "Further evaluation with contrasted computed tomography (CT) imaging showed a 3.3\u00d72.9\u00d72.6-cm ossified lesion in the left posterior-lateral cervical soft tissue near the atlanto-axial junction.", "The lesion was well circumscribed and separate from the underlying bone (Figure 1B).", "The gross pathology specimen showed a firm, irregular, encapsulated mass.A, Ultrasonography of the neck soft tissue demonstrating a neck mass with dense acoustic shadowing in the left posterior triangle.", "B, Axial computed tomographic imaging of the neck with contrast depicting a 3.3-cm well-circumscribed ossified mass that is separated from the C2 vertebral body.", "No aggressive-appearing periosteal reaction is present (arrowhead indicates calcified neck mass)."], "Treatment": ["The patient underwent excision of the mass without complication."]}
{"Patient Personal Background": ["He did not smoke and only drank alcohol occasionally.", "He was living in Japan and recently visited a neighboring island but denied any international travel.On examination, his blood pressure was 142/84 mm Hg; temperature, 38.3\u00b0C; pulse, 91/min; respiratory rate, 24/min; and oxygen saturation, 97% on ambient air."], "Patient Symptoms": ["Five days before arrival, he developed throat pain, rhinorrhea, nonproductive cough, and fever.", "Two days later he noticed a maculopapular rash on his neck and trunk, which later involved his upper and lower extremities."], "Examination and Results": ["He was alert and oriented.", "There were no mucosal lesions or conjunctival injection.", "A maculopapular rash was noted on the trunk and extremities (Figure) as well as the palms and soles.", "The face was not involved.", "The lungs were clear to auscultation.", "No hepatosplenomegaly was noted.", "Neurologic examination, including results of motor, sensory, and reflex testing, was unremarkable.", "There was no neck stiffness or lymphadenopathy.", "Laboratory testing showed a white blood cell count of 2900/\u03bcL (80% neutrophils, 13% lymphocytes, 6% monocytes, 0% eosinophils, and 0% basophils); hemoglobin level, 15.2 g/dL; and platelet count, 187\u2009\u00d7103/\u03bcL.", "Serum electrolyte levels were normal."]}
{"Patient Symptoms": ["She reported no cough, chest pain, orthopnea, leg swelling, or viral-like symptoms."], "Examination and Results": ["Her temperature was 36.8\u00b0C, heart rate 102/min, respiratory rate 22/min, and blood pressure 124/76 mm Hg.", "She had conjunctival pallor and scleral icterus, but no lymphadenopathy, hepatosplenomegaly, or ecchymosis.", "Results of initial laboratory testing are presented in the Table."]}
{"Patient Symptoms": ["The pain was described as crushing and substernal, but she denied radiation or associated dyspnea, nausea, vomiting, or diaphoresis."], "Examination and Results": ["On physical examination, her blood pressure was 167/105 mm Hg bilaterally, heart rate was 71/min, respiratory rate 18/min, and oxygen saturation 98% on room air.", "Initial laboratory evaluation revealed a troponin I level of 0.12 ng/mL (reference range, 0.00-0.04 ng/mL).", "An electrocardiogram showed normal sinus rhythm with diffuse ST-segment depressions but without q waves or ST-segment elevation (Figure, left).", "Computed tomography angiography did not show pulmonary embolism or aortic dissection.", "Echocardiography demonstrated a left ventricular ejection fraction of 53%, with apical akinesis and no valvular disease.Clinical findings from 12-lead electrocardiography (left) and right anterior oblique cranial angiography of the left anterior descending artery during diastole (right).The patient was started on aspirin and ticagrelor, heparin infusion, and metoprolol tartrate for treatment of non\u2013ST-segment elevation myocardial infarction."], "Treatment": [], "Diagnosis": []}
{"Patient Personal Background": ["He had a history of hypertension that was treated with an angiotensin receptor blocker."], "Patient Symptoms": ["On the second postoperative day, body temperature was 38.6\u00b0C.", "Blood pressure decreased from 145/72 mm Hg to 96/53 mm Hg with a heart rate of 105/min."], "Examination and Results": ["Preoperative estimated glomerular filtration rate (GFR) was 98 mL/min/1.73 m2.", "Chest x-ray revealed bilateral lung consolidations consistent with pneumonia.", "The patient was admitted to the intensive care unit (ICU) with acute respiratory failure and was placed on mechanical ventilation.", "In the ICU, urine output was 50 mL over 3 hours."], "Treatment": ["On day 3, he received 4.5 L of Ringer lactate over 12 hours."], "Diagnosis": ["Laboratory values are shown in the Table.The change in serum creatinine is within the coefficient of variation.The patient has acute kidney injury most likely related to sepsis.There are insufficient data to conclude that a decrease in glomerular filtration rate has occurred."]}
{"Patient Personal Background": ["His medical history was unremarkable, and he noted no environmental triggers or new medications."], "Patient Symptoms": ["He endorsed severe pruritus at these sites that would wake him up at night.", "He denied any recent trauma or history of similar lesions.", "He denied associated pain, blisters, or systemic symptoms (eg, fever, chills)."], "Examination and Results": ["Physical examination revealed 3 well-circumscribed, violaceous, annular patches without scale or erosion that are limited to his right axilla (Figure, A).", "No other lesions were noted on his skin or mucous membranes.", "A Wood lamp examination was negative.", "A punch biopsy specimen from a lesion was obtained (Figure, B and C).A, Clinical photograph shows oval and annular thin violaceous patches in the right axilla.", "B, Hematoxylin-eosin stain (original magnification \u00d740) demonstrates lymphocytes obscuring the dermal-epidermal junction.", "C, Hematoxylin-eosin stain (original magnification \u00d7200)."], "Treatment": ["Treatment with over-the-counter hydrocortisone cream, ketoconazole cream, and discontinuation of underarm deodorant yielded no improvement."]}
{"Patient Personal Background": ["She had a 15-year history of oral lichen planus (OLP) managed with betamethasone dipropionate, 0.05%, gel twice daily and clotrimazole troches, 10 mg, 3 times daily as needed for symptomatic OLP flares.", "Medical history revealed stage 1A mycosis fungoides/cutaneous T-cell lymphoma affecting the right calf and left thigh managed primarily with halobetasol, 0.05%, cream owing to intolerance of narrowband UV-B therapy and mechlorethamine, 0.016%, gel.", "Immunosuppression or history of infectious diseases, including human immunodeficiency virus (HIV), was not reported."], "Examination and Results": ["A 1.5\u2009\u00d7\u20091.0-cm nonremovable white, plaquelike lesion was observed on the left lateral tongue (Figure 1A).", "Biopsy specimens were obtained with a 3-mm punch instrument at 3 different sites, which demonstrated similar microscopic findings (Figure 1B and C).A, A corrugated, nonremovable white lesion on left lateral tongue.", "B, Histologic image showing hyperkeratotic, acanthotic stratified squamous epithelium exhibiting cells with lightly stained cytoplasm (balloon cells) throughout the stratum spinosum and superficial layer (hematoxylin-eosin).", "C, Histologic image showing several epithelial nuclei with peripheral chromatin margination also described as chromatin beading (arrowheads) (hematoxylin-eosin)."]}
{"Patient Symptoms": ["The lesion first appeared 12 months before presentation and was progressively growing.", "The lesion was asymptomatic."], "Examination and Results": ["He was otherwise well and denied any fevers or weight loss.Clinical examination revealed a dark brown longitudinal pigment band covering the full length of the toenail of the left second digit with corresponding nail thickening over the pigmented band.", "The pigment was the same width throughout the band and extended to the proximal nail fold (Figure, A).", "No other nail or skin lesions were found at the time of examination.", "A biopsy specimen was obtained from the nail plate and nail matrix and stained with hematoxylin-eosin (Figure, B-D).A dark brown longitudinal pigment band on the second toenail with pigment extends to the proximal nail fold (A)."], "Treatment": ["Histopathologic examination of the specimen with hematoxylin-eosin stain is seen at original magnification of \u00d740 (B), \u00d7100 (C), and \u00d7200 (D)."], "Others": ["This was his first time presenting to a physician for this problem, and no prior treatments had been attempted."]}
{"Patient Personal Background": ["He began college 6 months prior but had found the workload difficult and failed his examinations.", "He had no family history of mental disorders, denied any current or past use of drugs, and reported no significant medical history."], "Patient Symptoms": ["He reported that he no longer enjoyed his former interests and could not relate to people at college or to friends, but there were no clear signs of depressive disorders.", "He was 80% convinced that random people looked and talked about him when he was out in public but was able to question it.", "He stated that these people were probably commenting on the way he looked, but he did not believe these individuals meant him harm.", "He also reported a vague feeling of perplexity and derealization.", "These experiences began when he started college and continued to occur every day for up to an hour at a time, causing significant distress."], "Examination and Results": ["He was well kempt, was quiet during his interview, and provided short answers.", "No formal thought disorders were elicited."], "Others": ["He never acted on these thoughts."]}
{"Patient Personal Background": ["Her parents were nonconsanguineous, and her family history was unremarkable."], "Patient Symptoms": ["She had unsteadiness and frequent falls at gait initiation since age 16 months.", "There was a progressive worsening of her gait difficulties, and she complained of loss of balance.On examination, she had saccadic pursuit, subtle appendicular ataxia, and a spastic gait with a wide base."], "Examination and Results": ["She could not stand or walk with her feet in the tandem position.", "Her muscle strength was normal.", "Achilles tendon reflexes and plantar responses were absent, and vibration sense was decreased in her toes and ankles.Visual acuity, color vision, and visual fields were normal.", "Fundoscopy revealed increased visibility of retinal nerve fibers, hiding the contours of retinal vessels bilaterally.", "Optical coherence tomography (OCT) showed increased thickness in the retinal nerve fiber layer (RNFL) (Figure 1).Ophthalmological findings include color fundus photograph of the right eye (A) with increased visibility of the retinal nerve fiber layer, which hides retinal vessel contour; an optical coherence tomographic vertical B-scan revealing a markedly thickened retinal nerve fiber layer (asterisks) (B), captured along the green line seen on a red-free image of fundus (C)."]}
{"Patient Personal Background": ["History revealed multilevel cervical and lumbar fusion surgical procedures using anterior, left lateral, and posterior approaches over a 10-year period."], "Patient Symptoms": ["The patient subsequently noted a new, slowly enlarging bulge in her left midback that was bothersome with activities of daily living (Figure, A).", "She denied pain directly overlying the area and was otherwise tolerating a regular diet and having usual bowel function."], "Examination and Results": ["Physical examination revealed a soft bulge in the lateral left midback.", "There were no apparent associated skin changes, and the palpable mass appeared fixed and nonreducible.", "The mass was most apparent with upright posture and was accentuated with a cough impulse, but it was less distinct when examined in the prone position.", "Computed tomography of the abdomen and pelvis was obtained (Figure, B).Patient presentation (A) and computed tomography of the abdomen and pelvis (B)."]}
{"Patient Personal Background": ["On examination, he was noted to have some cervical midline spine tenderness."], "Patient Symptoms": ["He had been seen in his primary care physician\u2019s office about 2 weeks prior to emergency department presentation and had been treated for musculoskeletal symptoms.", "He admitted to paresthesia and pain radiating down his right arm but denied any weakness."], "Examination and Results": ["No weakness or sensory deficits were identified.", "A plain radiograph of the neck demonstrated tracheal deviation, and he then underwent computed tomography of the chest (Figure 1A) and magnetic resonance imaging of the cervical and thoracic spine (Figure 1B).Computed tomography scan and magnetic resonance image."], "Others": ["He had no history of recent trauma.", "He had no difficulty with speech or swallowing.", "He had no medical comorbidities or prior surgery.", "No palpable lymphadenopathy, swelling, or mass was noted.", "A, Coronal computed tomography image of the chest; B, sagittal magnetic resonance image of the cervical and thoracic spine."]}
{"Patient Personal Background": ["She denied additional ocular symptoms and reported no relevant medical, ocular, or family history; medication use; or allergies."], "Patient Symptoms": ["One week later, her symptoms had worsened, and she was referred for consultation.Best-corrected visual acuity was 20/15 OD and 20/60 OS."], "Examination and Results": ["The findings of a review of systems were unremarkable.", "Intraocular pressures, extraocular movements, visual fields by confrontation, and pupil responses were normal.", "Anterior segment examination and dilated fundus examination of the right eye had normal findings.", "However, the left eye had 3+ anterior chamber cell and 1+ flare, nongranulomatous keratic precipitates, and a clear lens.", "The dilated fundus examination revealed 2+ vitritis, a hyperemic disc with blurred margins, macular striae with a blunted foveal reflex, and vascular sheathing with segmental periarteriolar inflammatory plaques in multiple quadrants.", "The peripheral retina had well-demarcated peripheral retinal whitening with scalloped margins and intraretinal hemorrhages in all quadrants (Figure 1A and B).", "Four days later, repeat fundus photography showed that the peripheral lesions had coalesced into larger circumferential necrotic regions (Figure 1C).A, Color fundus photography montage of the left eye shows hyperemic disc with blurred margins, vascular sheathing, and peripheral retinal whitening.", "B, Magnified image of the temporal retina shows well-demarcated infiltrates with scalloped margins and adjacent intraretinal hemorrhages."], "Treatment": ["A workup for posterior uveitis was initiated, and the patient began therapy with oral antiviral and oral corticosteroid medications."]}
{"Patient Personal Background": ["Previous episodes had been treated successfully with oral prednisone, and the patient had numerous recurrences within the past 10 years.", "According to the patient\u2019s report, a biopsy was performed several years ago at an outside institution, and the diagnosis was xanthelasma."], "Patient Symptoms": ["She denied visual changes.A, External photograph demonstrating bilateral periorbital swelling greater in the left\u2009than right eyelids, with associated yellow lesions."], "Examination and Results": ["B, Axial computed tomographic scan with contrast demonstrating enlargement and homogeneous enhancement of the left lacrimal gland and left lateral rectus muscle and bilateral preseptal soft tissues.Visual acuity was 20/40 OU  and improved to 20/25 OU with pinhole testing.", "Intraocular pressures were normal, extraocular motility was full, and the pupils were round and reactive without an afferent pupillary defect.", "Results of the examination revealed yellow lesions on both eyelids, palpebral swelling greater in the left than the right eye, erythema, ptosis, an S-shaped deformity of the left upper eyelid, and a palpable mass of the left superolateral orbit (Figure 1A).", "Hertel exophthalmometry showed 2 mm of relative proptosis in the left eye.", "Results of slitlamp and dilated fundus examinations were unremarkable.", "A computed tomographic scan showed preseptal soft tissue swelling in both eyes and an extraconal left lacrimal gland mass extending behind the globe (Figure 1B)."], "Diagnosis": ["According to the patient\u2019s report, a biopsy was performed several years ago at an outside institution, and the diagnosis was xanthelasma."], "Others": ["We contacted the outside institution, and no reports of histopathologic examination of the biopsy specimen were found."]}
{"Patient Personal Background": ["The patient reported a negative review of systems and denied recent travel, trauma, use of antibiotics, or pregnancy."], "Patient Symptoms": ["During the session, the physician assistant removed the metal eye shield for better exposure, immediately after which the patient developed eye pain and blurred vision."], "Examination and Results": ["Her examination was notable for best-corrected visual acuity of 20/20 OU, anterior chamber (AC) pigment and flare in the left eye, and iris irregularities, including decreased iris reactivity, peripupillary transillumination defects (Figure, A), and posterior synechiae.", "She had mild intraocular pressure (IOP) asymmetry of 12 mm Hg OD and 17 mm Hg OS.A, An irregular pupil, iris atrophy, and peripupillary transillumination defects are observed.", "B, After discontinuation of the cycloplegic agent, posterior concavity of the iris and iris-lens touch consistent with reverse pupillary block are observed.Gonioscopy revealed increased trabecular meshwork pigmentation in the left eye.", "Ultrasonographic biomicroscopy and anterior segment optical coherence tomography demonstrated a normal anterior segment in the right eye and posterior bowing of the iris and lens-iris touch (Figure, B) with a normal AC depth in the left eye."], "Treatment": ["She was initially treated for acute iritis with difluprednate, 4 times daily, which was tapered to once daily, with minimal improvement in her symptoms."], "Others": ["Six weeks before, she received eyebrow laser epilation with an 800-nm diode laser (LightSheer; Lumenis)."]}
{"Examination and Results": ["Best-corrected visual acuity was 20/20 OU with a 2-diopter myopic shift in the left eye.", "There was no afferent pupillary defect, color vision was normal, and intraocular pressure (IOP) was 10 mm Hg OD and 8 mm Hg OS.", "Visual field testing revealed an enlarged blind spot in the left eye, and optical coherence tomography of the left eye revealed thickening of the retinal nerve fiber layer in all quadrants.", "The results of examination and testing of the right eye were unremarkable.", "The results of workup with a complete blood cell count, basic metabolic panel, angiotensin-converting enzyme measurement, Lyme disease testing, and antinuclear antibody measurement were unremarkable.Ophthalmic examination in the emergency department revealed diminished visual acuity to counting fingers, an IOP of 59 mm Hg, and a relative afferent pupillary defect in the left eye."], "Treatment": ["She was treated with a topical corticosteroid, with rapid resolution of iritis and commotio."], "Diagnosis": ["On her initial ophthalmic examination 3 weeks earlier, she was diagnosed with commotio retinae and traumatic iritis in the left eye after being struck with the brim of a hat."], "Others": ["However, she developed ipsilateral, asymptomatic grade 2 optic disc edema."]}
{"Patient Personal Background": ["He denied any visual or systemic symptoms, and his medical history was significant for hypertension and atrial fibrillation treated with cardiac catheterization and ablation.", "Medications included amlodipine besylate, 5 mg daily, and aspirin, 81 mg daily.", "His family and social history were unremarkable."], "Examination and Results": ["On examination, his visual acuity was 20/20 OU.", "The intraocular pressure in both eyes was normal, and there was no relative afferent pupillary defect.", "Extraocular motility and confrontational visual fields were also normal.", "On physical examination, facial plethora was evident (Figure 1A).", "Retinal examination of the left eye revealed 2 blot hemorrhages and dilatation of the retinal veins (Figure 1B).", "Retinal examination of the right eye also revealed dilatation of the retinal veins.", "Fluorescein angiography revealed a prolonged arm-to-retina transit time of 22.6 seconds (normal, 10-16 seconds).", "Optical coherence tomography scans of the macula in both eyes were normal.", "In addition, an area of bruising was noted on the right shoulder in the absence of any history of trauma to the shoulder.A, Facial plethora."], "Others": ["These abnormal findings were not present 1 year earlier."]}
{"Patient Symptoms": ["He denied any vision changes, eye pain, or light sensitivity.", "A comprehensive review of symptoms was negative, including no fatigue, weight loss, or night sweats."], "Examination and Results": ["Best-corrected visual acuity was 20/40 OD and 20/30 OS.", "Anterior segment examination revealed ocular surface dryness and a nuclear sclerotic cataract in the right eye.", "On dilated fundoscopy, multiple yellow-white subretinal deposits were scattered throughout the left posterior pole, with parafoveal coalescence but sparing the far periphery.", "There was no concomitant vitritis (Figure, A).", "Optical coherence tomography showed choroidal thickening and irregularity of the overlying retinal pigment epithelium (Figure, B).", "The right eye was unremarkable.A, Fundus photograph of the left eye shows scattered hypopigmented subretinal deposits with parafoveal coalescence.", "B, Optical coherece tomographic findings show patchy choroidal thickening with irregularity of the overlying retinal pigment epithelium (arrowhead).", "The neurosensory retina maintained its regular architecture."]}
{"Patient Personal Background": ["He smoked approximately 10 cigarettes per day for 4 years."], "Examination and Results": ["Results of the physical examination were unremarkable.", "Radiography of the chest revealed an ill-defined consolidation in the right lower lung field.", "Laboratory investigations were significant for elevated levels of lactate dehydrogenase (273 U/L; reference range, 135-225 U/L [to convert to microkatals per liter, multiply by 0.0167]), C-reactive protein (125.3 mg/L; reference range, 0.0-4.9 mg/L [to convert to nanomoles per liter, multiply by 9.524]), and alkaline phosphatase (217 U/L; reference range, 40-129 U/L [to convert to microkatals per liter, multiply by 0.0167]).", "Computed tomography of the chest confirmed the presence of a dense consolidation involving most of the right middle lobe with right hilar and subcarinal lymphadenopathy (Figure, A).", "He underwent endobronchial ultrasonography-guided transbronchial needle aspiration of a fleshy, whitish endobronchial lesion obstructing both uptakes to the medial and lateral segments.", "However, findings were negative for S-100, melan A, placental alkaline phosphatase, CD56, thyroid transcription factor-1, terminal deoxynucleotidyl transferase, CD45, and cytokeratin 7."], "Treatment": ["Histologic analysis revealed a poorly differentiated malignant neoplasm (Figure, B)."], "Others": ["Most of the cells were relatively monotonous, with enlarged vesicular nuclei, prominent nucleoli, and a high ratio of nucleus to cytoplasm.", "Foci of abrupt squamous differentiation, including keratinization and intercellular bridges, were identified.", "Immunohistochemical staining showed tumor cells to be strongly and diffusely positive for keratin AE1/AE3, cytokeratin 5/6, and p63.", "A positron emission tomography\u2013computed tomography scan showed a fludeoxyglucose-enhanced avid right middle lobe mass, a large right-sided pleural effusion, and fludeoxyglucose-enhanced avid mediastinal and right hilar lymph nodes, with extensive skeletal metastases to both proximal humeri and scapulae, the sacrum, spine, iliac bones, and both hips.A, Computed tomography of the chest revealed a dense consolidation in the middle lobe of the right lung with right hilar and subcarinal lymphadenopathy.", "B, Histologic analysis of the mass revealed a poorly differentiated malignant neoplasm.", "Most cells showed enlarged vesicular nuclei, prominent nucleoli, and a high ratio of nucleus to cytoplasm (hematoxylin-eosin; original magnification \u00d7200)."]}
{"Patient Personal Background": ["She had a history of deep vein thrombosis 3 years prior but was not receiving long-term anticoagulation."], "Patient Symptoms": ["She had pulseless electrical activity.", "She remained comatose and was intubated for airway protection."], "Examination and Results": ["A physical examination revealed a rapid irregular pulse, no jugular venous distension, clear lung fields, and no cardiac murmurs.", "There was no peripheral edema.", "Laboratory findings were notable only for a troponin T level of 2.41 ng/mL (to convert to micrograms per liter, multiply by 1).", "An electrocardiogram (ECG) and a point-of-care transthoracic echocardiogram (TTE) were obtained (Figure 1; Video)."], "Treatment": ["After resuscitation, the return of spontaneous circulation was achieved.", "She remained comatose and was intubated for airway protection."]}
{"Patient Symptoms": ["He denied any symptoms related to the lesion, including dysphonia or dysphagia, and reported no fevers or weight loss.", "Postoperatively, the patient was doing well and continued to have no symptoms of dysphagia or dysphonia."], "Examination and Results": ["Rigid stroboscopy revealed normal vocal fold mobility and a nodular cystic-appearing lesion on the posterior inferior border of the right vocal process (Figure, A).", "There was no overlying ulceration, and vocal fold mucosal wave was intact in the adjacent membranous vocal fold.Suspension microlaryngoscopy incisional biopsy of the right infraglottic lesion was performed in the operating room.", "Intraoperatively, there was submucosal white caseous debris in the substance of the lesion.", "Cultures were analyzed for the presence of fungus, bacteria, and mycobacteria."], "Treatment": ["The endotracheal tube was displaced anteriorly with the laryngoscope.", "The surgical specimen was sent for histopathologic analysis (Figure, B)."]}
{"Patient Symptoms": ["The swelling was mild at onset and gradually progressive.", "There was no history of associated pain, but he reported occasional pruritus over the swelling.", "There was no history of fever, weight loss, or loss of appetite.", "He denied any history of similar swelling elsewhere in his body."], "Examination and Results": ["General physical and systemic examination had normal results.", "On examination of the swelling on the right side, there was a diffuse swelling around the pinna measuring approximately 6 cm over the preauricular, postauricular, and infra-auricular region.", "It was a nontender, soft swelling without fluctuation and abnormal pulsations.", "There were similar findings in the left side.", "Mouth opening was adequate, secretions from both parotid ducts were normal, and facial nerve function was intact on both sides.", "A contrast-enhanced computed tomographic scan of the head and neck showed bilateral multiple enhancing lymph nodes in the postauricular region, the largest measuring 16\u2009\u00d7\u200911 mm2 on the right side and 15.4\u2009\u00d7\u200910.6 mm2 on the left, along with bilateral intraparotid nodes, the largest measuring 16.4\u2009\u00d7\u200910.2 mm2 on the right and 15.3\u2009\u00d7\u200910.7 mm2 on the left side.", "His serum eosinophil count was slightly elevated, and his erythrocyte sedimentation rate was 15 mm/h."], "Treatment": ["He was prescribed oral antibiotics for 1 week but showed no improvement."], "Diagnosis": ["The results of both were consistent with reactive lymphadenitis."], "Others": ["He had undergone fine-needle aspiration cytology and incisional biopsy.", "However, the IgE level was not measured.", "He was then scheduled for excisional biopsy at our center.", "The biopsy specimen included skin and subcutaneous tissue along with 2 underlying lymph nodes.Clinical photographs showing diffuse swelling of the preauricular, infra-auricular, and postauricular region."]}
{"Patient Symptoms": ["The patient had been seen repeatedly for odynophagia that persisted despite multiple courses of antibiotics, reflux medications, and steroids prescribed at clinics and emergency departments.", "All showed inconclusive results, and the mass progressively enlarged.", "Further confounding the clinical picture, a pacemaker was required for multiple episodes of sinus asystole due to mass effect on the carotid body."], "Examination and Results": ["At presentation for the present report, physical examination showed a 2-cm, well-mucosalized, left oropharyngeal mass not extending to the hard palate (Figure, A).", "Computed tomography (CT) revealed a 58-mm parapharyngeal mass lateralizing and narrowing the left carotid artery against the styloid process (Figure, B).", "A CT-guided fine-needle aspiration biopsy was performed but again was nondiagnostic.", "B, Left parapharyngeal mass measuring 4.3\u2009\u00d7\u20092.7\u2009\u00d7\u20095.8 cm and lateralizing the left carotid artery.", "C, Fascicular, storiformed architecture with spindly, polygonal-shaped cells with eosinophilic cytoplasm and indistinct borders (original magnification \u00d710).", "D, Positive findings for CD21 (left; original magnification \u00d710) and CD23 (right; original magnification \u00d720)."], "Treatment": ["Over the course of 5 months, he underwent a tonsillectomy and 3 separate biopsies at multiple institutions.", "To obtain the diagnosis of the parapharyngeal mass, the patient had a transcervical resection with transoral partial glossectomy, palatectomy, and pharyngectomy with reconstruction."], "Others": ["Results of immunohistochemical analysis of the removed tissue were positive for CD4 (weak), CD21, CD23, and vimentin with a low proliferation rate (Figure, C and D).A, A 2-cm well-mucosalized left oropharyngeal soft-palate mass anterior to the tonsillar bed with surrounding erythema."]}
{"Patient Personal Background": ["Her history included bariatric gastric bypass surgery (3 years prior), hysterectomy for uterine leiomyomas (5 years prior), and pulmonary thromboendarterectomy for chronic thromboembolic pulmonary hypertension (7 years prior).", "She had recently undergone ovarian stimulation for in-vitro fertilization.The patient\u2019s physical examination showed a tender abdomen without rigidity."], "Patient Symptoms": ["She had recently undergone ovarian stimulation for in-vitro fertilization.The patient\u2019s physical examination showed a tender abdomen without rigidity."], "Examination and Results": ["Auscultation revealed no abnormal findings.", "Results of routine blood testing were unremarkable.", "Imaging studies suggested intussusception at the jejunojejunal anastomosis and a right adnexal mass; the intussusception was successfully reduced laparoscopically.", "Multiple ruptured follicles were seen on the surface of the right ovary."], "Treatment": ["Imaging studies suggested intussusception at the jejunojejunal anastomosis and a right adnexal mass; the intussusception was successfully reduced laparoscopically."]}
{"Patient Personal Background": ["Two years ago, she immigrated to the United States from Bangladesh.", "Five months ago, she visited Bangladesh to get married."], "Patient Symptoms": ["She reported hypoesthesia over the lesion."], "Examination and Results": ["A biopsy of the lesion obtained there showed multiple perineural granulomas with inflammatory cells.", "Gram stain and acid-fast bacillary and fungal stains of the biopsy specimen were negative.", "The patient was prescribed 1 dose each of doxycycline, ofloxacin, and rifampin and experienced no improvement.On physical examination there was a mildly erythematous macule located over the medial aspect of the right palm, with loss of touch and temperature sensation over the involved area (Figure)."], "Treatment": []}
{"Examination and Results": ["He had no evidence of advanced liver disease (eg, thrombocytopenia).", "Liver ultrasound showed no signs of cirrhosis, such as nodularity.", "Vibration-controlled transient elastography (VCTE) performed prior to treatment was negative for signficant fibrosis at 6.7 kPa.", "Laboratory studies and VCTE were performed (Table 1).The patient requires a liver biopsy to confirm fibrosis stage."], "Treatment": ["Hepatitis C was cured, based on viral load, with simeprevir and sofosbuvir for 12 weeks."], "Others": ["He presents for follow-up."]}
{"Patient Personal Background": ["She had a non\u2013ST-segment elevation myocardial infarction 1 year ago and was treated with a drug-eluting stent in her right coronary artery.", "Additionally, the patient had generalized anxiety and panic disorders (treated with paroxetine, 30 mg), and she smoked for 90 pack-years but quit 2 months ago."], "Patient Symptoms": ["The patient\u2019s home BP measurements were often lower than 120/80 mm Hg but sometimes reached 200/100 mm Hg.", "Mean BP levels were 133/86 mm Hg overall (normal, <130/80 mm Hg); daytime, 135/88 mm Hg (normal, <135/85 mm Hg); and sleeping, 124/78 mm Hg (normal, <120/70 mm Hg).1 During the first sudden increase in BP (04:00-06:00; Figure), she awoke from sleep with a panic attack."], "Examination and Results": ["The patient\u2019s office BP measurement was 127/74 mm Hg.", "Her physical examination was unremarkable.Twenty-four-hour ambulatory BP monitoring was performed to evaluate patterns of elevated BP and potential etiologies.", "Mean BP levels were 133/86 mm Hg overall (normal, <130/80 mm Hg); daytime, 135/88 mm Hg (normal, <135/85 mm Hg); and sleeping, 124/78 mm Hg (normal, <120/70 mm Hg).1 During the first sudden increase in BP (04:00-06:00; Figure), she awoke from sleep with a panic attack."], "Treatment": ["Her antihypertensive medications included carvedilol (12.5 mg, twice daily), lisinopril (40 mg daily), and chlorthalidone (12.5 mg daily)."], "Others": ["The patient kept a log of her diet, sleep pattern, and symptoms.", "The second sudden increase (07:00-10:00) occurred after eating a high-sodium breakfast.The patient has normal BP since the office BP was normal."]}
{"Patient Personal Background": ["There was no known history of travel in relation to onset of the lesions."], "Patient Symptoms": ["The eruption had gradually spread from the left palm to the right palm and then focally onto the bilateral volar aspect of the wrists in recent months (Figure, A and B)."], "Examination and Results": ["Limited clinical examination revealed well-marginated brown atrophic patches on the bilateral palms extending focally onto the volar aspect of the wrist and centrally surmounted by spiny keratotic pits in the palmar creases."], "Others": ["She had not experienced involvement of the plantar surfaces.", "No additional concerns were reported, and there was no family history of similar lesions.", "Two punch biopsy specimens were obtained for diagnostic clarification (Figure, C and D).A, An atrophic hyperpigmented plaque with spiny papules in the palmar creases.", "B, Similar features extending onto the volar wrist.", "C and D, Histopathologic images (hematoxylin-eosin, original magnification \u00d7100)."]}
{"Patient Personal Background": ["Her medical history included a cadaveric renal transplant 2 years earlier for end-stage renal failure.", "Immunosuppressant medications included mycophenolate mofetil, 200 mg, twice daily and tacrolimus, 8 mg, twice daily."], "Patient Symptoms": ["Subsequently it spread to involve nose, chin, upper trunk, and extremities.", "The lesions were mildly pruritic."], "Examination and Results": ["Physical examination revealed multiple 1-mm flesh-colored follicular papules and keratin spines against a diffuse erythematous background affecting the face (Figure, A and B) and upper trunk.", "Her scalp and eyebrow hairs were unremarkable.", "Serology results were unremarkable.", "Results of skin biopsy from the right ear demonstrated dilatation and keratotic plugging of the hair infundibula with marked dystrophy and expansion of the inner root sheath.", "The inner root sheath cells were enlarged with irregular trichohyaline granules and apoptotic cells with abrupt cornification without formation of a granular layer (Figure, C).", "Immunohistochemical analysis for SV40 polyomavirus was positive (Figure, D).Photographs of (A) forehead and (B) nose depicting multiple follicular papules and keratin spines against a diffuse erythematous background."], "Others": ["C, Hematoxylin-eosin staining (original magnification \u00d740).", "D, SV40 polyomavirus stain (original magnification \u00d740)."]}
{"Patient Personal Background": ["She could not recall an arthropod bite prior to the skin eruption and denied having traveled outside Spain in the past few years.", "Such lesions had never appeared on the face, hands, or feet.", "She did not relate these lesions to any particular hobby or application of any skin care product."], "Patient Symptoms": ["She complained about mild pruritus that had not responded to conventional antihistamine therapy or topical steroids.", "She reported a 20-year history of the same annular plaques recurring on the trunk every single year by the beginning of summer and spontaneously resolving by the beginning of autumn."], "Examination and Results": ["Physical examination revealed a large, 35-cm semicircular erythematous plaque on her lower back with central clearing and a distinctive, well-demarcated papular border (Figure, A and B).", "After obtaining informed consent, 2 biopsy specimens were taken from the papular border of the plaque for both hematoxylin-eosin stain and direct immunofluorescence (Figure, C).A, Large erythematous semicircular plaque with central postinflammatory hyperpigmentation on the lower back.", "B, Absence of epidermal changes, mild edema of the papillary dermis, and a superficial sparse perivascular inflammatory infiltrate.", "C, Inflammatory infiltrate composed mainly by lymphocytes and few neutrophils."], "Treatment": ["After obtaining informed consent, 2 biopsy specimens were taken from the papular border of the plaque for both hematoxylin-eosin stain and direct immunofluorescence (Figure, C).A, Large erythematous semicircular plaque with central postinflammatory hyperpigmentation on the lower back."], "Others": ["D, Follow-up visit showing clinical resolution in October."]}
{"Patient Symptoms": ["He also reported a history of painful paresthesias at his feet beginning about 1 year prior.On examination, his visual acuity was initially 20/80 OD and 20/200 OS; it deteriorated over the next 2 months to finger counting bilaterally.", "An echocardiogram showed a left ventricle ejection fraction of 20% to 25%, which had been 55% to 60% at the last test 2 years prior."], "Examination and Results": ["The Weber test gave a nonlateralizing result, and bone conduction hearing was absent bilaterally.", "There was length-dependent loss of vibratory sensation and absent reflexes at both lower extremities.", "Magnetic resonance imaging demonstrated abnormal enhancement of bilateral optic nerves (Figure, A).", "Optical coherence tomography and fluorescein angiogram were normal.", "Nerve conduction studies showed mild sensory axonal polyneuropathy.", "Laboratory tests were notable for elevated thyrotropin (63 mlU/ml), low levels of free thyroxine (T4) (0.2 ng/dL), and elevated levels of cerebrospinal fluid protein (94 mg/dL).", "Cerebrospinal fluid IgG index, oligoclonal bands, aquaporin 4 antibody, paraneoplastic panel, and protein electrophoresis test results were all normal.", "No other lesions were seen in the brain.", "B, Axial T-2\u2013weighted magnetic resonance image of the right hip, demonstrating susceptibility artifact of orthopedic hardware, as well as soft tissue heterotopic ossification (corroborated by plain-film radiographs), consistent with pseudotumor of metallosis with decompression into the right hip joint space (blue asterisk), the subiliac bursa (red asterisk), greater trochanter bursa (yellow asterisk) extending into the gluteus maximus muscle (arrowheads), and into a potential space between the tensor fascia lata and the rectus femoris (black asterisk).Four months after initial presentation, the patient reported new symptoms of chest tightness and dyspnea on exertion.", "At 5 months after initial presentation, the patient developed acute worsening of dyspnea and was admitted for respiratory distress."], "Treatment": ["He was treated empirically with high-dose steroids and plasmapheresis, with no improvement in symptoms.A, Axial postgadolinium, fat-suppressed, T-1\u2013weighted magnetic resonance image of the orbits, demonstrating left greater than right enhancement of the optic nerves (arrowheads)."], "Diagnosis": ["He was found to have nonischemic cardiomyopathy and died on hospital day 13."], "Others": ["The enhancement is centrally located within the optic nerves on coronal sections (not shown)."]}
{"Patient Personal Background": ["She denied any hematochezia or history of peptic ulcer disease.", "She had no other surgical history and denied alcohol use or smoking."], "Patient Symptoms": ["She was locally tender to palpation in the right lower quadrant with rebound and voluntary guarding."], "Examination and Results": ["On examination, she was hypertensive (blood pressure, 185/85 mm Hg) although not tachycardic and was afebrile.", "Her abdomen was not tympanitic.", "The patient had no abdominal scars, hernias, or palpable masses.", "Laboratory results were significant for the following: leukocyte count, 23 600/\u00b5L (to convert to \u00d7109/L, multiply by 0.001) with neutrophilia (94%); blood urea nitrogen level, 28 mg/dL (to convert to millimoles per liter, multiply by 0.357); creatinine concentration, 0.01 mg/dL (to convert to micromoles per liter, multiply by 88.4); lipase concentration, 195 U/L (to convert to microkatals per liter, multiply by 0.0167); and lactate concentration, 2.02 mg/dL (to convert to millimoles per liter, multiply by 0.111).", "Electrolyte levels and liver function test results were within normal limits.", "An electrocardiogram showed normal sinus rhythm.", "Computed tomography of the abdomen and pelvis with oral and intravenous contrast enhancement was performed (Figure).Axial cross-sectional computed tomograms of the patient\u2019s abdomen and pelvis with oral and intravenous contrast enhancement show segmental mural thickening of the anterior cecum with wall hypoenhancement and pneumatosis, adjacent fat stranding, and a lucency medial to the cecum (A) and bilateral renal hypodensities (B)."]}
{"Patient Symptoms": ["The abdominal pain was associated with diarrhea, nausea, and abdominal bloating."], "Examination and Results": ["On examination, the patient was afebrile and her abdomen was soft and nondistended without guarding or rebound but tender in the left lower quadrant.", "The patient had a palpable nodule in the posterior vaginal fornix and fullness in the left lower quadrant of the abdomen on bimanual examination.Laboratory investigations had normal findings with the exception of an elevated cancer antigen 125 level of 158 U/mL (to convert to kilounits per liter, multiply by 1.0).", "Contrast-enhanced computed tomography (CT) revealed multiple abnormal findings that included a bulky uterus with a thickened myometrium, endometriomas, right pleural effusion, pelvic peritonitis and ascites, enlarged lymph nodes, and solid extracolonic implants in the omentum caudal to the transverse colon (Figure, A) and in the cul-de-sac adjacent to the upper rectum (Figure, B).", "Subsequent magnetic resonance imaging (MRI) showed 2 areas of focus corresponding with the extracolonic implants."]}
{"Patient Symptoms": ["Associated symptoms included dysphagia and fever and chills."], "Examination and Results": ["A previous otolaryngology evaluation revealed an intranasal mass with enlargement of multiple submandibular lymph nodes.", "A needle aspiration biopsy of 1 of the submandibular lymph nodes revealed atypical cells with mature lymphocytes.", "Computed tomography of the sinus confirmed a nasal polyp and a soft tissue mass in the right lacrimal gland region.", "The excised nasal polyp was benign.", "Incisional biopsy of the lacrimal gland lesion revealed chronic inflammatory infiltrate composed of predominantly T cells with scattered B cells and mature plasma cells, but no evidence of a lymphoproliferative process.", "On examination, visual acuity was 20/40 OD and 20/25 OS.", "Intraocular pressure was unremarkable and ocular motility was intact in both eyes.", "Clinical evaluation revealed a firm mass of 5\u2009\u00d7\u20094\u2009\u00d7\u20093 cm fixed to the superotemporal orbital rim in the right lacrimal gland region (Figure 1) with intact overlying skin.", "Slitlamp examination was unremarkable in both eyes without evidence of conjunctival inflammatory signs.", "Ophthalmoscopic examination was unremarkable in both eyes without compression of the optic nerve or disc edema.Color photograph depicting swelling over the right lacrimal gland region with intact epidermis and absence of inflammatory signs."], "Others": ["The patient was referred for evaluation in our clinic.Ocular history was noncontributory."]}
{"Patient Personal Background": ["He was born full term with no complications during pregnancy or delivery."], "Patient Symptoms": ["The parents noticed asymmetry between the child\u2019s eyes since birth and progressive right lower eyelid fullness."], "Examination and Results": ["On examination, the boy fussed when his left eye was covered, and his left eye was able to fixate and follow.", "The right globe could not be visualized within the palpebral fissure because of a large compressible mass that transilluminated (Figure, A).", "The remainder of the left eye examination findings were noncontributory.", "Orbital magnetic resonance imaging was ordered (Figure, B).A, Clinical photograph of child at presentation displaying a right orbital cyst.", "B, Coronal T2-weighted magnetic resonance image showing a large inferior right orbital cyst displacing the microphthalmic globe superiorly."], "Others": ["He was seen by his pediatrician, a general ophthalmologist, and a pediatric ophthalmologist before presenting to our institution."]}
{"Patient Personal Background": ["Additional history revealed that the boy had handled a bloody raccoon carcass without gloves several days before initial presentation."], "Patient Symptoms": ["On transfer to our institution for failure to improve and concern for orbital cellulitis, results of examination by the ophthalmology service revealed a unilateral hemorrhagic conjunctivitis without orbital signs, and computed tomography showed mild preseptal edema.", "The patient was discharged with a tentative diagnosis of viral conjunctivitis.Three days later, the patient returned with fever, prominent submandibular lymphadenopathy, and ipsilateral granulomatous conjunctivitis (Figure)."], "Examination and Results": ["On transfer to our institution for failure to improve and concern for orbital cellulitis, results of examination by the ophthalmology service revealed a unilateral hemorrhagic conjunctivitis without orbital signs, and computed tomography showed mild preseptal edema.", "Results of the remainder of the anterior segment and dilated examination were unremarkable.", "Results of laboratory tests revealed elevated inflammatory markers (C-reactive protein level, 9.47 mg/dL [to convert to nanomoles per liter, multiply by 9.524], and erythrocyte sedimentation rate, 48 mm/h), neutrophilic leukocytosis, and normocytic anemia."], "Treatment": ["He received oral trimethoprim-sulfamethoxazole and 2 days of intravenous clindamycin phosphate and ceftriaxone sodium."], "Diagnosis": ["The patient was discharged with a tentative diagnosis of viral conjunctivitis.Three days later, the patient returned with fever, prominent submandibular lymphadenopathy, and ipsilateral granulomatous conjunctivitis (Figure)."]}
{"Patient Personal Background": ["His medical history was remarkable for asthma and prostate cancer, and review of systems was negative except for his visual loss.On examination, his best-corrected visual acuity was 20/400 OD and 20/20 OS."], "Patient Symptoms": ["He denied any recent trauma, flashes, floaters, pain, or any prior similar episodes.", "His medical history was remarkable for asthma and prostate cancer, and review of systems was negative except for his visual loss.On examination, his best-corrected visual acuity was 20/400 OD and 20/20 OS."], "Examination and Results": ["Pupils were reactive with no relative afferent pupillary defect, and intraocular pressure measurements were unremarkable, as were results of the external and slitlamp examinations.", "Dilated fundus examination of the right eye showed submacular hemorrhage with pigment epithelial detachment (Figure 1A).", "Results of a dilated fundus examination of the left eye were unremarkable.", "Optical coherence tomography (OCT) of the right eye (Figure 1B) revealed subretinal and sub\u2013retinal pigment epithelium (RPE) hemorrhage; results were unremarkable in the left eye.A, Fundus photograph of the right eye shows macular hemorrhage."], "Others": ["B, Optical coherence tomography (OCT) scan of the right eye.", "Green line indicates the position of the OCT scan."]}
{"Examination and Results": ["On examination, his visual acuity was counting fingers at 3 ft OD and 20/20 OS.", "A slitlamp examination of the right eye revealed conjunctival hyperemia, nongranulomatous keratic precipitates in the inferior half of the corneal endothelium, and 3+ cells in the anterior chamber, while results of a dilated fundus examination showed 1+ vitritis, 360\u00b0 of optic nerve swelling, intraretinal hemorrhages predominantly along the distribution of the retinal arteries and arterioles, and perivascular sheathing, as well as macula involving retinal whitening, thickening, and subretinal fluid (Figure, A).", "Fluorescein angiography revealed late vascular leakage with both arterial and venous involvement (Figure, B) and peripheral ischemia.", "Examination of the left eye revealed no abnormalities.A, Wide-field photograph of the right eye demonstrates optic nerve edema (white arrowhead), scattered intraretinal hemorrhages (red arrowheads), perivascular sheathing (yellow arrowheads), and retinal whitening and thickening with subretinal fluid in the macula extending inferiorly (blue arrowheads).", "B, Fluorescein angiograph shows arterial and venous vasculitis and peripheral ischemia."]}
{"Patient Symptoms": ["She had persistent postoperative subretinal fluid inferonasally, and she was concerned about a central scotoma."], "Examination and Results": ["Her best-corrected visual acuity was 20/20 OD and 20/200 OS.", "Extraocular motility was full, but she displayed left exotropia.", "Confrontational visual fields were full for the right eye but showed a decreased field inferiorly for the left eye.", "Intraocular pressures as determined using Tonopen tonometry were 13 mm Hg OD and 12 mm Hg OS.", "A slitlamp examination revealed trace nuclear sclerosis and pigmented cells in the anterior vitreous of the left eye.", "An ophthalmoscopic examination indicated laser and cryotherapy scars 360\u00b0 around a horseshoe tear superotemporally in the left eye, whereas the right eye appeared normal.", "In addition, pre-equatorial subretinal fluid in the left eye between the 6-o\u2019clock and 8:30 position was associated with 2 tiny holes at the 7:30 position and with a small area of fibrotic tissue contraction consistent with early proliferative vitreoretinopathy.", "The macula had yellow-white, flat, vitelliform-like lesions with a surrounding high watermark (Figure).", "No cyst, exudate, or hemorrhage was detected in the macula.Color fundus photograph of the left eye demonstrating yellow-white vitelliform-like deposits in the fovea surrounded by a high watermark."], "Treatment": ["Three months earlier, she had undergone pneumatic retinopexy for macula-on retinal detachment (RD) with a superotemporal tear, followed by vitrectomy with gas injection for macula-on inferonasal detachment 1 month later."]}
{"Examination and Results": ["No known skin trauma occurred.", "The patient was afebrile, and vital signs were stable.", "On examination, a 4.0\u2009\u00d7\u20092.0-cm, oval-shaped violaceous to black plaque with a central hemorrhagic bulla and surrounding hyperemia was noted on the left lower back (Figure 1).", "A complete blood cell count revealed a white blood cell count of 1800/\u03bcL (to convert to \u00d7109/L, multiply by 0.001), with 2% neutrophils (absolute neutrophil count, 36/\u03bcL [to convert to \u00d7109/L, multiply by 0.001]), hemoglobin level of 8.2 g/dL (to convert to grams per liter, multiply by 10), and platelet count of 10\u2009\u00d7\u2009103/\u03bcL (to convert to \u00d7109/L, multiply by 1).", "Her blood glucose level was 326 mg/dL (to convert to millimoles per liter, multiply by 0.0555)."], "Treatment": ["The patient was administered broad-spectrum antibiotics empirically, and a dermatologist was consulted.", "Two punch biopsy specimens from the lower back plaque were obtained and sent for histologic analysis and tissue culture (bacteria, atypical mycobacteria, and fungus).Violaceous to black plaque with central hemorrhagic bulla on the left lower back of the patient."]}
{"Patient Personal Background": ["She reported gradual weight gain over the previous month despite diuretic and diet compliance, and outpatient laboratory testing demonstrated well-controlled international normalized ratios in the range of 3.0 to 3.5.Physical examination revealed jugular venous pressure of 13 cm H2O, crisp mechanical S1 heart sound, and pitting edema in the lower extremities."], "Patient Symptoms": ["She reported gradual weight gain over the previous month despite diuretic and diet compliance, and outpatient laboratory testing demonstrated well-controlled international normalized ratios in the range of 3.0 to 3.5.Physical examination revealed jugular venous pressure of 13 cm H2O, crisp mechanical S1 heart sound, and pitting edema in the lower extremities."], "Examination and Results": ["She reported gradual weight gain over the previous month despite diuretic and diet compliance, and outpatient laboratory testing demonstrated well-controlled international normalized ratios in the range of 3.0 to 3.5.Physical examination revealed jugular venous pressure of 13 cm H2O, crisp mechanical S1 heart sound, and pitting edema in the lower extremities.", "Transthoracic echocardiogram showed no pericardial effusion, normal left ventricular systolic function, a well-seated mitral valve prosthesis with normal gradients, a dilated and diffusely hypokinetic right ventricle, and an elevated mean tricuspid valve gradient (Figure 1).Transthoracic echocardiography Doppler recordings shows an elevated mean tricuspid valve gradient."]}
{"Patient Personal Background": ["He had no preceding head trauma or falls.", "He had a history of atrial fibrillation with an annual stroke risk of 2.9% (based on points accrued for hypertension and age \u226565 years using the CHA2DS2-VASc score1).", "He was being treated with rivaroxaban, 20 mg daily.", "Other medications included ramipril and rosuvastatin.On physical examination, the patient\u2019s blood pressure was 157/96 mm Hg, heart rate was 72/min, and Glasgow Coma Scale score was 14 (range, 3-15 with 15 indicating best neurological status)."], "Examination and Results": ["Other medications included ramipril and rosuvastatin.On physical examination, the patient\u2019s blood pressure was 157/96 mm Hg, heart rate was 72/min, and Glasgow Coma Scale score was 14 (range, 3-15 with 15 indicating best neurological status).", "Head computed tomogram (CT) showed a 2.5-cm left-sided acute subdural hematoma with mass effect.", "Laboratory test results are shown in the Table.The patient\u2019s hemostatic status is appropriate for surgery because aPTT is normal, which rules out anticoagulant effect from rivaroxaban.The patient\u2019s hemostatic status is not appropriate for surgery because the abnormal PT suggests anticoagulant effect from rivaroxaban.The patient\u2019s hemostatic status cannot be assessed because the thrombin clotting time is unknown.The patient\u2019s hemostatic status cannot be assessed because the INR is unknown."], "Treatment": ["He required urgent surgical evacuation and the neurosurgical team requested advice regarding his perioperative bleeding risk prior to surgery."], "Others": ["He took his last dose 14 hours prior to presentation."]}
{"Patient Personal Background": ["His medications were glipizide, metformin, metoprolol, and atorvastatin.", "He had no history of fractures or osteoporosis."], "Patient Symptoms": ["He had no headache, palpitations, fatigue, muscle weakness, or weight change."], "Examination and Results": ["His blood pressure was 139/88 mm Hg, heart rate 92 beats/min, and body mass index (BMI; calculated as weight in kilograms divided by height in meters squared) 37.0.", "Purple striae, proximal muscle weakness or supraclavicular fat pads were not present.", "The mass was round and homogenous with a CT attenuation of 24 Hounsfield units (HU)."], "Others": ["Laboratory evaluation was performed (Table).Perform an oral sodium load test for hyperaldosteronism."]}
{"Patient Personal Background": ["She was not sexually active and had no medical history of sexually transmitted infections."], "Patient Symptoms": ["Medical history included lower urinary tract symptoms of 1-week duration for which she was prescribed cotrimoxazole with no improvement.", "She also reported progressively worsening vulvar and buttock pain of 5 days\u2019 duration."], "Examination and Results": ["Anogenital examination revealed vulvar (Figure 1A) and buttock ulcers (Figure 1B) tender to palpation.", "Initial blood workup showed leukopenia with a white blood cell count of 2400 cells/\u03bcL (to convert to cells/L, multiply by 106), a differential of 72% neutrophils, and a hemoglobin level of 8.5 g/dL with a hematocrit differential of 27% (to convert hemoglobin to g/L, multiply by 10.0).", "C, Hematoxylin-eosin stain (original magnification \u00d740)."], "Treatment": ["Cotrimoxazole was discontinued on admission."], "Others": ["The patient was admitted to the intensive care unit 3 weeks prior to presentation for pneumonia and remained hospitalized for 10 days.", "A biopsy specimen was obtained from the left vulvar ulcer (Figure 1C).A and B, Clinical photographs showing vulvar and buttock ulcers at the time of presentation."]}
{"Patient Personal Background": ["Her medications included only an oral birth control pill."], "Patient Symptoms": ["On examination, on the cheeks and nasal bridge there were multiple erythematous, annular plaques with focal areas of atrophy.", "In addition, the patient began to develop a burning sensation in these areas."], "Examination and Results": ["Serum chemical analyses and complete blood cell count showed no abnormalities, and anti-Ro, anti-La, and qualitative ANA antibodies were negative."], "Treatment": ["She had been previously treated with doxycycline, 100 mg/d, and topical sulfacetamide with no effect.", "A clinical diagnosis was made, and over the next 9 months, treatments with minocycline, desonide, topical metronidazole, 0.75%, cream and azelaic acid, 15%, were unsuccessful, and the plaques developed more scarring and atrophy (Figure, A)."], "Others": ["A punch biopsy specimen was obtained and submitted for histopathologic review (Figure, B and C)."]}
{"Patient Personal Background": ["There was no family history of autoimmune disease, and the child had not experienced any fevers or exposures to ticks or other arthropods."], "Patient Symptoms": ["The eruption would wax and wane, with each episode lasting for approximately 1 week, without residual pigmentation."], "Examination and Results": ["Clinical examination was significant for faint, nonscaling annular serpiginous, erythematous plaques with central clearing, and barely elevated borders.", "Test results for erythrocyte sedimentation rate, complete blood cell count, antinuclear antibodies, anti-Ro/SSA and anti-La/SSB antibodies, and Borrelia burgdorferi antibodies were within normal limits.", "A punch biopsy specimen from the left thigh was obtained, and histopathological analysis was subsequently performed (Figure, B and C).A, Annular serpiginous plaques with areas of central clearing on the patient\u2019s right thigh and buttocks.", "B, Perivascular and inflammatory infiltrate.", "C, Perivascular and inflammatory infiltrate that includes eosinophils."], "Others": ["B and C, Histopathologic images (hematoxylin-eosin)."]}
{"Patient Personal Background": ["She reported, \u201cI wash everything anyone else touches\u2026I hardly let anyone into our home, and if I do, I wash down furniture and often have to wash the floors.\u201d She avoided handling groceries, mail, and money and would not visit with family members owing to concerns that they were contaminated.She had experienced OCD symptoms since age 10 years but did not formally receive a diagnosis until 10 years later.", "She reported mild hoarding symptoms but denied symptoms of body dysmorphic disorder, trichotillomania, excoriation disorder, or an eating disorder.", "She reported a history of motor and phonic tics including eye blinking and blurting out words."], "Patient Symptoms": ["Her OCD symptoms consisted of concerns about dirt or germs and fears that she or others would get sick because of spreading these contaminants.", "She had extensive rituals involving washing her hands repeatedly and cleaning household items.", "She reported, \u201cI wash everything anyone else touches\u2026I hardly let anyone into our home, and if I do, I wash down furniture and often have to wash the floors.\u201d She avoided handling groceries, mail, and money and would not visit with family members owing to concerns that they were contaminated.She had experienced OCD symptoms since age 10 years but did not formally receive a diagnosis until 10 years later.", "Augmentation trials of antipsychotic medications, including risperidone, olanzapine, and aripiprazole, were either ineffective or intolerable.In addition to OCD, she experienced periods of depression but denied any history of mania, psychosis, trauma, or substance abuse.", "She reported mild hoarding symptoms but denied symptoms of body dysmorphic disorder, trichotillomania, excoriation disorder, or an eating disorder.", "She reported a history of motor and phonic tics including eye blinking and blurting out words."], "Treatment": ["Treatment with selective serotonin reuptake inhibitors (SSRIs) resulted in little benefit even at maximum doses (eg, 400 mg of fluvoxamine daily, 200 mg of sertraline daily).", "A trial of clomipramine up to 250 mg daily also failed to reduce her OCD symptoms.", "Augmentation trials of antipsychotic medications, including risperidone, olanzapine, and aripiprazole, were either ineffective or intolerable.In addition to OCD, she experienced periods of depression but denied any history of mania, psychosis, trauma, or substance abuse."], "Diagnosis": ["She reported, \u201cI wash everything anyone else touches\u2026I hardly let anyone into our home, and if I do, I wash down furniture and often have to wash the floors.\u201d She avoided handling groceries, mail, and money and would not visit with family members owing to concerns that they were contaminated.She had experienced OCD symptoms since age 10 years but did not formally receive a diagnosis until 10 years later."]}
{"Patient Symptoms": ["She denied weakness, difficulty swallowing, or breathing.", "Over the subsequent weeks, she experienced worsening gait, falls, inattention, and short-term memory loss.Her brain magnetic resonance imaging (MRI) with contrast results were unremarkable."], "Examination and Results": ["On initial examination, she had a normal mental status, no pupillary abnormalities, normal visual acuity, and full visual fields.", "She had moderate exotropia, severe bilateral ptosis, impaired bilateral adduction and vertical ductions, and impaired convergence.", "Her abduction and vertical oculocephalic reflexes were intact.", "She had full strength and normal sensation and reflexes but had a slightly wide-based and unsteady gait.", "The test results for acetylcholine receptor antibodies and the muscle-specific kinase antibody were negative.", "Her electrodiagnostic test results with repetitive stimulation and single fiber electromyography were unremarkable and there was no evidence of neuropathy.", "The test results for thyrotropin, thiamine level, Lyme antibodies, rapid plasma reagin, and the serum ganglioside antibody panel were unremarkable.", "A cerebrospinal fluid (CSF) analysis revealed a nucleated cell count of 6/\u03bcL (to convert to \u00d7109 liters, multiply by 0.001) with 88% lymphocytes (to convert to the proportion of 1.0, multiply by 0.01), a red blood cell count of 10/\u03bcL, a protein level of 0.087 g/dL (to convert to grams per liter, multiply by 10), and glucose level of 63 mg/dL (to convert to millimoles per liter, multiply by 0.0555).", "Serum paraneoplastic antibody testing results were negative for anti-Hu, Ri, Yo, and voltage-gated potassium channel complex (VGKCC) antibodies, and the CSF had negative results for anti-VGKCC, voltage-gated calcium channel, Hu, Ri, Yo, and amphiphysin antibodies.", "A repeated brain MRI 3 weeks later revealed an interval development of T2-weighted fluid-attenuated inversion recovery hyperintensities in the right thalamus, inferior temporal gyrus, and hippocampus (Figure).Repeated brain magnetic resonance imaging 3 weeks after the patient\u2019s initial presentation: T2-weighted fluid-attenuated inversion recovery hyperintensities (arrowheads) in the right inferior temporal gyrus (A) and right thalamus (B)."]}
{"Examination and Results": ["Follow-up ultrasonography at 32 weeks\u2019 gestation identified fetal hydrops.", "The fetal ultrasonogram showed a large left-sided hydrothorax, mediastinal shift, and ascites.", "Results of follow-up ultrasonography on postoperative day 3 showed improvement in the fetal hydrothorax and resolution of hydrops and identified a feeding vessel originating from the descending aorta supplying a lung mass (Figure 1A).A, Feeding vessel (arrowhead) from descending aorta identified on ultrasonography at 32 weeks\u2019 gestation.", "B, Feeding vessel (arrowhead) to lung mass (outlined) over left hemidiaphragm on computed tomography at age 9 months.Owing to premature rupture of membranes, the mother delivered at 33 weeks.", "On the day of birth, radiographic findings showed a left-sided pleural effusion.", "During the following weeks, the thoracostomy tube output decreased, the tube was removed, and the patient was discharged home.", "At 9 months of age, follow-up computed tomography confirmed a lung mass with a feeding vessel (Figure 1B), and the patient returned for elective thoracoscopic resection."], "Treatment": ["After ruling out infectious causes, an ultrasonography-guided thoracoamniotic shunt was placed successfully at 32 weeks\u2019 gestation.", "The neonate showed no respiratory distress after birth, and the shunt was removed.", "Ongoing pleural effusion caused respiratory distress, and on day 3 of life, a temporary thoracostomy tube was placed."]}
{"Patient Personal Background": ["He had a medical history of basal cell carcinoma of his left cheek and brow, both removed several years previously.", "His medical history also included type 2 diabetes with diabetic neuropathy.Slitlamp examination revealed bilateral meibomian gland dysfunction with upper and lower eyelid laxity, scurf, and collarettes."], "Patient Symptoms": ["The patient complained of 6 months of worsening tearing and crusting of both eyes that was worse on the left.", "The patient tried this treatment, but his symptoms did not improve."], "Examination and Results": [], "Treatment": ["Three weeks before the evaluation, he was seen by his primary ophthalmologist, who epilated 2 misdirected eyelashes of the patient\u2019s left lower eyelid and recommended eyelid scrubs and artificial tears."], "Others": ["His ocular history was significant for cataracts, proliferative diabetic retinopathy, and macular degeneration."]}
{"Patient Symptoms": ["The patient reported blurry vision in both eyes for 1 week.Visual acuity was 20/100 OD and 20/50 OS."], "Examination and Results": ["Physical examination was notable for a genital vesicular rash; a culture of the skin lesion yielded herpes simplex virus (HSV).", "Blood cultures were positive for Candida glabrata, triggering an ophthalmology consultation to rule out ocular candidiasis.", "Intraocular pressures, pupillary responses, and results of a portable slitlamp examination were normal.", "Dilated fundus examination revealed bilateral optic nerve edema with disc hemorrhages in the right eye (Figure, A).", "On extended ophthalmoscopy, subtle areas of granular retinal whitening were noted in the peripheral retina.", "No vitritis was appreciable.", "Fluorescein angiography exhibited disc hyperfluorescence (Figure, A [inset]) and late peripheral staining in both eyes.", "Optical coherence tomography demonstrated thickening of the papillary nerve fiber layer (Figure, B).", "Automated perimetry demonstrated bilateral enlargement of the physiological blind spot and bilateral arcuate scotomas, greater in the right eye.A, Right fundus image shows optic nerve edema with disc hemorrhages and peripheral retinal whitening (arrowhead)."]}
{"Patient Personal Background": ["His medical history was significant for obesity and a recent 45-kg intentional weight loss.", "Visual acuity on presentation was 20/20 OD and 20/30 OS with full-color vision plate testing in both eyes and no relative afferent pupillary defect."], "Patient Symptoms": ["He reported ptosis and marked proptosis of his left eye for 3 weeks before presentation.", "He denied any signs of diplopia, change in vision, or systemic symptoms, including difficulty breathing, swallowing, or articulating speech."], "Examination and Results": ["By Hertel exophthalmometry, he had 2 mm of left-sided proptosis and hypoglobus, with right-sided eyelid retraction (Figure, A).", "Margin-to-reflex distance 1 in the left eye was 1.0 mm, worsening to \u22122 mm on prolonged eyelid opening, with subjective fatigue.", "On extraocular muscle (EOM) testing, the patient exhibited \u22122 restriction in upgaze of the left eye, with double vision in supraduction.", "Slitlamp examination showed no significant anterior segment findings, and examination of the patient\u2019s left optic nerve demonstrated no optociliary shunt vessels, edema, pallor, or hemorrhage.", "A computed tomography (CT) scan of the orbits was obtained (Figure, B), which showed enlargement of the left orbital fat compartments but no evidence of left orbital mass or EOM enlargement.A, The patient shows hypoglobus and ptosis in the left eye, with left lower eyelid and right upper eyelid retraction.", "B, Noncontrast axial computed tomography (CT) scan of the orbits shows mild proptosis in the left eye, absence of retro-orbital mass lesion or extraocular muscle enlargement, and mild fat compartment expansion."]}
{"Patient Personal Background": ["The pregnancy was full-term and uncomplicated, and he was delivered spontaneously without the use of forceps."], "Patient Symptoms": ["His corneal abnormalities were noted by the neonatologists on the first day of life."], "Examination and Results": ["A systemic survey revealed no other dysmorphic findings.", "Examination under anesthesia revealed bilateral corneal opacities with peripheral clearing and absent red reflexes.", "The white-to-white corneal diameters were 10 mm horizontally and vertically in both eyes, and B-scan ultrasonography revealed unremarkable posterior segments.", "Ultrasound biomicroscopy confirmed the diagnosis of Peters anomaly type I with iridocorneal adhesions and no apparent lens involvement."], "Treatment": ["At the same session, a large iridectomy with lysis of iridocorneal adhesions was performed in both eyes to establish a clear, noncentral optical axis.Shallowing of the anterior chamber was observed immediately after the iridectomy.", "However, the patient\u2019s corneal opacity precluded an accurate assessment of the chamber depth and stability (Figure 1).A temporal iridectomy was present, but the anterior chamber depth could not be assessed accurately owing to corneal opacity.Inflate the anterior chamber with ophthalmic viscosurgical device.Tilt the microscope for better visualization of the anterior chamber."], "Diagnosis": ["Ultrasound biomicroscopy confirmed the diagnosis of Peters anomaly type I with iridocorneal adhesions and no apparent lens involvement."], "Others": ["He was referred to the clinic for further evaluation and management."]}
{"Patient Personal Background": ["The patient reported taking 400 mg of hydroxychloroquine sulfate daily (6.3 mg/kg/d) during the past 2 years, with normal renal function, but denied any recent change in medications.On initial examination, visual acuity (VA) was counting fingers at 2 ft OD and at 3 ft OS."], "Patient Symptoms": ["The patient had initially seen a general ophthalmologist 1 week after noticing a change in vision and was diagnosed as having bilateral cataracts.", "Given a continued decline in vision over the next 2 weeks, the patient sought a second opinion."], "Examination and Results": ["Intraocular pressures were 14 mm Hg OD and 16 mm Hg OS.", "Pupils were equal and mildly sluggish to react to light but demonstrated no relative afferent pupillary defect.", "Slitlamp examination revealed 1+ nuclear sclerosis cataracts.", "Dilated fundus examination demonstrated normal-appearing retinal and optic nerve architecture with the exception of mild arteriolar narrowing bilaterally (Figure 1A).", "Results of optical coherence tomography (OCT) of the retinal nerve fiber layer and macula, as well as fundus autofluorescence, were normal (Figure 1B).", "In addition, magnetic resonance imaging (MRI) of the brain and orbits with and without gadolinium were unremarkable.A, Baseline color fundus photograph of the right eye demonstrates normal optic nerve color and contour, with mild arteriolar narrowing."], "Diagnosis": ["The patient had initially seen a general ophthalmologist 1 week after noticing a change in vision and was diagnosed as having bilateral cataracts."]}
{"Patient Symptoms": ["She was asymptomatic except for 2 years of progressive, painless, left-sided proptosis.", "Her physical examination findings were unremarkable except for resistance to retropulsion of the left globe and 5 mm of left-sided proptosis by Hertel exophthalmometry."], "Examination and Results": ["Her physical examination findings were unremarkable except for resistance to retropulsion of the left globe and 5 mm of left-sided proptosis by Hertel exophthalmometry.", "Magnetic resonance imaging (MRI) revealed a superonasal orbital mass that was T1 isointense to brain parenchyma and heterogeneously T2 hyperintense (Figure 1A), with a small cystic component and avid peripheral contrast enhancement (Figure 1B).", "Bony remodeling without destruction was noted, as well as displacement of the superior oblique and superior rectus muscles."]}
{"Patient Symptoms": ["The patient reported vague pain around the left ankle but no functional limitations and no history of trauma at that site."], "Examination and Results": ["A magnetic resonance imaging (MRI) scan showed an inhomogeneous nodule in the subcutaneous layer with a largest diameter of approximately 5 cm.", "No enlarged lymph nodes were detectable in the groin.", "Results of a complete blood cell count and levels of alkaline phosphatase, lactic dehydrogenase, and C-reactive protein were unremarkable.", "The patient then underwent disease staging with computed tomography (CT) of the chest and whole-body fluorodeoxyglucose positron emission tomography (FDG-PET).", "The CT findings were negative for secondary lesions; the FDG-PET scan demonstrated, as expected, high uptake in the right thigh (maximum standard uptake variable [SUVmax], 8.4) at the site of the subcutaneous tumor and at a second lesion in the left ankle joint (SUVmax, 12.0).", "A radiograph of the ankle did not show calcifications within the soft-tissue lesion.", "An MRI scan of the ankle showed a 1.5-cm soft tissue mass in the posterior recess of the ankle joint with a low to intermediate signal in T1- and T2-weighted sequences and moderate contrast enhancement throughout the lesion (Figure 1).Magnetic resonance imaging fast spin echo of the left ankle showing the soft-tissue mass in the posterior recess.", "The sagittal T1-weighted image shows an isointense, bean-shaped mass (arrowhead) (1.5\u2009\u00d7\u20090.7 cm) (A), whereas the sagittal T2-weighted image shows the isointense signal of the mass (arrowhead) (B)."], "Treatment": ["An ultrasonography-guided core needle biopsy was performed, and histopathologic evaluation showed the aspects of a small round-cell tumor, which was confirmed to be a Ewing sarcoma by immunohistochemical and molecular analysis (with positivity for the EWS-FLI1 fusion gene [OMIM 133450])."], "Diagnosis": ["An ultrasonography-guided core needle biopsy was performed, and histopathologic evaluation showed the aspects of a small round-cell tumor, which was confirmed to be a Ewing sarcoma by immunohistochemical and molecular analysis (with positivity for the EWS-FLI1 fusion gene [OMIM 133450])."]}
{"Patient Personal Background": ["His medical history included transcatheter aortic valve replacement (TAVR) 12 months earlier for symptomatic aortic stenosis with an uncomplicated placement of a balloon-expandable bioprosthetic valve.", "He also had a history of nonobstructive coronary artery disease, for which he was treated with atorvastatin and metoprolol.On presentation, he denied having chest pain, orthopnea, and lower extremity edema."], "Patient Symptoms": ["He was asymptomatic following TAVR until the recurrence of dyspnea 3 weeks before admission."], "Examination and Results": ["His blood pressure was 121/47 mm Hg, his pulse was regular at 83 beats per minute, and he was afebrile.", "His physical examination revealed a jugular venous pressure of 9 cm H2O, no stigmata of endocarditis, and an absence of peripheral edema.", "There were faint bibasilar rales and a harsh grade III/VI, late-peaking systolic murmur along the left sternal border that radiated to the carotids.", "Laboratory data included a negative troponin, NT-proB natriuretic peptide of 55 pg/mL.", "Serum chemistry levels and complete blood cell counts were otherwise normal.A TTE result showed an interval development of bioprosthetic aortic stenosis with mean gradient of 29 mm Hg."], "Treatment": ["He was discharged and prescribed aspirin at 81 mg and clopidogrel at 75mg daily."]}
{"Patient Personal Background": ["She was a former smoker and had unilateral conductive hearing loss associated with the mass."], "Patient Symptoms": ["She was a former smoker and had unilateral conductive hearing loss associated with the mass."], "Examination and Results": ["On examination, a large, nonmobile, and firm tumor extended from the postauricular region to the parotid gland, scalp, and a portion of the neck.", "There was no palpable lymphadenopathy.", "On otoscopy, the growth occluded view of the tympanic membrane.", "Computed tomographic imaging (Figure, A and B) demonstrated a mass emanating from the parapharyngeal space, measuring approximately 10\u2009\u00d7\u20097.3\u2009\u00d7\u20091.5 cm.", "There was no radiographic evidence of osseous extension or destruction.", "The patient underwent a staged procedure, including a radical resection of the scalp and neck mass, followed by a transcervical and transparotid approach to the parapharyngeal space.", "The scattered tumor cells were spindled to stellate shaped and had the morphology of myofibroblasts."], "Treatment": ["The tumor was noted to stretch the pes anserinus to 4 times its normal length and had to be resected off the internal carotid artery, as well as the fascia overlying the medial pterygoid muscle and the tympanomastoid suture."], "Others": ["The patient recovered well with only temporary marginal mandibular weakness.", "Microscopy (Figure, C) demonstrated a well-circumscribed, paucicellular spindle cell neoplasm with abundant myxocollagenous matrix."]}
{"Patient Personal Background": ["Despite taking omeprazole (20 mg once daily) 30 minutes before breakfast, avoiding foods that precipitated symptoms, and sleeping with his head elevated, heartburn and regurgitation while supine continued."], "Patient Symptoms": ["Despite taking omeprazole (20 mg once daily) 30 minutes before breakfast, avoiding foods that precipitated symptoms, and sleeping with his head elevated, heartburn and regurgitation while supine continued.", "He reported intermittent solid-food dysphagia for 2 years but no weight loss (254-lb [115 kg] body weight); physical examination results were unremarkable.Esophagogastroduodenoscopy (EGD) revealed normal esophageal mucosa and normal biopsies."], "Examination and Results": ["He reported intermittent solid-food dysphagia for 2 years but no weight loss (254-lb [115 kg] body weight); physical examination results were unremarkable.Esophagogastroduodenoscopy (EGD) revealed normal esophageal mucosa and normal biopsies.", "Given his persisting symptoms, an esophageal high-resolution manometry (HRM) study was performed (Table 1; eFigure in the Supplement)."], "Treatment": ["Despite taking omeprazole (20 mg once daily) 30 minutes before breakfast, avoiding foods that precipitated symptoms, and sleeping with his head elevated, heartburn and regurgitation while supine continued."]}
{"Patient Personal Background": ["The child was born via vaginal delivery at full term.", "Pregnancy was complicated by gestational diabetes.", "The child had no major medical issues and met all developmental milestones.", "There was no relevant family medical history."], "Patient Symptoms": ["The lesion had developed acutely over 48 hours, starting as symmetric pink patches leading to pustules, erosions, and ulceration.", "Associated symptoms included generalized fatigue, but no fevers, chills, or other systemic symptoms."], "Examination and Results": ["Dermatology was consulted prior to scheduled debridement and skin grafting.Physical examination revealed a well-appearing infant with normal vital signs.", "Extending from the gluteal cleft to just medial to the scrotum, there was a symmetric, well-defined ulcer with a cribriform base, central necrosis, and rolled, pink-to-violaceous, undermined border (Figure, A).", "Initial laboratory workup was significant for leukocytosis (22\u202f000/mm3) and thrombocytosis (764\u202f000/mm3).", "Serum zinc and alkaline phosphatase were within normal limits.", "A punch biopsy of the edge of the ulcer was obtained and stained with hematoxylin-eosin (Figure, B and C).", "Microbial stains were negative.", "Tissue cultures for anaerobic and/or aerobic, mycobacterial, and fungal organisms were all negative, though wound cultures grew Escherichia coli, Klebsiella oxytoca, and Enterococcus faecalis.", "Viral cultures were negative.A, Clinical photograph shows a symmetric, well-defined ulcer with a cribriform base, central necrosis, and rolled, pink-to-violaceous, undermined border extending from the gluteal cleft to just inferior and medial to the scrotum.", "B, Histopathology demonstrating an ulcer with surrounding mild epidermal hyperplasia and a neutrophil predominant perivascular and interstitial infiltrate.", "C, Histopathology demonstrating an ulcer with surrounding mild epidermal hyperplasia and a neutrophil predominant perivascular and interstitial infiltrate."], "Treatment": ["Broad-spectrum intravenous antibiotics were initiated on admission."], "Others": ["The child\u2019s parents denied any new topical exposures or medications."]}
{"Patient Symptoms": ["The dermatosis was characterized by polymorphic erythematous macules and plaques with elevated and indurated borders without evanescence to pressure (Figure, A and B).", "Dysesthesia was recorded on her lesions."], "Examination and Results": ["Results from complete blood cell count, erythrocyte sedimentation rate, and blood chemistry analyses were normal, as was a thyroid profile.", "A punch biopsy specimen from a trunk plaque was obtained, and histopathological analysis was performed (Figure, C and D).A, Polymorphic erythematous macules and plaques with elevated and indurated borders without in vitro pressure evanescence were noticed during consultation on patient\u2019s back.", "B, Polymorphic erythematous macules and plaques with elevated and indurated borders without in vitro pressure evanescence on the trunk and abdomen were present.", "C, Histopathological analysis revealed a chronic dermic granulomatous process, as well as (D) a chronic dermic nonencapsulated granulomatous infiltrate with a perineural distribution formed by mature epitheloid cells and encapsulated by lymphocytes."], "Treatment": ["Previous treatment included antihistamines and oral corticosteroids for several months without improvement."], "Diagnosis": ["She was referred from another clinic with the presumptive diagnosis of urticarial vasculitis."]}
{"Patient Symptoms": ["The patient reported that these asymptomatic lesions were present since birth and did not appear to change on sun exposure or with seasons."], "Examination and Results": ["She had no family history of similar cutaneous feature.Physical examination revealed that these lesions were distributed in a Blaschkoid pattern.", "On close inspection, numerous reddish punctate keratotic papules were observed on the patient\u2019s right forearm that coalesced into plaques on the dorsum of her right hand (Figure 1).", "No extracutaneous abnormalities were found.", "A skin biopsy specimen from the patient\u2019s right arm was obtained.Reddish linear keratotic papules and plaques on the right forearm and dorsal hand distributed in a Blaschkoid pattern."]}
{"Patient Personal Background": ["Medical history was unremarkable with no recent weight loss, travel, or trauma."], "Patient Symptoms": [], "Examination and Results": ["Visual acuity without correction was 20/20 OU.", "The right pupil was 3.5 mm and briskly reactive, while the left pupil was 8.5 mm and unreactive to light or near effort; there was no relative afferent pupillary defect.", "Results of testing with the use of an Amsler grid and Ishihara color plates were within normal limits.", "Visual fields were full to confrontation.", "The optic nerves and retina were normal in both eyes.", "External examination was notable for left periorbital swelling, proptosis, and moderate ptosis of the upper eyelid (Figure 1A).", "Extraocular motility examination results were normal in the right eye but demonstrated severe ophthalmoparesis of the left eye: 0% supraduction (Figure 1B), 20% of normal abduction/adduction, and 10% of normal infraduction (not pictured).", "Corneal reflex was normal in the right eye but diminished in the left eye, and facial strength was normal bilaterally.", "The remainder of the neurologic examination results were normal.An 8-year-old boy presented with 2 weeks of painless proptosis of the left eye (A) accompanied by upper eyelid ptosis and ophthalmoplegia of the left eye (B)."]}
{"Patient Symptoms": ["With fever, change in mental status, and a recent cardiac procedure, there was concern for infective endocarditis and septic emboli and he was transferred to our facility.On examination, the patient was drowsy with transient eye opening and significant expressive aphasia with mild receptive aphasia; he intermittently followed commands."], "Examination and Results": ["Laboratory studies were significant for elevated white blood cell count of 9500/\u03bcL (to convert to 109 per liter, multiply by 0.001).", "Cerebrospinal fluid revealed white blood cell count 0 cells/\u03bcL, red blood cell count 28 cells/\u03bcL, glucose level 76 mg/dL, and protein level 48 mg/dL.", "Magnetic resonance imaging showed left-hemisphere watershed areas of diffusion restriction.", "Examination revealed right-sided facial droop, right hemiparesis, and an up-going right toe.", "A second magnetic resonance image revealed worsening in both hemispheres with perivenular and leptomeningeal enhancement, areas of cortical diffusion restriction not typical of ischemic injury, and significant T2 changes (Figure 1A).A, Magnetic resonance imaging findings.", "B, Pneumocephalus on head computed tomography (CT), highlighted by white arrowheads.", "C, Sagittal computed tomography imaging of the chest with contrast.Transesophageal echocardiogram (TEE) showed no vegetation.", "Left-heart catheterization demonstrated nonocclusive coronary artery disease."], "Diagnosis": ["Blood cultures grew Streptococcus mitis."], "Others": ["While in the supine position for nursing care, he became abruptly hypotensive, bradycardic, hypoxic/cyanotic, and nonresponsive; an electrocardiogram demonstrated inferior ST-segment elevations."]}
{"Patient Personal Background": ["The patient had no significant medical story."], "Patient Symptoms": ["Swelling was intermittent and sore.", "The patient noted that tumefaction was more prominent in the morning on waking, and he denied any associated fever, weight loss, or other symptoms."], "Examination and Results": ["Physical examination showed a painless but tender right scrotal tumefaction in an apparently healthy obese man.", "No inguinal lymphadenopathy was observed.", "Swelling was not reducible, the right testicle was not palpable, and the transillumination test was nondiagnostic.", "Laboratory evaluation demonstrated a hemoglobin level of 13.5 g/dL (to convert to grams per liter, multiply by 10.0), leukocyte or white blood cell count of 11 350/\u03bcL (to convert to \u00d7109 per liter, multiply by 0.001), and lactate dehydrogenase level of 240 U/L (to convert to microkatal per liter, multiply by 0.0167).", "Unenhanced computed tomography of the abdomen and pelvis was performed (Figure 1).Computed tomographic images."], "Others": ["Axial (A) and coronal (B) reconstruction."]}
{"Patient Personal Background": ["She had a history of migraine headaches, for which she took nonsteroidal anti-inflammatory drugs for symptomatic relief."], "Patient Symptoms": ["At her examination, she reported feeling tired but denied other medical problems.On examination, her visual acuity was 20/20 OU."], "Examination and Results": ["Intraocular pressure was 15 mm Hg OU, extraocular motility was normal, and findings of the anterior segment examination were normal.", "There was no afferent pupillary defect, and dilated fundus examination revealed healthy-appearing optic nerves and normal retinas.", "Automated perimetry demonstrated a right-sided homonymous hemianopia."]}
{"Patient Personal Background": ["She had no other symptoms and was otherwise healthy with no medical history of any disease or surgeries.", "She was not taking any medications."], "Examination and Results": ["Her family history was also unremarkable.The patient\u2019s best-corrected visual acuity was 20/20 OU, results of pupillary examination were normal without relative afferent pupillary defect, and results of the rest of the anterior segment examination were unremarkable.", "Posterior segment examination of the right eye revealed a slightly elevated, white, multicystic lesion approximately 3 disc diameters that was located inferior to the optic nerve (Figure 1).", "Results of examination of the left eye were unremarkable."]}
{"Patient Personal Background": ["She had recently traveled to Ireland, where she rode a horse.", "She denied previous upper respiratory and gastrointestinal tract infections."], "Patient Symptoms": ["She denied any eye pain with ocular movement or positive visual phenomena during presentation.", "She had no other abnormal neurologic signs or symptoms."], "Examination and Results": ["Best-corrected visual acuity was 20/400 OD and 20/20 OS.", "Results of slitlamp examination were normal.", "A relative afferent pupillary defect 1+ was noted in the right eye.", "Dilated fundus examination showed no evidence of vitritis, optic nerve swelling, or retinal pigment epithelial abnormalities.", "Automated visual field testing showed a central scotoma in the right eye, and the visual evoked potential showed a delayed P100 response in the right eye.", "Results of an initial ophthalmologic workup, including fundus photography and fluorescence angiography, were considered to be unremarkable.", "Contrast-enhanced magnetic resonance imaging of the brain and orbit revealed no enhancement of the optic nerves.", "At a subsequent visit, 2 small glistening lesions in the retina were identified, and optical coherence tomography (OCT) showed an attenuated ellipsoid zone at a position nasal to the fovea (Figure 1).Fundus photography shows 2 small glistening lesions (white arrowheads) (A)."]}
{"Patient Personal Background": ["She was not taking any ophthalmic or neurotoxic medications such as ethambutol hydrochloride.", "Family history revealed vision loss in a maternal cousin that was attributed to optic neuritis from multiple sclerosis."], "Patient Symptoms": ["Symptom onset was approximately 3 months prior to presentation when the patient began reporting difficulty reading.", "Magnetic resonance imaging findings of the orbits were normal.At presentation 3 months after onset of decreased vision, the patient reported that her vision continued to worsen."], "Examination and Results": ["She was initially evaluated by her local eye care professional and noted to have visual acuity of 20/100 OD and 20/25 OS with cecocentral visual field defect in the right eye.", "Results of ophthalmoscopic examination of the optic nerves at this time revealed mild elevation of the optic nerves.", "Best corrected visual acuity was measured at 20/400 OD and 20/40 OS.", "Both optic nerves were found to be mildly hyperemic with a few telangiectatic vessels on the left and trace temporal pallor on the right.", "Color vision was 3/13 in the right eye and normal in the left.", "There was no relative afferent pupillary defect.", "The left eye had a very similar pattern.A, Fundus photograph of the right eye shows mild hyperemia of the optic nerve with trace temporal pallor.", "B, 24-2 Humphrey visual field shows a cecocentral scotoma.The patient had no significant medical history."], "Others": ["The patient\u2019s 24-2 Humphrey visual field in the right eye is shown in the Figure."]}
{"Patient Personal Background": ["He had traveled from Gabon to the United States 2 weeks earlier.", "He had no significant medical history except use of correctional lens due to myopia; his body mass index was normal.", "He had worked in Gabon as an engineer for the past 10 months and reported numerous insect bites, but denied other exposures.", "He was up to date on required vaccinations and had received doxycycline for the past 10 months for malaria prophylaxis."], "Patient Symptoms": ["The patient had no symptoms on presentation and denied fevers, headaches, or visual disturbances."], "Examination and Results": ["Examination of the fundus showed bilateral elevation of the optic nerve head with blurring of the disc margins (Figure); an ocular ultrasonography showed no optic nerve drusen.", "A magnetic resonance image of the brain with and without gadolinium was normal, and a magnetic resonance venogram showed no evidence of venous sinus thrombosis.", "A lumbar puncture demonstrated elevated intracranial pressure (ICP) of 35 mm Hg; white cells, 1/\u03bcL (to convert to \u00d7109/L, multiply by 0.001); protein, 0.02 g/dL (to convert to g/dL, multiply byt 10.0); glucose, 55 mg/dL (to convert to mmol/L, multiply by 0.0555); and a negative gram stain.Optic disc edema with a circumferential halo (arrowhead)."]}
{"Examination and Results": ["Physical examination showed short stature (height in the third percentile) with mild muscle wasting in both lower extremities.", "Visual acuity was 20/30 OU.", "He had an esotropia of 30 prism diopters with mild bilateral inferior oblique muscle overaction.", "External examination showed hypertelorism, bilateral upper eyelid ptosis, and a broad nasal bridge.", "Slitlamp biomicroscopy disclosed bilateral posterior embryotoxon, iris stromal hypoplasia, and translucent strands extending from the inferior segment of the iris toward the cornea in both eyes, with right corectopia (Figure, A).", "Intraocular pressures (IOPs) were 11 mm Hg OD and 10 mm Hg OS.", "Situs inversus of the optic discs and a cup-disc ratio of 0.2 in both eyes was noted.", "Results of the retinal examination were otherwise normal.", "SITA (Swedish Interactive Thresholding Algorithm) 24-2 visual field revealed superior arcuate defects in both eyes.", "Optical coherence tomography (OCT) showed mild peripapillary retinal nerve fiber layer thinning inferiorly in both eyes.", "Magnetic resonance imaging of the brain disclosed dysgenesis of the left cerebellar hemisphere and vermis (Figure, B)."], "Others": ["Family history and examination of other family members disclosed no similar abnormalities.A, Slitlamp biomicroscopy showing posterior embryotoxon, peripheral iris strands (arrowhead), and corectopia of the right eye.", "B, Axial T2-weighted magnetic resonance image showing dysgenesis of the left cerebellar hemisphere (arrowhead) and vermis (the unpaired median portion of the cerebellum that interconnects the 2 hemispheres [asterisk])."]}
{"Patient Personal Background": ["The patient was initially diagnosed with MDS 3 years ago and treated with azacitidine followed by CLAG (cladribine, cytarabine, granulocyte-colony stimulating factor)."], "Patient Symptoms": ["His physical examination on this presentation showed multiple dark brown cutaneous papules measuring at 3.0 to 5.0 cm (Figure, A), but the rest of the examination results were negative for hepatosplenomegaly or lymphadenopathy."], "Examination and Results": ["Posttreatment bone marrow biopsy findings at that time showed no evidence of disease.", "Complete blood cell count showed a white blood cell count of 3.3\u2009\u00d7\u2009109/L with absolute neutrophil count of 1.0\u2009\u00d7\u2009109/L, Hb 12.7g/dL, platelet counts 118\u2009\u00d7\u2009109/L and differential counts showed no evidence of circulating blasts.", "In addition, results of laboratory workup including peripheral blood culture, methicillin-resistant Staphylococcus aureus (MRSA) swab, human immunodeficiency virus test, and flow cytometry performed on his peripheral blood were all negative.", "Pathologic sampling from the skin lesion showed the presence of monomorphous small to medium cells extending through the dermis and into the subcutaneous fat (Figure, B).", "Immunohistochemical staining demonstrated CD4-, CD33-, CD43-, CD56-, CD123-, and TCL1-positive neoplastic cells with Ki-67 of 85%, but staining results for TdT, MUM1, CD3, CD20, Bcl-6, CyclinD1, and CD8 were negative (Figure, C).", "Results of bone marrow biopsy showed normocellular marrow maturing trilineage hematopoiesis with no increase of blasts or other abnormal populations.", "Cytogenetics results were abnormal, showing del(20)(q11.2q13.3)[8]/46,XY[12].A, Skin image showing a single, brownish nodule and adjacent scar from prior biopsy."], "Diagnosis": ["B, A section of cutaneous blastic plasmacytoid dendritic cell neoplasm with subepidermic confluent atypical cellular infiltrate composed of medium sized, round to oval, or elongated immature precursors with finely granular to open chromatin, inconspicuous to prominent nucleoli and a small amount of cytoplasm (hematoxylin-eosin stain, original magnification \u00d7600)."], "Others": ["C, CD56 (immunoperoxidase stain, original magnification \u00d7600)."]}
{"Patient Personal Background": ["She had 3 previous pregnancies (2 live births and 1 spontaneous abortion); her last child was born more than 5 years ago."], "Patient Symptoms": ["Her chest pain began spontaneously 1 hour prior to presentation and was described as retrosternal with radiation to her upper and middle back.On physical examination, her blood pressure was 128/88 mm Hg, her pulse was regular at 96 beats per minute, her respiratory rate was 16 breaths per minute, and her temperature was 36.9\u00b0 C. Pulse oximetry was 100% in room air."], "Examination and Results": ["The chest was nontender.", "Pertinent physical findings included normal central venous pressures, clear lung fields, normal first and second heart sounds, an audible fourth heart sound, and no murmurs.", "The electrocardiogram (Figure 1A) demonstrated anterior ST-segment elevations consistent with an anterior acute current of injury.", "Results from the chest radiography were normal.", "Initial troponin I concentration was 0.02 ng/mL but rose to 177.76 ng/mL over the ensuing 4 hours (the patient\u2019s chest pain had resolved by this time).", "Thrombolysis in myocardial infarction flow grade 2 was observed in the left anterior descending artery and second diagonal branch.A, Initial 12-lead electrocardiogram on presentation showing ST-segment elevation on anterior leads."], "Treatment": ["Urgent coronary angiography was performed (Figure 1B)."]}
{"Patient Symptoms": ["The patient\u2019s parents denied any associated fevers, chills, night sweats, sore throat, abdominal pain, or weight changes."], "Examination and Results": ["Medical history was noncontributory.Physical examination showed bilateral, mobile, nontender cervical lymphadenopathy without erythema or swelling.", "Tonsils were symmetric and not enlarged.", "There was no noticeable thyromegaly or nodules.", "Laboratory testing was significant for an elevated erythrocyte sedimentation rate (37 mmol/h).", "Ultrasonography demonstrated cervical lymphadenopathy bilaterally with the largest node measuring 3.8 cm in maximum dimension.", "Lymph node needle core biopsy demonstrated increased histiocytes and numerous plasma cells on tissue section (Figure, A).", "Scattered neutrophils and rare giant cells were also present.", "Findings of Grocott methenamine silver, acid-fast, and Warthin-Starry stains were negative.", "The CD-68 immunostain showed numerous histiocytes.", "The specimen stained positive for CD-30 and S-100 immunostains showing emperipolesis (Figure, B and C).", "Findings of a CD1a stain were negative.", "Lymphoid markers by flow cytometry showed a polyclonal mixed B-cell and T-cell population.Lymph node needle core biopsy specimens from the patient."]}
{"Patient Personal Background": ["He had no history of underlying medical diseases, such as hypertension, diabetes, hepatitis, and tuberculosis."], "Examination and Results": ["On physical examination, a whitish, firm, painless, nodular mass on the superficial layer of the left upper lip was observed (Figure, A).", "On histopathologic examination, an encapsulated salivary gland tumor with epithelial and myoepithelial cells, ductlike structures, and mixed stroma was observed (Figure, B)."], "Treatment": ["Given the possibility of a tumorous lesion, complete excision was planned under local anesthesia.", "In surgery, the 1.5\u2009\u00d7\u20091.2 cm, whitish, firm, nodular, and well-encapsulated mass was excised completely without rupture of the capsule from the surrounding mucosa."], "Diagnosis": ["On histopathologic examination, an encapsulated salivary gland tumor with epithelial and myoepithelial cells, ductlike structures, and mixed stroma was observed (Figure, B)."], "Others": ["One month after surgery, the surgical wound on the left upper lip was clean and well healed.", "One year later, there had been no recurrence, and the patient had no symptoms at the left upper lip.A, Clinical image of the left upper lip.", "B, Histopathologic image (hematoxylin-eosin, original magnification \u00d710) showing areas of ductal epithelial components with myxoid stroma."]}
{"Examination and Results": ["Physical examination revealed a single erythematous scaling plaque involving the left lower eyelid, including its border.", "Eyelashes were totally absent (Figure 1A).", "No other lesions were found after complete physical examination.", "Dermoscopy showed an erythematous background, telangiectatic vessels, whitish structureless areas, and whitish scales (Figure 1B).", "A 4-mm punch biopsy specimen was obtained (Figure 1C).A, Erythematous scaling plaque involving the left lower eyelid.", "B, Dermoscopy shows erythematous background, telangiectatic vessels, structureless whitish areas, and white scales.", "C, Histopathological analysis (hematoxylin-eosin)."]}
{"Patient Personal Background": ["No history of local trauma, prolonged standing, and occupational exposure to mineral dust or recent drug intake was recollected.", "He was not diabetic."], "Patient Symptoms": ["The lesions started to appear on the left pretibial region as small papules, which gradually increased in size and coalesced to form bigger plaques.", "There were no lesions elsewhere on the body."], "Examination and Results": ["On examination, large, ill-defined, erythematous plaques were present on the pretibial areas extending onto the lateral aspect of both legs.", "The plaques were surmounted by multiple, discrete atrophic scars.", "The periphery of the plaques showed increased vascularity in the form of telangiectasias and venous prominences, along with atrophy of the overlying skin (Figure, A).", "The periphery of the plaques shows telangiectasia.", "Some areas show venous prominence.", "B, Skin biopsy showing unremarkable epidermis and multiple epithelioid cell granulomas in the entire dermis.", "C, Compact, noncaseating, epithelioid cell granulomas with multiple Langhans giant cells."], "Treatment": ["D, Photograph after 6 weeks of treatment showing considerable decrease in erythema and induration."], "Others": ["A skin biopsy sample was obtained from the plaque and sent for histopathological examination (Figure, B and C).A, Clinical photograph on presentation showing ill-defined, erythematous plaques surmounted by multiple atrophic scars."]}
{"Patient Personal Background": ["Approximately 15 years earlier, he had sustained injuries from an accidental land mine explosion that had lacerated his face, neck, and thorax in several places.", "The wounds apparently healed without difficulty, leaving only scars of expected severity."], "Patient Symptoms": ["Approximately 6 months before presentation, the patient began to notice an increase in the size of these lesions."], "Examination and Results": ["Physical examination showed multiple firm, erythematous, nontender papules, nodules, and small plaques on his face, his chin, the anterior portion of his neck, and the anterior thorax (Figure 1).Multiple firm, erythematous, nontender nodules and small plaques on the patient\u2019s face."]}
{"Patient Symptoms": ["On examination, the patient reported moderate pain in the abdomen and right side and demonstrated a distended abdomen in the absence of any peritoneal signs."], "Examination and Results": ["Computed tomography (CT) showed a right-sided grade IV renal injury involving his known renal cyst with active arterial extravasation (Figure, A).", "The patient underwent selective angioembolization of the renal laceration.A, Abdominal computed tomography (CT) with contrast demonstrating grade IV laceration of the right kidney and active extravasation.", "B, Abdominal CT obtained on day 2 of hospitalization showing large right-sided retroperitoneal hematoma and grade IV renal laceration displacing the patient\u2019s abdominal viscera to the left, with contrast-filled structure medial to the liver.In the 24 hours after embolization, the patient required 2 U of red blood cells via transfusion for anemia.", "Contrast-enhanced CT of the abdomen and pelvis was performed to assess for a source of continued bleeding (Figure, B)."], "Treatment": ["The patient underwent selective angioembolization of the renal laceration.A, Abdominal computed tomography (CT) with contrast demonstrating grade IV laceration of the right kidney and active extravasation."]}
{"Patient Personal Background": ["He had been diagnosed as having type 2 diabetes for 10 years."], "Examination and Results": ["His visual acuity was 20/40 OU.", "Fundus examination showed venous dilatation, retinal hemorrhages, hard exudates, and serous macular detachment (arrowheads) (Figure 1).", "Optical coherence tomography scans showed intraretinal fluid accumulation with serous macular detachment in both eyes.", "Blood analysis revealed a low hemoglobin level of 8 g/dL, red blood cell count of 3.3\u2009\u00d7\u2009106/\u03bcL, white blood cell count of 3460/\u03bcL (15% neutrophils, 84% lymphocytes, and 1% monocytes), fasting blood glucose level of 120 mg/dL, normal lipid profile, serum urea nitrogen level of 45 mg/dL, and an increased serum creatinine level of 1.4 mg/dL (to convert hemoglobin to grams per liter, multiply by 10.0; red blood cell count to \u00d71012 per liter, multiply by 1.0; white blood cell count to \u00d7109 per liter, multiply by 0.001; blood glucose to millimoles per liter, multiply by 0.0555; serum urea nitrogen to millimoles per liter, multiply by 0.357; and serum creatinine to micromoles per liter, multiply by 88.4).A and B, Fundus photographs showing retinal venous dilatation, hemorrhages, hard exudates, and serous macular detachment (arrowheads)."], "Treatment": ["He received 3 intravitreal bevacizumab injections at 4 weekly intervals and 2 intravitreal triamcinalone acetonide injections in both eyes, with minimal resolution of edema."], "Diagnosis": ["He was diagnosed as having nonproliferative diabetic retinopathy with macular edema in both eyes."]}
{"Patient Personal Background": ["Her medical history was notable for cystic fibrosis, receipt of bilateral lung transplant, cytomegalovirus (CMV) viremia, and chronic kidney disease."], "Examination and Results": ["The findings of a workup for meningitis were unremarkable.", "Ophthalmic consultation occurred 1 week after admission.The patient\u2019s visual acuity was 20/30 OD and 20/25 OS.", "Pupils were minimally reactive and without an afferent pupillary defect.", "Intraocular pressures were 15 mm Hg OD and 12 mm Hg OS.", "Portable slitlamp examination findings included bilateral posterior synechiae and a shallow anterior chamber in the left eye.", "No anterior segment cell was appreciable by portable examination.", "The patient had early nuclear sclerosis and posterior subcapsular cataracts in both eyes.", "Results of a fundus examination demonstrated bilateral temporal choroidal elevations without vitritis, vascular sheathing, retinitis, or optic nerve abnormalities."], "Treatment": ["Earlier treatment for CMV viremia included valganciclovir hydrochloride therapy that was discontinued because of the development of drug resistance and foscarnet sodium therapy with resultant renal dysfunction.", "The patient was subsequently treated with intravenous renally dosed cidofovir therapy; however, she again developed a nephrotoxic reaction and required dosage reduction in the weeks before presentation.", "At admission, cidofovir therapy was discontinued because of acute kidney injury (creatinine level, 5.75 mg/dL) (to convert to micromoles per liter, multiply by 88.4)."]}
{"Patient Personal Background": ["Her medical history was remarkable for type 1 diabetes diagnosed at 16 years of age and proliferative diabetic retinopathy in both eyes that had been treated with panretinal photocoagulation 7 years earlier.", "She had undergone pars plana vitrectomy with endolaser to treat a tractional retinal detachment in her right eye 2 years before this presentation.", "She also had a history of hypertension and chronic kidney disease, and she was 15 weeks into pregnancy."], "Patient Symptoms": ["The patient was in no apparent distress and denied any headache, chest pain, or focal weakness.Ophthalmoscopic examination (Figure) revealed mild optic nerve head edema that was greater in the left eye than the right eye with associated nerve fiber layer hemorrhage in the left eye."], "Examination and Results": ["Visual acuity was 20/50 OD and 20/100 OS.", "Intraocular pressure was normal bilaterally, and no relative afferent pupillary defect was detected.", "Findings of an anterior segment examination were normal.", "Nerve fiber layer infarctions, dot and blot hemorrhages, and lesions caused by panretinal photocoagulation also were seen bilaterally.", "Optical coherence tomography showed macular edema that involved the center of the macula in both eyes (Figure, inset).Fundus photographs obtained at presentation that show bilateral peripapillary hemorrhages and mild optic nerve head edema."]}
{"Examination and Results": ["Two years before our examination, her visual acuity had been 20/200 OD and 20/60 OS.", "At our initial evaluation, her visual acuity was 20/300 OD and 20/250 OS.", "Optic nerve atrophy was noted, with no optociliary collaterals.", "Imaging of the retinal nerve fiber layer showed thinning in both eyes.", "Automated perimetry demonstrated general constriction of visual fields and bilateral central scotomas.", "Ocular motility was full, without pain, and orthotropic.", "Two years prior, initial magnetic resonance imaging (MRI) of the brain and orbits with and without contrast was read as normal.", "Retrospectively, those images were reviewed and noted to be limited due to artifact from dental braces and a lack of fat suppression.", "Two years prior, lumbar puncture revealed normal opening pressure.Complete blood cell count with differential was negative, as were test results for erythrocyte sedimentation rate, fluorescent treponemal antibody absorption, antinuclear antibody, angiotensin-converting enzyme, and serum neuromyelitis optica antibodies.", "Whole-exome genome sequencing was negative for genes associated with neurofibromatosis type 1 and type 2.", "After removal of dental braces, MRI of the brain and orbits with and without contrast demonstrated thickening and nodular enhancement of bilateral perioptic nerve sheaths extending up to the orbital apex.", "Patchy T2-weighted hyperintensity was noted within the bilateral optic nerves (Figure).A, T1-weighted fat-suppressed image demonstrates thick, nodular, circumferential enhancement in the bilateral optic sheaths."]}
{"Patient Personal Background": ["She denied a history of severe acne or other inflammatory skin disorders.", "The patient had no health problems and only had a distant medical history of an appendectomy and an oophorectomy.", "The only medication she was taking was hydroxychloroquine 200 mg twice daily that was initiated as treatment of her LPP and did not improve the appearance or symptoms of her facial papules."], "Examination and Results": ["On physical examination, she had numerous 1-mm skin-colored grouped monomorphic noninflammatory papules on the bilateral temples, the bilateral cheeks, and the chin.", "A 3-mm punch biopsy specimen was obtained for histopathologic examination of a representative lesion on the right chin (Figure, B and C).A, Clinical photograph shows numerous grouped 1-mm skin-colored monomorphic noninflammatory papules on the left cheek and chin.", "B and C, Histology of a 3-mm punch biopsy specimen of a lesion on the right chin using a hematoxylin-eosin stain."], "Treatment": ["The only medication she was taking was hydroxychloroquine 200 mg twice daily that was initiated as treatment of her LPP and did not improve the appearance or symptoms of her facial papules."]}
{"Patient Personal Background": ["She was previously diagnosed with hidradenitis suppurativa and treated with surgical excision and split-thickness skin grafting of the genitocrural folds with graft failure.", "Over the past 1.5 years, she had been admitted to the hospital on multiple occasions for cellulitis around the wounds, which responded to intravenous antibiotics, and she had received a diverting sigmoid colostomy and indwelling urinary catheter to decrease wound contamination.", "Her wound care required a nursing home.", "Just prior to presentation, she received adalimumab for 3 months without clinical improvement."], "Patient Symptoms": ["On physical examination there were linear moist, eroded, exophytic, condyloma-like plaques of the bilateral submammary folds (Figure, A), intergluteal cleft, and under the abdominal apron.", "There were ulcers of the bilateral genitocrural folds, as well as vulvar edema (Figure, B)."], "Examination and Results": ["On physical examination there were linear moist, eroded, exophytic, condyloma-like plaques of the bilateral submammary folds (Figure, A), intergluteal cleft, and under the abdominal apron.", "There were ulcers of the bilateral genitocrural folds, as well as vulvar edema (Figure, B).", "The lips, oropharynx, and ostomy were unremarkable.", "Similar plaques were present in the bilateral submammary fold, under the abdominal apron and in the intergluteal cleft.", "B, Clinical photograph of linear ulcers of the genitocrural folds, vulvar edema, and an indwelling urinary catheter."], "Treatment": ["Over the past 1.5 years, she had been admitted to the hospital on multiple occasions for cellulitis around the wounds, which responded to intravenous antibiotics, and she had received a diverting sigmoid colostomy and indwelling urinary catheter to decrease wound contamination.", "Just prior to presentation, she received adalimumab for 3 months without clinical improvement."], "Others": ["A wedge biopsy specimen of a submammary plaque was obtained, and histopathology was performed (Figure, C and D).A, Clinical photograph shows a submammary representative linear condyloma-like ulcerated plaque, as well as secondary irritant contact dermatitis from application of topical medications.", "C, Hematoxylin-eosin stain of a biopsy specimen from the submammary plaque.", "D, High-power image from the same specimen."]}
{"Patient Personal Background": ["He had previously been treated with various topical glucocorticosteroids and antibiotics without improvement.", "The family history was negative for skin disease."], "Patient Symptoms": ["The physical examination revealed multiple disseminated erythematous papules, petechial hemorrhages, and yellowish crusts on the scalp (Figure, A).", "The patient did not show any other obvious abnormalities, but his mother reported occasional otitis media."], "Examination and Results": ["The remaining skin and mucosal surfaces, as well as neck, axillary, and inguinal lymph nodes, were unremarkable.", "Routine blood examinations revealed no pathological findings.", "A whole-body magnetic resonance imaging (MRI) scan showed 2 osteolytic lesions on the right frontoparietal skull (Figure, B).", "A punch biopsy specimen of an erythematous papule on the scalp was obtained and stained with hematoxylin-eosin for histopathological analysis (Figure, C).", "In addition, immunohistochemical stainings were performed (Figure, D).A, Clinical photograph shows multiple disseminated erythematous papules, petechial hemorrhages and yellowish crusts on the scalp.", "B, Contrast-enhanced T1-weighted axial magnetic resonance image shows osteolytic lesions in the frontotemporal skull.", "C, Histopathological analysis of a punch biopsy of the scalp demonstrates a subepidermal infiltrate consisting of large cells with kidney-shaped nuclei, solitary lymphocytes, and eosinophilic granulocytes.", "D, The infiltrate stained positively for CD1A."]}
{"Patient Personal Background": ["His parents also reported atypical social and language development, disrupted sleep, and persistent impulsivity with attempts to elope.The patient had a complex medical history that was marked by prematurity at 32 weeks, slow postnatal growth, and severe gastroesophageal reflux.", "His pediatrician documented a normal neurological examination without dysmorphology or congenital anomalies.A developmental evaluation revealed delays in motor function and language development notable by age 2 years."], "Patient Symptoms": ["Tantrums were unpredictable and often resulted in severe head-butting.", "His parents also reported atypical social and language development, disrupted sleep, and persistent impulsivity with attempts to elope.The patient had a complex medical history that was marked by prematurity at 32 weeks, slow postnatal growth, and severe gastroesophageal reflux.", "The parents stated that he played repetitively, lining up toy cars and spinning their wheels.", "He did not seek or give comfort to others when distressed.", "He had tactile hypersensitivity but pain hyposensitivity, flicked light switches repetitively, and mouthed objects.In the office, the patient showed a minimal response to clinicians\u2019 social overtures and poor eye contact.", "He replayed videos on a smartphone while laughing, spinning around, and flapping his hands.", "He did not respond to prompts for joint engagement and no imaginative play was observed.", "When the videos stopped, he repeatedly climbed onto chairs and jumped off."], "Examination and Results": ["His pediatrician documented a normal neurological examination without dysmorphology or congenital anomalies.A developmental evaluation revealed delays in motor function and language development notable by age 2 years.", "Testing results revealed clinically significant scores on the Autism Diagnostic Observation Schedule.", "Cognitive testing results showed that his IQ was below average but was likely an underestimate due to noncompliance."], "Treatment": ["He attended a 0 to 3 program with intensive speech therapy and then moved to a self-contained preschool classroom with a 1:1 staff-to-student ratio.", "He received school-based speech, occupational, and physical therapies."]}
{"Patient Personal Background": ["The patient\u2019s medical history was otherwise unremarkable and she had no known history of atopic dermatitis."], "Examination and Results": ["Physical examination revealed well-demarcated desquamative patches with scales on both distal feet, showing a sandal appearance.", "No local heat, swelling, or discharge from the skin lesions was noted.", "A fungal smear skin test with potassium hydroxide preparation was performed on the lesion, which showed negative findings.Well-defined hyperkeratotic desquamation on both feet, representing a sandal appearance."]}
{"Patient Personal Background": ["The patient had a history of hyperlipidemia."], "Examination and Results": ["Results of examination revealed a palpable mass of about 15 cm in the left paraumbilical region.", "The patient had a normal right testis but a missing left testis.", "Results of a computed tomography scan of the thorax, abdomen, and pelvis revealed large intraperitoneal and retroperitoneal masses.", "The intraperitoneal heterogenous mass was 20\u2009\u00d7\u200915\u2009\u00d7\u200911 cm, with linear calcifications (Figure 1).", "There was a right moderate hydronephrosis.", "The retroperitoneal mass was homogeneous, with associated lymphadenopathy encircling the aorta, inferior mesenteric artery, and both renal arteries.", "A large left supraclavicular lymph node and left inguinal lymph node were also detected.", "There was no metastasis identified elsewhere.", "Serum lactate dehydrogenase was elevated at 1358 U/L (to convert to microkatals per liter, multiply by 0.0167), \u03b2 human chorionic gonadotrophin was elevated at 1485 mIU/mL (to convert to international units per liter, multiply by 1.0), and \u03b1 fetoprotein levels were normal.A computed tomography scan of the thorax, abdomen, and pelvis showing large intraperitoneal and retroperitoneal masses.", "The intraperitoneal heterogenous mass was 20\u2009\u00d7\u200915\u2009\u00d7\u200911 cm, with linear calcifications."]}
{"Patient Personal Background": ["The patient reported undergoing an appendectomy at age 23 years and having ulcerative colitis since he was aged 30 years.", "He had received treatment (mesalazine and corticosteroids) for inflammatory bowel disease that had been discontinued.Physical examination revealed paraumbilical ecchymosis (Figure 1A), general abdominal tenderness, and distension."], "Patient Symptoms": ["He described abdominal trauma caused by the bicycle handlebar.", "He had received treatment (mesalazine and corticosteroids) for inflammatory bowel disease that had been discontinued.Physical examination revealed paraumbilical ecchymosis (Figure 1A), general abdominal tenderness, and distension."], "Examination and Results": ["Body temperature, blood pressure, and heart and respiratory rates were normal.", "Laboratory test findings did not show abnormalities except for the leukocyte count (12\u202f300 cells/\u03bcL\u2009[to convert to \u00d7109/L, multiply by 0.001]); hemoglobin and hematocrit levels were within the reference ranges.", "An abdominal computed tomographic (CT) scan, performed immediately, revealed a pneumoperitoneum and free fluid in the lower quadrants of the abdomen (Figure 1B).Preoperative workup.", "A, Paraumbilical bruising.", "B, Abdominal computed tomography (CT) scan: coronal cut showing free fluid (white arrowhead) and pneumoperitoneum (red arrowheads)."]}
{"Examination and Results": ["Visual acuity was 20/400 in the left eye, improved to 20/100 with pinhole.", "Slitlamp examination revealed a small, nasal corneal scar, a small iris defect, iris heterochromia, and a cataract with overlying pigment (Figure 1A).", "Dilated funduscopic examination of the left eye demonstrated vitritis and a hazy view of the retina due to the opacity of the media.", "A color fundus photograph of the eye showed opacity of the media secondary to the cataract and vitritis and a slightly pale optic nerve.", "Fluorescein angiography (Figure 1B) demonstrated early hyperfluorescence of an inferotemporal chorioretinal lesion that increased slightly during the course of the study, consistent with possible leakage.", "There were multiple hypofluorescent dots throughout the retina and an appearance of segmentation of the vessels with slightly decreased venous filling and late staining.", "A computed tomography scan of the eye and orbit revealed a hyperdense foreign body located along the inferior aspect of the vitreous, approximately at the 5 o'clock position, abutting the retinal surface.", "Ultrasonography B scan revealed a highly reflective material causing posterior shadowing at the 5 o\u2019clock position.A, Cataract with overlying pigment (yellow arrowhead)."]}
{"Patient Personal Background": ["The kidney transplant was performed 4 years previously presumably secondary to diabetic nephropathy, and the patient was receiving daily 5 mg of oral prednisone and 1500 mg of mycophenolate mofetil hydrochloride."], "Patient Symptoms": ["The patient denied significant ocular history before this episode of vision loss."], "Examination and Results": ["On examination, his visual acuity was counting fingers OD at 2 ft and 20/20 OS.", "Intraocular pressures were measured at 15 mm Hg OD and 14 mm Hg OS, and normal pupillary and anterior segment examination findings were noted in each eye.", "The patient had several large pigment epithelial detachments (PEDs) with associated tears and scrolling of the retinal pigment epithelium (RPE) seen on enhanced-depth imaging optical coherence tomography in the right eye (Figure 1A).", "Intravenous fluorescein angiography demonstrated several large window defects with hyperfluorescence in the regions of the RPE tears in the late phase (Figure 1B).", "Indocyanine green angiography was also performed and did not reveal any hyperfluorescent regions.A, Enhanced-depth imaging optical coherence tomography (OCT) of a foveal cross-section at presentation shows a serous retinal detachment and a retinal pigment epithelium tear with scrolled edges seen along the Bruch membrane inferiorly in the image and the other edge of the tear seen attached to the retina at the top left."]}
{"Patient Personal Background": ["She was otherwise well and had no history of tuberculosis or underlying immunocompromise."], "Patient Symptoms": ["Three days after initial presentation, the patient developed acute binocular horizontal diplopia and disorientation.A, Color fundus photograph revealed bilateral swollen, hyperemic optic discs with multifocal choroidal lesions."], "Examination and Results": ["Her best-corrected visual acuity was 20/80 OD and 20/60 OS.", "Ophthalmoscopy revealed bilateral swollen, hyperemic optic discs with multifocal yellowish choroidal lesions located at the midperiphery and posterior pole of the retina.", "The lesions varied in size, ranging from one-fourth to twice the diameter of the optic disc.", "Punctate areas of choroiditis were also seen along the temporal arcades (Figure 1A).", "Results of fundus fluorescein angiography showed bilateral early hypofluorescence, with late staining and leakage from the optic discs.", "Results of systemic examination were normal, except for coarse crepitations of the right lung.", "The erythrocyte sedimentation rate was elevated, at 80 mm/h, as was the C-reactive protein level, at 20.2 mg/L (to convert to nanomoles per liter, multiply by 9.524).", "Chest radiograph showed consolidation in the right lower zone (Figure 1B).", "However, results of tuberculin skin test, sputum for acid-fast bacilli, and sputum culture were negative."]}
{"Patient Personal Background": ["Her ocular history included narrow angles and ocular hypertension that were managed with laser peripheral iridotomy and topical antiglaucomatous medications in both eyes."], "Patient Symptoms": ["During subsequent visits to the clinic, pigmentation was also noted in the auricles of both ears (Figure 1B).External photographs taken at initial presentation."], "Examination and Results": ["On examination, her visual acuity was 20/25 OD and 20/20 OS, with intraocular pressure of 21 mm Hg OD and 21 mm Hg OS.", "Slitlamp examination demonstrated mild cataract with narrow angles, with patent laser peripheral iridotomy in each eye.", "Ophthalmoscopic examination demonstrated peripheral paving-stone degeneration in the right eye and peripheral retinal pigmentary abnormalities in both eyes."], "Treatment": ["Her ocular history included narrow angles and ocular hypertension that were managed with laser peripheral iridotomy and topical antiglaucomatous medications in both eyes."], "Others": ["Arrowheads indicate pigmentation."]}
{"Patient Personal Background": ["The baby was an otherwise healthy girl born at full term.", "Her perinatal history was significant only for a positive maternal test for group B Streptococcus agalactiae, which was treated prior to delivery.Results of the initial examination were significant for conjunctival hyperemia or vasodilation of the right eye, with a 3\u2009\u00d7\u20094-mm central corneal ulcer."], "Patient Symptoms": ["The patient had received a diagnosis of conjunctivitis at 6 days of life but failed to respond to treatment with topical erythromycin ophthalmic ointment, 0.5%.", "Results of spinal ultrasonography demonstrated spinal cord tethering at L4, preventing lumbar puncture and collection of cerebrospinal fluid for culture.Two days later, the patient\u2019s right eye developed a hypopyon, and its intraocular pressure was elevated (Figure)."], "Examination and Results": ["Results of B-scan ultrasonography showed no posterior chamber involvement.", "Corneal cultures for bacteria, fungi, and herpes simplex virus were obtained.", "Results of spinal ultrasonography demonstrated spinal cord tethering at L4, preventing lumbar puncture and collection of cerebrospinal fluid for culture.Two days later, the patient\u2019s right eye developed a hypopyon, and its intraocular pressure was elevated (Figure).", "Results of another B-scan ultrasonography showed a normal posterior segment without inflammation."], "Treatment": ["Treatment with topical polymyxin B sulfate-trimethoprim and intravenous ampicillin, cefepime hydrochloride, and acyclovir sodium was initiated.", "The topical antibiotic eyedrops were changed to fortified vancomycin hydrochloride, 50 mg/mL, and tobramycin sulfate, 14 mg/mL, and topical timolol maleate, 0.5%, and dorzolamide hydrochloride, 2.0%, were added."], "Others": ["Owing to concern for systemic involvement of group B S agalactiae, herpes simplex virus, and other infectious causes, the patient was admitted to the children\u2019s hospital for a full sepsis workup.", "Anterior chamber fluid was sent for culture."]}
{"Patient Personal Background": ["He had no other pertinent medical history and no relevant ocular history other than anisometropia, for which he wears a corrective contact lens in his right eye."], "Examination and Results": ["At his initial ophthalmology visit, his best-corrected visual acuity was 20/40 OD and 20/20 OS.", "In both corneas, he had numerous multicolored, highly refractile crystals located primarily in the subepithelium and anterior stroma (Figure 1).", "No deposits were noted in the retina of either eye on funduscopic examination.External slitlamp examination of the left eye shows extensive subepithelial and anterior stromal crystals.", "Similar findings were seen in the right eye."]}
{"Patient Personal Background": ["He was otherwise asymptomatic and had no physical limitations.", "He had never smoked, and results of his physical examination were normal."], "Examination and Results": ["Results of complete blood cell counts, basic metabolic panel, and liver function tests were all within normal limits.", "A chest radiograph revealed a 10\u2009\u00d7\u20099-cm lobulated left lower lobe mass.", "Examination of a biopsy specimen showed a primary adenocarcinoma with an immunohistochemical profile of CDX2 positive, CK20 positive, TTF-1 negative, and napsin A negative.", "His EGFR (OMIM 131550), ALK (OMIM 105590), and ROS1 (OMIM 165020) genes were wild type, and results of testing for programmed cell death protein 1 (PD-1) and programmed death ligand 1 (PD-L1) were 0%.", "Results of upper gastrointestinal tract endoscopy and colonoscopy did not reveal any evidence of a primary malignant neoplasm.", "Positron emission tomography showed no evidence of mediastinal lymphadenopathy or extrathoracic disease.", "Surgical margins were negative for involvement, with no large vessel or perineural invasion seen.", "Five sampled lymph nodes were negative for involvement."], "Treatment": ["Given the patient\u2019s excellent performance status, he underwent a mediastinoscopy with left lower lobe lobectomy."], "Diagnosis": ["Examination of a biopsy specimen showed a primary adenocarcinoma with an immunohistochemical profile of CDX2 positive, CK20 positive, TTF-1 negative, and napsin A negative.", "Results of postoperative pathologic testing showed a 13-cm adenocarcinoma with similar immunohistochemical markers as in the prior biopsy specimen."], "Others": ["Repeat pathologic interpretation was performed (Figure).Initial pathologic testing of a left lower lobe biopsy specimen (hematoxylin-eosin stain, original magnification \u00d7100)."]}
{"Patient Personal Background": ["Her medications included 125 mcg digoxin daily and 2.5 mg apixaban twice daily.On presentation, she was afebrile."], "Patient Symptoms": ["She experienced severe pain over the left hip.", "She denied any head trauma or loss of consciousness but described occasional palpitations."], "Examination and Results": ["Her blood pressure was 168/96 mm Hg, her heart rate was 88 beats per minute, and her respiratory rate was 18 breaths per minute.", "Physical examination showed no gross physical deformity.", "The trachea was midline and the neck was supple, without any engorged veins.", "Lung sounds were clear to auscultation bilaterally.", "Precordial palpation revealed a nonpalpable apex beat.", "Heart sounds were appreciated loudest over the right parasternal area.", "S1 and S2 were normal.", "No S3, murmur, rub, or gallop were present.", "A soft S4 was heard.", "The 12-lead electrocardiogram showed marked right axis deviation with poor R wave progression across the precordial leads V1-V6 (Figure 1).Standard 12-lead electrocardiogram shows upright R wave in avR and R wave regression across the precordial leads."], "Treatment": ["Radiography of the hip showed a femoral neck fracture, and she was scheduled for emergent hip arthroplasty."], "Diagnosis": ["Radiography of the hip showed a femoral neck fracture, and she was scheduled for emergent hip arthroplasty."]}
{"Patient Personal Background": ["She had a remote 2 pack-year smoking history."], "Patient Symptoms": ["She was prescribed antibiotics and steroids by her family physician, which initially provided intermittent, symptomatic improvement; however, she ultimately experienced a progressive decrease in tactile sensation on her face, anosmia, and changes in her right peripheral vision."], "Examination and Results": ["Sinus computed tomography (CT) and neck magnetic resonance imaging (MRI) revealed a large expansile mass arising from the right side of the skull base and nasopharynx with extension into the pterygopalatine fossa, masticator, parapharyngeal, retropharyngeal, and carotid spaces.", "In addition, imaging showed involvement of the right posterior orbit with erosion of the posterior maxillary sinus wall, anterior and middle cranial fossa with erosion through the cribriform plate, and cavernous sinus.", "Physical examination revealed slight right-sided facial fullness, grossly intact extraocular motion, decreased vision in the right lateral field, and palpable bilateral level 2 neck lymph nodes.", "Flexible laryngoscopy revealed a right-sided lobulated mass involving the medial middle turbinate, posterior septum, and nasal floor, as well as the posterior aspect of the maxillary sinus extending superiorly to the nasopharynx and skull base posteriorly.", "The mass extended into the left superior nasopharynx and superior septum.", "In-office biopsy specimens were obtained and revealed a primitive small round cell tumor with the following immunohistochemical (IHC) staining profile: diffusely positive for desmin, myogenin, and CD56; focally positive for low-molecular-weight kininogen (LMWCK), p63, and S-100; and negative for AE1/AE3, CK 5/6, CK7, CK20, p40, chromogranin, SOX10, HMB45, CD99, and CD20 (Figure 1).Histopathologic images."], "Treatment": ["She was prescribed antibiotics and steroids by her family physician, which initially provided intermittent, symptomatic improvement; however, she ultimately experienced a progressive decrease in tactile sensation on her face, anosmia, and changes in her right peripheral vision."], "Others": ["A, Nests of primitive small round blue cells surrounded by fibrovascular septa.", "Hematoxylin-eosin.", "B, Diffuse, nuclear positivity.", "Myogenin stain."]}
{"Examination and Results": ["A noncontrast computed tomographic (CT) scan of the abdomen demonstrated splenomegaly, ascites, and a retroperitoneal mass posterior to the pancreatic head.", "Fine-needle aspiration from the retroperitoneal mass and ascitic fluid revealed no malignant cells.", "The patient subsequently developed a left-sided lateral chest wall hematoma, and, in retrospect, it was thought that the retroperitoneal mass was actually a hematoma because multiple follow-up studies demonstrated the mass steadily decreasing in size.", "Echocardiography showed right atrial and ventricular dilatation and increased thickness of the interventricular septum.", "Laboratory tests showed elevated results for serum-free \u03bb light chain and proteinuria levels and altered liver function tests but a normal coagulation profile.", "Routine surveillance noncontrast CT imaging of the neck demonstrated a submucosal soft-tissue mass containing few punctate calcifications centered in the epiglottis with clinically significant narrowing of the oropharyngeal and supraglottic laryngeal airways by the enlarged epiglottis (Figure).Computed tomographic images show a soft-tissue mass containing punctate calcifications centered on the epiglottis."]}
{"Patient Personal Background": ["She had not experienced hypertension, vertigo, sleep apnea, hyperthyroidism, hearing loss, head trauma, history of ear infections, otorrhea, rhinorrhea, ear surgery, or family history of ear problems."], "Patient Symptoms": ["She reported constant pulsatile tinnitus with a whooshing quality for 4 years.", "Factors exacerbating her symptoms included holding her breath and turning her head to the left.", "She reported that compression of her right neck and turning her head to the right decreased the loudness of the tinnitus."], "Examination and Results": ["The external auditory canals were clear bilaterally.", "Tympanic membranes were intact and mobile bilaterally.", "There was no evidence of any vascular masses in the middle ear space.", "Results from testing with tuning forks were normal.", "Toynbee stethoscope revealed a bruit in the right ear that could be stopped with gentle compression of the right side of the neck.", "An audiogram showed hearing within normal limits with slight air-bone gaps present at 250, 1000, and 3000 Hz on the right and within normal limits on the left.", "Speech reception threshold on the right was 10 dB with a word recognition score of 100% bilaterally.", "The tympanogram result revealed type A bilaterally, and acoustic reflexes were all present.", "A computed tomographic (CT) temporal bone scan was completed (Figure 1).Computed tomographic images of the right temporal bone."], "Others": ["The arrowheads indicate the findings."]}
{"Patient Personal Background": ["His medical history was significant for obstructive sleep apnea, gastroesophageal reflux disease, a right ear skin cancer excised by a dermatologist, and coronary artery disease with angina on stress test."], "Patient Symptoms": ["He described the pain as \u201celectric\u201d and \u201cstabbing.\u201d He reported no numbness of the region and had not experienced any other symptoms, including new neck masses."], "Examination and Results": ["His physical examination revealed a well-healed excision site of the right ear without new skin lesions.", "His facial nerve was fully intact.", "He had full strength of the shoulder and no numbness of the right ear or cheek.", "Palpation of the lateral neck demonstrated a mass running along the lateral border of the sternocleidomastoid (SCM) muscle.", "Magnetic resonance imaging (MRI) showed an elongated enhancing tubular structure along the lateral surface of the right SCM muscle (Figure 1).A and B, Anterior to posterior coronal fat-saturated T1-weighted postcontrast magnetic resonance imaging (MRI) with an enhancing tubular mass of the right side of the neck (yellow arrowhead) that extends posterior and deep to sternocleidomastoid (SCM) (blue arrowheads).", "C, Axial T1-weighted postcontrast MRI with an enhancing tubular mass (blue arrowheads) that extends posterior and deep to the SCM (blue arrowheads) (white arrowhead indicates external jugular vein)."]}
{"Patient Personal Background": ["His sister had diabetes mellitus and a similar rash in her axillae.", "Physical examination revealed irregularly thickened skin of the right axilla (Figure 1, left) and right lateral area of the neck (Figure 1, right) containing hyperpigmentation, hypopigmentation, multiple acrochordons (skin tags), malodorous crust, and areas of maceration and erosion."], "Patient Symptoms": ["It was worse during the summers, and blisters sometimes developed.", "Emollients were unhelpful."], "Examination and Results": ["Further examination of the skin revealed pseudofolliculitis barbae in the submental and mandibular regions bilaterally.", "The nails, oral cavity, and mucosal membranes appeared normal."], "Others": ["The patient was otherwise healthy.", "The patient performed indoor manual labor as a maintenance engineer and had no significant sun exposure.", "A biopsy of right axillary skin was performed (Figure 2).Left, Rash of right axilla."]}
{"Patient Personal Background": ["She was born full term to a primigravid mother, who had an uncomplicated pregnancy."], "Patient Symptoms": ["On examination, the baby was alert and healthy appearing, although her sclerae were icteric."], "Examination and Results": ["At parturition, the baby presented in occiput posterior position and remained partly crowned for more than 24 hours of maternal labor.", "Birth weight was 3.13 kg (15th percentile), head circumference was 31 cm (<1 percentile), and Apgar score was 9 of 9.", "The baby\u2019s head had a markedly elongate vertex, which the neonatal intensive care unit team diagnosed as cephalohematoma.", "On day 5 of life, her serum total bilirubin and conjugated bilirubin were 20.5 mg/dL (>95 percentile) and 0.3 mg/dL (to convert to micromoles per liter, multiply by 17.104), respectively.", "The vertex of her scalp was uniformly boggy, soft, and edematous, extending beyond suture lines, consistent with a diagnosis of caput succedaneum.", "Beneath the mat and extending laterally in both directions was a deep, 8\u2009\u00d7\u20091-cm, trenchlike ulcer with no drainage (Figure 1B)."], "Treatment": ["The girl was hospitalized for 1 day of phototherapy before being discharged home weighing 2.95 kg (\u22125.75%).", "Wound culture samples were sent for analysis, and she was given empirical intravenous clindamycin hydrochloride."], "Diagnosis": ["The baby\u2019s head had a markedly elongate vertex, which the neonatal intensive care unit team diagnosed as cephalohematoma.", "The vertex of her scalp was uniformly boggy, soft, and edematous, extending beyond suture lines, consistent with a diagnosis of caput succedaneum."], "Others": ["Finally, due to failure to progress, the baby was delivered by urgent cesarean delivery.", "She was exclusively breastfed.She was admitted to our hospital for evaluation of the scalp.", "Dermatology was consulted.", "On the right occiput, there was a mat of hair and thick serosanguineous crust adhering to the scalp (Figure 1A).", "It was nontender to palpation.A, Serosanguineous crust adhering to occipital scalp of a neonate.", "Prior to removing this crust it was being treated as an open ulcer.", "B, Trenchlike linear ulcer revealed after removal of the crust."]}
{"Patient Personal Background": ["He had a history of keratosis pilaris on the lower legs and was otherwise well with no fevers, recent upper respiratory infections, abdominal pain, vomiting, or diarrhea.Physical examination showed a man in no apparent distress."], "Patient Symptoms": ["The patient was well until 2 days prior to hospitalization when he developed bilateral lower extremity edema.", "The day prior to admission, he developed painful pink lesions on both legs.", "There was also a background of pinpoint folliculocentric papules on leg and thighs consistent with keratosis pilaris.", "There was 2+ pitting edema of the lower extremities."], "Examination and Results": ["On the bilateral anterior legs were scattered tender, pink to purple nodules, and plaques (Figure, A).", "A punch biopsy specimen was obtained for histopathology and microbiology cultures (Figure, B-D).", "Routine complete blood cell count and complete metabolic panel had results within normal limits.A, Clinical photograph shows scattered pink to purple nodules and plaques on the bilateral lower extremities.", "B, C, and D, Histopathologic images of a biopsy specimen (hematoxylin-eosin).", "B, Subcutaneous tissue with superficial and deep, dermal and perivascular inflammation, fibrosis, and fat necrosis.", "C, Lobular panniculitis.", "D, Dense neutrophilic infiltration of subcutaneous fat associated with fat necrosis and deposition of granular basophilic material (arrowhead)."], "Others": ["He had not applied any topical medications to his legs or had recent exposure to hot tubs or fish tanks at the home."]}
{"Patient Symptoms": ["The lesions previously resolved with topical corticosteroids but flared soon after treatment discontinuation.", "Some papules became pruritic and extended to the waist and anterior trunk in the past month."], "Examination and Results": ["Physical examination revealed multiple hypopigmented, flat-topped papules on the back, waist, and inframammary area without genital involvement (Figure, A).", "Most lesions were folliculocentric under close inspection.", "Dermoscopy revealed central keratin plugs and some foci of structureless, whitish, and homogenous areas with surrounding erythema (Figure, B).", "The results of laboratory tests for antinuclear antibody and hyperglobulinemia were negative.", "A biopsy specimen was obtained from the back for histologic analysis (Figure, C).A, Multiple hypopigmented, atrophic, keratotic, and folliculocentric papules are seen on the trunk.", "B, Dermascopic findings included 2 foci of central keratin plugs and another ill-defined, whitish, and homogenous area with surrounding erythema.", "C, Histopathologic examination of a biopsy specimen (hematoxylin-eosin, original magnification \u00d7100)."], "Treatment": ["The lesions previously resolved with topical corticosteroids but flared soon after treatment discontinuation."], "Others": ["No family history of similar lesions was recorded.", "Scale bar corresponds to 1 mm."]}
{"Patient Personal Background": ["In addition, the parent reported that, at birth, the patient failed multiple hearing tests and that he had small kidneys."], "Patient Symptoms": ["The parent noted that clear fluid drained from this bump when the patient ate."], "Examination and Results": ["Upon physical examination, the patient was noted to have a preauricular sinus and ear pit as well as a skin-colored papule on the antitragus of the right ear.", "He also had a pedunculated, skin-colored papule on the right lateral neck.Photograph of infant\u2019s lateral neck depicting skin-colored papule with clear drainage."], "Others": ["The patient was asymptomatic."]}
{"Patient Personal Background": ["He had a well-healed appendectomy scar."], "Patient Symptoms": ["The pain had no associated nausea, vomiting, or obstipation."], "Examination and Results": ["On examination, he was afebrile and had a normal heart rate but was notably hypotensive.", "His physical examination showed an abdomen that was soft but diffusely tender without rebound or guarding.", "Blood testing revealed an elevated creatinine level of 1.7 mg/dL (to convert to micromoles per liter, multiply by 88.4), an elevated lactate level of 29.7 mg/dL (to convert to micromoles per liter, multiply by 0.111), an international normalized ratio of 4.6, a lowered hemoglobin level of 10.7 g/dL (to convert to grams per liter, multiply by 10), and a lowered hematocrit level of 27.2%; all other results were unremarkable.", "Given his coagulopathy, low hematocrit level, and abdominal pain, a computed tomography angiogram was performed to rule out bleeding (Figure 1).A, Axial cross-section computed tomography without contrast of the abdomen and pelvis revealed gallstones in the neck of the gallbladder, high-density material within the lumen, and free intraperitoneal fluid."], "Treatment": ["He was given 2 L of crystalloid, and his blood pressure responded appropriately."]}
{"Patient Personal Background": ["In 2014, he experienced angina that resolved following placement of a drug-eluting stent in his LAD."], "Patient Symptoms": ["He reported dyspnea on exertion and left leg claudication at 23 m. At rest, his blood pressure was 146/65 mm Hg measured on the right arm and 85/50 mm Hg on the left arm."], "Examination and Results": ["He reported dyspnea on exertion and left leg claudication at 23 m. At rest, his blood pressure was 146/65 mm Hg measured on the right arm and 85/50 mm Hg on the left arm.", "Physical examination was notable for a diminished left radial pulse."], "Others": ["Coronary angiography via the left femoral artery is displayed in the Figure."]}
{"Patient Symptoms": ["He initially presented to his primary care physician reporting unintentional weight loss, fevers, and subacute visual decline."], "Examination and Results": ["Subsequent ophthalmic examination revealed mild anterior and posterior inflammation, raising suspicion for panuveitis.", "He was pseudophakic with bilateral mild anterior chamber inflammation, moderate vitreous haze, and inferior vitreous condensations.", "The posterior pole demonstrated bilateral diffuse retinal pigment epithelial alterations with a prominent leopard spot pattern and focal choroidal pigmented lesions.", "Macular subretinal fluid tracked to the inferior periphery in both eyes (Figure 1A).", "Optical coherence tomography confirmed bilateral subretinal fluid and retinal pigment epithelial irregularity (Figure 1B); nummular hypoautofluorescent lesions were interspersed within areas of hyperautofluorescence on autofluorescence imaging.", "The optic disc and peripheral vasculature leaked on fluorescein angiography.", "B-scan ultrasonography also showed diffuse choroidal thickening with focal choroidal thickening consistent with the pigmented choroidal lesions.", "Ultrasonographic biomicroscopy revealed ciliary cysts associated with anterior thickening of both ciliary bodies.A, Optos photograph of the left eye demonstrating diffuse retinal pigment epithelial alterations in a leopard spot pattern (white arrowhead) and focal choroidal pigmented lesions, as well as subretinal fluid that tracks to the inferior periphery."], "Diagnosis": ["However, a right upper lobe lung mass noted on the chest radiograph proved to be T2N2M0 stage III non\u2013small-cell lung cancer on biopsy.On presentation to us, the patient\u2019s visual acuity was 20/150 OD and 20/200 OS, but improved to 20/70 OU with pinhole."], "Others": ["Results of laboratory tests for sarcoidosis, Lyme disease, and syphilis were negative."]}
{"Patient Personal Background": ["He had no history of contact lens use, ocular trauma, or ocular surgery.", "His only other medications were oral vitamin D and folic acid."], "Patient Symptoms": ["He had no other symptoms other than occasionally noticing a sensation of a foreign body in that eye and denied any changes in his vision."], "Examination and Results": ["On examination, his visual acuity was 20/20 OD and 20/25 OS.", "Intraocular pressure was 16 mm Hg OD and 23 mm Hg OS.", "The lesion measured 6.5\u2009\u00d7\u20092.5 mm and was firm, nonvascular, slightly mobile, and located on the superotemporal portion of the bulbar conjunctiva (Figure 1).", "It was purulent in appearance, but no material was expressed with attempted incision and drainage at the slitlamp.", "A culture was positive only for Propionibacterium acnes.", "Tests for herpes simplex, cytomegalovirus, and Epstein-Barr virus polymerase chain reactions were negative.External slitlamp photograph showing conjunctival lesion at presentation."], "Treatment": ["He was initially treated with topical antibiotics followed by a course of oral sulindac, 200 mg twice daily, without any improvement."]}
{"Examination and Results": ["Examination with the patient under anesthesia with fluorescein angiography (Figure 1) revealed significant peripheral retinal avascularity, circumferential vascular loops at the border of vascular and avascular retina, and arteriovenous anastomoses in both eyes."]}
{"Patient Personal Background": ["Her other medical history was unremarkable.Six months prior to presentation, workup at her local hospital for the transient vision loss revealed an enhancing right orbital mass on magnetic resonance imaging (Figure, A)."], "Patient Symptoms": ["She reported 5 episodes, each lasting a few minutes and all occurring on awakening.", "Further inquiry revealed that symptoms always developed after using her electronic reader tablet in dim lighting while lying on her left side.", "Notably, the patient reported immediate resolution of vision loss on turning on the lights.", "She denied headaches, visual aura, or neurologic symptoms."], "Examination and Results": ["Carotid ultrasonography and head magnetic resonance angiography showed no abnormalities.", "Inflammatory marker levels were normal.", "Magnetic resonance imaging 3 months later showed a stable mass without change in size or appearance.A, T1-weighted magnetic resonance image (MRI) of the orbit with contrast shows a well-circumscribed, enhancing soft-tissue lesion in the right orbit superomedially (arrowhead).", "B, Computed tomographic (CT) scan of the orbit with contrast shows the mass (arrowhead); no change noted on Valsalva maneuver.On examination, visual acuity was 20/25 OD.", "Pupils, intraocular pressure, and motility were unremarkable.", "Anterior segment examination showed mild cataract and dry eye.", "Posterior pole examination revealed evidence of posterior vitreous detachment and normal optic nerves with 0.2 cup-to-disc ratio in each eye.", "The retina was flat without evidence of whitening or Hollenhorst plaques.", "Humphrey visual fields were full.", "Normal retinal nerve fiber and ganglion cell layer thickness were observed in each eye on optical coherence tomography."]}
{"Patient Personal Background": ["He had been diagnosed as having an orbital capillary hemangioma at 3 months of age after orbital magnetic resonance imaging (MRI), which had reportedly revealed an orbital mass with enlarged extraocular muscles."], "Patient Symptoms": ["He was treated with oral propranolol with no improvement.On examination, the patient had inferior displacement of the left globe with a severe limitation of supraduction and a mild limitation of horizontal movement in the left eye.", "He was unable to maintain fixation with the left eye."], "Examination and Results": ["Results of modified Krimsky testing showed 6 prism diopters (PD) of exotropia and 16 PD of left hypotropia.", "Retinoscopy disclosed a cycloplegic refraction of +2.00 diopters (D) in the right eye and +6.00 D in the left eye.", "Thyrotropin, thyroxine, and thyroid-stimulating immunoglobulin levels were all within reference ranges.", "Repeated MRI with coronal images showed massive enlargement of the superior, inferior, and medial rectus muscles (Figure 1).", "The medial rectus mass extended nasally to produce bowing of the lamina papyrecea, with no extension into adjacent structures.", "The enlarged extraocular muscles were hypointense on T1- and T2-weighted sequences.", "An abnormal curvilinear signal in the intraconal fat was isointense with muscle (Figure 1).A, Coronal T1-weighted magnetic resonance imaging (MRI) of both orbits shows enlarged inferior, medial, and superior rectus muscles with an isointense curvilinear signal in the intraconal fat (arrowhead)."], "Treatment": ["He was treated with oral propranolol with no improvement.On examination, the patient had inferior displacement of the left globe with a severe limitation of supraduction and a mild limitation of horizontal movement in the left eye."], "Diagnosis": ["He had been diagnosed as having an orbital capillary hemangioma at 3 months of age after orbital magnetic resonance imaging (MRI), which had reportedly revealed an orbital mass with enlarged extraocular muscles."]}
{"Patient Symptoms": ["Several days after YAG capsulotomy for posterior capsule opacification, his left eye had become red and painful and his visual acuity had declined to counting fingers.", "The macular edema improved with 4 times daily topical prednisolone acetate and ketorolac tromethamine.After 2 months, the patient reported recurrent pain, redness, and decreased visual acuity.", "A subsequent vitreous tap and injection of intravitreal vancomycin hydrochloride (1.0 mg) and ceftazidime (2.25 mg) were performed."], "Examination and Results": ["His visual acuity was 20/20 OD and 20/160 OS improving to 20/120 OS with pinhole.", "His intraocular pressure was 32 mm Hg OD and 20 mm Hg OS.", "The results of ophthalmic examination of the left eye were notable for pigmented keratic precipitates, a rare anterior chamber cell, 2+ (ie, 16-25 cells per field) anterior vitreous cells, epiretinal membrane, and cystoid macular edema.", "Tuberculosis, sarcoidosis, syphilis, and HLA-B27 laboratory test results were negative.", "At that time, the visual acuity in the left eye was 20/200E at 2 ft, and there were 4+ (ie, >50 cells per field) anterior chamber cells, a layered hypopyon and 2+ anterior vitreous cells."], "Treatment": ["Inflammation improved but persisted after vitreous tap and injection of intravitreal vancomycin hydrochloride (1.0 mg) and ceftazidime (2.25 mg) followed by intravitreal triamcinolone acetonide.", "The macular edema improved with 4 times daily topical prednisolone acetate and ketorolac tromethamine.After 2 months, the patient reported recurrent pain, redness, and decreased visual acuity.", "A subsequent vitreous tap and injection of intravitreal vancomycin hydrochloride (1.0 mg) and ceftazidime (2.25 mg) were performed."], "Others": ["Vitreous cultures yielded no growth.Six months after the patient\u2019s symptoms began, he presented to our clinic."]}
{"Patient Personal Background": ["Medications were switched to levetiracetam, and a tapering dose of steroid was prescribed."], "Patient Symptoms": ["Her skin lesions slightly improved.Two months later, she developed diffuse urticarial lesions of varying sizes over the old plaques.", "The T cell receptor \u03b3 gene (TRG) rearrangement analysis by polymerase chain reaction (PCR) was negative.The plaques and nodules worsened over a 6-month period, becoming more numerous and increasing in thickness, especially on the face, and early leonine facies developed (Figure 1B)."], "Examination and Results": ["These lesions were well-defined with demarcated borders and were minimally pruritic at the time.Given that her condition worsened despite changing her medication, the lesions were biopsied and analyzed, and the results were inconclusive, demonstrating atypical lymphoid infiltrate.", "The results from analysis of a second biopsy specimen showed dense band-like lymphoid infiltrate in the superficial dermis with mild epidermotropism.", "As her condition continued to worsen, a third biopsy specimen was obtained, and the result was consistent with the suspected diagnosis."], "Treatment": ["Medications were switched to levetiracetam, and a tapering dose of steroid was prescribed."]}
{"Patient Symptoms": ["Thirty-day event monitoring showed sinus tachycardia during episodes of palpitation."], "Examination and Results": ["Physical examination was unremarkable, except for sinus tachycardia.", "Laboratory test results were all within normal limits.", "The electrocardiogram showed sinus rhythm and early repolarization changes (Figure, A).", "The transthoracic echocardiogram is shown in Figure, B, and Video 1.", "The left ventricular ejection fraction was between 56% and 60%.", "The estimated pulmonary artery systolic pressure was 24 mm Hg.", "A transesophageal echocardiogram was also performed (Video 2 and Video 3).A, Electrocardiography showing sinus rhythm and early repolarization changes."]}
{"Patient Personal Background": ["He had no reported respiratory issues at birth and no feeding difficulties."], "Patient Symptoms": ["His symptoms included gasping and apneic episodes at night, as well as nighttime nasal congestion."], "Examination and Results": ["Nasal endoscopy in clinic revealed a firm, mobile mass in the nasopharynx.", "Magnetic resonance imaging of the brain revealed a 21\u2009\u00d7\u200914\u2009\u00d7\u200918-mm irregular, but well-defined, heterogeneously enhancing mass in the left nasopharynx with increased perfusion (Figure, A).", "Final pathologic results demonstrated keratinizing squamous cysts and collections of ductal structures set within a myxoid stroma, with small nests of primitive mesenchyme (Figure, C and D)."], "Treatment": ["He had been evaluated by an outside otolaryngologist, who had scheduled an adenoidectomy.", "Given the vascularity of the tumor, the boy underwent preoperative embolization with interventional radiology.", "He was subsequently taken to the operating room, where endoscopic resection of the mass and division of the pedicle were performed without complication (Figure, B)."], "Others": ["Intraoperatively, he was found to have a nasopharyngeal mass, and thus surgery was aborted."]}
{"Patient Symptoms": ["He stated that he had recently bitten his cheek and had since experienced increasing spontaneous pain and swelling."], "Examination and Results": ["There was no obvious swelling extraorally.", "Oral examination revealed an erythematous, 15\u2009\u00d7\u200910-mm lesion of the buccal mucosa, adjacent to the maxillary first molar.", "The lesion was hard and produced a small amount of bleeding with palpation (Figure 1)."]}
{"Patient Symptoms": ["She was initially prescribed a muscle relaxant without notable improvement."], "Examination and Results": ["Physical examination revealed a mild firmness in the left submandibular area.", "The mucosa of the oral cavity and floor of mouth was normal.", "Cranial nerve function, including tongue mobility and sensation, was also normal.", "Contrast-enhanced computed tomography (CT) demonstrated a 1.7\u2009\u00d7\u20091.5\u2009\u00d7\u20091.4-cm mass, adjacent to the left submandibular gland.", "Scattered, nonenlarged lymph nodes were observed (Figure, A).", "Histopathologic findings showed spindle cell neoplasm with morphologic features and no malignant neoplasm identified (Figure, C).", "Results from immunohistochemical analysis were positive for S100 (Figure, D) and negative for smooth muscle actin, CD34, and pankeratin.A, Contrast-enhanced computed tomographic (CT) image."], "Treatment": ["The patient underwent surgical exploration with left submandibular gland excision and resection of the left submandibular mass (Figure, B)."], "Others": ["An ultrasonography-guided fine needle aspiration biopsy was nondiagnostic owing to an inability to obtain sufficient tissue.", "B, Submandibular mass after removing the left submandibular gland.", "C, Hematoxylin-eosin\u2013stained frozen section of the mass.", "D, Positive S-100 immunohistochemical stain."]}
{"Patient Symptoms": ["This mass underwent progressive growth during the first year but subsequently stabilized.", "Despite causing occasional pruritus, the lesion was otherwise asymptomatic."], "Examination and Results": ["A shave biopsy specimen revealed islands of large epithelioid cells with increased mitotic index surrounded by a dense lymphocytic infiltrate (Figure, B and C).", "The tumor cells expressed p16 (Figure, D) and epithelial membrane antigen (EMA), p63, and CK903, and were negative for prostate-specific antigen, CDX2, thyroid transcription factor 1, S-100, chromogranin, synaptophysin, and CD56.", "In situ hybridization for Epstein-Barr virus (EBV) was negative.", "Otolaryngology referral was sought to rule out a head or neck primary neoplasm.", "With the exception of the cutaneous neoplasm, the findings from the otolaryngologic examination were unremarkable.", "A screening chest computed tomographic (CT) image showed multiple right lung nodules, the largest of which measured 2.4 cm in diameter.", "A biopsy of this pulmonary nodule showed a well-differentiated adenocarcinoma with lepidic pattern, and further workup revealed an intestinal tumor as the primary source.", "Positron emission tomography and CT imaging demonstrated a mildly fludeoxyglucose F 18\u2013avid superficial supraclavicular soft-tissue mass but no primary head or neck malignant neoplasm or local nodal metastases.", "A wide local excision of the cutaneous mass and a right level Vb neck dissection were performed.", "Clinical observation was recommended.A, 6.5\u2009\u00d7\u20092.5-cm erythematous, raised, nontender lesion localized to skin without underlying tethering.", "B, Carcinoma and rich lymphoplasmacytic infiltrate (original magnification \u00d7200).", "C, Carcinoma showing anaplasia and atypical mitoses (arrowhead) (original magnification \u00d7400)."], "Treatment": ["The final pathology report showed residual neoplasm with negative margins and 5 negative lymph nodes."]}
{"Patient Personal Background": ["She was prescribed proton pump inhibitor (PPI) therapy with esomeprazole 40 mg, which she took daily, 30 minutes before breakfast."], "Patient Symptoms": ["She had no dysphagia, gastrointestinal bleeding, weight loss, anemia, or exertional chest pain.", "Over-the-counter antacids provided incomplete benefit.", "Her heartburn did not improve and continued to bother her daily despite adding famotidine at bedtime.Esophagogastroduodenoscopy (EGD) results, with esophageal mucosal biopsies, were normal."], "Examination and Results": ["Her heartburn did not improve and continued to bother her daily despite adding famotidine at bedtime.Esophagogastroduodenoscopy (EGD) results, with esophageal mucosal biopsies, were normal.", "Twenty-four-hour ambulatory reflux monitoring was performed after acid suppressive medications were discontinued for 1 week (Table)."], "Treatment": ["She was prescribed proton pump inhibitor (PPI) therapy with esomeprazole 40 mg, which she took daily, 30 minutes before breakfast.", "Her heartburn did not improve and continued to bother her daily despite adding famotidine at bedtime.Esophagogastroduodenoscopy (EGD) results, with esophageal mucosal biopsies, were normal."], "Diagnosis": ["She was referred for esophageal physiologic testing for possible gastroesophageal reflux disease (GERD)."]}
{"Patient Personal Background": ["She was diagnosed 6 years ago with recurrent poorly differentiated serous ovarian carcinoma and underwent total abdominal hysterectomy and bilateral salpingo-oophorectomy, with multiple regimens of chemotherapy, most recently with ixabepilone and bevacizumab.", "Complications included a large bowel obstruction, for which she underwent a transverse loop colostomy 3 years ago.The nodule first appeared 1 year prior."], "Patient Symptoms": ["It appeared to increase in size after contact with fecal matter and decrease in size after cleaning of the ostomy site, although it never resolved completely.", "She reported no pain at the site but described mild burning with fecal-induced irritation.", "She noted \u201cpus-like\u201d drainage from the nodule and received several courses of antibiotics.Examination revealed a 3-cm firm, pink to violaceous, irregularly shaped multilobulated nodule with a central 1-cm ulcer with undermined borders, overlying an erythematous base (Figure)."], "Examination and Results": ["The nodule was rock-hard, with a friable yellow-red plaque between the nodule and ostomy site.", "The stoma was red, moist, and well-perfused."], "Treatment": ["She was diagnosed 6 years ago with recurrent poorly differentiated serous ovarian carcinoma and underwent total abdominal hysterectomy and bilateral salpingo-oophorectomy, with multiple regimens of chemotherapy, most recently with ixabepilone and bevacizumab.", "Complications included a large bowel obstruction, for which she underwent a transverse loop colostomy 3 years ago.The nodule first appeared 1 year prior."]}
{"Patient Personal Background": ["He was otherwise healthy, with no other underlying conditions, and he was taking no medications.", "He had no history of atopic dermatitis or other eczematous dermatoses."], "Patient Symptoms": ["His family medical history was relevant only in that his mother had systemic lupus erythematosus.On physical examination, there were several erythematous annular patches on the abdomen (flanks and periumbilical region), lower back, groin, wrists, and legs (Figure, A).", "The lesions showed slightly raised red-brown borders and a clear center in some patches with no visible scaling, hypopigmentation, induration, or atrophy."], "Examination and Results": ["There were no associated extracutaneous symptoms.", "Results of laboratory studies including complete blood cell count, biochemical analysis, complement levels, antinuclear antibodies, anti-Ro, anti-La, anti-ribonucleoprotein, anti-Smith, and anti-dsDNA antibodies, as well as serologic testing for syphilis and hepatitis B and C virus, were all normal or negative.", "A punch biopsy specimen was obtained for histopathologic evaluation (Figure, B and C).A, Clinical image shows several erythematous annular patches on the flanks and periumbilical region.", "B, Histopathologic analysis of a punch biopsy sample from the abdomen showing superficial lymphocytic infiltrates in the papillary and superficial reticular dermis.", "C, There are also prominent vacuolar changes at the dermoepidermal junction, and in some areas mild lymphocytic exocytosis."]}
{"Patient Personal Background": ["She had moved to Canada from China 30 years ago and was unsure about tuberculosis (TB) exposure and Bacillus Calmette\u2013Gu\u00e9rin vaccine status.", "Her medical history included atrial fibrillation, type 2 diabetes mellitus, dyslipidemia, cerebrovascular disease, hypertension, and Parkinson disease."], "Patient Symptoms": ["The first lesion appeared as an erythematous papule, which grew and subsequently ulcerated.", "Within a few months, she developed other indurated plaques on her legs.", "The ulcer was painful on palpation, but the plaques were mostly asymptomatic."], "Examination and Results": ["Physical examination showed a 5\u2009\u00d7\u20094-cm, well-demarcated, oval ulcer with a violaceous, dusky border and central yellow fibrin mixed with granulation tissue on the left lateral aspect of the calf (Figure, A).", "There were numerous violaceous to dull red, indurated plaques on the posterior aspect of the legs (Figure, B).", "Wound cultures were negative for bacteria, mycobacteria, and fungi (Figure, C and D)."]}
{"Patient Personal Background": ["She denied use of heating pads, space heaters, or other forms of external radiation."], "Examination and Results": ["Physical examination showed several discrete, erythematous, scaly papules admixed with light brown reticulated macules and patches (Figure, A and B).", "Punch biopsy specimens were obtained for further evaluation (Figure, C and D).A, Light brown macules and patches on the back show a strikingly reticular pattern.", "B, Discrete erythematous and scaly papules and overlying hyperpigmented patches are shown.", "C, Histopathologic examination shows eosinophilic spongiosis with interface dermatitis, dyskeratosis, and neutrophilic exocytosis (hematoxylin-eosin, original magnification \u00d720).", "D, Prominent dermal melanophages are present (hematoxylin-eosin, original magnification \u00d720)."], "Treatment": ["She was treated with potent topical corticosteroids and oral prednisone, with no improvement."], "Diagnosis": ["Before evaluation in our department, the patient had undergone a skin biopsy that showed spongiotic dermatitis, had patch testing that was reportedly negative, and received a diagnosis of atopic dermatitis."]}
{"Patient Personal Background": ["C, T2-weighted axial MRI at the basal ganglia level showing remarkable progression of the lesions in the right basal ganglia and thalamus with heterogeneous high signal intensity and multicystic change (arrowhead).There was no history of tumors elsewhere, and his family history was unremarkable."], "Patient Symptoms": ["Sixteen months earlier, the patient was admitted to a hospital for weakness of the left fingers and mild spasticity of the left lower extremity.", "Slight weakness in the left lower extremity was detected 3 months later.", "Neurological examination revealed distal left hemiparesis, left facial palsy, and decreased pinprick sensation in his left face and extremities."], "Examination and Results": ["Magnetic resonance imaging (MRI) at the time revealed a suspicious lesion in the right basal ganglia (Figure, A).", "In addition, carotid and intracranial angiography revealed no abnormalities (not shown).", "Magnetic resonance imaging revealed nonhomogeneous hyperintensity on T2-weighted images in the right basal ganglia without mass effect (Figure, B).", "Atrophy of the right cerebral hemisphere and right cerebral peduncle was observed (not shown).", "A, T2-weighted axial brain magnetic resonance imaging (MRI) at the basal ganglia level performed 16 months before the current hospitalization showing slight hyperintensity at the right putamen and posterior limb of the internal capsule (arrowhead).", "B, T2-weighted axial MRI performed 13 months before the current hospitalization showing moderate hyperintensity at the right basal ganglia without mass effect (arrowhead).", "On MRI, the lesion appeared larger than before (Figure, C), with remarkable heterogeneous enhancement (not shown).", "Human chorionic gonadotropin (HCG) levels in both serum and cerebrospinal fluid (CSF) were normal.", "A hormone assay disclosed normal pituitary function."], "Others": ["The patient was subsequently admitted to our hospital for further evaluation."]}
{"Patient Personal Background": ["No other relatives had hearing impairment.The child was born full term without complications."], "Examination and Results": ["Growth and language skills were appropriate for age.", "Hearing screening at birth and the repeated auditory evaluations at follow-up had normal findings.", "The physical examination was unremarkable except for some midfacial features consisting of a lateral displacement of the inner canthi of the eyes with a broad nasal root, small nostrils, and medial eyebrow flare (Figure, A).", "The same midfacial anomalies were observed in his father (Figure, B), in whom a hypopigmented patch on the left arm and bright blue eyes were also noticed."], "Diagnosis": ["Both parents were diagnosed with profound, nonprogressive sensorineural hearing loss within the first year of life.", "A homozygous mutation in the connexin 26 gene (GJB2 [OMIM 121011]) was found in the mother, whereas the father remained without a causative diagnosis."], "Others": ["Visual acuity and kidney function were normal, and no skeletal deformities were appreciated in the child or his father.The child and his father demonstrate a lateral displacement of the inner canthi."]}
{"Patient Personal Background": ["She received a diagnosis of UC 6 years earlier and has taken mesalamine to control UC.", "Review of systems was notable for diarrhea; however, she denied hematochezia, melena, emesis, fevers, or changes in urination.Her last colonoscopy was 3 years ago, and UC without evidence of dysplasia was confirmed.", "Otherwise, her medical history was unremarkable.", "Family history was negative for inflammatory bowel diseases and gastrointestinal malignancies."], "Patient Symptoms": ["She was discharged a week before this admission for a UC flare that was managed with prednisone.", "Review of systems was notable for diarrhea; however, she denied hematochezia, melena, emesis, fevers, or changes in urination.Her last colonoscopy was 3 years ago, and UC without evidence of dysplasia was confirmed.", "Her abdomen was tender to palpation in the left lower quadrant, which was soft and nondistended.The patient\u2019s complete blood cell count and comprehensive metabolic panel results were unremarkable.", "She started receiving piperacillin/tazobactam but began to have increased abdominal pain, emesis, and inability to tolerate oral intake."], "Examination and Results": ["On examination, she was afebrile with normal vital signs.", "Her abdomen was tender to palpation in the left lower quadrant, which was soft and nondistended.The patient\u2019s complete blood cell count and comprehensive metabolic panel results were unremarkable.", "Computed tomographic scan of the abdomen/pelvis demonstrated a thickened colon from the middescending colon to the rectosigmoid.", "There was also a 2.7-cm intramural abscess in the descending colon.", "A repeated computed tomographic scan performed 4 days after the original scan demonstrated that the intramural mass had increased to 3.5 cm and was partially obstructing the descending colon.", "She underwent a colonoscopy, which demonstrated multiple areas of inflammation in the rectum through the descending colon (Figure 1).", "Nothing proximal to the midtransverse colon was visualized because of a large fecal burden."], "Treatment": ["She started receiving piperacillin/tazobactam but began to have increased abdominal pain, emesis, and inability to tolerate oral intake."]}
{"Patient Symptoms": ["During his hospitalization, he was noted to have persistent fevers of unclear origin and neutropenia.", "He denied any pain or photophobia."], "Examination and Results": ["The findings of a previous inpatient eye examination performed 3 weeks earlier were unremarkable.", "Vision was 20/20 OD and 20/100 OS.", "Dilated fundoscopy revealed multiple yellow-white subretinal lesions with associated hemorrhages and vitritis in the left eye (Figure 1).Left eye fundus photograph shows multiple creamy white subretinal lesions with associated hemorrhages and optic nerve head edema.", "Vitritis accounts for the hazy view."], "Treatment": ["He was already admitted for induction chemotherapy after a relapse of his acute lymphoblastic leukemia.", "He was receiving prophylactic cefepime and amphotericin B prescribed by the infectious diseases service.", "Up to this point, the results of multiple systemic cultures were negative other than a skin biopsy specimen of a concerning papular rash that was noted to yield Candida tropicalis."], "Others": ["Anterior segment examination findings were unremarkable."]}
{"Patient Personal Background": ["His ocular history included exotropia and amblyopia in the right eye."], "Patient Symptoms": ["Severe pain was noted with supraduction and infraduction of the right eye."], "Examination and Results": ["The bullet passed through a wooden door before entering the patient\u2019s right orbit.", "An examination revealed normal pupillary light reflexes, a visual acuity of 20/70 OD and 20/40 OS, and normal color vision OU.There was 3 mm of proptosis in the right eye, as well as right-sided periocular ecchymosis.", "An entry wound was visible inferior to the right medial canthus, and the right upper and lower eyelids had full-thickness lacerations involving the canaliculi.", "The patient had a large-angle alternating exotropia, as well as mild supraduction, infraduction, and adduction deficits in the right eye.", "A slitlamp examination of the right eye revealed a normal anterior segment, while a mild vitreous hemorrhage, extramacular retinal whitening, and a subretinal hemorrhage in the inferonasal periphery was noted on ophthalmoscopic examination."]}
{"Patient Personal Background": ["Her medical history was negative for diabetes, hypertension, dyslipidemia, and smoking.", "Her only medication was oral contraception (OCP)."], "Examination and Results": ["The patient\u2019s uncorrected visual acuity was 20/20 OU, and intraocular pressures were 14 mm Hg OD and 15 mm Hg OS.", "Confrontational visual fields and results of external eye examination were normal.", "She had full ocular motility and no afferent pupillary defect.", "Results of the right eye fundus examination were unremarkable (Figure, A).", "The left eye (Figure, B) had tortuosity and dilation of all branches of the retinal vein, disc edema, scattered intraretinal hemorrhages, and nasal macula nerve fiber layer infarcts.", "The vitreous was clear, macula flat, and there was no retinal neovascularization.", "Results of optical coherence tomography confirmed the absence of cystoid macular edema and demonstrated nerve fiber layer thickening and hyperreflectivity, consistent with a nerve fiber layer infarct.A, Right fundus photograph demonstrating absence of vessel tortuosity and dilation, disc edema, infarcts, and hemorrhages."]}
{"Patient Symptoms": ["A review of systems was remarkable for unintentional weight loss, night sweats, and cough with scant sputum."], "Examination and Results": ["On presentation, best-corrected visual acuity was 20/20 OU.", "Intraocular pressure, pupillary reaction, and ocular motility were normal.", "The right eye had normal anterior and posterior segment examination findings.", "The left eye was notable for mostly superior conjunctival and scleral hyperemia with dilated scleral vessels and associated scleral thinning with a conjunctival epithelial defect (Figure 1).", "The results of posterior examination of the left eye were normal.", "Results of serologic tests, including Treponema pallidum particle agglutination assay, HIV, hepatitis B and C, Lyme antibody, rheumatoid factor, and anticyclic citrullinated peptide, were negative.", "Angiotensin-converting enzyme level, uric acid level, erythrocyte sedimentation rate, complete blood cell count, and basic metabolic panel results were within normal limits.", "The results of proteinase 3\u2013antineutrophil cytoplasmic antibody (ANCA) testing and interferon \u03b3 release assay using QuantiFERON-TB gold (QFT) (Qiagen) were positive.", "Chest computed tomography revealed tiny, scattered solid pulmonary nodules that were too small to characterize according to the radiology department.", "The patient was referred to the infectious diseases clinic, where the results of sputum culture and polymerase chain reaction for Mycobacteria tuberculosis were negative."]}
{"Patient Personal Background": ["He reported a small mass in the right scrotum that was evaluated 5 years previously and was reassured to be a nonmalignant lesion."], "Examination and Results": ["Physical examination was notable for a distended abdomen with a palpable left abdominal mass.", "Testicular examination revealed an approximately 1-cm firm right spermatic cord nodule.", "Laboratory tests showed lactate dehydrogenase levels of 818 U/L (to convert to \u03bckat/L, multiply by 0.0167), with no significant \u03b2-human chorionic gonadotropin and \u03b1-fetoprotein levels.", "Computed tomography (CT) of the abdomen (Figure, A and B) revealed innumerable masses throughout the abdomen and pelvis, with the largest measuring 17.5\u2009\u00d7\u200914\u2009\u00d7\u200914 cm and a 3.9-cm enhancing lesion in the left hepatic lobe, and a small amount of ascites.", "Testicular sonogram disclosed a 1.5-cm right epididymal cyst.", "Percutaneous biopsy and histologic examination of the dominant left abdominal mass revealed neoplastic cells (Figure, C) that were positive for cytokeratin, desmin but negative for S100.", "Fluorescence in situ hybridization (FISH) was positive for EWS-WT1 rearrangement.A, Coronal view and B, sagittal view contrast-enhanced computed tomographic imaging revealed innumerable abdominopelvic masses."], "Others": ["Blue arrowheads indicate the dominant mass and the red arrowhead indicates the liver mass.", "C, Hematoxylin-eosin stain (original magnification \u00d740)."]}
{"Patient Personal Background": ["Her risk profile included a family history of sudden cardiac death: her cousin died unexpectedly in his mid-40s while playing football."], "Examination and Results": ["A physical examination showed no remarkable findings.", "Her systolic blood pressure was 125 mm Hg, diastolic blood pressure was 70 mm Hg, and resting heart rate was 52 beats/min.", "Portions of her electrocardiogram (Figure 1A) and 24-hour Holter monitoring trace (Figure 1B) are shown.", "Echocardiographic findings included mildly impaired systolic function (left ventricular ejection fraction, 45%-50%) but were otherwise normal."]}
{"Patient Personal Background": ["He reported no antecedent neck trauma or neck infection, nor any history of swelling during childhood."], "Patient Symptoms": ["He experienced dyspnea, limitation of neck movements, and neck tightness owing to the bulkiness of the lesion."], "Examination and Results": ["The swelling had been present for approximately 12 months, and the growth was gradual and continuous.", "Contrast-enhanced T1- and T2-weighted magnetic resonance imaging (MRI) revealed a 15\u2009\u00d7\u20097-cm homogenous ovoid bilobulated cystic mass in the left lateral region of the neck with displacement of the surrounding musculature and vascular structures but no sign of invasion.", "The imaging of the lesion revealed fibrous septae in the central and inferior parts, with extension to the supraclavicular region (Figure, A and B).", "After written informed consent was obtained, the patient underwent total excision of the cystic mass through an apron flap incision combined with T-incision for preservation of cranial nerve XI and sternocleoidomastoid muscle (Figure, C).A, T1-weighted magnetic resonance image (MRI) shows a homogenous ovoid bilobulated hypointense cystic mass in left parapharyngeal area and posterior cervical region, extending to the supraclavicular triangle.", "B, T2-weighted MRI demonstrates thin-walled, markedly hyperintense cystic mass indenting neighboring structures.", "No fluid-fluid level is observed."], "Treatment": ["C, Cervical mass with preservation of the vital structures of the neck."]}
{"Patient Symptoms": ["She presented to her rhinologist for follow-up 6 weeks after surgery reporting improved nasal obstruction and olfaction, but complained of 2 weeks of throat pain and swelling.", "Two weeks later her symptoms returned, now accompanied by new-onset snoring and nasal obstruction."], "Examination and Results": ["Physical examination revealed bilateral tonsillar erythema, exudate, tenderness, and peritonsillar edema.", "Nasal endoscopy revealed nasopharyngeal soft-tissue swelling with mucopurulent secretions on the left side.", "She was referred for a computed tomographic scan with contrast, which showed a rim-enhancing, multilocular hypodense collection extending from the left nasopharynx inferiorly to the level of the right palatine tonsil (Figure 1).", "Intraoperative endoscopy revealed ulceration and necrotic debris in the nasopharynx and oropharynx."], "Treatment": ["She was prescribed amoxicillin\u2013clavulanic acid for presumed tonsillitis and began to improve.", "On the basis of the radiographic findings, she was taken to the operating room urgently.", "Culture and biopsy specimens were obtained."]}
{"Patient Personal Background": ["However, her medical history was otherwise unremarkable."], "Patient Symptoms": ["The lesions were first reported when she was 5 years of age and gradually increased in size.", "There was significant bilateral exophthalmos (the left eye was more pronounced), with visual changes, and dental malocclusion."], "Examination and Results": ["On clinical examination, the lesions were hard in consistency with normal overlying skin.", "However, there were no clinical signs of endocrinopathy.", "A skeletal survey showed no involvement of other bones.", "The patient\u2019s serum calcium, phosphate, alkaline phosphatase, thyroid, and parathyroid hormone levels were within normal limits.", "A computed tomographic (CT) examination of the craniofacial skeleton was performed (Figure).Noncontrast axial bone algorithm computed tomographic images of the facial bones."]}
{"Patient Personal Background": ["His remaining medical, surgical, family, and social history was noncontributory."], "Patient Symptoms": ["He was otherwise healthy and exhibited no constitutional complaints.", "Examination showed a healthy-appearing child with left abducens nerve palsy and an afferent pupillary defect."], "Examination and Results": ["There was no chemosis, exophthalmos, or enophthalmos.", "Findings from nasal endoscopy were unremarkable.", "A computed tomographic scan of the sinuses without contrast showed a well-circumscribed posterior-medial extraconal mass extending into the orbital apex with smooth, nonaggressive bony remodeling and expansion of the left superior orbital fissure with further dorsal extension into the left cavernous sinus (Figure, A).", "Magnetic resonance imaging of the orbits showed that orbital component was inseparable from medial rectus muscle.", "Tumor also resulted in lateral displacement and compression of the left optic nerve (Figure, B)."], "Treatment": ["The patient underwent an image-guided left endoscopic orbital decompression with biopsy of the orbital mass."], "Others": ["Representative hematoxylin-eosin\u2013stained sections are shown in the Figure, C and D. The tumor was negative for FUS (FUsed in Sarcoma; also termed TLS, Translocated in LipoSarcoma)-CHOP (C/EBP HOmologous Protein; also termed DDIT3, DNA Damage-Inducible Transcript 3) fusion oncogene on fluorescent in situ hybridization (FISH).A, Axial cut of noncontrast computed tomographic (CT) scan of facial bones.", "B, Axial cut of T1-weighted magnetic resonance image (MRI).", "C and D, Representative hematoxylin-eosin\u2013stained histologic sections of the lesion."]}
{"Patient Personal Background": ["Her medical history was significant for streptococcal glomerulonephritis and 2 prior kidney transplants.", "Her medications included prednisone, tacrolimus, and mycophenolate mofetil."], "Patient Symptoms": ["In the few months before presentation, she experienced partial nail loss and her nail had become painful with intermittent drainage."], "Examination and Results": ["Physical examination of the left second fingernail showed a tender ulcerated nodule encompassing the nail bed with near-complete nail loss and purulent drainage (Figure 1, left).", "The specimen was analyzed by histopathology with hematoxylin-eosin staining and once again showed a pyogenic granuloma\u2013like response characterized by proliferating blood vessels in a background of fibrosis and reactive plasmacytic infiltration (Figure 1, right).", "Careful inspection of the pyogenic granulomatous process at higher power demonstrated atypical epithelioid and spindled cells adjacent to blood vessels.Left, Physical examination of left second fingernail."], "Treatment": ["A previous biopsy showed a pyogenic granuloma, and she had been treated with curettage and electrodessication.", "A nail biopsy was repeated by performing a 4-mm punch through the nail bed."]}
{"Patient Symptoms": ["Three weeks later, he presented again with abdominal pain."], "Examination and Results": ["A computed tomography (CT) scan demonstrated fluid collections adjacent to the ascending colon and bowel wall thickening with intestinal pneumatosis consistent with ischemic bowel.", "Superior mesenteric vein thrombosis was redemonstrated on CT scan.", "One day following surgery, a CT scan demonstrated a new left femoral vein thrombosis and pulmonary embolism."], "Treatment": ["He was diagnosed with superior mesenteric vein thrombosis with mesenteric ischemia and treated with partial small bowel resection and 2 weeks of enoxaparin while hospitalized.", "An intravenous course of piperacillin-tazobactam was started, and an exploratory laparotomy with bowel resection was performed.", "Postoperatively, intravenous heparin was started."], "Diagnosis": ["He was diagnosed with superior mesenteric vein thrombosis with mesenteric ischemia and treated with partial small bowel resection and 2 weeks of enoxaparin while hospitalized.", "Superior mesenteric vein thrombosis was redemonstrated on CT scan."]}
{"Patient Personal Background": ["A diagnosis of multibacillary leprosy was considered previously in another health care facility for which multidrug therapy with rifampicin, 600 mg/mo, dapsone, 100 mg/d, and clofazimine, 50 mg/d, was administered for 6 months."], "Patient Symptoms": ["The lesion had started on the left foot as a painful blister that eventually ruptured to form an ulcer, which subsequently progressed.", "During this time, multiple hypopigmented asymptomatic lesions appeared on his face and scalp."], "Examination and Results": ["On physical examination, an 8\u2009\u00d7\u20096-cm ulcer was noted on the lateral aspect of the dorsum of the left foot (Figure, A).", "The ulcer was well defined with regular margins, and the floor was covered by a yellowish slough.", "Perilesional tenderness and pitting edema were observed.", "Multiple ill-defined, hypopigmented patches of various sizes were present on the scalp and face (Figure, B).", "Inguinal lymph nodes on both sides were enlarged, nontender, and movable.", "Peripheral nerve trunks were not thickened, and peripheral arteries could be easily palpated.", "Lesional skin appendages are preserved.", "C, Histologic analysis showing acute ulceration of the epidermis with granulation tissue and infiltrating neutrophils and macrophages (hematoxylin-eosin, original magnification \u00d7100)."], "Treatment": ["There was no appreciable clinical improvement."], "Others": ["Lesional appendages and sensations were preserved.", "Skin punch biopsy specimens were obtained from the ulcer (Figure, C and D) and a hypopigmented facial lesion.A, Nonhealing ulcer.", "B, Ill-defined hypopigmented macules on the left side of the face."]}
{"Patient Symptoms": ["The asymptomatic patch had slowly enlarged since initial onset, but remained confined to the single extremity."], "Examination and Results": ["Physical examination revealed agminated and discrete erythematous macules as well as interspersed fine, reticulated telangiectases over the right pretibial leg (Figure, B).", "No edema or warmth of the affected area was observed, and there was no evidence of mucosal, conjunctival, or nail involvement.", "Findings on review of systems were negative for bleeding tendencies or hypercoagulability.", "A punch biopsy was performed (Figure, C and D).A, Reticulated, blanchable, salmon-colored patch on the pretibial leg.", "B, Individual fine, telangiectatic erythematous macules identified on closer inspection.", "C, Concentric deposits of hyaline material surround dilated and markedly thickened capillaries within the papillary dermis (original magnification \u00d7200).", "D, Perivascular hyaline deposits are highlighted strongly by periodic acid\u2013Schiff stain (original magnification \u00d7200)."]}
{"Patient Personal Background": ["His medical history was significant for primary hyperparathyroidism 6 years prior to presentation, for which the patient refused therapeutic management."], "Patient Symptoms": ["The patient was cachectic and exhibited significant muscular weakness.", "Clinical examination revealed a large tumor on the distal part of the right fourth finger (Figure, A) that had gradually enlarged in recent months."], "Examination and Results": ["Radiography revealed complete lysis of the underlying phalanx and periosteal bone resorption in the phalangeal tuft band.A, The patient initially presented with a large tumor on the distal part of the right fourth finger.", "B, Histopathology shows numerous giant cells with multiple osteoclastlike nuclei, and (C) giant multinucleated cells dispersed in contact with fibers associated with the presence of a few small vessels.Laboratory evaluation revealed hypercalcemia at 3.6 mmol/L (reference range for total calcium, 2.05-2.55 mmol/L [to convert to mg/dL, divide by 0.25]), hypophosphatemia at 0.65 mmol/L (reference range for phosphate, 0.87-1.45 mmol/L), and elevated serum parathyroid hormone at 380 pmol/L (reference range, 1.6-6.9 pmol/L [to convert to ng/L, multiply by 1.355]).", "A chest radiograph revealed an important and unexplained deformation of the ribs.We performed a 3-mm punch skin biopsy on the tumor and performed histopathological analysis (Figure, B and C)."]}
{"Patient Symptoms": ["The mother stated that the patient was born with normal-appearing dark hair that fell out days after birth.", "This was replaced with \u201cpeach fuzz,\u201d with no subsequent regrowth of normal hair.", "She denied pruritus."], "Examination and Results": ["On physical examination, short, brittle terminal hairs of varying lengths covered the entire scalp.", "Follicular hyperkeratosis and perifollicular erythema were present, most prominently on the parietal and occipital scalp (Figure, A).", "Mild perifollicular keratotic papules were noted on the posterior upper arms.", "Teeth and nails showed no abnormalities.", "Her eyebrows and lashes were not affected.", "Results of trichography are shown (Figure, B).Photograph of a young patient with hair loss depicts shortened, thin hairs on the scalp of a child with follicular hyperkeratosis.", "Light microscopy of hair shaft at 4\u2009\u00d7\u2009magnification shows a beaded appearance."], "Others": ["Family history was significant for similar hair loss in the patient\u2019s maternal grandmother and maternal cousin.", "The patient had otherwise normal development."]}
{"Patient Symptoms": ["He complained about abdominal pain and had vomited twice.", "The next day, his vomiting persisted, especially after oral intake."], "Examination and Results": ["At physical examination, according to the Advanced Pediatric Life Support protocol, he had normal vitals results with pain during palpation of the left abdominal region without guarding.", "His hemoglobin level was 12.3 g/dL (to convert to grams per liter, multiply by 10) (normal value, 10.5-16.1 g/dL), amylase 68 U/L (to convert to microkatals per liter, multiply by 0.0167) (normal value, <85 U/L), and lipase 25 U/L (normal value, <60 U/L).", "A plain chest radiography result showed no signs of traumatic injury.", "Abdominal ultrasonography results showed a bowel loop with a thickened wall in the left abdominal region with no free abdominal fluid.", "He was admitted to the pediatric ward for close observation."], "Treatment": ["Computed tomography with oral and intravenous contrast was performed (Figure 1).Computed tomography, axial reconstruction (A) and coronal reconstruction (B)."]}
{"Patient Personal Background": ["A transvaginal ultrasonographic scan confirmed normal intrauterine gestation with a vital embryo."], "Patient Symptoms": ["On examination she had tenderness in the RIF with a positive Blumberg sign; blood testing showed leukocyte count 10\u202f450/\u03bcL (to convert to \u00d7109/L, multiply by 0.001) without any shift, C-reactive protein 1.29 mg/dL (to convert to nanomoles per liter, multiply by 0.331), and hemoglobin 11.4 g/dL (to convert to grams per liter, multiply by 10).", "Three days later she returned to the emergency department with recurrent pain; the clinical and ultrasonographic findings were unchanged, without evidence of complicated appendicitis, intra-abdominal fluid collection, or abscess."], "Examination and Results": ["On examination she had tenderness in the RIF with a positive Blumberg sign; blood testing showed leukocyte count 10\u202f450/\u03bcL (to convert to \u00d7109/L, multiply by 0.001) without any shift, C-reactive protein 1.29 mg/dL (to convert to nanomoles per liter, multiply by 0.331), and hemoglobin 11.4 g/dL (to convert to grams per liter, multiply by 10).", "A transabdominal ultrasonographic scan showed a tubular structure in the RIF consistent with a mildly inflamed appendix and stratification of the appendiceal wall (7 mm in the proximal and 11 mm in the appendiceal distal tract).", "A small amount of free fluid was present in the Douglas pouch.", "Working diagnosis was uncomplicated appendicitis and initial conservative management was amoxicillin clavulanate because of the potential risks of miscarriage associated with performing an avoidable appendectomy and general anesthesia during early gestation.", "The Alvarado score was 5.", "The surgeon on call requested an urgent magnetic resonance imaging (MRI) investigation (Figure 1).Magnetic resonance imaging showed the gestational chamber and a normal intrauterine pregnancy as well as the presence of a tubular structure in the right iliac fossa (RIF) (A) and what appeared to be an inflamed, thickened appendix (9.83 mm in the proximal appendix) (B)."], "Treatment": ["Working diagnosis was uncomplicated appendicitis and initial conservative management was amoxicillin clavulanate because of the potential risks of miscarriage associated with performing an avoidable appendectomy and general anesthesia during early gestation.", "The patient initially improved and was discharged home 2 days later with an Alvarado score of 4; oral antibiotic therapy was continued.", "The patient was admitted to the surgical ward and given intravenous antibiotics."], "Diagnosis": ["Working diagnosis was uncomplicated appendicitis and initial conservative management was amoxicillin clavulanate because of the potential risks of miscarriage associated with performing an avoidable appendectomy and general anesthesia during early gestation."], "Others": ["The Alvarado score was 7.", "In the next 48 hours the symptoms and pain did not resolve, although inflammatory markers were low and the patient was not septic."]}
{"Examination and Results": ["This patient was recently discharged from the hospital for West Nile virus (WNV) encephalitis (confirmed seropositive for IgM and IgG antibodies against WNV).", "Polymerase chain reaction analyses detected no DNA for Epstein-Barr virus, BK virus, cytomegalovirus, or herpes simplex virus types 1 and 2.", "Neither HIV antibody nor antigen was detected.", "Cerebrospinal fluid culture analysis findings were normal.", "She received supportive treatment and made a full recovery.The patient\u2019s corrected visual acuity was 20/20 OU, and her intraocular pressure was 14 mm Hg OU.", "Anterior segment examination findings were unremarkable for both eyes.", "Dilated fundus examination revealed microaneurysms, a dot-blot hemorrhage, and scattered, deep, white, chorioretinal lesions in the posterior pole and periphery that were more numerous in the right than left eye (Figure 1A).", "Vitritis was absent.", "Fluorescein angiography showed chorioretinal lesions with central hypofluorescence and peripheral hyperfluorescence (Figure 1B).A, Deep, white, creamy lesions (arrowheads) are observed in the posterior pole of the right eye.", "The dot-blot hemorrhage inferior to the fovea is secondary to nonproliferative diabetic retinopathy."], "Treatment": ["She received supportive treatment and made a full recovery.The patient\u2019s corrected visual acuity was 20/20 OU, and her intraocular pressure was 14 mm Hg OU."], "Diagnosis": ["This patient was recently discharged from the hospital for West Nile virus (WNV) encephalitis (confirmed seropositive for IgM and IgG antibodies against WNV)."]}
{"Patient Symptoms": ["One day prior, she developed a new-onset right facial palsy in addition to bilateral eyelid, lip, and feet swelling."], "Examination and Results": ["Ophthalmologic evaluation revealed visual acuities of 20/20 OD and 20/800 OS.", "The left eye showed a relative afferent pupillary defect and decreased color vision.", "Extraocular movements, confrontation visual fields, and intraocular pressures were within normal limits.", "Anterior segment examination was unremarkable in both eyes.", "Dilated fundus examination revealed optic nerve head edema and peripapillary hemorrhages bilaterally, greater in the left eye than in the right eye (Figure 1).", "Scattered peripheral hemorrhages were present, consistent with thrombocytopenia at the time.Clinical photograph demonstrating optic nerve head edema.", "A, Fundus photograph of the right eye demonstrating lymphomatous optic nerve infiltration and peripapillary hemorrhages."]}
{"Patient Personal Background": ["Her ocular history included myopia with a spherical equivalent of \u22125.50 OD and \u22124.00 OS, normal-tension glaucoma controlled with latanoprost in both eyes, and mild cataracts.", "Systemic medical history included use of aspirin, 81 mg/d, and a multivitamin.", "She frequently consumed alcohol; however, she denied smoking or recreational drug use."], "Patient Symptoms": ["She had no ocular complaints."], "Examination and Results": ["She denied any known allergies, and findings of review of systems were unremarkable.Best-corrected visual acuity was 20/20 OU.", "Extraocular movements were intact, and pupils were round and reactive with no afferent pupillary defect.", "Intraocular pressure by pneumotonometry was 16 OD mm Hg and 19 mm Hg OS, and visual fields by confrontation were full in both eyes.", "Anterior segment examination showed 1+ nuclear sclerosis in both eyes.", "Dilated fundus examination revealed a posterior vitreous detachment and tilted optic nerves with adjacent myopic crescents in both eyes.", "A small, yellowish orange discontinuity was found in the inferior peripapillary region of the optic conus in the right eye (Figure, A).", "The macula was flat with a sharp foveal reflex, and the peripheral retina was unremarkable in both eyes.Color fundus photography (A) and optical coherence tomography (B) of peripapillary changes."], "Others": ["The color fundus image demonstrates a yellow-orange region inferior to the optic nerve, with arrowheads denoting the full extent of the peripapillary intrachoroidal cavitation."]}
{"Patient Symptoms": ["Two weeks later, he developed pain and redness while receiving a steroid taper, and examination revealed episcleritis and a small scleral depression temporally.", "Topical prednisolone therapy was increased; however, during subsequent weeks, his pain intensified."], "Examination and Results": ["His baseline visual acuity was count fingers OD.", "The day after treatment, the patient was comfortable with an intraocular pressure of 23 mm Hg.", "Two weeks later, he developed pain and redness while receiving a steroid taper, and examination revealed episcleritis and a small scleral depression temporally."], "Treatment": ["Transscleral cyclophotocoagulation (TSCPC) was recommended over filtering surgery because of extensive conjunctival scarring and lagophthalmos.", "Transscleral cyclophotocoagulation was performed with 19 spots (1300-1500 mW) at 3 seconds each, without audible pops, and sparing the superotemporal quadrant.", "Topical prednisolone therapy was increased; however, during subsequent weeks, his pain intensified."]}
{"Patient Personal Background": ["She had a history of tobacco use and stopped smoking cigarettes in the 1970s.", "Physical examination and laryngoscopy findings confirmed a painless lesion on the left side of the palate and immobility of the left vocal cord."], "Patient Symptoms": ["Physical examination and laryngoscopy findings confirmed a painless lesion on the left side of the palate and immobility of the left vocal cord."], "Examination and Results": ["No other mucosal lesion was identified.", "The PET scan results showed focal fludeoxyglucose F 18 localization within the known oral cavity SCC (Figure 1A) and in a small, level IIA lymph node, located lateral to the upper right internal jugular vein.", "There was unexpected, prominent, metabolic activity in the medial and asymmetrically enlarged left vocal cord (Figure 1B).A, Positron emission tomography reveals focal fludeoxyglucose F 18 uptake in biopsy-confirmed squamous cell carcinoma of the left palatal graft margin (arrowhead)."], "Treatment": ["Each malignant neoplasm was locally resected and the patient was also treated with adjuvant radiotherapy for the last episode.", "She remained asymptomatic, and a routine surveillance clinical examination uncovered a sixth lesion at the margin of a palatal graft.The patient\u2019s medical history was also noted for a total thyroidectomy in the 1950s, complicated by recurrent laryngeal nerve injury."], "Diagnosis": ["Her oncologic history began 16 years ago with diagnosis and local resection of a lesion on the palate.", "Cancer recurrence at the left buccal mucosa was identified and excised 10 years later.", "She then was diagnosed with 3 recurrences of SCC in rapid succession.", "The PET scan results showed focal fludeoxyglucose F 18 localization within the known oral cavity SCC (Figure 1A) and in a small, level IIA lymph node, located lateral to the upper right internal jugular vein."], "Others": ["Positron emission tomography (PET) was performed to assess extent of disease and to plan treatment."]}
{"Patient Personal Background": ["He had no relevant medical history and was taking no medications.", "He denied smoking, drugs, or alcohol abuse."], "Patient Symptoms": ["The patient reported an incremental decline of daily activities because of progressive muscle weakness."], "Examination and Results": ["He denied chest pain, orthopnea, and paroxysmal nocturnal dyspnea.", "Physical examination was significant for normal heart sounds with bilateral basal rales on lung auscultation and swollen lower extremities with trace edema.", "Bloodwork revealed a mildly elevated alanine aminotransferase level of 77 U/L (normal level, <41 U/L; to convert to microkatals per liter, multiply by 0.0167) and aspartate aminotransferase level of 47 U/L (normal level, <38 U/L; to convert to microkatals per liter, multiply by 0.0167).", "Cardiac profile showed normal troponin-I levels, mildly elevated brain-type natriuretic peptide level of 142 pg/mL (normal level, <125 pg/mL; to convert to nanograms per liter, multipy by 1), and elevated serum creatine kinase level of 666 U/L (normal level, 20-200 U/L; to convert to microkatals per liter, multiply by 0.0167) and creatine kinase\u2013MB fraction level of 10 ng/mL (normal level, <6.7 ng/mL; to convert to micrograms per liter, multiply by 1).", "Echocardiography showed global hypokinesia with a left ventricular ejection fraction (LVEF) of 35%.", "The right ventricle was moderately dilated with impaired systolic function."], "Others": ["Family history was significant for early death of his maternal uncle who had congestive heart failure.", "His younger brother also had progressive weakness but no dyspnea.", "Electrocardiogram  (ECG) on presentation is shown in Figure 1, which has not changed compared with an ECG a year before presentation."]}
{"Patient Personal Background": ["She denied a history of localized trauma, substance abuse, or prior endonasal surgery."], "Examination and Results": ["Examination revealed a nontender, 8-mm, pink-red, soft, fleshy growth just posterior to the membranous septum near the nostril apex.", "Histopathological analysis demonstrated a well-circumscribed submucosal lesion comprised of bland, round, syncytial cells, arranged in a concentric fashion around variably sized slit-like vascular spaces, a minority of which were staghorn in appearance (Figure, A-C).", "No significant perivascular hyalinization was identified.", "The overlying nasal mucosa and surrounding submucosal glands were unremarkable.", "Immunohistochemical stains demonstrate the cellular population to be strongly positive for smooth-muscle actin (SMA), muscle-specific actin, and CD34 (Figure, D), but negative for B-catenin and epithelial membrane antigen.Histopathology of asymptomatic septal mass shows (A) a well-circumscribed, unencapsulated lesion based in the submucosa with an intact overlaying squamous and respiratory mucosa (hematoxylin-eosin); (B) bland, vaguely spindled cells arranged around prominent thin-walled vessels with a \u201cstaghorn\u201d branching configuration (hematoxylin-eosin); (C) the lesional cells are oval to spindle-shaped with abundant cytoplasm and ill-defined cell borders (hematoxylin-eosin); (D) the lesional cells are stained diffusely with myoid markers, including smooth-muscle actin and muscle-specific actin (muscle-specific actin stain)."]}
{"Patient Personal Background": ["Tobacco history was minimal and distant, and alcohol use was social only."], "Examination and Results": ["Physical examination, including flexible nasolaryngoscopy, was notable for a large smooth nonulcerated right base of tongue mass with almost complete pharyngeal airway obstruction, and a 4-cm right level II lymph node.", "Computed tomography (CT) imaging revealed a 3-cm base of tongue\u2013lingual tonsil mass with multiple right Ib, IIa, and II/III nodes, the largest of which was 2.0 cm by 3.0 cm.", "Awake tracheotomy and direct laryngoscopy with biopsy of right base of tongue mass lesion was performed.Histological analysis showed sheets and clusters of small round-oval uniform cells with minimal cytoplasm, granular chromatin pattern, and prominent nuclear molding (Figure, A) with positive immunoreactivity for cytokeratin (CK) 7 (Figure, B) and synaptophysin (Figure, C); a high mitotic rate was also exhibited (Figure, D).", "The cells were negative for CK 5 and 6, CK 20, NUT, p63, and chromogranin.", "Polymerase chain reaction (PCR) detected human papillomavirus (HPV) 16 DNA and did not detect HPV 6, 11, and 18 DNA.Histopathological analysis of the tongue lesion shows (A) sheet-like growth pattern with Azzopardi-type crush artifactual distortion of the neoplastic cells (original magnification \u00d7100) (the insert shows round-oval compact molded nuceli, a high nuclear:cytoplasmic ratio, and granular chromatin pattern without conspicuous nucleoli [original magnification \u00d7400]); B, cytokeratin 7\u2013positive immunoreactivity (original magnification \u00d7200); C, synaptophysin-positive tumor cells (original magnification \u00d7200); and D, a high proliferation rate by Ki-67 staining (original magnification \u00d7200)."], "Treatment": ["Awake tracheotomy and direct laryngoscopy with biopsy of right base of tongue mass lesion was performed.Histological analysis showed sheets and clusters of small round-oval uniform cells with minimal cytoplasm, granular chromatin pattern, and prominent nuclear molding (Figure, A) with positive immunoreactivity for cytokeratin (CK) 7 (Figure, B) and synaptophysin (Figure, C); a high mitotic rate was also exhibited (Figure, D)."]}
{"Patient Personal Background": ["Approximately 1 month prior he had been admitted to the hospital and treated for meningitis."], "Patient Symptoms": ["At the otolaryngologist\u2019s office, the patient stated that he had not experienced otalgia, otorrhea, tinnitus, or vertigo."], "Examination and Results": ["During his hospital course, a computed tomographic (CT) scan of his head revealed a lytic lesion of the left occipital bone.", "His examination revealed clear nasal discharge and a normal otoscopic finding.", "His audiogram demonstrated normal sloping to moderate sensorineural hearing loss with type A tympanometry result on the right and type A on the left.", "His word recognition score was 100% bilaterally.", "To evaluate for a skull base defect and cerebrospinal fluid (CSF) leak, a noncontrast CT scan of the temporal bones was obtained (Figure, A and B).", "This demonstrated a large area of bony destruction and osteolysis involving the left occipital bone.", "A T2-weighted MRI sequence showed a lesion, isointense to CSF, with thinning of the bony cortex (Figure, C and D).", "Based on the imaging, the differential diagnosis included metabolic, infectious, or metastatic lesions to the bone.A and B, Noncontrast temporal bone computed tomographic images.", "C, T2-weighted fast imaging using steady state acquisition magnetic resonance imaging sequence demonstrating a signal isointense to cerebrospinal fluid in the left occipital bone."], "Treatment": ["After treatment with intravenous antibiotics and steroids, his neurologic examination results returned to baseline, and he was discharged home."], "Others": ["Magnetic resonance imaging (MRI) was deferred to the outpatient setting.", "The collection of nasal discharge for \u03b2-2 transferrin analysis was attempted, but insufficient quantity was obtained.", "D, Reformatted postcontrast T1 image shows the herniation of nonenhancing meninges through the defect."]}
{"Patient Personal Background": ["She was of Italian, German, and Slovak ancestry.", "She had a history of congenital horizontal nystagmus, which was pendular, ie, occurring in 2 phases of equal speed (Video)."], "Examination and Results": ["She had fair skin, platinum white hair (Figure 1, left panel), and blue eyes.", "Best-corrected visual acuities were 20/60 bilaterally.", "The irides were blue, although by retro-illumination with a light beam perpendicular to the iris plane, they appeared reddish-pink (Figure 1; eFigure in the Supplement).Left, Hypopigmented platinum hair.", "Right, Hypopigmented eyelashes, and iris lucency on retro-illumination."], "Treatment": ["At age 24 years, she underwent resection of a cutaneous melanoma (stage T1bN1a) from the upper chest, with no signs of recurrence or metastasis."]}
{"Patient Personal Background": ["She had no history of immunosuppression."], "Patient Symptoms": ["She denied fevers, joint pain, joint stiffness, inciting trauma, or recent outdoor activity."], "Examination and Results": ["Results of a recent complete blood cell count and comprehensive metabolic profile were unremarkable.", "Physical examination showed a single 25-mm, firm, dome-shaped subcutaneous nodule with central ulceration on the lateral aspect of the right fifth digit (Figure 1).", "There was no erythema, edema, fluctuance, induration, or lymphangitis surrounding the lesion.", "No lymphadenopathy was present.Dome-shaped subcutaneous nodule with central ulceration on the lateral aspect of the right fifth digit."]}
{"Patient Symptoms": ["Treatment with griseofulvin and clotrimazole had not improved the rash.", "One day prior to presentation he had developed a fever and was diagnosed with otitis media in the emergency department."], "Examination and Results": ["Acetaminophen, ibuprofen, and amoxicillin were used for treatment, but the child was receiving no other medications.Physical examination revealed multiple annular, indurated, dusky red plaques with central clearing and trailing scale ranging from 1 to 6 cm in diameter on his trunk (Figure, A and B).", "A 4-mm punch biopsy of the largest lesion on his back was performed and sent for histopathologic examination (Figure, C).A and B, Annular dusky red indurated plaques on the right flank with central clearing and trailing scale.", "Scattered caf\u00e9 au lait macules and annular dusky red indurated plaques with central clearing and trailing scale on the back.", "C, Hematoxylin-eosin stain (original magnification \u00d740) demonstrates perivascular and periadnexal infiltrate.", "D, Hematoxylin-eosin stain (original magnification \u00d7400)."], "Treatment": ["Treatment with griseofulvin and clotrimazole had not improved the rash.", "One day prior to presentation he had developed a fever and was diagnosed with otitis media in the emergency department.", "Acetaminophen, ibuprofen, and amoxicillin were used for treatment, but the child was receiving no other medications.Physical examination revealed multiple annular, indurated, dusky red plaques with central clearing and trailing scale ranging from 1 to 6 cm in diameter on his trunk (Figure, A and B)."], "Diagnosis": ["One day prior to presentation he had developed a fever and was diagnosed with otitis media in the emergency department."]}
{"Patient Personal Background": ["Her medical history was notable for essential thrombocytosis, which had been complicated by portal vein thrombosis, and she had been receiving treatment with hydroxyurea and rivaroxaban for the past 2 years."], "Patient Symptoms": ["Despite worsening cutaneous disease, she otherwise felt well and denied associated fevers, weakness, weight loss, myalgias, arthralgias, or other constitutional symptoms.Physical examination revealed atrophic and reticulated violaceous plaques with a striking photoaccentuated distribution on the patient\u2019s dorsal hands and forearms (Figure, A)."], "Examination and Results": ["Scaly, violaceous plaques were also present on the thenar eminences and radial aspects of her first 2 fingers bilaterally (Figure, B).", "Prominent poikiloderma was seen on her sun-exposed chest and neck, and a large, stellate ulcer was present on her left distal lower leg (Figure, C).", "A lesional skin biopsy was performed on the patient\u2019s left forearm (Figure, D).A, Clinical photograph of violaceous reticulated plaques on the dorsal aspect of the hands."], "Others": ["B, Clinical photograph of violaceous, scaly plaques on the thenar and radial aspects of the thumb and second digit (mechanic hands).", "C, Clinical photograph of a shallow ulcer with stellate margins on the left distal lower leg.", "D, Histopathology (hematoxylin-eosin stain, original magnification x100)."]}
{"Patient Personal Background": ["Her medical history was significant for 5 strokes over the past 6 years and Raynaud syndrome for the past 2 years.", "In the past, despite extensive workup, no definitive diagnosis had been established."], "Patient Symptoms": ["Annular patches of violaceous erythema forming an irregular net-like pattern were noted on her trunk and extremities (Figure, A and B).", "The patient stated that these skin changes had appeared 2 years prior."], "Examination and Results": ["Complete blood cell count, liver function tests, creatinine, C-reactive protein, erythrocyte sedimentation rate, and urinalysis results were normal.", "Antinuclear antibodies and complement C3 and C4 levels were unremarkable.", "Antiphospholipid antibody and lupus anticoagulant screening results were repeatedly negative and no evidence of thrombophilia was found.", "Magnetic resonance imaging showed acute dot-like diffusion anomalies in the medial and posterior cerebral artery-supplied areas, as well as old stroke residues (Figure, C).", "Transesophageal echocardiography showed no abnormalities.", "A skin biopsy sample was taken from the patient\u2019s left thigh (Figure, D).A, Patient\u2019s lower back and buttocks and, B, thighs and upper calves show generalized, irregular, violaceous, net-like erythema.", "C, Magnetic resonance imaging of the brain showing old stroke residues.", "D, Hematoxylin-eosin stain (original magnification \u00d710)."]}
{"Patient Symptoms": ["Brain magnetic resonance imaging during second attack: resolution of the initial left frontal lobe lesion now with T2-weighted and FLAIR recovery hyperintensity in the left parietotemporal region (C) with associated patchy enhancement (D).She presented again, 15 months later, with 2 weeks of dysarthria and progressive ataxia without change in mental status.", "The patient received pulse dose corticosteroids (intravenous solumedrol, 30 mg/kg per dose every 24 hours) for 5 days with resolution of her truncal ataxia during hospitalization."], "Examination and Results": ["Brain magnetic resonance imaging (MRI) revealed T2-weighted and fluid-attenuated inversion recovery changes with associated patchy enhancement in the brainstem, left frontal lobe, left cingulate gyrus, and left parietal lobe without restricted diffusion (Figure, A and B).", "Cervical spine imaging results were negative.", "Cerebral spinal fluid (CSF) study results were unremarkable (red blood cell count, 0\u2009\u00d7\u2009106/\u00b5L [to convert to \u00d71012/L, multiply by 12]; white blood cell count, 0/\u00b5L [to convert to \u00d7109/L, multiply by 0.001]; glucose, 61 mg/dL [to convert to millimoles per liter, multiply by 0.0555]; and total protein, 19 g/dL [to convert to grams per liter, multiply by 10]), and CSF cytologic test results were negative for malignancy.", "She was diagnosed with acute demyelinating encephalomyelitis (ADEM) and received 5 days of high-dose intravenous corticosteroids followed by a 1-month course of oral prednisone with improvement back to baseline in 3 weeks.Brain magnetic resonance imaging during initial presentation: T2-weighted and fluid-attenuated inversion recovery (FLAIR) hyperintensity in the left frontal lobe (A) and associated enhancement on T1-weighted postcontrast imaging (B).", "Subsequent brain MRI revealed resolution of the prior supratentorial involvement and new T2/fluid-attenuated inversion recovery changes with patchy enhancement in the brainstem and a large new lesion in the left parietotemporal area (Figure, C and D).", "Head magnetic resonance angiography findings were unremarkable.", "The CSF studies revealed a mild lymphocytic pleocytosis (white blood cell count of 11/\u00b5L with 3 neutrophils, 6 lymphocytes, and 2 monocytes) with 1 red blood cell, glucose level of 57 mg/dL, and total protein level of 39 g/dL.", "The results of the CSF viral polymerase chain reaction studies, including cytomegalovirus, varicella-zoster virus, herpes simplex virus, enterovirus, and Epstein-Barr virus, were negative.", "The CSF bacterial culture returned without growth.", "The results of tests for the CSF oligoclonal bands and IgG index were negative."], "Treatment": ["The results of serum cell-based aquaporin 4 antibody tests were negative.", "She was discharged with a month-long oral prednisone taper starting at 20 mg/d.", "When tapered down to prednisone, 5 mg every other day, she developed a right facial droop with recurrent ataxia."], "Diagnosis": ["She was diagnosed with acute demyelinating encephalomyelitis (ADEM) and received 5 days of high-dose intravenous corticosteroids followed by a 1-month course of oral prednisone with improvement back to baseline in 3 weeks.Brain magnetic resonance imaging during initial presentation: T2-weighted and fluid-attenuated inversion recovery (FLAIR) hyperintensity in the left frontal lobe (A) and associated enhancement on T1-weighted postcontrast imaging (B)."]}
{"Patient Symptoms": ["The patient reported the presence of a stable red lesion since he was 7 years old; however, over the preceding month, this lesion developed new black spots within it.", "There was no associated pain, pruritus, or bleeding."], "Examination and Results": ["His family history was notable for dysplastic nevus syndrome in his father and melanoma in a paternal uncle and cousin.On examination of the right lower back, there was a cluster of 1-mm flat purple-black papules coalescing into a 1.5\u2009\u00d7\u20091.0-cm oval plaque with surrounding erythema (Figure, A).", "On reinspection of the lesion at a subsequent visit, the morphology had significantly changed; there were 1-mm skin-colored to pink thin-walled vesicles clustered within a 1.5\u2009\u00d7\u20091.0-cm oval telangiectatic plaque (Figure, B).A, Flat purple-black papules coalescing into an oval patch with surrounding erythema.", "B, Skin-colored to pink thin-walled vesicles making up an oval telangiectatic patch."]}
{"Patient Personal Background": ["The patient denied history of local trauma, and his family history was negative regarding breast or ovarian cancers.", "The patient had no history of liver disease, hormonal therapy, or radiation to the chest wall."], "Examination and Results": ["The physical examination disclosed an obese man with no signs of hypogonadism or liver failure.", "There was a 3\u2009\u00d7\u20094-cm hard, irregular, mobile nodule in the retroareolar area of the right breast, tethered to the overlying skin but not fixed to the underlying muscle.", "There were no other masses on the chest wall.", "The ipsilateral lymph nodes were palpable.", "The left breast and axilla were normal.", "Right mediolateral oblique mammography (Figure, A) and computed tomography scan of the chest (Figure, B) are shown.A, Right mediolateral oblique view of male breast showing a breast mass and axillary lymph nodes.", "B, Computed tomography of the chest showing the right breast mass involving the skin but not the pectoralis muscle."]}
{"Patient Personal Background": ["He was previously healthy and had no prior abdominal operations.", "The rest of his history was noncontributory."], "Patient Symptoms": ["The patient noted pencil-thin stools that occurred during the past several months but had not had a colonoscopy in more than a decade."], "Examination and Results": ["He was mildly tachycardic but normotensive and afebrile.", "Physical examination revealed a lethargic patient with a distended abdomen, diffuse rebound tenderness, and involuntary guarding.", "No surgical scars or inguinal hernias were apparent on examination.", "The only abnormal laboratory values were as follows: sodium concentration, 126 mEq/L (reference range, 135-145 mEq/L) (to convert to millimoles per liter, multiply by 1); lactate concentration, 58.6 mg/dL (reference range, 0-18.0 mg/dL) (to convert to millimoles per liter, multiply by 0.111); and white blood cell count, 18 500/\u03bcL (reference range, 3400-10 000/\u03bcL) (to convert to \u00d7109/L, multiply by 0.001).", "Computed tomography revealed diffuse free fluid but without free air and several loops of dilated small bowel with thickened, hypoenhancing bowel walls.", "The mesentery was markedly edematous (Figure).", "The rest of the small bowel were dilated and air and fluid filled but had normal bowel wall enhancement."], "Treatment": ["He was resuscitated with 2 L of lactated Ringer solution and underwent computed tomography of the abdomen and pelvis with intravenous contrast."], "Others": ["The colon was normal.Axial computed tomography image of the abdomen and pelvis."]}
{"Patient Symptoms": ["The infant\u2019s mother reported a small blue bump present at birth near the medial canthus."], "Examination and Results": ["Otherwise, the infant was stable, nontoxic appearing on examination, and feeding well.", "The admitting team collected a complete blood cell count, basic metabolic panel, and blood cultures and performed a lumbar puncture for cerebrospinal fluid analysis, the results of which were within normal limits.", "A maxillofacial computed tomographic scan was also obtained by the admitting service owing to concerns over displacement of the right globe (Figure 1).", "By day 3 of admission, the edema and preseptal cellulitis had improved.External appearance of the right eye (A) with adjacent coronal maxillofacial computed tomographic scan on admission (B).", "The white arrowhead indicates the lacrimal sac enlargement; black arrowhead, dilated nasolacrimal duct; and the yellow arrowhead, intranasal cystic mass."], "Treatment": ["The patient was admitted for broad-spectrum intravenous vancomycin and piperacillin/tazobactam for treatment of acute dacryocystitis with overlying preseptal cellulitis.", "The patient continued treatment with intravenous antibiotics and on day 2 of admission, ophthalmology was consulted.", "A bedside beveled percutaneous needle drainage was performed with a 25-gauge syringe.", "The lacrimal sac was decompressed and 3 mL of purulent discharge was aspirated."], "Diagnosis": ["The patient was admitted for broad-spectrum intravenous vancomycin and piperacillin/tazobactam for treatment of acute dacryocystitis with overlying preseptal cellulitis."]}
{"Patient Personal Background": ["She had a history of chronic migraines and reported worsening headaches during the past 3 months.", "The patient was not taking any medications and denied a history of illicit drug use."], "Patient Symptoms": ["The patient experienced intermittent episodes of numbness of her tongue, teeth, and upper extremities.", "She reported intermittent tinnitus but denied transient visual obscurations or hearing changes."], "Examination and Results": ["Results of a review of systems were otherwise unremarkable.", "Her best-corrected visual acuity was 20/100 OD and 20/70 OS.", "Extraocular movements were intact, and pupils were round and reactive with no afferent pupillary defect.", "Her intraocular pressure was 14 mm Hg OD and 10 mm Hg OS.", "Results of the patient\u2019s anterior segment examination were within normal limits.", "Results of examination of her fundus are shown in the Figure, A.", "Magnetic resonance imaging (MRI) of the brain revealed diffuse abnormalities on T2-weighted fluid-attenuated inversion recovery sequences (Figure, B).A, Color fundus photograph of the right eye demonstrates severe optic disc edema, retinal hemorrhages, cotton-wool spots, and macular exudates.", "B, Magnetic resonance imaging scan of the brain in axial T2-weighted fluid-attenuated inversion recovery sequences reveals diffuse T2-weighted signal abnormality involving the cerebral hemispheres, brain stem, and cerebellum."]}
{"Patient Personal Background": ["Her ocular history included optic neuropathy 5 years prior to presentation.", "Her medical history included acute lymphocytic leukemia (currently in remission) after an allogenic hematopoetic stem cell transplant.", "Two months before presentation, she developed Bell palsy on the right side of her face for which she was being treated with oral prednisone; her other medications were oral contraceptives and multivitamins."], "Patient Symptoms": ["As her Bell palsy was improving, she noted worsening of her visual acuity."], "Examination and Results": ["Her best-corrected visual acuity was hand motion OD and 20/400 OS.", "Tensions were 12 mm Hg bilaterally.", "A slitlamp examination revealed normal anterior segments in each eye.", "The vitreous was free of cells in each eye.", "A dilated ophthalmoscopic examination revealed mild optic nerve pallor (associated with her past episodes of optic neuritis) (Figure)."], "Treatment": ["Two months before presentation, she developed Bell palsy on the right side of her face for which she was being treated with oral prednisone; her other medications were oral contraceptives and multivitamins."]}
{"Patient Symptoms": ["The patient returned 2 days later with persistent fever, worsening eyelid edema, and a new macular rash over her buttocks and shins."], "Examination and Results": ["Results of urinalysis revealed pyuria, and she was prescribed oral cephalexin, 250 mg every 12 hours, for a presumed urinary tract infection.", "Motility and pupil reactions were normal.", "There was moderate edema of the upper and lower eyelids bilaterally with erythema and several areas of shallow ulceration that were weeping a yellowish serous discharge (Figure, A).", "This type of edema was associated with moderate hyperemia of the palpebral conjunctiva (Figure, B).", "Results of the ocular surface examination revealed minimal bulbar conjunctival injection, the cornea was clear, and there was no discharge."], "Treatment": ["Results of urinalysis revealed pyuria, and she was prescribed oral cephalexin, 250 mg every 12 hours, for a presumed urinary tract infection.", "Cephalexin was discontinued, the patient was admitted, and a diagnostic workup was initiated, including swabs from the eyelid lesions and conjunctiva for bacterial cultures and viral polymerase chain reaction testing."], "Diagnosis": ["At this time, the ophthalmology service was consulted owing to concern for Stevens-Johnson syndrome precipitated by the treatment with cephalexin.On examination, her visual acuity was central, steady, and maintained in each eye."]}
{"Patient Personal Background": ["There was no medical history of trauma, fever, or hematuria.", "She was receiving therapy for mantle cell lymphoma and had previously undergone 1 cycle of the Nordic protocol (comprising cyclophosphamide, doxorubicin, vincristine, prednisolone, cytarabine, and rituximab).1 However, this resulted in tumor lysis syndrome and neutropenic sepsis.", "The patient was reluctant to undergo further infusional therapy and was switched to ibrutinib, 560 mg, once daily.", "During the 2-month period that she was receiving ibrutinib therapy, there were no concurrent administrations of anticoagulants."], "Patient Symptoms": ["At presentation, she was hypotensive (blood pressure, 79/45 mm Hg) with conjunctival pallor and left renal angle tenderness."], "Examination and Results": ["The patient\u2019s hemoglobin count was low (7.6 g/dL; reference range, 12-16 g/dL; to convert to g/L, multiply by 10.0), which represented a significant decrease from the baseline (10.6 g/dL) measured 1 month before presentation.", "She was also found to have acute-onset thrombocytopenia (40\u00d7109/L; reference range, 140-400\u00d7109/L) and leukocytosis (12.75\u00d7109/L, reference range, 4-10\u00d7109/L).", "Her coagulation profile (prothrombin time) was normal.", "A computed tomographic (CT) scan of the abdomen and pelvis was performed (Figure 1A) and compared with a similar scan performed 4 months prior (Figure 1B)."], "Treatment": ["The patient was reluctant to undergo further infusional therapy and was switched to ibrutinib, 560 mg, once daily.", "During the 2-month period that she was receiving ibrutinib therapy, there were no concurrent administrations of anticoagulants."], "Others": ["A, Findings from computed tomographic scan at presentation.", "B, Previous findings from computed tomographic scan."]}
{"Patient Personal Background": ["There was no history of illicit drug use, autoimmune disease, or cardiopulmonary disease."], "Patient Symptoms": ["Physical examination was remarkable only for asthenia."], "Examination and Results": ["Cardiac examination was normal.", "Chest computed tomography (CT) demonstrated multiple pulmonary nodules, a spiculated mass in the right medial upper lobe, vertebral metastases, and small bilateral subsegmental pulmonary emboli.", "Cranial CT showed scattered subacute embolic cortical infarcts and dural metastases.", "Serum troponin was 2.6 ng/mL (type 2 myocardial infarction) with nonspecific electrocardiographic changes.", "Transthoracic echocardiogram showed normal biventricular function with normal wall motion and shaggy, bulky masses on the tips of both mitral valve leaflets (Figure) (Video 1).", "A saline contrast bubble study was negative for an intracardiac shunt, and commercial intravenous contrast showed no clot.", "Transesophageal echocardiogram showed large, 1.4\u2009\u00d7\u20090.5-cm, frondlike, mobile masses on the atrial surface of the mitral leaflets with mild mitral regurgitation.", "In addition, a large 1.1 \u2009\u00d7\u20091.6-cm multilobulated, mobile mass was seen on the subvalvular chordae of the tricuspid valve, with trace tricuspid regurgitation.", "Gated cardiac CT angiogram confirmed mobile hypoattenuating masses on the mitral valve leaflets that prolapsed to the left atrium during systole (Video 2).", "No myocardial, pulmonary vein, or pericardial involvement was seen.Transthoracic echocardiogram.", "A, Parasternal long axis showing masses on the tips of both mitral valve leaflets (arrowheads).", "B, Parasternal long axis view showing mild mitral regurgitation.", "C, Right ventricular inflow view demonstrating an echogenic mass on the tricuspid valve chordae (arrowhead).", "D, Right ventricular inflow view showing mild tricuspid regurgitation."]}
{"Patient Personal Background": ["She had no history of sinus infections or allergic rhinitis."], "Patient Symptoms": ["She had been treated with several courses of oral antibiotics and intranasal steroids without improvement of symptoms.", "Nasal obstruction was constant and associated with right paranasal pressure."], "Examination and Results": ["Results from a head and neck examination, including cranial nerve, were normal, except for the results from nasal endoscopy, which showed a deviated septum and a soft-tissue mass emanating from the right middle meatus inferior to the middle turbinate that seemed to have a polypoid appearance superiorly and a papillomatous appearance inferiorly.", "A computed tomographic (CT) scan of the sinuses without contrast showed complete opacification of the right paranasal sinuses with mass effect on the medial maxillary wall with mild hyperostosis posterolaterally.", "A magnetic resonance image (MRI) of the face with contrast was obtained postoperatively to further delineate the mass and evaluate for intracranial extension.", "Initial histologic stains showed the tumor to be positive for S-100 and actin (Figure, C and D) and negative for GFAP, CD34, and cytokeratin.", "Additional immunostains showed the tumor to be negative for SOX-10 and B-catenin.Histopathologic images."], "Treatment": ["The patient underwent an endoscopic right sinonasal mass biopsy.", "Intraoperatively, further excision of the mass was aborted owing to an unusual appearance of the mass as well as clear fluid exuding from the mass during microdebridement."], "Others": ["Pathologic analysis of the biopsied tissue revealed a uniform spindle cell tumor comprised of cellular fascicles and tumor cells with bland nuclei (Figure, A and B).", "A and B, Hematoxylin-eosin.", "C, S-100 immunohistochemical stain.", "D, Smooth muscle actin immunohistochemical stain."]}
{"Patient Personal Background": ["He had a history of asthma, chronic otitis media with effusion, and obstructive sleep apnea and had undergone 3 sets of tympanostomy tubes and an adenotonsillectomy."], "Patient Symptoms": ["Physical examination demonstrated a 3-cm firm and tender right parotid mass."], "Examination and Results": ["Clear saliva could be expressed from the Stensen duct.", "A computed tomographic (CT) scan was performed, showing a discrete 2\u2009\u00d7\u20092-cm necrotic mass in the right parotid gland (Figure, A).", "A fine-needle aspirate (FNA) yielded a cellular sample with spindloid features, suggesting a neoplasm of uncertain subtype.", "Additional studies, including flow cytometry and tissue cultures, were obtained.A, Coronal computed tomographic (CT) image demonstrating right parotid mass and level II adenopathy.", "B, The normal parotid gland architecture is effaced by confluent granulomata with necrosis (hematoxylin-eosin, original magnification \u00d7200)."], "Treatment": ["Per recommendation of the head and neck multidisciplinary tumor board, the patient underwent total parotidectomy and neck dissection because the mass was grossly infiltrative of the parotid, and several enlarged level IB and II lymph nodes were observed at the time of surgery.", "The mass was shaved off the marginal mandibular branch of the facial nerve because it was adherent to it."], "Others": ["He had no history of fevers or other constitutional symptoms.", "A broad differential diagnosis was raised, including both benign and malignant salivary neoplasms.", "Permanent histopathologic images showed normal parotid gland architecture effaced by confluent granulomata with Langhans-type giant cells and central necrosis (Figure, B)."]}
{"Patient Personal Background": ["His medical history was significant for prematurity, born at 26 weeks, and a 60-day intubation during a 99-day neonatal intensive care unit stay."], "Patient Symptoms": ["His noisy breathing had been present since birth, constant, exacerbated with feeding, sleeping, and supine positioning.", "He fed poorly from the bottle with frequent choking, grunting, and irritability, and had minimal weight gain with 1 cyanotic event while feeding.", "Nasopharyngolaryngoscopy showed no laryngomalacia, laryngeal lesions, or cord paralysis.Shortly after this visit, the patient presented to the emergency department with increased work of breathing, tachypnea, retractions, weak cry, and stridor.", "Examination was significant for subcostal retractions, and biphasic stridor."], "Examination and Results": ["The physical examination was remarkable only for biphasic stridor and a weak cry.", "Nasopharyngolaryngoscopy showed no laryngomalacia, laryngeal lesions, or cord paralysis.Shortly after this visit, the patient presented to the emergency department with increased work of breathing, tachypnea, retractions, weak cry, and stridor.", "Examination was significant for subcostal retractions, and biphasic stridor.", "A few days later he was taken to the operating room for direct laryngoscopy and bronchoscopy.During sedation, a prolonged expiratory phase with quick chest wall rise on inspiration and slow fall with expiration was observed.", "Capnography showed a restrictive \u201cshark fin\u201d waveform (Figure, A).", "The direct laryngoscopy and bronchoscopy were performed (Figure, C and D).Images show the (A) preintervention and (B) postintervention capnography wave form as seen on the anesthesia monitor."], "Treatment": ["Due to a lack of response to racemic epinephrine, albuterol, and steroids, he was admitted to the intensive care unit for heliox and intravenous steroids, resulting in mild improvements.", "Endoscopy images on (C) expiration and (D) inspiration."], "Others": ["A viral panel was positive for rhinovirus."]}
{"Patient Personal Background": ["His medical history included prostate cancer, hypertension, anxiety disorder, hyperlipidemia, gastroesophageal reflux disease, and diverticulosis.", "His medications included omeprazole, alprazolam, amlodipine besylate, atenolol, simvastatin, and valsartan."], "Patient Symptoms": ["His intertrigo improved, but he then developed bright red, burning and painful nodules around his scrotum (Figure 1)."], "Examination and Results": ["On physical examination, there were 2 symmetrical solitary erythematous nodules in the right and left inguinal folds adjacent to the scrotum.Clinical image of well-demarcated erythematous solitary papule in the right inguinal fold."]}
{"Examination and Results": ["Physical examination revealed annular red plaques with scale and superficial erosions over the trunk and extremities.", "Strikingly, plaques on both arms showed a corymbiform pattern, with a central and multiple satellite lesions (Figure, A).", "On the lower limbs, infiltrated plaques with prominent crusts were seen (Figure, B).", "Also, there were papulosquamous lesions on the left sole, but the palms were spared.", "The genital area was not involved.", "There was neither regional lymph node enlargement nor systemic involvement.", "Two biopsy specimens from both types of lesions were obtained for histopathologic evaluation, showing an identical histologic pattern (Figure, C and D)."], "Treatment": ["He had been treated with a course of high-potency topical corticosteroids without any improvement."]}
{"Patient Personal Background": ["His medical history is significant for diabetes mellitus type 2 and hypothyroidism.", "Medications included glipizide, metformin, and levothyroxine.A, Nodules are 4 to 6 cm in diameter on the right upper extremity."], "Patient Symptoms": ["He was renovating a commercial cannabis grow-house in California at time of onset.", "He described the construction site as being filled with intoxicating mold.", "He reported shortness of breath and a 20-pound weight loss.", "Most concerning was the inability to use his right upper extremity.", "Also, he developed a pathological fracture of his right foot (Figure, B)."], "Examination and Results": ["Clinical examination of his forearms revealed several yam-size (4-6 cm), nontender, nonulcerated, boggy subcutaneous nodules in a sporotrichoid pattern and large nodules scattered on his trunk and abdomen.", "There was no palpable lymphadenopathy or lower extremity lesions.", "B, A pathological fracture on the fifth metatarsal on the right foot is indicated by the white arrowhead.", "C, Histopathology shows pale, nodular aggregations of inflammatory cells in the deep dermis, extending into the fibrotic subcutis, as well as (D) aggregations composed of epitheliod histiocytes with few other inflammatory cells, so called \u201cnaked granulomas.\u201dThe patient\u2019s laboratory tests showed fasting glucose of 122.0 mg/dL (reference range, 65.0-115.0 mg/dL); total calcium, 10.2 mg/dL (reference range, 8.5-10.5 mg/dL); blood urea nitrogen, 16.0 mg/dL (reference range, 10.0-24.0 mg/dL); creatinine, 1.30 mg/dL (reference range, 0.6-1.3 mg/dL); hemoglobin A1c, 6.7 (reference range, 4.0-6.0); 1,25-OH vitamin D 70, ng/mL (reference range, 15.9-55.6).Liver enzymes were within normal limits along with a negative purified protein derivative and quantiferon test results.", "A culture from a cutaneous nodule with microbial stains for bacteria, fungal culture, and acid-fast bacilli was negative.", "Computed tomography of the chest revealed hilar lymphadenopathy.", "An incisional biopsy of a nodule on the right wrist was obtained, which showed nodular aggregations of epithelioid histiocytes with sparse peripheral lymphocytes, extending from the deep dermis into the subcutis (Figure C and D)."]}
{"Patient Personal Background": ["His medical history included diagnoses of eczema and multiple food allergies.", "Owing to concerns about food triggers of his eczema, the child had a restrictive diet consisting solely of potato, pork, lamb, apples, cucumber, and Cheerios."], "Patient Symptoms": ["He also had a long-standing complaint of dry eyes.", "The vision loss was not associated with pain, headache, fever, or photopsias (flashes of light)."], "Examination and Results": ["On examination, the child\u2019s visual acuity was limited to detecting hand motion at 30 cm.", "His conjunctiva had dry, keratinized patches with foamy appearance (Figure 1A).", "The cornea showed areas of marked epitheliopathy with opacity (Figure 1B).", "His pupils were equal and reactive to light with no relative afferent pupillary defect.", "His funduscopic examination showed mild optic nerve pallor.", "He had normal extraocular movements.A, Photograph of the patient\u2019s eye before treatment."], "Others": ["There was no history of redness, discharge, or trauma to the eyes.", "Arrowheads indicate dry keratinized patches (Bitot spots).", "B, Photograph of the patient\u2019s eye before treatment demonstrating marked corneal epitheliopathy with opacity."]}
{"Patient Personal Background": ["Other than a previous open hemorrhoidectomy, the patient had no significant medical history.", "Of note, he had no family history of intestinal disease.On examination, he had a fever with a temperature of 39\u00b0C and tachycardia with a heart rate of 102 beats per minute."], "Patient Symptoms": ["This was associated with diarrhea, vomiting, fevers, and chills.", "He denied any history of weight loss, melena, or hematochezia."], "Examination and Results": ["On abdominal examination, there was localized tenderness with guarding and fullness in the right lower quadrant.", "Results from his blood laboratory investigations demonstrated leukocytosis, with white blood cell count of 17\u202f000/\u00b5L (to convert to \u00d7109/L, multiple by 0.001) and a C-reactive protein level of 205 mg/L (to convert to nmol/L, multiple by 9.524).", "Transverse computed tomographic scan indicated a large right-sided inflammatory phlegmon measuring 7.5 cm in transverse diameter in a 48-year-old man."], "Treatment": ["He reported some relief of symptoms with loperamide.", "He then underwent an exploratory laparotomy."], "Others": ["However, given the clinical history, the patient underwent a computed tomographic (CT) scan of the abdomen and pelvis with intravenous contrast (Figure 1)."]}
{"Patient Symptoms": ["The patient described a 4-day history of progressively worsening abdominal pain and diarrhea and denied fevers, chills, diaphoresis, or any previous similar episodes.", "Her abdomen was distended and mildly tender, and her pain was disproportionate to the findings of her physical examination."], "Examination and Results": ["Her abdomen was distended and mildly tender, and her pain was disproportionate to the findings of her physical examination.", "There were no abnormal laboratory test findings.", "The abdominal computed tomography (CT) scan from her initial admission (Figure, A) and the abdominal CT angiogram on readmission (Figure, B) showed dramatic progression of her disease.A, Coronal view of computed tomography (CT) scan from 3 days prior to readmission demonstrating isolated duodenal thickening; B, coronal view of CT angiography scan on readmission demonstrating thickened small bowel and free fluid."]}
{"Patient Personal Background": ["The patient was previously healthy and did not take any medications.Appearance of the optic nerves in fundus photographs taken 4 weeks after the patient\u2019s injury at work."], "Patient Symptoms": ["On awakening, he reported that he was unable to see out of each eye."], "Examination and Results": ["He also had a left leg degloving injury, distal femur fracture, and posterior knee dislocation with bleeding through the open fractures and wounds.", "He was profoundly hypotensive (blood pressure, 70/40 mm Hg) and anemic (hemoglobin level, 5.6 g/dL [to convert to grams per liter, multiply by 10]) from extensive blood loss.", "Bedside examination revealed no light perception vision with 7-mm pupils that were nonreactive bilaterally.", "Extraocular movements were full and there was no ptosis.", "Slitlamp examination findings were normal, and fundus photographs of the posterior pole in each eye are presented in the Figure.", "Magnetic resonance imaging of the brain performed earlier in the hospitalization was normal.", "The optic discs are characterized by diffuse pallor, with no evidence of edema or hemorrhages."], "Treatment": ["He was urgently transfused and taken to the operating room for bilateral lower extremity irrigation and drainage and reconstruction of the left leg.", "Unfortunately, postoperative infection necessitated a left leg above-knee amputation.The patient was admitted to the intensive care unit, intubated, and sedated for 1 month."]}
{"Patient Personal Background": ["His medical history included ischemic heart disease and hypercholesterolemia, and he was an ex-smoker of 20 pack-years.Examination revealed unaided visual acuity of 20/20 OD and 20/20 OS."], "Patient Symptoms": ["He had been seen 2 weeks previously with similar symptoms and was diagnosed as having blepharitis and discharged with instructions for eyelid hygiene.", "His symptoms failed to improve, and he visited his family physician the following week.", "His physician prescribed a course of amoxicillin and clavulanate potassium, but the symptoms remained.The patient had no other ocular history or history of facial surgery."], "Examination and Results": ["He had no evidence of proptosis, no relative afferent pupillary defect, and a full range of extraocular eye movement.", "Slitlamp examination demonstrated moderate bilateral blepharitis and extensive punctate keratopathy of the right eye.", "Findings from posterior segment examination were unremarkable.", "Examination of the cranial nerves demonstrated reduced sensation in the distribution of the ophthalmic and maxillary branches of the right trigeminal nerve, including complete corneal anesthesia."], "Treatment": ["His physician prescribed a course of amoxicillin and clavulanate potassium, but the symptoms remained.The patient had no other ocular history or history of facial surgery."], "Diagnosis": ["He had been seen 2 weeks previously with similar symptoms and was diagnosed as having blepharitis and discharged with instructions for eyelid hygiene."]}
{"Patient Personal Background": ["The patient was born at term; had an unremarkable delivery; and had no history of developmental delay, trauma, or systemic illness.", "There was no family history of strabismus, amblyopia, or congenital ptosis."], "Patient Symptoms": ["Her mother reported that, since infancy, the child\u2019s left eye has twitched during feeding and mealtimes."], "Examination and Results": ["Her best-corrected visual acuity was 20/30 OD and 20/40 OS.", "Pupils were reactive to light bilaterally, and there was neither an afferent pupillary defect nor anisocoria.", "Extraocular motility was full.", "There was notable asymmetry in the following eyelid measurements: palpebral fissure height (10 mm OD; 5-6 mm OS) and margin reflex distance 1 (3.5 mm OD; 0.5-1.5 mm OS).", "In addition, elevation of the left upper eyelid was observed with lateral jaw thrust but not with anterior-posterior jaw movements or with mouth opening and closing.", "The levator function was 14 mm OU, and the margin crease distances were 5 mm OD and 6 mm OS."], "Others": ["Her ocular history was significant only for bilateral mixed astigmatism (\u22120.25\u2009+\u20090.75\u2009\u00d7\u2009145 OD and \u22120.25\u2009+\u20091.00\u2009\u00d7\u2009005 OS)."]}
{"Patient Personal Background": ["Her medical history includes breast cancer, diagnosed in 2000 and treated with lumpectomy and radiotherapy.", "A mammogram, completed 4 months before her ophthalmology visit, was reported as stable."], "Patient Symptoms": ["More recently, she noted that her left eye \u201cdrifts out at times.\u201d She also reported drooping of the left upper eyelid and binocular, variable horizontal or vertical diplopia at distance.", "She also complained of itchy eyes but denied any pain or headaches."], "Examination and Results": ["On presentation, her visual acuity was 20/20 OD and 20/40 OS.", "She had slightly decreased color vision (8/10 Ishihara plates) of the left eye and there was no relative afferent pupillary defect.", "Confrontation visual fields were full.", "External examination revealed mild left proptosis and severely limited adduction of the left eye.", "Both optic nerves appeared normal on retinal examination.", "Magnetic resonance imaging of the brain (Figure 1) showed a 2.3-cm intraconal mass inseparable from the left lateral rectus muscle.", "The mass medially deviated the left optic nerve and conformed to the shape of the orbital globe with mild bony remodeling of the lateral orbital wall.T1-weighted magnetic resonance imaging of the brain shows a 2.3-cm intraconal mass (black asterisk) molding to the left orbital globe with medial deviation of the optic nerve (blue asterisk)."]}
{"Examination and Results": ["A computed tomographic scan showed lytic lesions, and bone marrow biopsy findings revealed 30% \u03ba-restricted plasma cells.", "Three weeks after therapy initiation, follow-up SPEP-IF demonstrated an M-IgA \u03ba at 0.1 g/dL.", "Two months later, SPEP-IF demonstrated a new M-IgG \u03ba band in the same electrophoretic position as the M-IgA \u03ba, with the 2 distinguishable only by IF and measured at 0.1 g/dL.", "Three months later, SPEP-IF demonstrated only the M-IgG \u03ba, with the original M-IgA \u03ba not detected.", "Over the next 8 months, the patient received maintenance therapy with VRD-E, and monthly SPEP-IF consistently showed M-IgG \u03ba at 0.1 g/dL, with the original M-IgA \u03ba consistently not detected.", "The serum free \u03ba/\u03bb ratio gradually decreased to 4.86 one year later."], "Treatment": ["He was assigned to the bortezimib-lenalidomide-dexamethasone\u2013elotuzumab (VRD-E) arm of a phase 3 trial.", "Over the next 8 months, the patient received maintenance therapy with VRD-E, and monthly SPEP-IF consistently showed M-IgG \u03ba at 0.1 g/dL, with the original M-IgA \u03ba consistently not detected."], "Others": ["The Table summarizes assay data.Clonal evolution of myeloma cells to both IgG- and IgA-secreting cells.Immune dysregulation from multiagent therapy resulting in a new M-protein.New MGUS or B-cell lymphoproliferative disorder, such as monoclonal B lymphocytosis.Therapeutic monoclonal antibody at serum concentration detectable by SPEP-IF."]}
{"Examination and Results": ["On arrival, he was afebrile, with a blood pressure of 120/80 mm Hg, heart rate of 35/min, respiratory rate of 16/min, and pulse oximetry of 98% on ambient air.", "His examination revealed regular bradycardia without cannon A waves, clear lung fields to auscultation, and warm extremities.", "Chest radiography revealed hilar adenopathy.", "Electrocardiography showed sinus bradycardia, first-degree atrioventricular block, left posterior fascicle, and right bundle branch blocks (Figure 1A).", "Transthoracic echocardiography revealed an ejection fraction of 50% without regional variation.", "On exercise stress single-photon emission computed tomography, the patient completed 9 minutes of a standard Bruce protocol and developed transient high-grade atrioventricular block but had no ischemic ST-segment changes or defects on perfusion imaging.", "Cardiac magnetic resonance imaging (cMRI) with gadolinium contrast-enhanced first-pass myocardial perfusion imaging at rest and contrast-enhanced late gadolinium enhancement imaging revealed low-normal left ventricular systolic function but no other abnormalities (Figure 1B)."]}
{"Patient Symptoms": ["On posttransplant day 10, he developed fever (38.4\u00b0C).", "On posttransplant day 14 he developed new-onset pruritic, confluent, erythematous, blanching morbilliform macules and papules on his trunk and extremities (Figure, left).", "Review of systems was notable for diarrhea and a 6-pound weight gain since transplantation and negative for headache, cough, shortness of breath, or abdominal pain.Left, Macules and papules on the trunk of the patient."], "Examination and Results": ["Right, Axial chest computed tomography of the patient.On examination, there was no lymphadenopathy or hepatosplenomegaly.", "The patient\u2019s heart rate was 100/min, blood pressure was 106/68 mm Hg, and he occasionally experienced mild hypoxia to 94% on ambient air.", "Results of a basic metabolic panel were normal, with a blood urea nitrogen level of 10 mg/dL (3.57 mmol/L) and creatinine level of 0.7 mg/dL (61.88 \u03bcmol/L).", "White blood cell (WBC) count was 7300/\u03bcL, and absolute neutrophil count (ANC) was 5480/\u03bcL.", "Neutrophil recovery occurred beginning on posttransplant day 10, with WBC count of 700/\u03bcL and ANC of 532/\u03bcL on posttransplant day 10, correlating with the onset of the patient\u2019s fevers.", "Platelet count was 48\u2009\u00d7\u2009103/\u03bcL, and hemoglobin was 8.2 g/dL.", "Results of liver function tests were normal.", "Blood, urine, sputum, and respiratory viral cultures were negative.", "Tests for cytomegalovirus, Epstein-Barr virus, human herpesvirus-6, adenovirus, parvovirus, cryptococcal antigen, aspergillus galactomannan antigen, \u03b2-glucan, and Clostridium difficile were negative.", "Chest computed tomography demonstrated multifocal ground-glass and consolidative pulmonary opacities (Figure, right).", "Computed tomography of the abdomen was unremarkable."], "Treatment": ["He was started on empirical treatment with cefepime; however, his fevers persisted despite antibiotic therapy."]}
{"Patient Personal Background": ["Her pain was related to multiple vertebral fractures due to chronic steroid use for an inflammatory polyarthritis that was not responsive to hydroxychloriquine and methotrexate."], "Patient Symptoms": ["Her pain was related to multiple vertebral fractures due to chronic steroid use for an inflammatory polyarthritis that was not responsive to hydroxychloriquine and methotrexate."], "Examination and Results": ["A comprehensive urine drug screen using immunoassay and mass spectrometry was ordered (Table 1).The patient is taking methadone, hydromorphone, and codeine.The patient is taking methadone, morphine, hydromorphone, and codeine."], "Treatment": ["Her pain medication regimen (methadone, 20 mg [3\u00d7/d]; immediate-release morphine, 30 mg [5\u00d7/d]; gabapentin, 1200 mg [2\u00d7/d]; duloxetine, 60 mg/d; and celecoxib, 200 mg [2\u00d7/d]) helped her independently complete instrumental activities of daily living.", "A comprehensive urine drug screen using immunoassay and mass spectrometry was ordered (Table 1).The patient is taking methadone, hydromorphone, and codeine.The patient is taking methadone, morphine, hydromorphone, and codeine."], "Others": ["She reported no adverse effects (eg, somnolence or constipation)."]}
{"Patient Symptoms": ["Dexamethasone was prescribed to reduce the risk of ATRA syndrome, a potentially life threatening complication seen in these patients and characterized by fever, pulmonary infiltrates, hypotension, and leucocytosis.After 12 days of treatment, the patient developed pyrexia and was started on empiric antibiotics.", "Two days later he developed tender black spots on the scrotum that progressed to painful ulcers over 8 days (Figure, A).", "As scrotal ulceration progressed, they enlarged and became necrotic with a black eschar."], "Examination and Results": ["Peripheral blood cultures and skin swabs from the lesions did not identify bacterial or viral infection.", "Scrotal ultrasonography showed a subcutaneous hypervascular lesion with no abscess.", "The development and progression of scrotal ulceration coincided with recovery in neutrophil count from 0.3\u2009\u00d7\u2009109/L to 1.2\u2009\u00d7\u2009109/L and persistent pyrexia.", "A specimen was obtained for histopathology.A, Clinical photograph of scrotum and penis shows ulceration and necrosis of penile and scrotal skin with surrounding inflammation."], "Treatment": ["He was commenced on treatment with the PETHEMA LPA 20051 protocol consisting of all-trans retinoic acid (ATRA) and idarubicin, an anthracycline based chemotherapy.", "Dexamethasone was prescribed to reduce the risk of ATRA syndrome, a potentially life threatening complication seen in these patients and characterized by fever, pulmonary infiltrates, hypotension, and leucocytosis.After 12 days of treatment, the patient developed pyrexia and was started on empiric antibiotics.", "Systemic antifungal and antiviral therapy were added with no improvement.", "Peripheral blood cultures and skin swabs from the lesions did not identify bacterial or viral infection."], "Diagnosis": ["Acute promyelocytic leukemia (APML) was diagnosed by bone marrow aspirate morphology, immunophenotyping, and detection of the bcr1 variant of the PML-RAR\u03b1 fusion transcript in peripheral blood."]}
{"Patient Personal Background": ["An abdominal computed tomographic scan showed findings consistent with bowel perforation, and she was admitted to the intensive care unit after emergent exploratory laparotomy.Her medical history was significant for 1 other episode of idiopathic bowel perforation 3 years prior.", "She denied taking any medications."], "Patient Symptoms": ["Dermatology was consulted to evaluate an asymptomatic skin eruption that had been present for at least 8 months before her hospitalization."], "Examination and Results": ["Physical examination revealed numerous 5- to 10-mm nontender papules with a porcelain-white atrophic center and an erythematous halo, alongside scattered atrophic white scars (Figure, A and B).", "The lesions were distributed across her trunk, neck, and upper and lower extremities.", "Palms, soles, scalp, genitalia, and mucosal surfaces were spared.", "Her neurological and mental state examination had unremarkable results.", "A, Papules on the back with white atrophic center and an erythematous rim.", "B, Lesions on the thigh similar to those of the back, alongside atrophic white scars.", "C, Thigh biopsy shows hyperkeratosis and wedge-shaped avascular necrosis in dermis and subcutaneous tissue (hematoxylin-eosin stain, original magnification \u00d710).", "D, Back biopsy shows occlusion of dermal blood vessels, perivascular lymphocytic infiltration, and mucin deposition (hematoxylin-eosin stain, original magnification \u00d740)."], "Treatment": ["An abdominal computed tomographic scan showed findings consistent with bowel perforation, and she was admitted to the intensive care unit after emergent exploratory laparotomy.Her medical history was significant for 1 other episode of idiopathic bowel perforation 3 years prior.", "Biopsy specimens from her thigh and back were obtained (Figure, C and D).Clinical photographs and biopsy specimens."]}
{"Patient Personal Background": ["The patient had a history of type 2 diabetes and hypertension and was treated with glimepiride, sitagliptin phosphate hydrate, and amlodipine besylate.", "The patient also had polymyalgia, which was treated with a low dose of prednisolone.", "The prednisolone therapy had been discontinued 2 months before her visit to the dermatology clinic when she had been hospitalized with pneumonia.", "Multiple tense blisters had subsequently appeared on the palms."], "Patient Symptoms": ["The erythema did not respond to topical corticosteroid, oral roxithromycin (300 mg/d), or narrow-band UV-B phototherapy.", "Multiple tense blisters had subsequently appeared on the palms.", "Physical examination at the first visit revealed scaly erythematous plaques on the whole body and tense blisters on the arms, hands, soles, and buttocks."], "Examination and Results": ["Physical examination at the first visit revealed scaly erythematous plaques on the whole body and tense blisters on the arms, hands, soles, and buttocks.", "Neither scar formation or mucosal involvement was observed.", "A skin biopsy specimen was obtained from a bulla on the forearm.", "Histopathologic analysis revealed a subepidermal bulla with inflammatory infiltrates of neutrophils.", "The results of an IgG chemiluminescence enzyme immunoassay for bullous pemphigoid (BP) 180 noncollagenous (NC) 16A were negative."], "Treatment": ["The erythema did not respond to topical corticosteroid, oral roxithromycin (300 mg/d), or narrow-band UV-B phototherapy.", "After treatment with oral prednisolone, 20 mg/d, the lesions healed without scar or milia formation (Figure 1).Clinical features before (A) and after (B) treatment with oral prednisolone, showing no scar formation."]}
{"Patient Personal Background": ["The child did not attend day care.", "Family history was noncontributory and her parents denied consanguinity.The child was hospitalized on multiple occasions during infancy for the fevers, and she had comprehensive sepsis evaluations, including lumbar punctures, with negative results."], "Patient Symptoms": ["The child had fevers (maximum temperature, 40\u00b0C) that lasted 3 to 5 days.", "Her mother reported that the fevers resolved spontaneously but continued to recur almost every month.", "The fever symptoms were associated with bilateral conjunctivitis, arthralgias, and irritability.", "The hivelike, nonpruritic urticaria did not improve with antihistamine medication and there were no known precipitating or aggravating factors.", "Despite extensive evaluation, a definitive source for the fevers was not identified, and the patient was referred to our institution.On physical examination, the patient was febrile (temperature, 39\u00b0C) and appeared fussy."], "Examination and Results": ["Findings from chest and abdominal imaging and bone marrow aspiration with biopsy were negative for a malignant process.", "Growth measure findings were normal.", "Skin examination confirmed nonpruritic, macular and urticarial lesions on the face, back, and lower extremities (Figure).", "Bilateral conjunctival hyperemia without drainage was noted.", "There was neither swelling nor redness of the joints.", "Her right ankle and knee examination showed limited active and passive range of motion secondary to pain symptoms.", "Findings from the remainder of physical examination were normal.Erythematous macular and urticarial lesions with areas of confluence on back and lower extremities."]}
{"Patient Symptoms": ["The following day, the patient developed right upper extremity pain and swelling.", "Physical examination revealed tense and tender swelling of the right upper extremity that was more marked in the upper arm and caused significant impairment in motor function, but sensation to touch and pin prick was intact (Figure 1A)."], "Examination and Results": ["She was afebrile with a heart rate of 120 beats/min on admission and leukocytosis (white blood cell count, 23\u202f000/\u03bcL [to convert to \u00d7109/L, multiply by 0.001]).", "Computed tomography of the abdomen and pelvis and transvaginal ultrasonography revealed a large intrauterine abscess.", "The right radial pulse was absent, but biphasic Doppler arterial signals were present in the right radial and ulnar artery."], "Treatment": ["An attempt to insert a peripherally inserted central catheter (PICC) into the right basilic vein was unsuccessful.", "An intravenous catheter in the left hand was established for the administration of antibiotics."]}
{"Patient Personal Background": ["He had no history of previous surgery or trauma."], "Patient Symptoms": ["A physical examination revealed moderate epigastric tenderness with rebound and guarding."], "Examination and Results": ["His systolic blood pressure was 109 mm Hg, his diastolic blood pressure was 70 mm Hg, and his pulse rate was 100 beats/min.", "Laboratory test results were remarkable for a white blood cell count of 13\u202f970/\u03bcL, hemoglobin level of 8.4 g/dL, serum creatinine level of 1.67 mg/dL, serum amylase level of 57 U/L (reference range, 30-110 U/L), and serum triglyceride level of 282.42 mg/dL, with no evidence of coagulopathy.", "Contrast-enhanced computed tomography (CECT) and mesenteric angiography were performed (Figure 1).A, Contrast-enhanced computed tomographic (CECT) image showing an intra-abdominal hyperdense mass (arrowhead) and free fluid in the upper abdomen.", "B, Visceral artery angiogram revealing an aneurysm (arrowhead)."], "Others": ["(To convert the white blood cell count to \u00d7109 per liter, multiply by 0.001; hemoglobin level to grams per liter, by 10; serum creatinine level to micromoles per liter, by 88.4; serum amylase level to microkatals per liter, by 0.0167; and serum triglyceride level to millimoles per liter, by 0.0113.)"]}
{"Patient Symptoms": ["He denied notable ocular history aside from a recently documented elevated intraocular pressure (IOP) of 36 mm Hg OS and shallow anterior chamber (AC).", "The AC was shallow, and episcleral vessels were congested."], "Examination and Results": ["Subsequently, a choroidal mass was discovered, and he was referred for our opinion.On examination, refractive error was +3.00 D OU, and best-corrected visual acuity was 20/25 OD and 20/40 OS.", "Results of examination in the right eye were unremarkable, and IOP was 17 mm Hg.", "Examination of the left eye revealed elevated IOP of 26 mm Hg while the patient was taking dorzolamide/timolol.", "Ophthalmoscopic examination and wide-angle scanning laser ophthalmoscopy (Figure 1A) documented a ring-shaped peripheral ciliochoroidal mass accompanied by shallow serous retinal detachment inferiorly.", "Globe transillumination revealed an undefined mottled choroidal shadow inferiorly.", "B-scan ultrasonography (Figure 1B) and ultrasound biomicroscopy suggested an echolucent ciliochoroidal elevation without intrinsic vascular pulsations.", "Magnetic resonance imaging of the orbits confirmed the ring-shaped ciliochoroidal elevation with nonenhancement of the mass.", "Doppler ultrasonography showed normal flow parameters without evidence of a dural-cavernous fistula.A, Wide-angle fundus photograph demonstrating peripheral choroidal elevation, most prominent superotemporally, and numerous choroidal folds."], "Treatment": ["Laser peripheral iridotomy had been performed but failed to deepen the AC."]}
{"Patient Symptoms": ["Serum GQ1b ganglioside IgG antibodies associated with internal ophthalmoplegia in Fisher syndrome were not detected.Within the following 2 weeks, progressive generalized autonomic dysfunction developed including reduced food intake and weight loss, constipation, urinary retention, anhidrosis, xerostomia, and xerophthalmia."], "Examination and Results": ["Ophthalmologic examination revealed bilateral mydriasis, with a reduced pupillary response to light and accommodation (Figure).", "Uncorrected Snellen visual acuity was 20/32 OU for distance and 20/200 OU for near.", "Ocular motility was normal.", "Results of slitlamp examination and ophthalmoscopy showed no abnormalities.Bilateral mydriasis with a reduced pupillary response to light and accommodation in an 11-year-old boy.Results of complete blood cell counts, serum chemistry examination, cerebrospinal fluid examination, and virologic studies of blood and stool performed for exclusion of infection were all negative.", "Tumor, aneurysm, or traumatic lesion were excluded by cranial magnetic resonance imaging.", "Ophthalmologic reexamination showed unaltered pupillary abnormality.", "Results of Schirmer test without topical anesthesia showed 0 mm of tear production.", "Lissamine green staining of the exposed interpalpebral areas showed moderate changes of the conjunctiva.", "Mild corneal staining was evaluated with cobalt blue illumination after fluorescein instillation."], "Treatment": ["Diluted norepinephrine (0.1%) was instilled in both eyes, which elicited supersensitive dilatation of the pupils bilaterally owing to reinnervation and upregulation of the postsynaptic receptors, consistent with tonic pupils."]}
{"Patient Symptoms": ["She also stated that she had pain to the eye.A, Slitlamp photography of the left eye demonstrating the pupil peaked toward the 9:30 area."], "Examination and Results": ["On slitlamp examination, a peaked pupil was noted (Figure 1).", "No new pigment was noted on the ocular surface."], "Treatment": ["The patient subsequently underwent a complete excision of the tumor and supplemental cryotherapy to the resection bed.", "Three months later, she had a new pigment deposition adjacent to the limbus in the area of the prior resection, for which she underwent additional excision and cryotherapy.", "Pathology specimens from this excision were negative for atypia.", "The patient was given mitomycin C as adjuvant therapy.Two months later, the patient presented for follow-up."], "Diagnosis": ["Pathological results confirmed the diagnosis of conjunctival melanoma."], "Others": ["She had an 11-mm pigmented conjunctival lesion that was suspicious for melanoma with significant involvement of the caruncle, bulbar conjunctiva, and palpebral conjunctiva.", "The tumor had invaded the medial canthus and medial rectus insertion; however, no scleral invasion was observed during the intraoperative examination.", "Her visual acuity and intraocular pressure were at baseline and within normal limits, respectively."]}
{"Patient Personal Background": ["His ocular history was significant for mild nuclear sclerosis.", "His current medications included multivitamins and fish oil.Automated Humphrey visual field (VF) shows a right, dense inferior arcuate scotoma (A)."], "Examination and Results": ["His VF loss was recognized on automated Humphrey VF screening and had remained unchanged during the subsequent 5 years (Figure, A).", "The VF loss is stable when compared with previous VF testing.", "Color fundus photograph demonstrates small tilted right optic nerve with peripapillary atrophy (B).", "GHT indicates Glaucoma Hemifield Test; MD, mean deviation; PSD, pattern standard deviation; and VFI, visual field index.Neuro-ophthalmic examination revealed visual acuities of 20/30 OD and 20/25 OS that matched with the density of his cataracts.", "Color vision was within normal limits bilaterally.", "Pupils were symmetric without afferent defects.", "Applanation tonometry pressures were 18 mm Hg OD and 17 mm Hg OS.", "Slitlamp examination revealed mild nuclear sclerosis in each eye.", "Repeated automated Humphrey VF testing revealed bilateral inferior arcuate defects (mean deviation, \u22124.80 dB OD and \u22122.6 dB OS)."]}
{"Patient Personal Background": ["His posttransplant course was notable for moderate cellular rejection (International Society for Heart and Lung Transplantation grade 2R) within the first 6 weeks, which was treated with a pulse of corticosteroids."], "Patient Symptoms": ["Three days prior to this presentation, he experienced an episode of mild chest pain associated with radiation down his left arm and vomiting.", "Over the preceding days, he developed progressive dyspnea on exertion, which prompted him to present to the emergency department."], "Examination and Results": ["His electrocardiogram (ECG) on presentation is shown in Figure, A.", "His bedside echocardiogram showed anteroseptal akinesis with apical thrombus and reduced left ventricular function (Figure, B and Video).A, Patient\u2019s admission electrocardiogram demonstrated new ST elevations of 1 to 2 mm in the anterolateral leads with Q waves in I, aVL, and across the precordial leads.", "B, His bedside echocardiogram demonstrated anteroseptal akinesis with apical thrombus (arrowhead) and reduced left ventricular function.Order an emergent coronary angiogram and endomyocardial biopsy."], "Treatment": ["His posttransplant course was notable for moderate cellular rejection (International Society for Heart and Lung Transplantation grade 2R) within the first 6 weeks, which was treated with a pulse of corticosteroids."], "Others": ["Subsequently, he had normal allograft function with no further rejection noted on routine surveillance biopsies.", "He did not seek medical attention at that time as he felt the pain was unlikely to be coming from his heart."]}
{"Patient Personal Background": ["She had a complex history of breast cancer on the left side that was first diagnosed in 1991 and was treated with lumpectomy, radiotherapy, cyclophosphamide, methotrexate, and fluorouracil.", "In 2001, she experienced local disease recurrence and underwent complete mastectomy with axillary lymph node dissection on the left side and received adjuvant treatment with tamoxifen citrate and anastrozole.", "In 2014, she developed axillary lymphadenopathy on the right side and was found to have metastatic disease.", "She subsequently underwent axillary lymph node dissection on the right side, followed by treatment with doxorubicin hydrochloride and cyclophosphamide."], "Patient Symptoms": ["At the time of her evaluation, the patient\u2019s physical examination was remarkable for discrete erysipeloid plaques on her chest, back, and right shoulder (Figure 1A).", "The lesions were warm and indurated but nontender to palpation."], "Examination and Results": ["Her most recent mammogram and positron-emission tomography\u2013computed tomography (PET/CT) showed no evidence of active disease.", "Serum chemistry profile, complete blood cell counts, and hepatic and renal function testing had normal results.", "Lesional skin biopsies were performed (Figure 1B).A, Clinical examination shows discrete erysipeloid plaques on the anterior chest."], "Others": ["B, Histopathologic analysis (hematoxylin-eosin stain, original magnification \u00d7100)."]}
{"Patient Personal Background": ["Her birth history was unremarkable, and her growth and development were normal."], "Examination and Results": ["Her family history was unremarkable.Physical examination revealed 7 sharply marginated, irregularly shaped, polymorphic hyperpigmented macules of 10 to 15 mm in diameter, without scales, on the back and thighs.", "Vital signs were normal.", "There was no lymphadenopathy or hepatosplenomegaly."], "Others": ["The hyperpigmented macules were of orange hue, with unevenness of the pigmentation (Figure 1)."]}
{"Patient Personal Background": ["She had not visited a physician for several years but reported feeling well with no active symptoms.", "She had no risk factors for hepatitis B, hepatitis C, or HIV and reported no use of nonsteroidal anti-inflammatory drugs or herbal medications."], "Patient Symptoms": ["One year ago, her urine was tea-colored during an upper respiratory tract infection."], "Examination and Results": ["Examination results were normal except for elevated blood pressure (154/90 mm Hg).", "Although her hemoglobin concentration was low (10.5 g/dL; reference range, 11.6-15.2 g/dL), white blood cell count, platelet count, and electrolytes were normal.", "Her kidneys appeared structurally normal on ultrasound."], "Diagnosis": ["Urine studies were performed (Table).Urinary tract infection is the most likely diagnosis."]}
{"Patient Personal Background": ["She had a long-standing history of several outbreaks of skin lesions limited to both axillae and groin.", "Previous episodes had been successfully treated with various topical drugs that were administered by her primary care physician.", "No family history of similar lesions was recorded."], "Patient Symptoms": ["She had a long-standing history of several outbreaks of skin lesions limited to both axillae and groin."], "Examination and Results": ["Physical examination revealed multiple annular erythematous plaques surrounded by a peripheral crusted and pustular collarette on her trunk (Figure, B).", "No active lesions were present in her axillae, inframammary folds, or groin.", "After obtaining informed consent, 2 biopsy specimens were taken from the periphery of the lesion for hematoxylin-eosin stain and direct immunofluorescence (Figure, C and D).", "A skin swab specimen from a pustular lesion was taken for microbiological culture.A, Multiple erythematous and crusted plaques diffusely distributed on the dorsal trunk at presentation.", "B, An erythematous annular plaque, surrounded by a crusted and focally pustular peripheral collarette.", "C, Biopsy specimen revealing suprabasilar acantholysis (original magnification \u00d74).", "D, Specimen from generalized lesions at clinical presentation (original magnification \u00d740)."], "Treatment": ["Previous episodes had been successfully treated with various topical drugs that were administered by her primary care physician."], "Others": ["C and D, Histopathologic images, hematoxylin-eosin."]}
{"Patient Personal Background": ["The patient reported previous orolabial melanotic macules.", "Her medical history was significant for hypertension, hypercholesterolemia, asthma, and breast cancer.", "Medications included levalbuterol, nadolol, and cetirizine.", "Family medical history was significant for breast cancer and social history was unremarkable."], "Patient Symptoms": ["Review of systems was positive for cutaneous ephelides."], "Examination and Results": ["Physical examination revealed a 7 mm \u00d7 6 mm asymmetric, heterogeneously pigmented lesion without indurated borders on the gingiva associated with the left maxillary central incisor tooth (number 9) (Figure, A).", "A lesion similar in clinical appearance, although smaller, was observed on the gingiva associated with the right mandibular first premolar tooth (number 28) (Figure, B).", "Biopsy specimens were obtained with a 3 mm punch instrument from both lesions for routine histology which demonstrated similar microscopic findings (Figure, C and D).A, Heterogeneously pigmented lesion of the gingiva associated with the left maxillary central incisor.", "B, Heterogeneously pigmented lesion of the gingiva associated with the right mandibular first premolar.", "C, Mucosal epithelium exhibiting spongiosis and a diffuse proliferation of heavily pigmented dendritic melanocytes that extend the full thickness of the epithelium (arrowheads).", "Melanin incontinence is also noted (hematoxylin-eosin stain, original magnification \u00d7100).", "D, Squamous mucosa exhibiting spongiosis with diffuse pigmentation in the basal cell layer and dendritic melanocytes (arrowheads) in the stratum spinosum (hematoxylin-eosin stain, original magnification \u00d7200)."]}
{"Patient Symptoms": ["Seventeen days after her last day of chemotherapy, while neutropenic, she became febrile and developed several vesicles with an erythematous base on the lower back (Figure, A) and left thigh."], "Examination and Results": ["Tissue and blood cultures and a punch biopsy specimen of a vesicle on the lower back were obtained.", "Hematoxylin-eosin (Figures, B and C), gram (Figure, D), and periodic acid-Schiff stains were performed on the punch biopsy.", "Testing for herpes simplex virus and varicella zoster virus were also ordered.A, Scattered vesicles with an erythematous base on the lower back."], "Others": ["B, Hematoxylin and eosin stain (original magnification \u00d7200).", "C, Hematoxylin and eosin stain (original magnification \u00d7600).", "D, Gram stain (original magnification \u00d7600)."]}
{"Patient Personal Background": ["There was no history of tumors elsewhere.", "Family history was unremarkable."], "Patient Symptoms": ["She began to limp intermittently ten years earlier.", "She refused further investigations until a year earlier, when she developed mild headache.", "One month before hospital admission, her headache aggravated and became intolerable.", "Her consciousness was intact, but her memory and concentration were poor."], "Examination and Results": ["A brain magnetic resonance imaging (MRI) showed multiple parenchymal lesions involving the pons, bilateral amygdala, and the left temporal pole (Figure 1A).", "Magnetic resonance imaging showed minor focal enlargement of the lesions in the left temporal pole.", "Enhanced MRI showed remarkable progression of the lesions in the left temporal lobe, involving the temporal pole and the parasylvian region, along with a newly developed mass in the third ventricle and obstructive hydrocephalus.", "The lesions in the pons and the right amygdala remained stable (Figure 1B).", "Spinal cord MRI was normal.", "Pupil reflection was normal.", "There were multiple congenital nevi distributed over the body, 2 of which on the legs were more than 5 cm in diameter, and another 3 on her back and face were more than 3 cm.", "There were no focal motor or sensory deficits.", "Muscle stretch reflexes were normal.", "The rest of the neurologic and systemic examination was unremarkable.", "Gene examinations showed a mutation in the N-ras-2 gene.A and B, T1-weighted axial brain magnetic resonance imaging at the levels of pons, midbrain, and thalamus, performed ten years earlier, shows multiple parenchymal lesions including the pons, bilateral amygdala, and the left temporal pole (arrowheads).", "Sequence, spin echo; repetition time, 650.0 milliseconds; echo time, 14.0 milliseconds; field of view, 144\u2009\u00d7\u2009230; slice, 5.0 mm; window, 1054; contrast, 640.", "C and D, Enhanced, T1-weighted axial brain magnetic resonance imaging at the levels of pons, midbrain, and thalamus, performed at the most recent hospital admission, shows remarkable progression of the lesions in the left temporal lobe, involving the temporal pole and the parasylvian region, along with a newly developed mass in the third ventricle (arrowhead) and obstructive hydrocephalus."]}
{"Patient Symptoms": ["Ten days prior, he had presented to a referring hospital\u2019s emergency department for nausea and vomiting and was given 20 mg of intramuscular dicyclomine.", "He reported severe pain at the time and site of injection.", "Within a few hours, he noticed swelling and purpura overlying the site of injection.Over the next 2 weeks, the swelling persisted and the purpura intensified, becoming black centrally (Figure A and B).", "Pain worsened over this period, initially restricting use of the leg, then preventing any weight bearing, prompting his admission to our hospital 10 days after the injection.", "He also reported numbness and occasional tingling of the skin involved.", "The patient denied fever or chills, and his nausea and vomiting had resolved.A, Teenage boy with development of retiform purpura of the left thigh following intramuscular dicyclomine injection."], "Examination and Results": ["At 2 days after injection, red to purple retiform changes developed on the left thigh.", "B, Worsening retiform purpura with central necrosis was noted 13 days after the injection.Findings of a physical examination were significant for retiform purpura of the left thigh, approximately 8 \u00d7\u200912 cm in size.", "Palpation of the area elicited severe pain.", "Popliteal, posterior tibial, dorsalis pedis, and femoral pulses were strong.", "There was no swelling of the remainder of the leg, and findings of joint examinations were normal.", "Sensation was intact throughout the leg with the exception of the skin involved, which had diminished light touch.Blood test results revealed a normal complete blood cell count, normal coagulation profile, and an elevated creatine phosphokinase level of 477 U/L (normal range, 22-198 U/L; to convert to microkatals per liter, multiply by 0.0167).", "Magnetic resonance imaging of the thigh was completed, and a skin biopsy was performed for culture and histology."], "Treatment": ["Ten days prior, he had presented to a referring hospital\u2019s emergency department for nausea and vomiting and was given 20 mg of intramuscular dicyclomine."], "Others": []}
{"Patient Symptoms": ["She had presented to an outside emergency department 2 days prior with lower abdominal pain that subsequently localized to the right lower quadrant.", "Her pain was accompanied by anorexia and nonbloody, nonbilious emesis.", "She denied fevers or chills."], "Examination and Results": ["She was noted to have voluntary guarding and focal right lower quadrant tenderness to palpation.", "Laboratory analyses demonstrated a mild leukocytosis (white blood cell count\u2009=\u200914\u2009\u00d7\u2009103/\u03bcL [to convert to \u00d7109/L, multiply by 0.001]) and normal urinalysis results.", "Abdominal ultrasonography images were obtained that failed to show her appendix and demonstrated no secondary signs of inflammation.", "Computed tomography images of the abdomen and pelvis were obtained, and the representative images are shown in Figure 1.", "In our emergency department, pelvic ultrasonography images were obtained that failed to show both the appendix and right adnexal structures.Computed tomographic images."], "Treatment": ["Because of her notable tenderness, she was admitted for observation at the referring facility.", "However, her right lower abdominal pain persisted, prompting further evaluation."], "Others": ["No antibiotics were initiated, and her activity improved with intravenous hydration.", "She was transferred to our facility for surgical evaluation."]}
{"Patient Personal Background": ["She had been recently treated at an outpatient facility for a viral illness with multiple episodes of forceful coughing."], "Patient Symptoms": ["There was no recent history of trauma to the neck or chest.Physical examination revealed normal vital signs and soft tissue swelling over the left supraclavicular area."], "Examination and Results": ["No overlying skin changes or crepitus were appreciated.", "Laboratory data revealed leukocytosis (white blood cell count, 18\u202f000/\u00b5L; to convert to \u00d7109 per liter, multiply by 0.001).", "A computed tomographic scan demonstrated extensive edema of the left neck, with fat stranding seen in the subcutaneous tissues extending into the left jugular, carotid, and esophageal spaces (Figure, A).", "Mediastinal edema and bilateral pleural effusions were also seen on computed tomographic scan (Figure, B).", "Owing to the concern for esophageal perforation, a barium swallow was performed, showing no extravasation of contrast.A, Computed tomographic scan shows extensive soft tissue inflammation in the left neck (arrowhead)."]}
{"Patient Symptoms": ["Her visual acuity was 20/20 OD and 20/70 OS."], "Examination and Results": ["Computed tomography scan results of her head did not reveal any acute intracranial pathology.", "Her systemic inflammatory markers were elevated, including a left-shifted leukocytosis with a white blood cell count of 15\u202f200 \u03bcL (normal values, 4100-8900 \u03bcL) (to convert to \u00d7\u2009109/L, multiply by 0.001), a platelet count of 458\u2009\u00d7\u2009103 \u03bcL (150-450\u2009\u00d7\u2009103 \u03bcL) (to convert to \u00d7\u2009109/L, multiply by 1.0), and a C-reactive protein level of 17.3 mg/L (<8.0 mg/L) (to convert to nanomoles per liter, multiply by 9.524).", "Cerebrospinal fluid studies were suggestive of aseptic meningitis: elevated protein levels (0.139 g/dL, 0-0.035 g/dL) (to convert to grams per liter, multiply by 10.0), increased neutrophils (32%, 2%\u2009\u00b1\u20094%), normal opening pressure, and normal glucose levels.On day 2 of her hospitalization, she complained of left-eye blurred vision.", "Both eyes had normal pupillary responses, color vision, and intraocular pressures.", "The results of an anterior chamber examination were unremarkable in each eye.", "The results of a dilated fundus examination of both eyes revealed significant inflammation, including 1+ vitreous cell levels, marked disc edema, intraretinal hemorrhages, and extensive sheathing of the retinal venules (Figure).Bilateral fundus photographs of the right eye (A) and left eye (B) on presentation."]}
{"Patient Symptoms": ["He was initially agitated and admitted to the intensive care unit with hemodynamic instability.", "A significant amount of clear fluid was noted to be continually draining from the wound site."], "Examination and Results": ["The patient\u2019s medical history at this point was unknown.From an ophthalmic standpoint, a single, deep laceration extended inferomedially from the right upper zygoma across the nasal dorsum and involving the eyelid-cheek junction (Figure 1)."], "Others": ["The oral-maxillofacial surgery service was consulted for assessment of the facial lacerations, and the oculoplastic service was consulted for possible damage to the nasolacrimal system."]}
{"Patient Personal Background": ["Her ocular history was notable for a previous uncomplicated cataract surgery in the left eye that had a good visual outcome."], "Examination and Results": ["On postoperative day 1, her visual acuity was 20/60 OD, attributed to mild corneal edema, with an intraocular pressure of 18 mm Hg.", "At postoperative week 1, the best-corrected visual acuity was 20/50 OD, her intraocular pressure was 17 mm Hg, and there was no afferent pupillary defect.", "The cornea was clear and there were trace anterior chamber cells.", "A dilated examination revealed multiple spots of retinal whitening with tiny intraretinal hemorrhages concentrated in the posterior pole (Figure, A).", "Optical coherence tomography revealed intraretinal cystoid abnormalities in the macula and hyperreflective patches in the nerve fiber layer and inner nuclear layer (Figure, B).A, Fundus photograph of the right eye demonstrating multifocal patches of inner retinal whitening in the posterior pole.", "B, Optical coherence tomography through the macula demonstrating mild intraretinal cystoid abnormalities and hyperreflective thickened areas in the nerve fiber and inner nuclear layer, corresponding to the white retinal patches."], "Others": ["A dilated fundus examination was not performed.", "The patient was referred urgently for consultation by a retina specialist."]}
{"Patient Personal Background": ["His medical history was pertinent for a dual-chamber pacemaker implant 3 years earlier for intermittent symptomatic second-degree atrioventricular (AV) block.", "Additional comorbidities included hypertension and well-controlled type 1 diabetes with no recent changes in his medications.", "His pacemaker was programmed to a DDDR (dual-chamber, rate-adaptive) pacing mode with an AV delay of 300 milliseconds and tracking rates from 60 to 110 pulses per minute."], "Patient Symptoms": ["For the past several weeks he had noted generalized weakness and fatigue."], "Examination and Results": ["There was no associated loss of consciousness, chest pain, dyspnea, or palpitations.", "Initial vital signs showed a systolic blood pressure of 110 mm Hg and results of physical examination demonstrated clear lungs.", "Results of cardiovascular examination demonstrated no gallops, murmurs, or rubs.", "Results of electrocardiography performed on admission are shown in Figure 1."]}
{"Patient Personal Background": ["The patient had a history of IgG\u03ba multiple myeloma, diagnosed approximately 6 months earlier."], "Examination and Results": ["At that time, flow cytometry showed a \u03ba-restricted plasma cell population positive for CD38 and CD138 but negative for CD3, CD20, and CD45 expression.", "Cytogenetic analysis with fluorescent in situ hybridization did not reveal high-risk genetic markers.", "The patient demonstrated no evidence of end organ disease, and her myeloma was classified as stage II.", "Physical examination revealed scattered red-violaceous nodules, with the largest measuring approximately 6.0\u2009\u00d7\u20095.5\u2009\u00d7\u20092.5 cm (Figure, A).", "They were found in the mouth, the trunk, and on all 4 extremities.", "The lesions were nonulcerated, round with a smooth surface, fixed, and firm and tender to touch.", "Serum protein levels were normal.", "An ultrasound-guided needle biopsy and immunohistochemical analysis of the largest lesion on the patient\u2019s right shoulder were performed (Figure, B and C)."], "Treatment": ["Since her initial diagnosis, she had completed 4 cycles of lenalidomide, bortezomib, and dexamethasone (RVD) therapy in addition to irradiation for lytic lesions of the thoracic and lumbar spine."], "Diagnosis": ["The patient demonstrated no evidence of end organ disease, and her myeloma was classified as stage II."]}
{"Patient Personal Background": ["He was taking 20 mg prednisone and 150 mg azathioprine daily.On examination, he was afebrile and had diffuse rhonchi and expiratory wheezes."], "Patient Symptoms": ["He was taking 20 mg prednisone and 150 mg azathioprine daily.On examination, he was afebrile and had diffuse rhonchi and expiratory wheezes."], "Examination and Results": ["He was taking 20 mg prednisone and 150 mg azathioprine daily.On examination, he was afebrile and had diffuse rhonchi and expiratory wheezes.", "A chest computed tomography (CT) scan revealed bilateral nodular infiltrates and a 1.3-cm cavitary nodule in the right upper lobe.", "Blood and bronchoalveolar lavage fluid test results are presented in the Table.The patient does not meet criteria for invasive pulmonary aspergillosis.The patient is not at risk for invasive pulmonary aspergillosis and the results reflect colonization."], "Treatment": ["Bronchoscopy was performed on day 2."], "Diagnosis": ["Blood and bronchoalveolar lavage fluid test results are presented in the Table.The patient does not meet criteria for invasive pulmonary aspergillosis.The patient is not at risk for invasive pulmonary aspergillosis and the results reflect colonization."]}
{"Patient Personal Background": ["The boy was otherwise healthy, with an unremarkable medical history and with no history of trauma or exposure to radiation."], "Patient Symptoms": ["The lesion started as a hyperpigmented macule 3 years ago and since then had been gradually increasing in size and developing into a pink nodule.", "The lesion was pruritic at times and sometimes bled with minor trauma."], "Examination and Results": ["On physical examination, there was a 1-cm well-circumscribed, symmetrical, pinkish, dome-shaped nodule with central erosions on the left cheek (Figure 1).", "Hair, nails, and mucosae were of normal appearance, and the remainder of the examination was unremarkable."]}
{"Patient Personal Background": ["Taking 2 to 3 tablets of hydrocodone/acetaminophen daily improved her back pain from 5 to 2 on a 10-point scale.", "The patient had not achieved pain control with prior nonopioid pharmacologic pain management, including duloxetine and gabapentin.", "Although past cocaine use was a risk factor for opioid misuse, a trial of hydrocodone was initiated, after discussion of risks and benefits, with a plan for careful monitoring."], "Patient Symptoms": ["Taking 2 to 3 tablets of hydrocodone/acetaminophen daily improved her back pain from 5 to 2 on a 10-point scale."], "Examination and Results": ["A urine immunoassay drug screen was ordered to evaluate for medication misuse and illicit use (Table).The patient is not using hydrocodone but is using cocaine.The patient is not using hydrocodone but may be using cocaine.The patient may be using hydrocodone but is using cocaine.The patient may be using both hydrocodone and cocaine."], "Treatment": ["She reported no recent illicit substance or drug use and stated her last dose of hydrocodone was that day.", "Although past cocaine use was a risk factor for opioid misuse, a trial of hydrocodone was initiated, after discussion of risks and benefits, with a plan for careful monitoring."], "Others": ["The state prescription drug monitoring program showed no other prescribers of controlled substances."]}
{"Patient Personal Background": ["He reported no trauma, surgery, recent prolonged mobility limitation, or family history of thrombosis.", "His only medication was aspirin, 81 mg daily."], "Patient Symptoms": ["On examination, his heart rate was 106/min, respiratory rate was 28/min, and swelling of the right calf was noted."], "Examination and Results": ["On examination, his heart rate was 106/min, respiratory rate was 28/min, and swelling of the right calf was noted.", "A heparin drip was initiated for suspected pulmonary embolism, which was confirmed with computed tomography pulmonary angiography.", "Routine laboratory values were unremarkable.", "Two days later, results revealed elevated titers of anticardiolipin and anti\u2013\u03b22 glycoprotein I antibodies and negative lupus anticoagulant screening assays (Table 1).Results should be repeated in 12 weeks to confirm diagnosis of antiphospholipid syndrome."], "Treatment": ["A heparin drip was initiated for suspected pulmonary embolism, which was confirmed with computed tomography pulmonary angiography.", "Warfarin was administered for long-term anticoagulation."], "Diagnosis": ["A heparin drip was initiated for suspected pulmonary embolism, which was confirmed with computed tomography pulmonary angiography.", "Given the unprovoked thrombotic events at a young age, a hypercoagulable state was suspected, and testing for the antiphospholipid syndrome was performed."]}
{"Patient Personal Background": ["Detailed anamnesis revealed a history of intense diarrhea in prior months."], "Patient Symptoms": ["He complained of substantial, progressive seborrheic hyperplasia and flushing episodes over the past year, accompanied by ocular manifestations that included swelling of his eyelids."], "Examination and Results": ["Ophthalmological examination showed features of chronic blepharitis and lagophthalmos.", "A biopsy specimen from the skin of the forehead was obtained and analyzed under hematoxylin-eosin staining (Figure, C).", "A computed tomography (CT) scan completed the etiological investigation (Figure, D).A, Immunohistochemical analysis of the earlier lung tumor using chromogranin A; panoramic view shows that most of the cells diffusely express chromogranin (original magnification \u00d720).", "C, Forehead skin shows scarce lymphocytic infiltrate close to follicular structure along with sebaceous hyperplasia (hematoxylin-eosin, original magnification \u00d740).", "D, Liver computed tomographic (CT) image showing multiple metastatic hepatic masses."], "Others": ["B, Leonine facies presentation shows phymatous changes, diffuse erythema, pustular lesions, and seborrheic hyperplasia."]}
{"Patient Symptoms": ["The lesions had been present for months and increased gradually."], "Examination and Results": ["Mucosae were unaffected.", "Skin examination revealed multiple flaccid pustules on scaly, erythematous plaques on her trunk, with an annular and circinate pattern (Figure, A and B).A and B, Clinical presentation showed flaccid pustules on scaly, erythematous plaques on the trunk.", "C, Subcorneal acantholysis of keratinocytes (yellow arrowheads) resulting in intraepidermal separation/blistering and an inflammatory infiltrate consisting of neutrophilic granulocytes (black arrowheads) (hematoxylin-eosin staining, original magnification \u00d7 100; inset original magnification \u00d7 400).", "D, Discrete subcorneal intercellular IgA depositions (white arrowheads) (direct immunofluorescence with FITC-labeled antihuman IgA antibodies, original magnification \u00d7 400)."], "Treatment": ["Treatment with topical steroids showed no lasting effect."]}
{"Patient Symptoms": ["The tender area was beneath an adhesive bandage placed where she had received DTaP (diphtheria-tetanus-pertussis) and polio vaccinations 3 weeks earlier.", "Removing the bandage revealed a tender indurated gray-violet plaque (Figure, A)."], "Examination and Results": ["Otherwise, she appeared remarkably well, and her vital signs were normal.", "White blood cell and neutrophil counts were low at 0.4 K/\u03bcL (normal range, 4.86-13.18 K/\u03bcL) and 0.18 K/\u03bcL (normal range, 1.60-8.29 K/\u03bcL), respectively.", "Blood culture findings were negative.", "Punch biopsy specimens were obtained for histopathologic analysis (Figure, B) and fungal culture (Figure, C).A, Gray-violet plaque on posterior upper arm at site of adhesive portion of bandage.", "B, Broad nonseptate hyphae surrounding and infiltrating dermal blood vessels (hematoxylin-eosin; original magnification \u00d7400).", "Of note, occasional septae are seen in this specimen, consistent with the characteristic finding that mucormycetes are pauciseptate, rather than aseptate, molds.", "C, Nonseptate hyphae with round terminal sporangia and free spores (lactophenol cotton blue mount; original magnification \u00d7400)."]}
{"Patient Personal Background": ["History was notable for preterm premature rupture of membranes for 10 days.", "The mother was otherwise in good health with normal prenatal care and had no history of sexually transmitted diseases."], "Patient Symptoms": ["During the first few days of life, the neonate had recurrent hypoxic episodes.", "Per the primary team, the rash was first noted at 3 days of life.Physical examination demonstrated a small, ill-appearing neonate with multiple, grouped vesicles and punched-out ulcerations on his scalp, axilla, extremities, and scrotum (Figure, A-D).", "He also had witnessed respiratory desaturations requiring urgent intubation."], "Examination and Results": ["Per the primary team, the rash was first noted at 3 days of life.Physical examination demonstrated a small, ill-appearing neonate with multiple, grouped vesicles and punched-out ulcerations on his scalp, axilla, extremities, and scrotum (Figure, A-D).", "Initial laboratory evaluation demonstrated a normal complete blood cell count and serum chemistry with the exception of a high lymphocyte count (34%, normal level <25% [to convert to proportion of 1.0, multiply by 0.01]) and high aspartate aminotransferase level (117 IU/L, normal level 8-39 IU/L  [to convert to microkatals per liter, multiply by 0.0167]).", "A chest radiograph demonstrated increased pulmonary markings bilaterally.Neonate with grouped vesicles on an erythematous base on the scalp and bilateral lower extremities."], "Treatment": ["He was receiving intravenous antibiotics for suspected sepsis and bacitracin for the topical lesions."], "Others": ["The neonate was born via urgent cesarean delivery owing to breech positioning."]}
{"Patient Personal Background": ["She had no family history of breast or ovarian cancer and no history of drug addiction or hyaluronic acid or free silicone injections in the breast."], "Patient Symptoms": ["She had neither fever nor skin redness but was experiencing fatigue.Initial presentation of the patient.", "She denied any trauma to the breast.On physical examination, the patient had a 6-cm hard mass without nipple discharge or retraction and left axillary palpable lymph nodes."], "Examination and Results": ["A, Asymmetric mass in the upper quadrant of the left breast.", "B, Breast ultrasonogram revealing hypoechogenicity of the breast tissue with periductal small cysts.The patient had stopped breastfeeding 10 months before the emergency department admission, and she had a recent history of pneumonia self-medicated with antibiotics.", "Breast ultrasonography revealed diffuse nonspecific hypoechogenicity of the breast tissue with periductal small cysts (Figure 1B).", "Mammography revealed asymmetric density and distortion in the left upper quadrants.Multiple 14-gauge ultrasound-guided biopsies in the upper quadrants of the left breast and fine-needle aspiration cytologic testing of an enlarged lymph node revealed granulomatous inflammation with epithelioid histiocytes, lymphocytes, plasma cells, and eosinophils.", "Lymph nodes were normal.Blood test results were as follows: hepatitis B surface antigen, hepatitis C antibody, human immunodeficiency virus enzyme-linked immunosorbent assay, and whole-blood interferon \u03b3 release assay (QuantiFERON), negative; IgG cytomegalovirus, positive; fibrinogen level, 234 mg/dL (to convert to micromoles per liter, multiply by 0.0294); erythrocyte sedimentation rate, 4 mm/h; leukocyte count, 7660/\u00b5L (to convert to \u00d7109/L, multiply by 0.001); no acquired immunosuppression; and no hematologic disorders."]}
{"Patient Personal Background": ["He denied any history of systemic symptoms, pain, urinary symptoms, or abnormal bowel function but described 6 years of decreased appetite."], "Patient Symptoms": ["He denied any history of systemic symptoms, pain, urinary symptoms, or abnormal bowel function but described 6 years of decreased appetite."], "Examination and Results": ["Contrast-enhanced computed tomography demonstrated an incidental right infrarenal, retroperitoneal mass measuring 9.7\u2009\u00d7\u20097.7\u2009\u00d7\u20099.1 cm (Figure 1A), with dilated tortuous supply from a lumbar artery branch and retroperitoneal lymphadenopathy.", "Laboratory evaluation of plasma-free metanephrine levels showed a slight elevation in normetanephrine levels (1.21 nmol/L)."], "Treatment": ["B, Flush aortogram outlining supply to the mass from a hypertrophied lumbar artery (blue arrowhead) and from a branch of the internal iliac artery (red arrowhead).At preoperative embolization, initial aortography identified the predominant lumbar artery branch and also demonstrated supply from a branch of the internal iliac artery (Figure 1B).", "These branches were embolized and the mass was devascularized.", "Twenty-four hours following embolization, surgical exploration was performed through a periumbilical midline incision.", "With no evidence of distant metastasis (peritoneal or liver), the mass was resected with partial resection of the iliopsoas muscle to achieve negative margins in conjunction with aortocaval lymphadenectomy of the enlarged lymph nodes."], "Others": ["Given the dramatic arterial enhancement and hypertrophied perivascular plexus, biopsy was not performed, and preoperative arterial embolization was deemed appropriate to minimize intraoperative blood loss.A, Contrast-enhanced computed tomography scan demonstrating an incidental right infrarenal, retroperitoneal mass measuring 9.7\u2009\u00d7\u20097.7\u2009\u00d7\u20099.1 cm, with dilated tortuous supply from a lumbar artery branch.", "The mass was running parallel to the right ureter, which was meticulously dissected, and the right kidney was successfully saved.", "There were no complications, and the postoperative course was uneventful."]}
{"Patient Personal Background": ["He denied risk factors for human immunodeficiency virus, and serologic testing results were negative.", "His ocular history was unremarkable."], "Patient Symptoms": ["He had completed treatment for keratouveitis and reported some residual blurring of his vision in the right eye."], "Examination and Results": ["His uncorrected visual acuity was 20/60 OD and 20/40 OS.", "Pupillary responses, confrontation visual fields, motility, external examination, and intraocular pressure were normal.", "Slitlamp examination revealed superficial keratitis and anterior stromal haze in the right eye but otherwise was normal.", "Fundus examination (Figure, A) revealed a poor foveal light reflex with an irregular-shaped area of red discoloration in the fovea and surrounding subtle flecking of the retina in both eyes.", "Spectral-domain optical coherence tomography (Figure, B) showed an irregular foveal contour with trace epiretinal membrane formation, with no evidence of foveoschisis or outer retinal changes.", "Fundus autofluorescence was normal.A, Color fundus photograph demonstrating pseudohole formation with pigment mottling, right eye."], "Others": ["No other abnormalities were found on ophthalmoscopic examination.", "B, Spectral-domain optical coherence tomography revealing distortion of foveal contour without epiretinal membrane formation, right eye."]}
{"Patient Personal Background": ["She denied any history of hypertension, hyperlipidemia, type 2 diabetes, or human immunodeficiency virus exposure but had a 20 pack/year cigarette smoking history.Uncorrected visual acuity was 20/25 OU."], "Patient Symptoms": ["She denied eye pain, transient vision loss, photophobia, or photopsias but reported right-sided jaw pain migrating to include both temples, ears, neck, and left shoulder.", "The jaw became more painful and fatigued with chewing, associated with an 3.6-kg weight loss over 3 months."], "Examination and Results": ["Automated perimetry revealed a small paracentral relative scotoma in the left eye.", "Superficial temporal artery pulses were palpable without tenderness, and anterior segment examination was unremarkable in both eyes.", "Fundus examination revealed healthy-appearing optic discs in both eyes and an arc-shaped area of retinal whitening in the nasal macula concentric to the optic disc in the left eye (Figure 1, A).", "Optical coherence tomography through the lesion showed localized hyperreflectivity and thickening of the retinal nerve fiber and ganglion cell layers (Figure 1, B).", "Fluorescein angiography revealed normal choroidal and retinal arterial perfusion.", "Erythrocyte sedimentation rate was 2 mm/h, C-reactive peptide level was 0.49 mg/dL (to convert to nanomoles per liter, multiply by 9.524), and platelet count was 270 \u00d7103/\u00b5L (to convert to \u00d7109/L, multiply by 1).A, Fundus photograph shows a normal left optic disc with an adjacent arc-shaped patch of retinal whitening and no other macular pathology."], "Treatment": ["A mouth guard prescribed by her dentist for temporomandibular joint disease had provided substantial relief over the past 2 months."]}
{"Patient Personal Background": ["She had been receiving care for dry eye syndrome, hyperopia, and presbyopia by another eye care clinician, and on routine examination a circumscribed elevation of her right iris was found.", "She did not have any significant medical or family history, and review of symptoms was unremarkable.On examination, corrected distance Snellen acuity was 20/20 OU."], "Patient Symptoms": ["She noted intermittent shooting pain responsive to artificial tears in this eye; otherwise, she was without ophthalmic symptoms."], "Examination and Results": ["Intraocular pressures were 12 mm Hg OD and 10 mm Hg OS.", "Slitlamp examination revealed a circumscribed elevation of the right iris inferotemporally (Figure, A).", "Her iris was uniformly pigmented, and gonioscopy revealed an iridocorneal angle open to scleral spur with a circumscribed area of iris insertion anterior to the Schwalbe line inferotemporally, not deepening on compression.", "Her lens was clear, and no iridociliary lesions were appreciated after pupillary dilation.", "The optic nerve and fundus appeared normal.", "The left eye appeared healthy with a uniformly deep anterior chamber.A, Low-powered slitlamp examination of the right eye showing irregularity of the posterior light reflection inferotemporally, indicating iris elevation."]}
{"Patient Symptoms": ["When he descended to 35 ft during his dive, the patient experienced blurred vision in the right eye and sharp pain in the right temporal area.", "At 50 ft of depth, vision in the right eye went completely black.", "He ascended back to the surface at an appropriate speed and his vision recovered, but he was left with a mild residual blur.", "This was associated with a pain and pressure sensation in the right eye lasting 30 minutes and noticeable bruising on the right upper eyelid.", "After this episode, he noticed constant, binocular, diagonal diplopia in all gazes that was worse in upgaze.He was seen in our ophthalmology clinic the next day.", "His visual blur had resolved, but double vision persisted."], "Examination and Results": ["On examination, visual acuity was 20/20 OU.", "There was no relative afferent pupillary defect.", "Color vision tested with Ishihara pseudoisochromatic plates was normal.", "Confrontation visual fields were full in both eyes.", "He had restricted supraduction and proptosis of 2.5 mm in the right eye.", "Intraocular pressure was 10 mm Hg OU.", "There was ecchymosis of the right upper eyelid.", "Results of dilated eye examination were unremarkable.", "24-2 Humphrey visual fields were normal in both eyes.", "Magnetic resonance angiography of the head showed no vascular abnormalities.", "Magnetic resonance imaging of the orbits showed a fusiform heterogeneous peripherally enhancing extraconal mass within the superior orbit on the right, resulting in proptosis with downward displacement of the right globe (Figure).T1-weighted magnetic resonance imaging of orbit with contrast shows a fusiform heterogeneous peripherally enhancing extraconal mass within the superior orbit on the right (arrowhead), resulting in proptosis with downward displacement of the right globe."]}
{"Patient Symptoms": ["At 48 hours after her skin lesions flared up, a change in her rhythm was noted on telemetry: her baseline sinus rhythm with heart rate of 90 beats per minute (bpm) was changed to bradycardia."], "Examination and Results": ["In the emergency department, chest radiography showed multifocal airspace consolidations involving both lungs.", "Her baseline ECG obtained a day earlier showed normal sinus rhythm with first-degree atrioventricular (AV) block (PR interval of 240 milliseconds)."], "Treatment": ["After 3 days in the intensive care unit, vasopressors were weaned off, and she was extubated.", "Steroid and immunosuppressive medication doses were increased, and pulse methylprednisolone was started."], "Diagnosis": ["Her bone marrow transplant had been complicated with severe graft-versus-host disease (GVHD) of skin and liver, diagnosed by biopsies 1 month after her transplant.", "She was subsequently diagnosed as having methicillin-resistant Staphylococcus aureus pneumonia.", "Skin biopsy confirmed the diagnosis.", "Her hospital course was complicated with diffuse alveolar hemorrhage, possibly from pulmonary GVHD."], "Others": ["Because of respiratory distress, she was admitted to the intensive care unit.", "Respiratory failure developed, and the patient was intubated and treated with vasopressors.", "On hospital day 5, she was noted to have generalized erythematous skin with mild elevated liver enzyme, suggesting acute flare of chronic GVHD.", "A 12-lead electrocardiogram (ECG) is shown in the Figure.", "The patient denied symptoms associated with bradycardia."]}
{"Patient Personal Background": ["He also had a medical history significant for obstructive sleep apnea, gastroesophageal reflux disease with Barrett esophagitis, diabetes, and degenerative joint disease."], "Patient Symptoms": ["In addition, he reported a 22.7-kg weight loss."], "Examination and Results": ["Findings from his head and neck physical examination were normal except for the laryngeal examination.", "Laryngeal endoscopy revealed a large, well-mucosalized mass emanating from the left pyriform sinus, with mass effect on the larynx (Figure, A).", "The bilateral true vocal folds (TVFs) were visualized and were normal, but the full range of mobility of the left TVF could not be assessed owing to mass effect.", "A computed tomographic scan with contrast of the neck was obtained and revealed a 5\u2009\u00d7\u20096-cm, nonenhancing, well-circumscribed laryngeal mass (Figure, B).", "The tumor was originating from the left pyriform sinus and did not appear to be locally invasive."], "Treatment": ["Given these findings, the patient underwent direct laryngoscopy for transoral carbon dioxide laser\u2013assisted excision without complications."], "Others": ["Microscopic examination of the mass demonstrated polygonal cells with peripherally placed nuclei and eosinophilic cytoplasm containing cross-striations (Figure, C).", "Postoperatively, the patient reported improvement in dysphagia, voice quality, sleep, and breathing patterns.A, A large left pyriform sinus mass with mass effect on the larynx.", "B, Preoperative computerized tomography scan showing a large laryngeal mass without local invasion.", "C, Polygonal cells with peripherally placed nuclei and eosinophilic cytoplasm containing cross-striations (hematoxylin-eosin, original magnification \u00d740)."]}
{"Patient Personal Background": ["The patient had not received any chemotherapy or antimicrobial prophylaxis.", "Cellular cytogenetics of his AML were notable for a 5q deletion and p53 mutation."], "Patient Symptoms": ["He had abruptly developed a painful eruption on his scalp, face, and left leg 24 hours prior to presentation after being scratched in these areas by his pet cat."], "Examination and Results": ["Physical examination revealed an ill-appearing, diaphoretic, thin man with multiple erythematous to violaceous, tender, edematous, targetoid nodules and plaques with central dusky appearance on the left forearm and right upper thigh (Figure, A).", "Vital signs included temperature of 39.7\u00b0 C, blood pressure of 141/69 mm Hg, and pulse of 122 bpm.", "His white blood cell count was 1.8\u2009\u00d7\u2009103/\u00b5L (reference range, 4.5-11\u2009\u00d7\u2009103/\u00b5L; to convert to \u00d7109/L, multiply by .001), and absolute neutrophil count was 246 cells/\u00b5L (reference range, 1520-6370 cells/\u00b5L).", "Other laboratory values were remarkable for a red blood cell count of 2.13\u2009\u00d7\u2009106/\u00b5L (reference range, 3.9-5.5\u2009\u00d7\u2009106/\u00b5L; to convert to \u00d71012/L, multiply by 1), hemoglobin of 6.1 g/dL (reference range, 14-17.5 g/dL; to convert to g/L, multiply by 10), and platelet count of 14\u2009\u00d7\u2009103/\u00b5L (reference range 150-350\u2009\u00d7\u2009103/\u00b5L, to convert to \u00d7109/L, multiply 1).", "A brisk neutrophilic infiltrate was seen on histopathology (Figure, B).A, 1.5 cm-long, edematous plaque with dusky central erythema on upper thigh.", "B, Punch biopsy specimen with hematoxylin-eosin staining (original magnification \u00d740); arrowhead indicates brisk dermal neutrophilic infiltrate."], "Treatment": ["Punch biopsy specimens from the right arm and left thigh were performed for histopathologic evaluation and tissue culture."]}
{"Patient Personal Background": ["His mood had been controlled with bupropion, 300 mg/d, for the past several years; however, the recent death of his husband led to increased hopelessness, insomnia, and decreased energy."], "Patient Symptoms": ["His mood had been controlled with bupropion, 300 mg/d, for the past several years; however, the recent death of his husband led to increased hopelessness, insomnia, and decreased energy.", "His total score on the Patient Health Questionnaire 9 (PHQ-9) was 16 (Table 1).The patient has depressive symptoms of at least moderate severity."], "Examination and Results": ["Results of laboratory studies (thyroid-stimulating hormone, complete blood cell count, and metabolic profile) were unremarkable."]}
{"Patient Personal Background": ["Her medical history was significant for chronic hepatitis B infection, for which tenofovir was initiated 4 months ago.", "She was not taking any other medications.The patient was in no acute distress, and her vital signs were within normal limits."], "Patient Symptoms": ["The eruption had been present for approximately 8 months and consisted of asymptomatic, self-resolving, and continuously appearing macules and papules.", "Review of systems was positive only for occasional arthralgias in her knees and ankles."], "Examination and Results": ["On physical examination, there were purpuric, erythematous macules coalescing into patches on the upper extremities, abdomen, and lower extremities (Figure).", "A skin punch biopsy showed extravasated erythrocytes, a neutrophilic infiltrate, fibrinoid necrosis, and broken-down neutrophils releasing nuclear debris, consistent with leukocytoclastic vasculitis (Figure).", "A second skin punch biopsy was performed for direct immunofluorescence, which was negative.", "Results of a complete blood cell count and comprehensive metabolic panel were unremarkable.Physical examination of the lower extremities."], "Treatment": ["Her medical history was significant for chronic hepatitis B infection, for which tenofovir was initiated 4 months ago."], "Diagnosis": ["A skin punch biopsy showed extravasated erythrocytes, a neutrophilic infiltrate, fibrinoid necrosis, and broken-down neutrophils releasing nuclear debris, consistent with leukocytoclastic vasculitis (Figure)."], "Others": ["She had no oral or genital involvement and no joint effusions or deformities.", "Dotted areas indicate areas of the skin that were biopsied.", "Inset, Photomicrograph from first skin punch biopsy (hematoxylin-eosin, original magnification \u00d7200)."]}
{"Patient Symptoms": ["Review of systems was remarkable for hypohidrosis, photophobia, and a history of recurrent sinopulmonary infections, including pneumonia, requiring hospitalization."], "Examination and Results": ["Physical examination revealed normal fingernails and toenails, dermatoglyphics, and dentition.", "Additionally, there was no evidence of alopecia or keratoderma.", "A punch biopsy specimen was obtained (Figure, C and D).A, Reticulate hyperpigmentation involving the lower and upper distal extremities, including the dorsal surface of the hand.", "B, Diffuse reticulate hyperpigmentation of the trunk and flexures, including the posterior neck and axilla.", "C, Hematoxlyn-eosin stain (original magnification \u00d7200).", "D, Congo red stain (original magnification \u00d7200)."], "Others": ["Family history was notable for similarly affected men on the patient\u2019s mother\u2019s side."]}
{"Patient Personal Background": ["She had no significant past medical history and took no medications or supplements."], "Patient Symptoms": ["She denied any history of trauma or prior lesions at these sites and could not pinpoint any exacerbating or alleviating factors.", "She denied fever, arthralgias, myalgias, or constitutional symptoms."], "Examination and Results": ["A physical examination revealed several 2-mm to 4-mm round, hyperpigmented macules symmetrically distributed over the lower extremities and dorsal feet (Figure, A).", "A skin biopsy was performed (Figure, B-D)."], "Treatment": ["No prior treatments had been attempted."]}
{"Patient Personal Background": ["She had no notable medical or family history."], "Patient Symptoms": ["The lesions first appeared in her right axilla 6 months prior and were asymptomatic.", "The patient also noted a 3-month history of polyuria, polydipsia, and nocturia."], "Examination and Results": ["Review of symptoms was otherwise negative.", "On physical examination there were no other sites of involvement including mucosal surfaces.", "Shave biopsies were obtained from the right (Figure, C) and left axillae (Figure, D) and sent for histopathological examination.A, Clinical images show punctate yellow-brown papules on the upper eyelids and infraorbital rims; B, numerous red-brown papules in the right axilla.", "C, Histopathology of a shave biopsy sample from the right axilla (original magnification \u00d7200).", "D, Histopathology of a shave biopsy sample taken from the left axilla (original magnification \u00d7200)."]}
{"Patient Personal Background": ["Her medical history was significant for atopic dermatitis that was well controlled with topical triamcinolone, 0.1%, cream."], "Patient Symptoms": ["Three weeks prior, she had returned from school with 2 itchy papules on her right hand.", "The papules continued to enlarge over the course of the day and progressed to form blisters.", "The following day, she noticed similar lesions appearing on her left hand.", "On further questioning, she recalled similar itchy papules appearing on her feet without progression to blisters."], "Examination and Results": ["Physical examination demonstrated numerous skin-colored tense bullae on her bilateral hands (Figure 1, A).", "Xerosis was on the trunk and extremities.", "On her dorsal and plantar feet, there were macerated, erosive plaques without vesicles or bullae (Figure 1, B).", "Results of herpes simplex virus polymerase chain reaction, bacterial culture, potassium hydroxide preparation, mineral oil preparation, and direct immunofluorescence were negative.A, Bilateral palms with at least 20 tense, white-gold bullae, several with violaceous borders and overlying tapioca-like appearance, present diffusely but concentrated on the palmar surfaces.", "B, Bilateral dorsal feet with macerated, erosive plaques."], "Treatment": ["She was evaluated by her pediatrician, who prescribed oral cefdinir and hydrocortisone, 2.5%, cream, but there was no substantive improvement."]}
{"Patient Personal Background": ["Before this admission, she was healthy, with no previous medical problems."], "Patient Symptoms": ["She denied any change in her bowel habits or having experienced rectal bleeding."], "Examination and Results": ["She had a normal appetite and had no history of weight loss.", "On examination, her vital signs were within normal limits.", "She was mildly tender in the right iliac fossa and there was a large mobile mass, at least 10 cm in diameter, that was easily palpable in the right iliac fossa.", "She was initially investigated with a computed tomography (CT) scan of the abdomen (Figure 1).", "She underwent a colonoscopy that showed no intraluminal mucosal abnormalities or masses, but evidence of external compression at the cecum was noted.Coronal (A) and transverse (B) computed tomographic images show a large intra-abdominal cystic mass in the right iliac fossa."]}
{"Patient Personal Background": ["Given a history of pancreaticoduodenectomy, the patient underwent computed tomography of the abdomen and pelvis with oral and intravenous contrast for further evaluation (Figure).A, Axial cross-section of patient's computed tomographic scan of his abdomen and pelvis after a Whipple procedure."], "Patient Symptoms": ["He admitted to nausea but no vomiting, fevers, or chills.", "He reported having normal bowel movements and passing flatus without difficulty."], "Examination and Results": ["On examination, he was afebrile and not tachycardic.", "He had a well-healed abdominal midline wound.", "His abdomen was soft, not distended, and mildly tender diffusely, worse in the epigastrium, without rebound, guarding, or any palpable masses.", "His bloodwork revealed an elevated lipase level of 2842 U/L (to convert to microkatals per liter, multiply by 0.0167) without leukocytosis or any electrolyte abnormalities.", "Liver function test results were within normal limits.", "The stomach is distended with oral contrast and an air fluid level.", "A tubular solid structure can be seen within the body of the stomach.", "B, Coronal view demonstrating the tubular solid mass within the distended stomach."]}
{"Patient Personal Background": ["He had a history of chronic lymphocytic leukemia for which he had received allogeneic bone marrow transplantation; his course was complicated by extensive graft-vs-host disease including ocular manifestations.", "His graft-vs-host disease was treated with systemic tacrolimus.", "He also had a history of herpes simplex keratitis with fungal infection in the right eye that led to corneal perforation requiring penetrating keratoplasty."], "Examination and Results": ["His best-corrected visual acuities were 20/125 OD and 20/60 OS.", "Slitlamp examination of the right eye revealed eyelid margin hyperemia, penetrating keratoplasty graft in place, a deep and quiet anterior chamber, a normal iris, and posterior chamber intraocular lens.", "Examination of the left eye revealed eyelid margin hyperemia, an apparent soft tissue lesion on the palpebral conjunctiva of the left lower eyelid, inferior bulbar conjunctival injection, a small paracentral anterior stromal scar, a deep and quiet anterior chamber, a normal iris, and posterior chamber intraocular lens.", "The conjunctival lesion had vascular and papilliform elements (Figure) and had not been noted on a routine examination 6 months prior.Clinical photograph showing a soft-tissue lesion on the palpebral conjunctiva of the left lower eyelid, accompanied by inferior bulbar conjunctival injection."], "Treatment": ["His graft-vs-host disease was treated with systemic tacrolimus."]}
{"Patient Symptoms": ["He denied experiencing decreased vision, pain, redness, photophobia, or recent trauma."], "Examination and Results": ["His best-corrected visual acuity was 20/25 OD and 20/30 OS, his intraocular pressures were 12 OD and 13 OS, and his pupils were reactive to light bilaterally without an afferent pupillary defect or anisocoria present.", "His extraocular motility demonstrated a mild limitation on elevation and abduction.", "His confrontational visual fields were intact.", "His color vision was normal and his trigeminal and facial nerve function were intact.", "His external examination revealed 4 mm of relative proptosis OS and 2 mm of hypoglobus OS.", "His anterior slitlamp examination and dilated fundus examinations yielded unremarkable results."], "Others": ["The remainder of his review of systems was unremarkable."]}
{"Patient Personal Background": ["His medical and surgical history included prostate cancer, status postcryotherapy, osteoarthritis, and migraines.", "His social history was significant for active cigarette smoking and immigration from a Middle Eastern country.", "His medications included naproxen at 500 mg as needed, tamsulosin at 0.4 mg daily, and aspirin at 81 mg daily.On examination, his best-corrected visual acuities were 20/40 OD and 20/25 OS.", "His pupils were reactive, his extraocular motility was full, and the intraocular pressures were 16 mm Hg in both eyes."], "Patient Symptoms": ["He had no systemic symptoms and denied having eye redness, pain, and photophobia."], "Examination and Results": ["His pupils were reactive, his extraocular motility was full, and the intraocular pressures were 16 mm Hg in both eyes.", "The results of the external examination and anterior slitlamp examinations were unremarkable, and there was no anterior chamber or anterior vitreous cell or flare.", "The dilated fundus photography examination revealed yellow-gray, curvilinear, and puzzle piece\u2013shaped subretinal macular lesions in both eyes (Figure).", "The lesions were hyperfluorescent with hypofluorescent borders on fundus autofluorescence testing results (Figure).", "Optical coherence tomography revealed that the involved areas exhibited a disruption of the outer retinal layers (including and deep to the outer nuclear layer) along with hyperreflectivity of the outer retina, retinal pigment epithelium, and choroid.", "There was no involvement of the inner retina.", "The patient underwent laboratory testing for syphilis and tuberculosis, which yielded negative results.Fundus photographs showing yellowish, puzzle piece\u2013shaped, curvilinear lesions in the maculae of the right eye (A) and left eye (B)."]}
{"Patient Personal Background": ["His medical and ocular history included only pterygium surgery many years ago.", "His social history was significant for multiple male and female sexual partners.On examination, his visual acuity was counting fingers OD and 20/70 OS."], "Patient Symptoms": ["His review of systems was otherwise negative for unusual findings, and he denied any pain, photophobia, or eye redness."], "Examination and Results": ["Pupils were reactive, extraocular motility was full, and intraocular pressure was 21 mm Hg OU.", "The external and slitlamp examinations were unremarkable except for 1+ anterior vitreous cells in both eyes.", "Dilated fundus examination revealed mild optic disc edema and hyperemia along with large, pale-yellowish, placoid lesions within the macula of both eyes (Figure 1).", "Optical coherence tomography of both eyes (Figure 1, inset) revealed extensive disruption of the ellipsoid and interdigitation zones.", "Contrast-enhanced magnetic resonance imaging and venography of the brain and orbits revealed an empty sella and hypoplasia of the left transverse sinus, without enhancement of the optic nerves.", "A lumbar puncture revealed an opening pressure of 1.6 cm of water.Fundus photographs and optical coherence tomography of both eyes.", "Examination of the posterior pole of both eyes revealed mild optic disc edema and hyperemia along with large, pale-yellowish, outer retinal lesions within or adjacent to the macula of both eyes."]}
{"Examination and Results": ["Her heart rate was 135 beats/min, and her blood pressure was 160/100 mm Hg.", "A 12-lead electrocardiogram documented wide complex tachycardia (WCT, Figure 1)."]}
{"Patient Personal Background": ["He passed his first kidney stone at age 27 and had 2 additional episodes of spontaneous stone passage.", "He had no other significant medical history.", "His typical daily consumption included 3 dairy servings, 2 to 3 L of water, 1 to 2 servings of animal protein (meat, poultry, fish, and eggs), and restricted dietary salt.", "Family history was significant for nephrolithiasis in his mother."], "Examination and Results": ["Physical examination results were unremarkable (body weight, 77 kg).", "Laboratory studies revealed normal serum levels of calcium, phosphorus, potassium, bicarbonate, creatinine, and parathyroid hormone."], "Treatment": ["His only medication was tamulosin (\u03b11a-adrenergic receptor antagonist), which was prescribed as needed for stone passage."], "Others": ["His stone analysis showed 95% calcium oxalate (CaOx) and 5% calcium phosphate.", "He reported no diarrhea or consumption of foods with high oxalate content (eg, spinach, beets, nuts, and chocolate).", "Twenty-four-hour urine studies are shown in the Table.The patient has hypercalciuria due to distal renal tubular acidosis.The patient has hypercalciuria due to high animal protein intake.The patient has hypercalciuria due to high salt intake.The patient has hypercalciuria due to idiopathic hypercalciuria."]}
{"Patient Personal Background": ["Her medical history included recurrent acute otitis media requiring tympanostomy tube placement."], "Patient Symptoms": ["At the 2-week follow-up, the swelling had largely resolved with a now-firm, slightly mobile, subcentimeter mass palpable in the anterior parotid gland.", "Four days later the mass enlarged and became painful."], "Examination and Results": ["On physical examination, the left parotid gland was diffusely full and firm, which was consistent with viral parotitis.", "A magnetic resonance imaging (MRI) study identified a 1.2\u2009\u00d7\u20091.7\u2009\u00d7\u20091.6-cm solid mass in the anterior parotid gland with well-defined borders and indention into the masseter muscle.", "The mass was isointense to muscle on T1, hyperintense on T2, with strong contrast enhancement, heterogeneous internal enhancement and a central focal area of hypointensity (Figure, A).", "Microscopically, the tumor was composed of spindle cells with elongated nuclei in a storiform pattern embedded in moderately dense admixed lymphohistiocytic infiltrate with no atypia (Figure, B).", "Immunohistochemical analysis (IHC) was positive for activin-like kinase-1 (Alk-1) (Figure, C), vimentin, CD68, and factor XIIIa, and negative for smooth muscle actin (SMA), desmin, cytokeratin, and CD34.A, Postcontrast axial magnetic resonance image (MRI) demonstrating mass (arrowhead) with strong contrast enhancement, heterogeneous internal enhancement with a central focal area of hypointensity."], "Treatment": ["Gland massage, warm compress, sialagogues, and increased hydration were recommended.", "The patient underwent a left superficial parotidectomy."], "Others": ["Grossly the lesion was nonencapsulated, firm, dark colored, and was located within the anterior superficial lobe of the parotid gland.", "B and C, Histopathologic images, original magnification \u00d7200.", "B, Spindle cells with elongated nuclei in a storiform pattern embedded in moderately dense admixed lymphohistiocytic infiltrate with no atypia.", "C, Positivity for Alk-1."]}
{"Patient Personal Background": ["Further testing led to a diagnosis of HIV/AIDS, and at that time she was started on highly active antiretroviral therapy (HAART) therapy as well as bactrim prophylaxis."], "Patient Symptoms": ["She had presented 3 months prior with neurologic and vision changes and was diagnosed as having varicella zoster encephalitis and cytomegalovirus retinitis.", "Physical examination revealed left-sided facial fullness and a left-sided violaceous, vascular-appearing lesion involving the left maxillary gingiva (Figure, A)."], "Examination and Results": ["The patient was afebrile, her white blood cell count was 3300/\u03bcL, and her CD4 count was 210 \u03bcg/mL.", "Magnetic resonance imaging (MRI) of the face revealed a poorly enhancing mass arising from the left maxilla and extending into the left maxillary sinus (Figure, B).", "Histologic analysis and immunophenotype of the specimen showed a dual population of lymphoma cells with plasmablasts having large vesicular nuclei and centrally located eosinophilic nucleoli and \u201cplasmacytic\u201d cells with comparatively smaller darker nuclei and smaller scanty nucleoli (Figure, C).", "Immunohistochemical expression was strongly positive for CD138 (Figure, D) and Epstein-Barr virus\u2013encoded small nuclear RNA (EBV-EBER), and the Ki-67 index (marker of mitotic division) was greater than 90%, negative for CD45, CD20, HHV-8, TdT, CD34, PAX5, CD3, CD99, ALK-1, and CD30."], "Treatment": ["Further testing led to a diagnosis of HIV/AIDS, and at that time she was started on highly active antiretroviral therapy (HAART) therapy as well as bactrim prophylaxis.", "An incisional biopsy was undertaken, during which excessive bleeding was encountered."], "Diagnosis": ["She had presented 3 months prior with neurologic and vision changes and was diagnosed as having varicella zoster encephalitis and cytomegalovirus retinitis.", "Further testing led to a diagnosis of HIV/AIDS, and at that time she was started on highly active antiretroviral therapy (HAART) therapy as well as bactrim prophylaxis."], "Others": ["Flow cytometry was noncontributory."]}
{"Examination and Results": ["Palpation detected a smooth, soft, and fluctuant mass in his left supraclavicular region.", "Fiberscopic examination of the pharynx and larynx revealed no abnormalities.", "Contrast-enhanced computed tomography (CT) demonstrated a poorly circumscribed, heterogeneous, and cystic mass near the sternocleidomastoid muscle (SCM).", "The SCM around the tumor was thickened, suggesting invasion of the SCM.", "There was no continuity between the tumor and the thyroid gland (Figure, A).", "Magnetic resonance imaging revealed a poorly marginated, heterogeneous, and partially tubular mass.", "Fine-needle aspiration cytology revealed cystic elements but no atypical cells.", "Positron emission tomography showed hypermetabolism (maximum standardized uptake value, 1.6) in the mass, but no other hypermetabolic foci.", "At surgery, the tumor was attached to the medial side of the origin of the left SCM.", "No extensive adhesions were observed, and dissection of the tumor from the adjacent tissues was straightforward.", "The lesion measured 2.5\u2009\u00d7\u20093.0\u2009\u00d7\u20094.0 cm, was a solitary well-circumscribed roundish nodule with a thin capsule, and its cut surface had a yellowish white homogeneous surface (Figure, B).", "Pathological examination revealed that the mass comprised an irregular combination of squamous epithelial and spindle cells, with a mature adipose tissue component (Figure, C and D).", "Immunohistochemical analysis revealed that the epithelial component was diffusely positive for cytokeratin AE1/AE3.A, Contrast-enhanced neck computed tomographic (CT) image."], "Others": ["B, Macroscopic findings.", "C and D, Histopathologic images, hematoxylin-eosin.", "C, Original magnification \u00d7100.", "D, Original magnification \u00d7200."]}
{"Patient Personal Background": ["He had not experienced prior nasal trauma or surgery and had quit smoking 30 years ago."], "Patient Symptoms": ["He also reported intermittent right-sided epistaxis occurring multiple times per day."], "Examination and Results": ["At the outside institution, a nasal mass was found on examination and biopsied.", "Endoscopic examination showed a dark, soft-tissue mass filling the right nasal cavity.", "Computed tomography (CT) of the sinuses revealed opacification of the right nasal cavity with tissue protruding into the nasopharynx and complete opacification of the right maxillary, anterior ethmoid, and frontal sinuses (Figure, A and B).", "Histopathologic analysis from both the outside hospital and our institution revealed sheets of atypical, pleomorphic epithelioid cells, some with prominent pigment (Figure, C).", "Immunohistochemical stains were positive for HMB-45 (Figure, D) and S-100.A and B, Noncontrast computed tomographic images of the paranasal sinuses."], "Treatment": ["The patient underwent surgical resection.", "Removal of the mass required a right medial maxillectomy, septectomy, and excision of the right nasolacrimal duct via endoscopic approach.", "Resection also necessitated removal of the anterior maxillary sinus wall via Caldwell-Luc procedure.", "Biopsy specimens were taken throughout."], "Others": ["He was referred to our office for further management.", "C and D, Histopathologic images.", "C, Hematoxylin-eosin."]}
{"Patient Personal Background": ["He had a history of gastroesophageal reflux disease and allergic rhinitis.", "His medications included esomeprazole, fluticasone nasal spray, and supplemental cholecalciferol."], "Examination and Results": ["Physical examination revealed multiple ecchymoses on the extremities and abdomen but was otherwise unremarkable.", "Laboratory evaluation showed a white blood cell count of 2.4\u2009\u00d7\u2009103/\u00b5L, with 13% neutrophils, 32% lymphocytes, 1% monocytes, 0% eosinophils, 0% basophils, and 54% blasts.", "Hemoglobin level was 10.3 g/dL, and platelet count was 20\u2009\u00d7\u2009103/\u00b5L.", "Prothrombin time was 14.5 seconds; international normalized ratio, 1.4; partial thromboplastin time, 27 seconds; D-dimer level, 2.524 \u03bcg/mL (13.82 nmol/L); and fibrinogen level, 68 mg/dL (2 \u03bcmol/L)."]}
{"Patient Personal Background": ["There was no history of weight loss, hypertension, medication use, or a family history of genetic syndromes such as von Hippel-Lindau."], "Patient Symptoms": ["She reported increasing symptoms possibly affected by stress, left lateral recumbent position, and physical activity."], "Examination and Results": ["Physical examination revealed a body mass index of 25.9, blood pressure of 112/74 mm Hg, and a heart rate of 82 beats/min without cardiac or renal artery murmurs or skin lesions.", "Laboratory tests were performed (Table 1)."]}
{"Patient Symptoms": ["She reported that the mass had been present for 2 to 3 weeks and was increasing in size.", "It was not painful but bled when she brushed her teeth or ate sharp foods, which made it difficult to eat.", "There was no discharge from the area."], "Examination and Results": ["She had no fevers, no trauma to the area, and no history of a similar condition.Vital signs included a temperature of 36.4\u00b0C, blood pressure of 106/57 mm Hg, and heart rate of 93/min.", "Physical examination revealed a 3\u2009\u00d7\u20095\u2013cm soft, compressible, nodular mass on the upper right gum line adjacent to the lateral incisors (Figure).", "The mass was friable, pedunculated, and covered with a thin white film.", "There was some gingival erythema near the adjacent teeth but no lymphadenopathy.", "The examination results were otherwise unremarkable."]}
{"Patient Personal Background": ["She experienced no symptoms of weight loss, headache, sweating, palpitations, pallor, anxiety, menstrual abnormalities, or mood changes; had no known history of cancer or hypertension; and was not taking any medications."], "Examination and Results": ["On physical examination, her blood pressure was 135/73 mm Hg, and her heart rate was 82/min.", "There was no truncal or facial obesity, acne, striae, hirsutism, or proximal muscle weakness.", "Laboratory analysis showed normal blood cell counts and levels of electrolytes, liver enzymes, and lactate dehydrogenase.", "Further biochemical evaluation revealed normal levels of plasma and urinary cortisol, serum aldosterone and 17-hydroxyprogesterone, and urinary metanephrines.", "A computed tomography (CT) scan revealed a 5.5\u2009\u00d7\u20094.3\u2013cm left adrenal tumor with heterogeneous appearance, a hypodense central area, and irregular margins, with a density of 36 Hounsfield units (HU).", "Relative and absolute adrenal washout values (a measure of the disappearance of contrast media from a mass after 10 minutes) were 23% and 47%, respectively."]}
{"Patient Symptoms": ["He was found to have scattered petechiae and hemorrhagic vesicles, with most concentrated on the hands and feet (Figure, A and B).", "Palpable purpura were noted across the extremities.", "Several lesions were studded with pustules.", "He had an enlarging bulla on his left wrist.", "An abrasion on his left elbow was attributed to his recent falls."], "Examination and Results": ["He underwent a stroke workup, including transesophageal echocardiography (TEE), results of which were negative.", "One was sent for histopathological examination, and the other was sent for fungal, bacterial, and mycobacterial cultures.", "A bacterial culture swab was obtained from the tense bulla on his left wrist.A, Pustule on dorsal surface of fingers.", "B, Acral eruption on the dorsal surface of the foot.", "C and D, Skin biopsy specimens, hematoxylin-eosin.", "C, Specimen from the dorsal side of the right foot.", "D, Focal ulceration and underlying vascular thrombosis with extramural fibrin deposition."], "Treatment": ["On presentation to the emergency department, he received antibiotics owing to a concern for aspiration pneumonia.", "The infectious disease department was also consulted, and the patient was given broad-spectrum antibiotics owing to concern about endocarditis."], "Others": ["He was noted to have a progressing cutaneous eruption during his admission, and the dermatology department was consulted.", "As part of his dermatological workup, two 4-mm punch biopsy specimens were obtained (Figure, C and D)."]}
{"Patient Personal Background": ["The patient did not smoke and denied any medical history of chronic rhinosinusitis."], "Patient Symptoms": ["The lesion bled with minimal trauma but did not obstruct his breathing."], "Examination and Results": ["Physical examination revealed a 1-cm, nontender, exophytic, verrucous, skin-colored plaque on the right nasal vestibule (Figure, A and B).", "C, Histologic sections display papillary fronds with slender fibrovascular cores that are lined by nonkeratinizing squamous epithelium (original magnification \u00d7200).", "D, Higher magnification shows mucin-containing goblet cells.", "Neither cytologic atypia nor atypical mitotic figures are present (original magnification \u00d7400)."], "Treatment": ["A diagnostic shave biopsy specimen was taken after informed consent was obtained (Figure, C and D).A and B, An exophytic, verrucous, and skin-colored plaque on the right nasal vestibule."]}
{"Patient Personal Background": ["She recalled having a small abrasion on her left leg before wading waist-deep in search of trout.", "Prior to presentation, she was unsuccessfully treated by 3 different physicians for allergic contact dermatitis and cellulitis."], "Patient Symptoms": ["The left leg was tender to palpation."], "Examination and Results": ["Physical examination revealed erythematous, crusted, edematous plaques and pustules with weeping of yellow exudate on the left leg (Figure, A).", "Plaques extended from the lower mid-shin to the thigh in a sporotrichoid spread, ending with a palpable enlarged lymph node in the left groin.", "The patient reported no history of cutaneous eruptions on her legs or feet, and there was no obvious thickening, yellowish discoloration, or subungual debris of the fingernails or toenails on examination.", "A laboratory work-up, potassium hydroxide scraping (Figure, C), and punch biopsies for histopathologic analysis and fungal, bacterial, and atypical mycobacterial tissue cultures were performed.A, Erythematous, crusted, edematous plaques and pustules on the left leg prior to definitive treatment."], "Treatment": ["Attempted treatments included topical and oral corticosteroids, trimethoprim-sulfamethoxazole, ceftriaxone, doxycycline, and clindamycin.", "Following 1 month of failed treatment, she presented to the dermatology clinic."], "Others": ["B, Near complete resolution of pustules and resultant postinflammatory hyperpigmentation after definitive treatment.", "C, Potassium hydroxide scraping taken from the left leg."]}
{"Patient Symptoms": ["The eruption was accentuated in the inguinal folds, antecubital fossae, and popliteal fossae."], "Examination and Results": ["Physical examination revealed a strikingly symmetrical eruption of erythematous, edematous, annular plaques with superimposed small pustules at the periphery, and associated desquamation (Figure, A and B).", "Laboratory evaluation was significant for leukocytosis with neutrophilia (26000 \u03bcL; to convert to \u00d7\u2009109 per liter, multiply by 0.001).", "Neutrophil levels were 66.7% (to convert to proportion of 1.0, multiply by 0.01), and lymphocyte levels were 9.9% (to convert to proportion of 1.0, multiply by 0.01).", "C-reactive protein and erythrocyte sedimentation rate levels were within normal limits.", "Test results for anti-DNase B antibodies, a respiratory viral panel, and blood and throat cultures were all negative.A, Right arm with erythematous edematous plaque with superimposed pinpoint pustules and associated superficial desquamation.", "B, Bilateral buttocks with well-demarcated, erythematous plaques with pustules at the periphery.", "Superficial desquamation is present at the superior aspect of the buttocks.", "C, Hematoxylin-eosin stain (original magnification \u00d7\u200920).There was no ocular or mucosal involvement and no lymphadenopathy.", "There was no family history of psoriasis.Biopsy of the left thigh revealed a subcorneal pustule with underlying neutrophilic spongiosis, with associated psoriasiform epidermal hyperplasia and rare individually necrotic keratinocytes.", "There was edema of the papillary dermis and a mild superficial perivascular lymphocytic infiltrate with scattered neutrophils (Figure, C)."]}
{"Patient Personal Background": ["She underwent a tonsillectomy at age 5 years.", "She smoked for 1 year but quit 20 years before this presentation.", "There was no family history of malignancy."], "Patient Symptoms": ["On further inquiry, the patient acknowledged right shoulder pain that had been progressing over 5 months and leading to a limited mobility of the right upper extremity.Cross-sectional computed tomography demonstrating a mass of the right shoulder (arrowhead).Her comorbidities included hypertension, morbid obesity, fibromyalgia, and obstructive sleep apnea dependent on positive pressure ventilation.", "There was fullness involving the right scapula.", "She could not abduct her right arm."], "Examination and Results": ["After ruling out acute coronary syndrome or pulmonary embolus, a computed tomography scan of her thorax revealed lytic lesions of the sternum and second rib and a large mass involving the right scapula (Figure 1).", "On examination she was morbidly obese with a body mass index (calculated as weight in kilograms divided by height in meters squared) of 63.", "Laboratory testing included comprehensive metabolic panel and complete blood cell count results within the normal range, except for a calcium level of 10.4 mg/dL (for millimoles per liter, multiply by 0.25) (reference range, 8.4-10.2) and alkaline phosphatase level of 400 U/L (for micokatals per liter, multiply by 0.0167) (reference range, 36-126).", "She was referred to our Cancer Center with a diagnosis of a metastatic giant cell tumor."], "Diagnosis": ["A computed tomography\u2013guided biopsy of the mass gave a broad differential."]}
{"Patient Symptoms": ["The lesion progressively developed several days after an unintentional exposure to blood with a blade used to drain an abscess of the oral cavity.", "A soft tissue abscess of the digit appeared 7 days after the initial trauma.", "Forty-eight hours after surgery, pustules appeared.", "One year later, the surgeon presented with prodromal burning pain of the same index finger, and a similar soft tissue abscess recurred after 48 hours at the same site of the original lesion with a small painful vesicle progressively developed (Figure, B).A, Clinical aspect of the index finger 2 days after the second surgery."], "Examination and Results": ["The bacteriological samples were found to be sterile."], "Treatment": ["Antibiotic therapy combining amoxicillin and clavulanate was started, without any significant improvement.", "Surgery was performed urgently, with excision of the wound entrance and washing of the flexor tendon sheath.", "An antibiotic regimen with amoxicillin/clavulanate was prescribed.", "The surgeon was hospitalized for infusions combining piperacillin/tazobactam and teicoplanine, carried out over 72 hours.", "An oral antibiotic regimen with amoxicillin/clavulanate (3 g every 24 hours) was prescribed for 10 additional days."], "Others": ["The patient presented a deep wound induced by the bistoury piercing of the index finger pulp of the right hand, with a disrupted epidermal barrier.", "Both the patient who was operated on and the surgeon were negative for human immunodeficiency virus and hepatitis B/C virus testing.", "Bacteriological swabs were performed in the same time.", "Further drainage and washing of the sheath were repeated (Figure, A).", "The lesions completely resolved within 2 weeks.", "B, Recurrence of the soft tissue abscess."]}
{"Patient Personal Background": ["Her medical history was remarkable for type 2 diabetes (which was well-controlled with insulin), and a review of systems found that she had not experienced headache, pain, or neurologic complaints.", "Fluorescein angiography was deferred because of her pregnancy.A and B, Fundus photographs demonstrating macular edema, prominent flame hemorrhages, and a mild tortuosity of the retinal venules."], "Examination and Results": ["Her blood pressure was 102/54, and her best-corrected visual acuity was 20/50 OD and 20/40 OS without afferent pupillary defect, motility disturbance, or intraocular pressure abnormalities.", "A fundus examination was remarkable for bilateral hyperemic discs and macular edema and subretinal fluid, with numerous flame-shaped hemorrhages in 4 quadrants without microaneurysms, exudates, or neovascularization (Figure).", "There was no evidence of intraocular inflammation.", "C, Spectral-domain optical coherence tomography (OCT) of the right eye with subretinal fluid and macular edema.", "Central macular thickness, 1095 \u03bcm.A complete blood cell count, antithrombin III, protein C, prothrombin mutation, antiphospholipid, anticardiolipin, diluted Russell viper venom test, and antinuclear antibody testing results were within normal limits."]}
{"Patient Personal Background": ["He had been treated approximately 4 months prior at an outside facility for cerebral infarct with resultant right lower extremity weakness.", "He had no history of head trauma or surgery."], "Patient Symptoms": ["On presentation, he complained of headache and nasal congestion but denied diplopia or rhinorrhea."], "Examination and Results": ["Findings from the ophthalmologic examination revealed bilateral visual acuity of 20/100 with intact visual fields.", "Findings from a head and neck examination were otherwise within normal limits, with cranial nerves III to XII intact.", "Computed tomography (CT) of the sinuses with image guidance protocol revealed a 5.6\u2009\u00d7\u20092.7\u2009\u00d7\u20092.0-cm, well-circumscribed expansile mass occupying the left petrous apex and sphenoid sinus (Figure, A).", "Magnetic resonance imaging (MRI) demonstrated that this mass was heterogeneous on T1-weighted images (Figure, B) and hyperintense on T2-weighted images.", "The mass did not enhance with gadolinium.", "The position of the internal carotid artery was not obviously displaced in either a posterior or anterior direction (Figure, A and B).", "Therefore, it was not entirely clear from imaging if this lesion originated in the petrous apex or sphenoid sinus."], "Treatment": ["The patient was taken to the operating room in conjunction with the neurosurgery team for an endoscopic, transnasal approach to this lesion.", "A wide sphenoidotomy was performed, and a cystic mass was identified within the sphenoid sinus (Figure, C).", "On entering the capsule, a golden-brown fluid was encountered (Figure, D)."]}
{"Patient Personal Background": ["Pertinent medical history included obesity, type 2 diabetes mellitus, allergic rhinitis, and chronic lymphocytic leukemia (CLL).", "The CLL had been treated successfully with chemotherapy and had been in remission for the past 6 years."], "Patient Symptoms": ["He had previous complaints of left-sided aural pressure and intermittent clear otorrhea that were unsuccessfully treated at another center with 2 sets of pressure equalization tubes (PETs) and 3 courses of ototopical antibiotics.", "In the month before presenting to us, the otorrhea had turned bloody.", "He had not experienced fever, malaise, weight loss, lymphadenopathy, skin lesions, or vertigo."], "Examination and Results": ["The only notable finding from the physical examination was a hypomobile left tympanic membrane with an anterior-inferior PET plugged by granulation tissue.", "Facial nerve function was normal bilaterally.", "Audiometry results demonstrated a left moderate sloping to profound mixed hearing loss and speech discrimination score of 68%.", "A fine-cut, temporal bone computed tomographic (CT) scan was obtained, which demonstrated near-complete opacification of the left mastoid air cells, and middle ear (Figure, A)."], "Treatment": ["Bulky soft tissue was removed from the middle ear and mastoid."], "Others": ["The patient underwent a left tympanomastoidectomy for continuing otorrhea.", "Cytopathologic examination revealed numerous, small, basophilic cells (Figure, B).", "Immunostaining showed that the cells were CD20 positive (Figure, C) and CD3 negative (Figure, D).A, Coronal computed tomographic (CT) scan showing near-total opacification of the left mastoid air cells.", "B-D, Histopathologic images, original magnification \u00d740.", "B-D, Histopathological images, original magnification \u00d740.", "B, Biopsy specimen demonstrating homogenous, small basophilic cells.", "C, Positive immunostaining with anti-CD20 antibodies."]}
{"Patient Personal Background": ["Treatment of allergic rhinitis with cetirizine and intranasal fluticasone had provided only partial relief."], "Patient Symptoms": ["There was no associated history of diplopia or worsening visual acuity.", "She had not experienced facial trauma or sinus surgery.", "On examination, there was proptosis and periorbital edema of the left eye without any restriction of extraocular movements."], "Examination and Results": ["The left supraorbital area was tender to palpation, with no abnormal masses appreciated.", "A computed tomographic (CT) scan demonstrated extensive thickening of the left frontal bone, extending over the entire roof of the orbit posteriorly (Figure, A and B).", "Changes within the frontal sinus were consistent with a soft-tissue component of the mass.", "Subsequent magnetic resonance imaging (MRI) (Figure, C and D) showed markedly hypertrophic bone in the frontal region and a homogeneously enhancing lesion within the left frontal sinus that was hyperintense on T2-weighted images, with left extraconal superior orbital and left frontal intracranial extension with dural enhancement."], "Treatment": ["A combination above-and-below approach combining unilateral frontal sinusotomy with a trephination was performed.", "Abnormal tissue appearing in the left frontal sinus was removed, along with diseased tissue that extended into the orbital roof and orbit."], "Others": ["Specimens were sent for pathologic evaluation, and findings demonstrated bony spaces containing lobules and whorls of spindle cells.A and B, Preoperative computed tomography (CT).", "A, Extensive thickening of the left frontal bone.", "B, Soft-tissue component in left frontal sinus.", "C and D, Magnetic resonance imaging (MRI).", "C, Enhancement of the lesion.", "D, Lesion within the left frontal sinus, with superior orbital and intracranial extension."]}
{"Patient Symptoms": ["He reported a 2-day history of left-sided jaw pain preceding the swelling but had no other clinically significant history."], "Examination and Results": ["Physical examination showed trismus, rightward tracheal deviation, and a hoarse voice.", "The left side of his neck was diffusely swollen without palpable fluctuance, induration, or a discrete mass.", "A complete blood cell count revealed no abnormalities.", "A contrast-enhanced computed tomographic (CT) scan of the neck showed a large hyperdense mass interposed between the left common carotid artery and the hypopharynx (Figure, A-C).", "There was resultant lateral deviation of the left common carotid artery and medial deviation on the supraglottic larynx and hypopharynx, resulting in airway compromise.", "Of note, the density of the mass was identical to that of the adjacent vasculature.", "There was extensive edema surrounding the primary abnormality.", "Additional findings include periapical dental abscesses in 2 teeth (Figure, D)."]}
{"Patient Personal Background": ["A review of his systems was significant for bilateral lower leg swelling, a rash of the torso, painful \u201cbumps\u201d on his neck, reduced hearing abilities, and tinnitus.His medical history was significant for human immunodeficiency virus, controlled with antiretroviral therapy (Strilbild; Gilead Sciences Inc).", "His ocular history was unremarkable.", "He was homosexual, did not smoke, and denied intravenous drug use.His best-corrected visual acuity was hand motion OD and 20/20 OS."], "Patient Symptoms": ["There were no associated feelings of pain, flashes, or floaters.", "A review of his systems was significant for bilateral lower leg swelling, a rash of the torso, painful \u201cbumps\u201d on his neck, reduced hearing abilities, and tinnitus.His medical history was significant for human immunodeficiency virus, controlled with antiretroviral therapy (Strilbild; Gilead Sciences Inc)."], "Examination and Results": ["His cluster of differentiation 4 count was 600, and his viral load was undetectable.", "No afferent pupillary defect was apparent.", "His intraocular pressures were 19 mm Hg in OU.", "His external and anterior segment examinations were within normal limits.", "There was 1+ vitritis in the right eye.", "The posterior segment of the left eye was unremarkable.", "A physical examination revealed a tender lymphadenopathy of the posterior neck and a maculopapular rash of the torso.", "Right eye optical coherence tomography was performed (Figure 1B).A, A fundus photograph illustrates a yellowish placoid lesion.", "B, Optical coherence tomography demonstrates an irregular thickening of the retinal pigment epithelium layer with small nodular elevations."], "Others": ["Figure 1A shows the findings of the posterior segment examination of the right eye.", "The remainder of the examination was unremarkable."]}
{"Patient Personal Background": ["He denied any medication use and had no previous history of ocular surgery or known ophthalmic disorders.On examination, visual acuity with correction was 20/400 OD and 20/100 OS."], "Examination and Results": ["Intraocular pressure was within normal limits.", "Both pupils were briskly reactive without an afferent pupillary defect.", "Slitlamp examination was unremarkable.", "Dilated fundus examination of both eyes revealed peripapillary retinal whitening emanating from the optic nerve and encroaching into the macula, more pronounced in the right eye (Figure 1A).", "Late-phase frames of fluorescein angiogram in both eyes revealed hypofluorescence corresponding to the areas of retinal whitening and obscuring the choroidal fluorescence in these areas, along with nasal peripapillary hyperfluorescence in the areas of retinal whitening (Figure 1B).Fundus photograph (A) and late-phase frame fluorescein angiography (B) of the right eye.", "Arrowheads indicate areas of retinal opacification."]}
{"Examination and Results": ["Visual acuity was 20/25 OD, and intraocular pressure was 39 mm Hg OD.", "A pigmented iris lesion was noted, spanning from the pupillary margin to the anterior chamber angle, with several satellite lesions (Figure 1A).", "Gonioscopy showed a pigmented mass infiltrating the anterior chamber angle from the 2-o\u2019clock position to the 5-o\u2019clock position, with extensive pigmentation of the remaining angle structures.", "Anterior segment optical coherence tomography demonstrated a hyperreflective lesion invading into the anterior chamber angle.", "Ultrasound biomicroscopy revealed a mid-low reflective anterior ciliochoroidal lesion measuring 4.4 mm in height and 14.5\u2009\u00d7\u20099.1 mm in largest basal dimensions, centered in the nasal quadrant and extending circumferentially from the 12-o\u2019clock position to the 7-o\u2019clock position (Figure 1B).", "Examination of the posterior pole and of the fellow eye was unremarkable.", "Contrasted computed tomography scans of the chest, abdomen, and pelvis were performed, along with baseline liver enzymes, which revealed no evidence of metastatic disease.Clinical appearance of the lesion."], "Others": ["A, Slitlamp photograph of a pigmented iris lesion distorting the pupil, with nasal sentinel vessels."]}
{"Examination and Results": ["Laboratory data are summarized in the Table.", "Bone marrow karyotyping revealed a normal karyotype; 46 XX [20].", "Multigene polymerase chain reaction (PCR) testing of the bone marrow identified a 44\u2013base pair (bp) internal tandem duplication in the FLT3 gene (OMIM 136351), with an allelic ratio of 0.57 (range, 0.01 to >100).", "No other mutations on the panel (CEBPA, NPM1, KIT, IDH1, and IDH2) were detected.The patient is more likely to have a worse prognosis.The patient\u2019s prognosis is unaffected because the length of the duplication is small.The patient\u2019s prognosis is unaffected because of low mutation burden.Gene sequencing is needed to identify the exact mutation and prognosticate."], "Diagnosis": ["He was diagnosed with acute myeloid leukemia (AML) complicated by leukostasis."], "Others": []}
{"Patient Personal Background": ["Medical history included glaucoma, gastroesophageal reflux disease, and osteoarthritis.", "His home medications included lansoprazole, probiotics, vitamin B12, folic acid, vitamin D3, prednisone (10 mg/d), and timolol eye gel.", "He had no sick contacts or recent travel and reported no alcohol or tobacco use.On examination, the patient was afebrile and normotensive, with a pulse of 88/min."], "Patient Symptoms": ["The rash improved initially but recurred at the 10-mg/d prednisone dosing.", "He had an erythematous rash, characterized by a combination of palpable purpura and petechiae extending from the axilla to the lower abdomen, back, and lower extremities (Figure 1A)."], "Examination and Results": ["He had no sick contacts or recent travel and reported no alcohol or tobacco use.On examination, the patient was afebrile and normotensive, with a pulse of 88/min.", "The face, neck, chest, upper extremities, and oral and nasal mucosa were spared.", "The abdomen was nontender, with a healed postoperative scar.", "Cardiopulmonary and musculoskeletal examination results were unremarkable.Left, Cutaneous findings on physical examination.", "Right, Punch biopsy of rash on lower abdomen (hematoxylin-eosin, \u00d7200).Laboratory tests revealed normal blood cell counts and normal values for renal and hepatic panels.", "Urinalysis showed microscopic hematuria (6-10 red blood cells) and 1+ proteinuria.", "A spot urine protein-to-creatinine ratio on morning void was 1.17 mg/mg creatinine."], "Treatment": ["Six weeks ago, he underwent sigmoid colon resection with fistula repair.", "He was prescribed prednisone when the rash first presented (starting at 30 mg/d and decreased by 10 mg every 4 days)."], "Diagnosis": ["For the past year, he had recurrent episodes of diverticulitis complicated by colovesical fistula."], "Others": ["He had no fever, abdominal pain, dysuria, or urinary frequency."]}
{"Patient Personal Background": ["She was a current smoker, was taking oral contraceptives, and delivered a healthy infant (2.5 months prior)."], "Patient Symptoms": ["One week later, she had new-onset ascites and diffuse abdominal pain."], "Examination and Results": ["The patient was not jaundiced, but her abdomen was distended without rebound or guarding.", "An ultrasound of her right upper quadrant showed hepatic vein thrombosis that was confirmed by magnetic resonance imaging of the abdomen.", "A laboratory workup and bone marrow biopsy were performed (Table)."]}
{"Patient Personal Background": ["The patient reported that these asymptomatic lesions had been present since her adolescence, and she was easily bruised with minimal trauma since birth."], "Patient Symptoms": ["There was no family history of similar cutaneous findings.Clinically, arciform to annular plaques surround white atrophic patches on the left antecubital fossa (A), and skin atrophy is apparent on the dorsal aspects of the hands (B)."], "Examination and Results": ["C, Histopathologically, a punch biopsy specimen from a papule on the left arm was analyzed with Verhoeff\u2013van Gieson stain (original magnification \u00d7100).On close inspection, the plaques were found to be composed of individual 2- to 4-mm keratotic papules surrounding white atrophic patches.", "Physical examination also revealed remarkable skin atrophy on the dorsal aspects of her hands (Figure, B) and feet.", "The patient\u2019s skin was generally pale and translucent with visible veins, especially on the chest and abdomen.", "The face appeared to be emaciated, with a pinched nose, thin lips, sunken cheeks, and prominent eyes."], "Others": ["A punch biopsy specimen from an individual papule from the left arm was obtained and analyzed under Verhoeff\u2013van Gieson stain (Figure, C)."]}
{"Patient Personal Background": ["The patient was born at 38\u00bd weeks by normal spontaneous vaginal delivery.", "His medical history was notable for tongue tie from birth."], "Patient Symptoms": ["The lesion had been present since loss of the umbilical stump at 1 week of life.", "It bled easily with Valsalva maneuver or trauma."], "Examination and Results": ["On examination, he was an alert and healthy-appearing child.", "The umbilicus demonstrated a bright red, friable, 5-mm papule (Figure, A).", "A shave biopsy specimen was obtained for histologic examination (Figure, B and C).A, Clinical photograph of the red friable papule in the umbilicus.", "B and C, Hematoxylin-eosin\u2013stained shave biopsy specimen showing an ulcerated epidermis, colonic mucosa, and granulation tissue (B, original magnification \u00d72.7; C, original magnification \u00d710)."], "Treatment": ["The lesion was treated as an infantile hemangioma with timolol by an outside dermatologist and as an umbilical pyogenic granuloma with silver nitrate by the patient\u2019s pediatrician, with minimal improvement."]}
{"Patient Personal Background": ["His medical history included alcohol abuse and cognitive impairment."], "Patient Symptoms": ["Purpura and ecchymoses, initially periorbital, progressed over the previous 12 months."], "Examination and Results": ["Elder abuse was excluded.", "Examination demonstrated waxy yellow papules and plaques with purpura in the periocular, neck, axillary, trunk, and inguinal regions (Figure, A).", "Investigations revealed anemia, abnormal liver function test results, and renal impairment with moderate proteinuria.", "The patient\u2019s serum protein electrophoresis (SPEP) and immunofixation urine protein electrophoresis test results were normal.", "Radiological studies were unremarkable.", "B, Punch biopsy specimen (hematoxylin-eosin, original magnification \u00d7 4).", "C, Punch biopsy specimen stained with Congo red (original magnification \u00d7 10).", "D, Punch biopsy specimen under polarized microscopy (original magnification \u00d7 10)."], "Others": ["Subsequently, a 4-mm punch biopsy specimen was obtained (Figure, B-D).A, Waxy yellow discoloration of the skin with papules and purpura in the periorbital region."]}
{"Patient Personal Background": ["He was a construction supervisor and had daily contact with moist earth.", "No relevant family history was reported."], "Patient Symptoms": ["The muscle weakness started from the right lower limb and gradually spread to the upper limb and contralateral side.", "Urinary retention developed 1 month later.", "The symptoms ameliorated in the first week but thereafter deteriorated with fever."], "Examination and Results": ["The cranial nerve was intact, but he had quadriplegia with a Medical Research Council muscle scale grade of 0 of 5 power, decreased tendon reflexes, and bilateral positive Babinski sign.", "Pinprick and vibration sensation were markedly impaired below the nipples.", "Multiple enlarged cervical lymph nodes could be palpitated.", "The skin was extraordinarily dry, and a pigmentation of 10 mm in diameter at the T2 vertebrae, just on the midline of the back, was noticed.", "Total blood T-cell count (CD3+) was 1643/uL (to convert to \u00d7109 per liter, multiply by 0.001), and the patient had a CD4+/CD8+ ratio of 0.89.", "Results of blood testing for human immunodeficiency virus, syphilis, and tuberculosis were negative.", "Cerebrospinal fluid testing revealed pleocytosis (72 cells/uL; mononuclear cells, 59 of 72), elevated protein concentration (200 mg/dL), and a decreased glucose level (36.0 mg/dL [to convert to millimoles per liter, multiply by 0.0555]), but no organisms were identified on Gram stain or on stain for acid-fast bacilli.", "Pulmonary computed tomography showed enlarged lymph nodes in mediastinum and axillary regions.", "Results from magnetic resonance imaging of the brain were normal, while magnetic resonance imaging of the cervical spine revealed multiple intramedullary lesions with enhancement (Figure 1).Magnetic resonance imaging of the cervical spine.", "Multiple intramedullary lesions and enlarged lymph nodes with strong enhancement were revealed.", "A, Lateral view of the cervical cord.", "The subcutaneous abscess beneath the pigmentation on the back is also shown.", "Inset, photograph of the skin lesion on the back.", "B, Coronal view of the cervical cord."], "Treatment": ["Because he was suspected of having tubercular meningomyelitis, he received an antituberculosis regimen plus dexamethasone (10 mg daily) for 10 days."], "Others": ["He had no history of central nervous system injury or drug overuse."]}
{"Patient Personal Background": ["The patient\u2019s history was otherwise unremarkable, he had no recent travel outside the United States, and his vaccinations were up to date.On physical examination, the patient had multiple pale, nontender papules distributed over the anterior third of his tongue (Figure)."], "Patient Symptoms": ["His mother reported that multiple masses would develop and resolve spontaneously over the course of days to weeks.", "The lesions were usually white and the size of a pinhead, and located on the anterior portion of the tongue.", "Occasionally they would grow in size and progress to red-filled vesicles that did not burst or bleed."], "Examination and Results": ["No other masses were noted to the remainder of his oropharynx.", "He was afebrile and had no signs or symptoms of airway obstruction.Multiple discolored masses located on the anterior surface of the tongue."], "Others": ["The timing of the lesions was not associated with fever or other rashes."]}
{"Patient Symptoms": ["His family members and caregivers accompanied him.", "At physical examination the patient was pale, sweaty, peripherally hypoperfused, tachypnoeic, and dehydrated, and the abdomen was extremely distended, diffusely tympanic, and tender at palpation."], "Examination and Results": ["His blood pressure was 90/70 mm Hg, his heart rate was 114 beats per minute, his oxygen saturation was at 90%, his arterial blood gas pH level was 7.43, his partial pressure of carbon dioxide was 32, his partial pressure of oxygen 68, his laceration lactate level was 5.0, and his white blood cell count was 24\u202f000 mm3.", "A plain abdominal radiograph showed a huge colonic distension (Figure 1A).", "A computed tomography scan with multiplanar reconstruction was also performed (Figure 1B).A, A plain abdominal x-ray shows a huge colonic distension and a clear coffee-bean-like or \u201cbent inner tube\u201d sign is visible.", "B, A computed tomography scan with multiplanar reconstruction."]}
{"Patient Personal Background": ["Her medical history was significant for heavy smoking, reflux, and surgical procedures including a right inguinal hernia repair, total abdominal hysterectomy, and bilateral salpingo-oopherectomy, all more than 5 years prior."], "Patient Symptoms": ["She reported a failure to pass stool or flatus since the onset of symptoms.", "She denied hematochezia, melena, or hematemesis."], "Examination and Results": ["On examination, she had a distended and tympanic abdomen with tenderness, guarding, and rebound in the epigastrium and right upper quadrant.", "Vital signs and standard laboratory test results were unremarkable.An upright abdominal plain radiograph showed a distended, thickened stomach and multiple dilated loops of small bowel with air-fluid levels.", "Contrast-enhanced computed tomography demonstrated a focal area of mixed fat density involving the distal small bowel concerning for a lead point with adjacent mesenteric fat stranding (Figure 1).", "The scan also revealed multiple bilateral lung nodules.Computed tomography of abdomen.", "A, Coronal view demonstrating obstructing intraluminal lesion (arrowhead).", "B, Transverse view demonstrating obstructing intraluminal lesion (arrowhead)."], "Treatment": ["The patient was subsequently taken to the operating room for exploratory laparotomy and found to have an obstruction in the distal ileum."]}
{"Patient Symptoms": ["He had no palpitations."], "Examination and Results": ["The electrocardiogram showed several premature ventricular contractions.", "Results of 30-day Holter monitoring were obtained, and more than 5000 premature ventricular contractions were recorded, including occasional polymorphic ventricular couplets.Transthoracic echocardiography showed normal left ventricular internal dimensions and systolic function.", "All valves were structurally normal with trace mitral and tricuspid regurgitation.", "A treadmill exercise stress test demonstrated 2 mm horizontal ST-segment depression in inferior and apical leads with exercise.", "Cardiac catheterization of the left side of the heart was performed (Figure, A) and can be viewed in the Video.Retrograde filling of the right coronary artery emptying into the main pulmonary artery (A) and a medium-sized area of moderate stress-induced ischemia throughout the right coronary artery territory (B)."]}
{"Patient Personal Background": ["He was subsequently tried on various statins, but owing to hip pain thought possibly because of these agents, a rise in liver enzymes, and persistently elevated LDL-C, he was referred to the Boston Medical Center Lipid Clinic Fasting lipid profile in December 2013 on no lipid-lowering agents included an LDL-C level of 232 mg/dL."], "Patient Symptoms": ["He restarted atorvastatin at 40 mg daily because it was determined that his hip pain was more likely because of arthritis than statin therapy."], "Examination and Results": ["He was subsequently tried on various statins, but owing to hip pain thought possibly because of these agents, a rise in liver enzymes, and persistently elevated LDL-C, he was referred to the Boston Medical Center Lipid Clinic Fasting lipid profile in December 2013 on no lipid-lowering agents included an LDL-C level of 232 mg/dL.", "The adherence and effectiveness of lipid-lowering therapy were then routinely monitored by measuring direct LDL-C levels, which dropped to 113 mg/dL in June 2014 and 115 mg/dL in October 2015, respectively.", "Interestingly, his directly measured LDL was 115 mg/dL in October 2015, but a calculated LDL-C was 170 mg/dL in December 2015.", "Repeat fasting lipid profiles with simultaneously calculated and directly measured LDL-C levels, apolipoprotein B (Apo B), and lipoprotein (a) (Lp[a]) were subsequently assessed in April 2016 and June 2016.", "They confirmed a marked difference between the direct LDL-C level and calculated LDL-C levels (Table).The marked discordance between the direct and calculated LDL levels is the result of a laboratory error.The patient has familial dysbetalipoproteinemia (type III hyperlipidemia).The marked discordance between the direct and calculated LDL levels is related to the effects of very LDL (VLDL), intermediate-density LDL (IDL), and/or Lp(a).The marked discordance between the direct and calculated LDL levels is the result of excess VLDL cholesterol only."], "Treatment": ["He restarted atorvastatin at 40 mg daily because it was determined that his hip pain was more likely because of arthritis than statin therapy."], "Diagnosis": ["They confirmed a marked difference between the direct LDL-C level and calculated LDL-C levels (Table).The marked discordance between the direct and calculated LDL levels is the result of a laboratory error.The patient has familial dysbetalipoproteinemia (type III hyperlipidemia).The marked discordance between the direct and calculated LDL levels is related to the effects of very LDL (VLDL), intermediate-density LDL (IDL), and/or Lp(a).The marked discordance between the direct and calculated LDL levels is the result of excess VLDL cholesterol only."]}
{"Patient Personal Background": ["His medical history was notable for allergic rhinitis and well-controlled type 2 diabetes mellitus."], "Patient Symptoms": ["Physical examination revealed tenderness to palpation over the right nasal bridge and mild right proptosis."], "Examination and Results": ["The prior biopsy diagnosis from the area of swelling was inflammatory nasal polyp.", "Flexible and rigid nasal endoscopy demonstrated a right-sided exophytic mass visible between the middle turbinate and nasal septum.", "Computed tomography showed a large, right-sided mass centered in the ethmoid sinus with expansion into the anterior skull base, anterior cribriform plate, and right medial orbit.", "Magnetic resonance imaging showed vascularity in the lesion and early intracranial involvement with transdural spread but no evidence of invasion into the meninges or brain.", "The final pathology report showed an infiltrative, low-grade, malignant spindle cell neoplasm with immunoreactivity for BCL2 protein and neural marker, S-100 protein, and focal immunoreactivity for smooth muscle markers SMA and HHF35 (Figure).", "Cytoplasmic immunoreactivity for \u03b2-catenin was noted, and nonreactive immunostains included CD31, CD34, epithelial membrane antigen (EMA), and CD99.", "In addition, there was minimal mitotic activity, and no tumoral necrosis was present.", "There was no regional or distant metastasis, and TNM staging was cT4N0M0.Histopathologic photomicrographs of a biopsy specimen from a mass centered in the ethmoid sinus.", "A and B, Hematoxylin-eosin.", "C, Tissue section showing strong nuclear and cytoplasmic immunologic staining for S-100 protein.", "D, Immunologic staining for smooth muscle actin showing patchy immunoreactivity in tumor cells."], "Treatment": ["The patient was taken for surgery, and findings from intraoperative frozen section analysis were consistent with a spindle cell neoplasm.", "Definitive skull base resection of the mass was deferred until final pathological diagnosis was obtained, given the morbidity with skull base resection."], "Diagnosis": ["The final pathology report showed an infiltrative, low-grade, malignant spindle cell neoplasm with immunoreactivity for BCL2 protein and neural marker, S-100 protein, and focal immunoreactivity for smooth muscle markers SMA and HHF35 (Figure)."], "Others": ["A, Spindle cells in fascicular pattern.", "B, Invagination of respiratory-type epithelium."]}
{"Patient Personal Background": ["Her medical history was significant for herpes zoster and self-limited vertigo approximately 3 years prior."], "Patient Symptoms": ["Her physical examination was remarkable for left-sided facial swelling."], "Examination and Results": ["No deficits of the facial or trigeminal nerves were detected.", "Magnetic resonance imaging (MRI) was performed (Figure).Magnetic resonance imaging, axial views.", "A. T1-weighted image demonstrating a mass lying on the anterior surface of the eroded left mandibular condyle with homogeneous isointensity relative to skeletal muscle.", "B, Postcontrast T1-weighted image with fat suppression showing homogeneous, avid enhancement of the mass.", "C, T2-weighted image showing homogeneous moderately hyperintense signal.", "D, Diffusion-weighted image is significant for marked diffusion restriction."]}
{"Examination and Results": ["Fine-needle aspiration was performed twice, each time with inconclusive results.", "Computed tomography (CT) of the neck showed a heterogeneous mass located immediately adjacent to the tail of the left parotid.", "No other masses were noted.", "Pathologic findings revealed a 3.0\u2009\u00d7\u20092.9\u2009\u00d7\u20091.9-cm, encapsulated, tan, soft nodule within the specimen.", "The nodule had peripheral cystic spaces as well as focal areas of hemorrhage and a 0.5\u2009\u00d7\u20090.4\u2009\u00d7\u20090.4-cm area of calcification within the periphery.", "The entire tumor was confined within a periparotid lymph node, almost completely replacing it.", "Histopathologic findings (Figure) showed a mixture of dark, granular, basophilic acinar cells and eosinophilic intercalated ductal cells.", "The acinar cells contained periodic acid\u2013Schiff\u2013positive, diastase-resistant intracytoplasmic granules, whereas the ductal cells were both fusiform and cuboidal forming small ductlike structures.", "The neoplasm also exhibited focal areas of hyaline sclerosis without necrosis."], "Treatment": ["He underwent a left superficial parotidectomy with en bloc removal of the mass."]}
{"Patient Symptoms": ["This change prompted a visit to an optometrist, who found a mild decrease in visual acuity and minor cataract in the right eye.", "His primary care physician diagnosed his ear pain as acute otitis media and prescribed a course of amoxicillin-clavulanate; however, the young man\u2019s vision continued to deteriorate and became associated with the onset of right eye swelling and forehead tenderness.", "The patient had not experienced nasal congestion, epistaxis, weight loss, fevers, or chills."], "Examination and Results": ["A repeat eye examination by an ophthalmologist was performed and showed normal peripheral visual acuity with a decrease in central vision and confirmed proptosis.", "Physical examination included right eye proptosis and restricted eye movement.", "A computed tomographic (CT) scan with contrast of the face showed a small relatively homogenous mass in the right anterior nasal cavity invading the right orbit, and a magnetic resonance image (MRI) with contrast showed a right superior nasal cavity mass, with invasion of the right orbit and right ethmoidal sinus with extension to the overlying soft-tissue scalp (Figure).", "A 30\u00b0 endoscope was used to visualize the superior nasal cavity and revealed a fleshy red soft-tissue mass.", "Several biopsy specimens were taken and sent for frozen pathologic evaluation.A, Postintravenous contrast computed tomographic (CT) scan of the face showing a relatively homogenous mass of the right ethmoid complex with invasion of the orbit and extension to the nasal cavity (arrowhead).", "B, Fast spin echo (FSE) T2 magnetic resonance image (MRI) of the right ethmoidal/orbital soft-tissue mass (arrowhead).", "C, Positron emission tomographic (PET) scan of the face with fludeoxyglucose F 18 showing increased uptake within the right ethmoid air cells and nasal cavity, and in the medial right orbit."], "Treatment": ["His primary care physician diagnosed his ear pain as acute otitis media and prescribed a course of amoxicillin-clavulanate; however, the young man\u2019s vision continued to deteriorate and became associated with the onset of right eye swelling and forehead tenderness."]}
{"Patient Personal Background": ["Her ocular history was significant only for refractive error.", "Her medical history revealed systemic hypertension, depression, and obesity.", "Her current medications included hydrochlorothiazide and fluoxetine."], "Patient Symptoms": ["On review of systems, she endorsed nausea as well as paresthesia in her hands.Neuro-ophthalmic examination revealed visual acuities of 20/20 OD and 20/40 OS, with no pinhole improvement.", "With the Amsler grid, she reported significant metamorphopsia in the left eye."], "Examination and Results": ["Color vision (Ishihara pseudoisochromatic plates) was within normal limits bilaterally, although it was noted to be slightly slower in the left eye.", "Pupils were symmetric with slow responses bilaterally but without afferent defects.", "Applanation tonometry revealed pressures of 16 mm Hg OD and 17 mm Hg OS.", "Slitlamp examination revealed no cells in the anterior chamber or the anterior vitreous in either eye.", "Automated (Humphrey) visual field testing revealed enlargement of the blind spot in the right eye (mean deviation, \u22122.91 dB) and generalized, nonspecific depression in the left eye (mean deviation, \u22123.41 dB).", "Examination of her fundus was notable for bilateral optic disc swelling (Fris\u00e9n grade 2 in each eye) as well as unilateral macular exudates, subretinal fluid, and subretinal hemorrhages in the left eye (Figure 1)."], "Others": ["Results from brain magnetic resonance imaging with magnetic resonance venography with and without contrast were normal.A, Color fundus photograph demonstrating Fris\u00e9n grade 2 optic disc edema."]}
{"Examination and Results": ["On examination, visual acuity was 20/25 OD with correction, and the superior cornea showed an intact epithelium, mild stromal thinning, and pannus with faint yellow-white subepithelial deposits at the leading edge (Figure 1A).", "There were no other abnormalities reported on examination.", "B, Appearance of the cornea 1 year later, with more prominent neovascularization and progression of deposits toward the visual axis.A year later, best-corrected visual acuity had decreased to 20/30 OD with against-the-rule astigmatism."], "Treatment": ["The patient was treated conservatively with lubrication."], "Others": ["Slitlamp photographs of corneal findings.", "A, Appearance of the cornea at time of the initial presentation."]}
{"Patient Symptoms": ["Within 24 hours he developed prodromal flu like myalgias and malaise.", "After 48 hours, the patient experienced severe bilateral photophobia, conjunctival injection, lacrimation, and blurred vision.", "His photophobia peaked at 72 hours but had significantly improved by the time of his initial ophthalmic review 4 days after the infusion."], "Examination and Results": ["His uncorrected visual acuities were 6/5 bilaterally.", "His intraocular pressures were within normal limits.", "An anterior segment examination demonstrated symmetric bilateral nasal sectoral subconjunctival hemorrhages (Figure).", "The corneas were clear.", "Examination of his anterior chambers revealed a 2+ cell count and 2+ flare count in both eyes without hypopyon or synechiae.", "The posterior segment was unremarkable, with no evidence of vitritis, retinitis, or macular edema.Routine investigations returned results of an elevated alkaline phosphatase level (230 U/L) and mild-positive (1:160) antinuclear antibody speckled pattern.", "The complete blood cell count and coagulation profile were normal.", "The results for extractable nuclear antigen antibodies, antidouble-stranded deoxyribonucleic acid, rheumatoid factor, human leukocyte antigen B27, QuantiFERON-TB Gold (Quest Diagnostics), syphilis serology, elevated serum angiotensin-converting enzyme level, and a chest radiography were all negative."], "Treatment": ["Topical dexamethasone, 0.1%, and homatropine, 2%, were commenced, with complete resolution of uveitic signs within 2 weeks.", "Dexamethasone frequency was initially once hourly for 3 days and was followed by a standard weekly tapering course."]}
{"Patient Symptoms": ["Over subsequent days, he developed right periorbital erythema, edema, and pain, with blisters appearing on the eyelid skin 1 day prior to presentation.On examination, his pulse was 120 beats per minute, blood pressure was 92/62 mm Hg, and temperature was 38.2\u00b0C.", "The right upper and lower eyelids were warm, erythematous, edematous, and tender, with large fluctuant blisters (Figure, A).", "Erythema tracked down the cheek, and there was right cervical lymphadenopathy."], "Examination and Results": ["Over subsequent days, he developed right periorbital erythema, edema, and pain, with blisters appearing on the eyelid skin 1 day prior to presentation.On examination, his pulse was 120 beats per minute, blood pressure was 92/62 mm Hg, and temperature was 38.2\u00b0C.", "The right upper and lower eyelids were warm, erythematous, edematous, and tender, with large fluctuant blisters (Figure, A).", "Erythema tracked down the cheek, and there was right cervical lymphadenopathy.", "The patient did not cooperate for a visual acuity assessment, but there was no afferent pupillary defect.", "Limited penlight examination revealed a normal anterior segment except for 360\u00b0 conjunctival chemosis.", "Noncontrast computed tomography of the orbits demonstrated extensive right preseptal soft tissue swelling and slight enlargement of the right lateral rectus muscle with minimal orbital fat stranding.", "The right globe was slightly proptotic (Figure, B).", "Laboratory testing revealed a white blood cell count of 32.6 K/\u00b5L (to convert to \u00d7\u2009109 per liter, multiply by 0.001), with 95% polymorphonuclear lymphocytes.A, External photograph of the right eyelids demonstrates significant erythema and edema with large blisters."]}
{"Patient Personal Background": ["She had no history of dysphagia, dyspnea, recent upper respiratory tract infection, injury, or surgery.", "She also had no weight loss, pain, or fever and had no history of tobacco or alcohol use, radiation exposure, family history of thyroid cancer, and no previous thyroid dysfunction.", "She had a medical history of high-grade osteosarcoma with areas of leimyosarcoma of the tibia which had been treated with right above-knee amputation and chemotherapy 4 years prior to presentation.", "She was followed up in the oncology clinic without any recurrence or metastases.", "Her last visit was 6 months earlier.", "She was also diagnosed with squamous cell carcinoma of the cervix 2 months earlier and was awaiting surgery."], "Examination and Results": ["Thyroid function test results were normal.", "Physical examination revealed a palpable nontender, firm mass and no cervical lymphadenopathy.", "Computed tomography (CT) of the neck revealed a 6.0\u2009\u00d7\u20093.4\u2009\u00d7\u20094.4-cm calcified left thyroid lobe mass (Figure, A).", "Positron emission tomography\u2013computed tomographic (PET-CT) imaging showed increased uptake in the left thyroid gland.", "The neoplastic cells were positive for p53, vimentin, and smooth muscle actin, and negative for S-100, thyroid transcription factor-1 (TTF-1), and CD34 (Figure, B).A, Computed tomographic image reveals a calcified mass (blue arrowhead)."], "Treatment": ["She underwent a left thyroid lobectomy."]}
{"Patient Personal Background": ["He was born by spontaneous vaginal delivery at 36 weeks\u2019 gestational age with a birthweight of 3048 g (6.7 lb) with Apgar scores of 9 and 10.", "There were no complications during the prenatal and perinatal periods.", "His mother had no history of ringworm infection, positive IgG antibodies against rubella virus and herpes zoster virus, and serology findings negative for human immunodeficiency virus, hepatitis B virus, and syphilis.", "His family history was unremarkable.On examination, he had a temperature of 38.0\u00b0C, a heart rate of 150/min, and a respiratory rate of 60/min."], "Patient Symptoms": ["Slightly scaly annular erythematous plaques with central atrophy and raised margins were present on the forehead and periorbital areas (Figure)."], "Examination and Results": ["His family history was unremarkable.On examination, he had a temperature of 38.0\u00b0C, a heart rate of 150/min, and a respiratory rate of 60/min.", "Slightly scaly annular erythematous plaques with central atrophy and raised margins were present on the forehead and periorbital areas (Figure).", "The remainder of the physical examination was unremarkable."]}
{"Patient Personal Background": ["The GVHD occurred secondary to a bone marrow transplant in 2014 for treatment of chronic lymphocytic leukemia."], "Patient Symptoms": ["One month prior to commencing oral azathioprine therapy, the patient noted the growth of nodules on the genital and perianal region, with 1 ulcerated nodule in the perianal area associated with painless bleeding on trauma.", "Additionally, she had sclerodermatous plaques on the lower legs, scarring alopecia on the scalp with minimal hyperkeratosis, nail dystrophy and lichenoid changes, erythematous changes in both feet, and desquamation in the lower legs and on the back and arms suggestive of eczematous or postlichenoid changes as part of her lichenoid GVHD."], "Examination and Results": ["The lesions were otherwise asymptomatic.On examination she had several yellow-colored nodules, some of them ulcerated with extrusion of yellow-colored discharge on the left labia majora and on the perianal area with surrounding inflammatory reaction (Figure 1).", "Initial investigations revealed a white blood cell count of 13.1\u2009\u00d7\u2009103/\u03bcL (to convert to billions per liter, multiply by 0.001); however, the results of the rest of her blood tests including the full blood count and electrolytes, urea and creatinine, and liver function tests were otherwise stable and unremarkable.Clinical photographs of cutaneous nodules in a woman with graft-vs-host disease.", "A, Multiple erythematous eroded nodules in the perianal area.", "B, yellowish nodules located on the left labia majora."], "Treatment": ["At the time of review she was being treated with oral azathioprine (50 mg twice daily), tacrolimus (0.5 mg twice daily), and prednisone (25 mg daily) therapy.", "She was also receiving monthly intravenous immunoglobulin, prophylactic oral fluconazole, acyclovir, sulfamethoxazole-trimethoprim, and penicillin."]}
{"Patient Personal Background": ["She reported a distant history of discoid lupus, and was taking 2 antihypertensives but no other oral or topical medications."], "Patient Symptoms": ["She reported that these appeared 1 to 2 months following placement of the tattoo and were restricted to areas where the artist created pink zones by layering white ink over red ink.", "She denied pain, fevers, and chills and had no history of skin cancer."], "Examination and Results": ["Physical examination revealed well-demarcated erythematous to violaceous verrucous nodules on the right lateral leg and dorsal foot (Figure 1A).", "A punch biopsy specimen from a representative nodule was obtained, with an additional biopsy for tissue culture (Figure 1B).A, Verrucous nodules are restricted to zones of pink pigment within the tattoo, sparing other colors present.", "B, Histologic reaction pattern from punch biopsy specimen of right lower leg nodule (hematoxylin-eosin, original magnification \u00d74)."]}
{"Patient Personal Background": ["Six days prior to this admission, she had been hospitalized for a photo-induced flare of acute cutaneous lupus erythematosus (ACLE)."], "Patient Symptoms": ["At readmission, she was febrile with a temperature of 101.5\u00b0F, and on examination, she had a worsening, exquisitely tender rash with several blisters across her right arm."], "Examination and Results": ["Physical examination revealed erythematous plaques with superficial desquamation in the malar distribution of the face, nose, ears, and medial forehead (Figure, A), as well as bilateral extensor arms, chest, posterior neck, and upper back.", "Several large bullae were located on the right arm (Figure, B).", "Numerous flat and raised 2-zoned atypical targets with dusky centers were appreciated on the forearms, abdomen, back (Figure, C), thighs, legs, palms and soles.A, Dusky malar erythema with focal heme crusting.", "B, Flaccid bullae and target lesions.", "C, Diffuse typical and atypical target lesions of the back.", "D, High-power view (original magnification 100\u00d7) of punch biopsy obtained from left abdomen demonstrating dyskeratosis with superficial perivascular inflammation and interface changes.Hemogram test results revealed a normocytic anemia (mean corpuscular volume, 99 fL; hemoglobin, 11.7 g/dL [to convert to g/L, multiply by 10.0]; hematocrit, 33.4%), in addition to thrombocytopenia (platelet count, 81 K/\u03bcL).", "Other pertinent laboratories included hypocomplementemia (C3 of 42 mg/dL; C4 of 3 mg/dL), a speckled antinuclear antibody titer of 1:1280, and an antidouble-stranded DNA titer of 1:80, along with positive anti-Smith, antiribonucleoprotein, and SSA/anti-Ro antibodies.", "Bacterial blood, urine, stool and cerebrospinal fluid cultures, and a hepatitis panel revealed no infectious source.", "Punch biopsy of an abdominal atypical target lesion was performed (Figure, D)."]}
{"Patient Personal Background": ["No significant history of illness was noted in the patient or among family members.Neurological examination on admission revealed normal mental status, and the results of cranial nerve examination were normal."], "Patient Symptoms": ["Although these symptoms had resolved after 3 hours\u2019 rest, they recurred 2 hours prior to hospital admission.", "In addition, the patient had begun to experience weakness and numbness of his limbs, with more severe symptoms on the right side.", "The symptoms began to gradually resolve 2 hours following admission, and normal function had returned within 2 days."], "Examination and Results": ["Although the patient had cavus feet, no atrophy was observed in the distal lower limbs (Figure, A).", "Muscle strength was classified as grade 4 for the left limbs and grade 3 for the right limbs, according to Medical Research Council criteria, and muscle tone was diminished.", "The sensory examination was unremarkable.", "Deep reflexes were diminished or absent.", "However, bilateral positive Babinski signs were observed.", "Results from laboratory examinations, including blood electrolytes, cerebrospinal fluid, and lactate, were normal.", "Oligonucleotide bands and aquaporin 4 detection were negative.", "Craniocervical computed tomographic angiography results were normal.", "Cerebral magnetic resonance imaging (MRI) revealed abnormal bilateral increases in T2 signal and diffusion restriction in the periventricular areas and the splenium of corpus callosum (Figure, B).", "Interestingly, a significant reduction of the abnormal signal was noted on MRI 3 months later.", "Electrophysiological examination of peripheral nerves revealed extensive bilateral nerve conduction abnormalities.", "Significantly reduced motor nerve conduction velocity was also observed in the median nerves (38.3 m per second in the left and 36.5 m per second in the right).A, Image shows patient\u2019s pes cavus."]}
{"Patient Personal Background": ["Her relevant history included a pituitary macroadenoma, which had been resected 30 years prior, followed by radiation.", "There was no evidence of subsequent recurrence.", "There was no family history of ptosis, ophthalmoplegia, or myopathy."], "Patient Symptoms": ["Diplopia was frequently present after repeatedly changing direction of gaze.", "She also noted mild right ptosis.", "There was no associated headache or ocular or periorbital pain.", "She had not noticed any injection of the sclera.", "Her family and friends made no comments regarding exophthalmos.", "She had not noticed any deficits in axial or appendicular strength, rapid fatigability, or dysphagia.", "Her symptoms did not exhibit diurnal variation.", "Her weight was stable.", "She had not noted any changes in her hair, skin, or nails.", "She had no subjective disturbance of thermoregulation."], "Examination and Results": ["Her visual acuity was unaffected.", "The patient was a retired English teacher.Examination demonstrated anisocoria (right pupil larger than left), which was accentuated in bright ambient light; mild right ptosis; and mildly restricted supraduction, adduction, and infraduction of the right eye (Video, prepared by N.T.).", "The second half of the Video (from 24 seconds on) demonstrates marked restriction of elevation, depression, and abduction in the right eye after eccentric gaze.", "Ductions in the left eye were normal.", "The patient\u2019s neurological examination demonstrated a normal level of consciousness, fluent speech, normal comprehension, good attention, normal cranial nerve function aside from the aforementioned deficits, full strength, normal sensation to proprioception and temperature, symmetric reflexes, absence of ataxia, and a stable, narrow-based gait.", "A recent contrast-enhanced brain magnetic resonance image showed a stable intracanalicular vestibular schwannoma on the left, which had been monitored for 8 years."]}
{"Patient Personal Background": ["He had a family history of ischemic heart disease (both parents) but no family history of neurological disorder.", "He exercised regularly (5 times per week) and consumed 2 to 4 standard drinks per week.", "He was a former smoker with a 2-year pack history and denied any illicit drug use.Cognitive testing revealed deficits in executive function and speed of information processing."], "Patient Symptoms": ["When questioned, he described subtle balance problems without falls developing over the past 3 years.", "With the exception of profound difficulties with handwriting, motor symptoms did not affect livelihood or activities of daily living.", "There was no tremor reported in the nondominant hand or other limbs or symptoms of autonomic dysfunction.", "Neither he nor his wife reported any changes in cognitive function."], "Examination and Results": ["Examination of eye movements and speech revealed jerky eye pursuit, saccadic dysmetria, and moderate slurring of speech.", "Additional motor signs included abnormal handwriting (Figure 1A), bilateral intention tremor, mild rigidity (upper extremities), and moderately impaired heel tapping.", "He demonstrated moderate body sway while standing, was unable to stand on 1 foot for more than 10 seconds, and had impaired tandem walking.", "B, T2-weighted fluid-attenuated inversion recovery image from brain magnetic resonance imaging showing white matter hyperintensities in the middle cerebellar peduncles.Routine blood test results were normal.", "Brain magnetic resonance imaging showed moderate volume loss in the cerebral hemispheres bilaterally as well as the cerebellum and brainstem.", "Abnormal signal intensity was noted in the cerebral hemispheric white matter bilaterally, the middle cerebellar peduncles (Figure 1B), the cerebellar white matter, and the pons."], "Others": ["His medical history comprised surgeries of the hand (laceration repair), leg (fracture repair), knee (reconstruction), and ear (stapedectomy); these were not related to the presenting symptoms.", "Facial expression was normal.", "There was no head or resting tremor.", "Gait, posture, and walking capacities during a timed 6-m walk were normal.A, Handwriting task from the motor examination showing abnormal handwriting."]}
{"Patient Personal Background": ["Pregnancy was uncomplicated and there was no history of teratogenic exposure or family history of congenital defects."], "Patient Symptoms": ["She was asymptomatic, moving all limbs, urinating, and defecating normally."], "Examination and Results": ["These skin changes included a red patch on the central lower back with a soft nodule located on top of the patch.", "Additionally, she had a pedunculated red papule positioned on top of the red stain and soft nodule.", "Her prenatal screens, including 20-week ultrasonography, were normal.", "Ultrasonography of the spine obtained prior to the visit showed no abnormalities.Photograph depicting a red patch with overlying soft nodule and red pedunculated papule in the lower midback of a neonate."]}
{"Patient Personal Background": ["Medications at the time of referral were 1000 mg per day of ursodeoxycholic acid and 2 g of colestipol twice daily for symptomatic relief of pruritus."], "Patient Symptoms": ["She first noted the appearance of periorbital xanthelasmata 2 years after PSC diagnosis (Figure 1A).", "Approximately 6 months prior to referral, she developed marked worsening of biliary obstruction, deterioration of liver function, and clinical jaundice (aspartate aminotransferase, 145 U/L; alanine aminotransferase, 111 U/L; alkaline phosphatase, 726 U/L; and bilirubin, 6.7mg/dL), and she noted palmar xanthomata in the creases of her palms and fingers (Figure 1B)."], "Examination and Results": ["She was normocholesterolemic prior to the diagnosis of PSC (total cholesterol [TC], 188 mg/dL [to convert to millimoles per liter, multiply by 0.0259]).", "Following the diagnosis of PSC, she developed moderate hypercholesterolemia (representative TC, 256 mg/dL).", "Periorbital xanthelasmata (A, arrowheads) and palmar xanthomata (B, arrowheads) in a patient with severe hypercholesterolemia and primary sclerosing cholangitis.At the time of referral, she had severe hypercholesterolemia (TC, 832 mg/dL; triglycerides, 114 mg/dL [to convert to millimoles per liter, multiply by 0.0113]; and high-density lipoprotein cholesterol, 18 mg/dL; low-density lipoprotein cholesterol was not calculated).", "The majority of TC (719 mg/dL) consisted of free cholesterol (518 mg/dL) instead of the usual esterified cholesterol.", "Serum phospholipids levels were high (1186 mg/dL), while triglycerides were normal (97 mg/dL).", "Fast protein liquid chromatography analysis of serum lipoproteins, after ultracentrifugation to remove very-low-density lipoprotein, indicated the unique composition and distribution of lipid classes in a special form of dyslipidemia known as lipoprotein X (LpX), ie, high unesterified cholesterol and phospholipids in large lipid-containing particles."], "Treatment": ["Medications at the time of referral were 1000 mg per day of ursodeoxycholic acid and 2 g of colestipol twice daily for symptomatic relief of pruritus."], "Diagnosis": ["Following the diagnosis of PSC, she developed moderate hypercholesterolemia (representative TC, 256 mg/dL).", "Periorbital xanthelasmata (A, arrowheads) and palmar xanthomata (B, arrowheads) in a patient with severe hypercholesterolemia and primary sclerosing cholangitis.At the time of referral, she had severe hypercholesterolemia (TC, 832 mg/dL; triglycerides, 114 mg/dL [to convert to millimoles per liter, multiply by 0.0113]; and high-density lipoprotein cholesterol, 18 mg/dL; low-density lipoprotein cholesterol was not calculated).", "Fast protein liquid chromatography analysis of serum lipoproteins, after ultracentrifugation to remove very-low-density lipoprotein, indicated the unique composition and distribution of lipid classes in a special form of dyslipidemia known as lipoprotein X (LpX), ie, high unesterified cholesterol and phospholipids in large lipid-containing particles."]}
{"Patient Symptoms": ["She had not experienced otalgia, otorrhea, or tinnitus."], "Examination and Results": ["Physical examination revealed a mass obstructing the right external auditory canal and House-Brackmann grade 2 facial nerve weakness on the right.", "Audiogram revealed right-sided moderate to profound mixed hearing loss.", "Computed tomography revealed a soft-tissue mass emanating from the middle ear involving the facial canal with surrounding bony erosion, including dehiscence of the tegmen, cochlea, bony labyrinth, lateral semicircular canal, and jugular foramen.", "The patient underwent transtemporal mastoidectomy and debulking.", "Magnetic resonance imaging during embolization revealed intense enhancement in the right middle ear extending from the epitympanum to the hypotympanum with extension into the right external auditory canal (Figure, B).", "The mass was adherent to the underlying bone and had invaded the facial canal but not the nerve itself.", "Both malleus and incus were eroded."], "Treatment": ["However, owing to the mass\u2019s vascularity and significant bleeding, the operation was aborted, and she was sent for embolization (Figure, A).", "She returned to the operating room, and the vascular mass was found to extend inferiorly to the jugular bulb and carotid and anteriorly into the eustachian tube."], "Others": ["Immunohistochemical stains of the specimen indicated cells positive for synaptophysin with a sustentacular pattern of cells positive for S-100 (Figure, C and D).A, Mastoidectomy, visualization of vascular mass.", "B, T1-weighted axial magnetic resonance image (MRI) showing enhancement of right middle ear extending to external auditory canal.", "C, Hematoxylin-eosin, original magnification \u00d740.", "Clusters of cells surrounded by vascular tissue.", "D, Synaptophysin stain, original magnification \u00d740.", "Nests of strongly staining neuroendocrine cells separated by vasculature."]}
{"Patient Personal Background": ["His medical history revealed a long-term history of substance abuse with active alcohol and tobacco consumption, chronic obstructive pulmonary disease, and epilepsy (tonic-clonic seizures, badly controlled owing to a lack of adherence to therapy)."], "Patient Symptoms": ["This lesion had developed spontaneously 3 months prior to consultation without an identifiable inciting event.", "He could recall no trauma and described a slow but progressive increase in the volume of this otherwise asymptomatic lesion."], "Examination and Results": ["Clinical intraoral examination of this fully edentulous patient revealed a nontender, mobile, cystic nodule, approximately 1\u2009\u00d7\u20091 cm on the vestibular side of the lower left lip with outflow of a clear serous fluid on palpation (Figure, A).", "After hematoxylin-eosin staining, light microscopy revealed an endophytic growing lesion, which consisted of an acanthotic epidermoid epithelium organized in broad papillary folds, with at its periphery an infiltrating border.", "At the surface of these papillae, the epithelium was sometimes columnar.", "Mucocytes were present, individually dispersed throughout the epithelium, but also organized in small tubuloacinar structures emptying onto the surface.", "The epithelium was infiltrated by neutrophils.", "Atypia or mitotic figures were absent, and the subepithelial stroma contained normal-appearing seromucous acini (Figure, B and C).A, Clinical presentation of the cystic lesion of the lower left lip.", "The papillary fronds lining the interior of the lesion.", "The lesion is well demarcated from the subepithelial stroma, and has an infiltrating border.", "The cells at the surface of the epithelial folds are columnar.", "Mucocytes organized in acinar structures empty on the surface epithelium but are also individually dispersed between the epidermoid cells."], "Treatment": ["The lesion was excised surgically and the specimen sent for additional histological examination."], "Others": ["B and C, Histopathologic images, hematoxylin-eosin.", "C, Detail at the base of one of the papillae."]}
{"Patient Symptoms": ["On presentation, he also reported decreased acuity in his left lower visual field, continued swelling with increasing pain, and worsening trismus.", "The patient also reported hypoesthesia of the left maxillary division of the trigeminal nerve."], "Examination and Results": ["No purulence or clinically significant bleeding was identified.", "Physical examination revealed mild tenderness over a mass that extended inferiorly to the zygoma into the buccal cavity and posterolaterally to the left superior molars.", "Fiber-optic scope of the nasopharynx revealed a small lesion posterior to the left middle turbinate.", "Contrast-enhanced magnetic resonance imaging of his head, neck, and brain was performed (Figure, B and C).A, Computed tomographic (CT) image shows a uniformly hyperdense mass extending into the left infratemporal fossa with slight extension of the mass through the medial aspect of the posterior wall of the maxillary sinus and widening of the sphenopalatine foramen.", "B, Contrast-enhanced magnetic resonance image (MRI) with fat saturation shows a mass with mild punctuate areas of hypointense signal (suggestive of vascularity) terminating in the left buccinator space with extension into the nasal cavity, maxillary sinus and inferior orbital fissure.", "C, A heterogenous mass in the left retromaxillary region and infratemporal fossa with hyperintense signal and mild salt-and-pepper appearance consistent with vascularity.", "D, Gross specimen is in similar orientation as mass seen in panel B."], "Treatment": ["He underwent a third maxillary molar extraction and attempted incision and drainage of the area with no improvement in symptoms."], "Others": ["A contrast-enhanced computed tomographic (CT) scan was performed (Figure, A), and the patient was referred to the otolaryngology clinic."]}
{"Patient Symptoms": ["She noted a discretely palpable mass in the left parotid region during these episodes.", "The patient returned days later with acutely worsening left facial swelling, which she noticed while straining.", "On presentation, she was diagnosed as having malignant hypertension and had a palpable parotid lesion noted on physical examination.", "When asked to perform a Valsalva maneuver, she was noted to have more pronounced left facial swelling (Figure, A)."], "Examination and Results": ["However, at the time of clinic presentation, she had no palpable masses on physical examination.", "Ultrasonography performed on the day of initial evaluation revealed no intraparotid masses, lesions, or stones.", "A short tau inversion recovery (STIR) image is shown in the Figure, B.", "Magnetic resonance angiogram was obtained (Figure, C and D).A, The patient performed a Valsalva maneuver, with increased left parotid gland and neck swelling.", "B, Coronal T2-weighted short tau inversion recovery (STIR) image demonstrating a T2 hyperintense lesion measuring 3.7\u2009\u00d7\u20093.4\u2009\u00d7\u20097.4 cm involving the left parotid gland and extending to the left side of the neck.", "C and D, T1-weighted, fat-suppressed, gadolinium-enhanced angiography.", "C, Arterial section demonstrating no evidence of significant high flow component.", "D, Delayed phase demonstrating a homogenous contrast enhancing lesion."], "Treatment": ["The patient was encouraged to return if she noticed acute return of swelling so that she could be evaluated when symptomatic."], "Diagnosis": ["On presentation, she was diagnosed as having malignant hypertension and had a palpable parotid lesion noted on physical examination."]}
{"Patient Personal Background": ["She had a history of upper respiratory tract infection with nasal congestion and discharge being treated with oral antibiotics."], "Patient Symptoms": ["She also recently received a diagnosis of migraines."], "Examination and Results": ["Computed tomographic imaging from an outside hospital 3 weeks prior was reported as unremarkable.", "The patient had an uncorrected visual acuity of 20/50 OU.", "Her pupils were round and reactive without an afferent pupillary defect.", "Confrontation visual fields revealed superotemporal, inferotemporal, and superonasal defects in both eyes.", "The results of her motility examination showed a complete absence of abduction on both eyes, consistent with bilateral sixth nerve palsy.", "The results of a fundus examination showed blurred optic nerve margins nasally (Figure 1).Fundus photographs demonstrating blurred nasal margins of the right (A) and left (B) discs."], "Diagnosis": ["She also recently received a diagnosis of migraines."]}
{"Patient Personal Background": ["He had a history of hypertension and non-Hodgkin lymphoma, which was last treated in 2012 without evidence of recurrence."], "Patient Symptoms": ["The patient was told to follow-up as needed.About 2 months later, the patient called on the telephone to say that he had a new onset of blurry vision and photopsias in the right eye that started about 2 days prior."], "Examination and Results": ["His visual acuity was 20/25 OU, and neither fundus was seen to be abnormal.", "The vitreous was clear in both eyes.", "Optical coherence tomography (OCT) revealed vitreomacular adhesion in the right eye and a macular posterior vitreous detachment in the left.", "The anterior segment and the anterior vitreous of his right eye were still clear.", "However, an examination of the posterior pole of the right eye revealed a light white, deep subretinal/choroidal ring surrounding the optic nerve, with smaller rings around the edge of the larger ring (Figure, A).", "The left eye still appeared normal.", "Optical coherence tomography of the right eye revealed loss of the outer retina (more nasal than temporal to the fovea), whereas OCT of the left eye revealed that it was normal (Figure, B).", "The results of fluorescein angiography and fundus autofluorescence were both unremarkable (data not shown).A, Fundus photograph of the right eye at the time of presentation shows a white-gray ring centered on the optic nerve.", "B, Optical coherence tomography (OCT) of the right eye reveals significant loss of the outer retina, especially nasal to the fovea."], "Treatment": ["He denied any recent viral-type illness."], "Others": ["The patient was asymptomatic at the time."]}
{"Patient Symptoms": ["He also had associated ear pain, hearing loss, and severe headaches.On presentation, his visual acuity was light perception OD and 20/600 at 1 m OS.", "He also had ear drainage with inflamed tympanic membranes and ear tubes in place bilaterally."], "Examination and Results": ["The right eye had a 1+ afferent pupillary defect.", "A dilated fundus examination revealed grade 2 optic disc edema with an inferior disc hemorrhage in the right eye and grade 1 edema in the left eye.", "The remainder of the examination was unremarkable.Laboratory results revealed elevated C-reactive protein levels and erythrocyte sedimentation rates at 78 mg/L and 77 mm/h, respectively, with negative antinuclear antibody test results (to convert C-reactive protein to nanomoles per liter, multiply by 9.524).", "His white blood cell count was elevated at 14\u202f910/\u03bcL without eosinophilia (to convert to \u00d7\u2009109/L, multiply by 0.001).", "Cerebrospinal fluid studies were remarkable only for an elevated white blood cell count of 72/\u03bcL (79% lymphocytes) and elevated protein level at 97 mg/L, while Gram stain and culture were negative.", "Opening pressure was 17 cm H2O.A magnetic resonance venogram with and without contrast ruled out venous occlusions.", "Finally, magnetic resonance imaging demonstrated diffuse pachymeningeal (dural-arachnoid) enhancement (Figure) without leptomeningeal (pial) enhancement, left-sided mastoiditis, and subtle optic nerve enhancement.Coronal T1 with gadolinium showing dural enhancement (blue arrowhead) and optic nerve enhancement (white arrowheads)."]}
{"Patient Symptoms": ["Review of systems was remarkable for concomitant hearing loss and vertigo for 1 month.", "She was alert but confused and disoriented, and she manifested gait imbalance and ataxia."], "Examination and Results": ["White blood cell count was elevated at 14\u202f600/\u03bcL (to convert to \u00d7109 per liter, multiply by 0.001).", "Results from computed tomography of the head were normal, but magnetic resonance imaging of the brain revealed multifocal punctate areas of restricted diffusion.", "A lumbar puncture showed lymphocytosis (80%), normal glucose levels, and protein levels greater than 125 mg/dL.", "Results from cerebrospinal fluid polymerase chain reaction were negative for herpes simplex virus, varicella zoster virus, and cytomegalovirus.", "Results from laboratory tests for hypercoagulable states, antinucleolar antibodies, antineutrophilic cytoplasmic antibodies, human immunodeficiency virus, Lyme disease, and tuberculosis were unrevealing.Ophthalmology was consulted.", "Visual acuity was 20/20 OU with normal pupil response, visual fields to finger counting, motility, and intraocular pressure.", "Anterior segment biomicroscopy was normal without vitreous cell or haze.", "The optic discs were pink with sharp margins.", "The macula appeared flat, and there were scattered peripheral retinal hemorrhages and areas of retinal vascular nonperfusion in both eyes.", "Optical coherence tomography showed inner retinal thinning with preservation of outer retinal architecture."]}
{"Patient Symptoms": ["In the emergency department, the patient was awake but restless and combative and was subsequently intubated."], "Examination and Results": ["He was a restrained driver noted to be awake at the scene of the collision and had to be extracted from the vehicle.", "He was hemodynamically stable on route to the hospital.", "He was hypotensive on arrival but responded transiently to fluid resuscitation.", "Multiple closed long bone fractures of the upper and lower extremities were noted.", "The chest radiography (Figure 1A) showed marked elevation of the left hemidiaphragm.", "The pelvic radiography revealed an unstable fracture involving bilateral pubic rami and the left sacroiliac joint.", "Computed tomography of the head and cervical spine showed no evidence of injury."], "Treatment": ["The pelvis was splinted in the emergency department.", "He remained transiently responsive to fluid resuscitation and was taken for emergent computed tomography.", "A computed tomographic scan of the chest (Figure 1B) and abdomen was then performed, and the patient was taken to the operating room.A, single-view supine chest radiography."]}
{"Patient Personal Background": ["Her previous abdominal surgery included a hysterectomy for menorrhagia."], "Patient Symptoms": ["These episodes started approximately 4 years prior, occur approximately every 3 to 4 months, and are associated with crampy abdominal pain."], "Examination and Results": ["Colonoscopies were significant only for diverticulosis without a clear source of bleeding.", "She had computed tomography of the abdomen and pelvis that showed eccentric and irregular masslike thickening of the sigmoid colon of approximately 7 cm with a wall thickness of 1.4 cm (Figure 1).", "Repeat colonoscopy showed an exquisitely painful nodule at the rectosigmoid junction.", "There were no stigmata of recent bleed, and biopsy showed normal colonic mucosa.Axial (A) and coronal (B) computed tomography of the pelvis with rectal contrast.", "The images show thickening and narrowing of the sigmoid colon (arrowheads)."], "Others": ["Although she has been hospitalized, she never required a transfusion.", "There is no family history of colon cancer.Physical examination showed no abnormalities."]}
{"Patient Symptoms": ["In the week following her first treatment, the patient reported a few mild morning headaches that improved with acetaminophen.", "After receiving 3 cycles of ipilimumab, 3 mg/kg, and nivolumab, 1 mg/kg, and 8 weeks after her first treatment, the patient reported experiencing daily headaches for at least the prior week and a half.", "The location of her headaches varied, and there was no associated eye or temple pain.", "Also at this time, the patient reported low energy levels and difficulty reading; however, physical examination showed no gross visual field defects."], "Examination and Results": ["Laboratory workup conducted 8 weeks after initiating treatment included adrenocorticotropic hormone (ACTH) and cortisol levels that were measured at 25 pg/mL (reference range, 10-60 pg/mL) and 16.8 \u03bcg/dL (reference range, 6-24 \u03bcg/dL), respectively.", "Thyroid-stimulating hormone (TSH) level was 0.82 mIU/L (reference range, 0.5-5.0 mIU/L), which was gradually decreasing compared with 1.41 mIU/L 5 weeks earlier and 1.21 mIU/L 2 weeks earlier.", "Her total triiodothyronine level was measured at 73 ng/dL (reference range, 80-200 ng/dL) and free thyroxine level was 1.0 ng/dL (reference range, 0.9-1.7 ng/dL).", "Her serum sodium level was measured at 138 mEq/L; 1 week later it was measured at 135 mEq/L (reference range, 135-145 mEq/L)."], "Treatment": ["After receiving 3 cycles of ipilimumab, 3 mg/kg, and nivolumab, 1 mg/kg, and 8 weeks after her first treatment, the patient reported experiencing daily headaches for at least the prior week and a half."], "Others": ["Contrast-enhanced magnetic resonance imaging (MRI) of the brain was performed for further assessment (Figure).Magnetic resonance imaging (MRI) of the brain obtained 8 weeks after initiating ipilimumab (A-C) and nivolumab treatment and at follow-up (D)."]}
{"Patient Personal Background": ["She was previously healthy, did not consume alcohol, and had no personal or family history of liver disease.", "She took no prescription medications; however, approximately 6 months prior to the onset of symptoms, she began taking a nutritional supplement (Nature Made Beta Carotene, Otsuka Pharmaceutical) manufactured in Japan and available online in China.", "This supplement contained 1.8 mg of beta carotene per tablet, and she had been taking 2 tablets daily for the past 6 months.", "She had no other dietary changes during this period, in particular, no increased intake of carrots or other yellow- or orange-colored fruits or vegetables."], "Examination and Results": ["Physical examination revealed yellow-orange pigmentation of her palms and soles (Figure).", "There was no scleral icterus."]}
{"Patient Personal Background": ["His only medication was omeprazole (20 mg daily)."], "Patient Symptoms": ["He felt well until 6 days prior, when he awoke with diffuse muscle cramps following a strenuous day of moving boxes.", "He subsequently developed oliguria that progressed to anuria."], "Examination and Results": ["His usual fluid intake had not changed.Physical examination was notable for moist mucous membranes, clear lungs, no lower extremity or periorbital edema, and no jugular venous distension.", "Examination was otherwise unremarkable.", "Bladder scan showed 50 mL of urine, which was collected via straight catheterization.", "Three liters of normal saline was administered, with no further urine production.Laboratory testing revealed a blood urea nitrogen level of 90 mg/dL (32.1 mmol/L) (reference range, 7-21 mg/dL [2.5-7.5 mmol/L]) and creatinine level of 14.1 mg/dL (1246.4 \u03bcmol/L) (reference range, 0.6-1.17 mg/dL [53.0-103.4 \u03bcmol/L]); baseline levels 3 months prior were 37 mg/dL (13.2 mmol/L) and 3.3 mg/dL (291.7 \u03bcmol/L), respectively.", "Hemoglobin level was 10.6 g/dL (reference range, 13-17 g/dL); calcium, 8.1 mg/dL (reference range, 8.5-10.1 mg/dL); potassium, 6.2 mmol/L (reference range, 3.5-4.7 mmol/L); and phosphorous 8.8 mg/dL (2.8 mmol/L) (reference range, 2.5-4.9 mg/dL [0.81-1.58 mmol/L]).", "Creatine kinase level was within normal limits.", "Urinalysis showed minimal albuminuria (100 mg/dL); however, spot urine protein to creatinine ratio predicted 11\u202f139 mg/g (reference range, 0-200 mg/g) proteinuria.", "Renal ultrasound showed no hydronephrosis.", "Serum protein electrophoresis and immunofixation electrophoresis identified a small monoclonal IgG \u03ba band."], "Treatment": ["Serum \u03ba free light chain (FLC) level was 20\u202f765 mg/L (reference range, 3.3-19.4 mg/L) with a free \u03ba to \u03bb ratio of 296 (reference range, 0.37-3.1).1 Hemodialysis was initiated and a bone marrow biopsy obtained.Bone marrow biopsy showed a normocellular bone marrow with 10% \u03ba-restricted plasma cells (Figure, left panel)."], "Others": ["Immunohistochemical staining demonstrated positivity for the plasma cell marker CD138 (Figure, right panel).Left, Bone marrow biopsy sample (hematoxylin-eosin, original magnification \u00d7400).", "Right, Immunohistochemical staining of biopsy sample (immunohistochemical stain for CD138, original magnification \u00d7400)."]}
{"Patient Personal Background": ["He was born in the United States but had traveled to Sierra Leone for a period of 3 weeks and had returned 1 week prior to presentation.", "He did not take any form of malaria prophylaxis, nor did he use insect repellent while traveling.", "He previously received the yellow fever vaccine but not hepatitis A or typhoid vaccination.Physical examination revealed a temperature of 39.3\u00b0C, heart rate of 120/min, blood pressure of 119/60 mm Hg, respiratory rate of 32/min, and oxygen saturation of 98% on room air."], "Patient Symptoms": ["The patient was jaundiced, with scleral icterus, and was alert and oriented, although he had a fluctuating attention span and was unable to complete basic tasks."], "Examination and Results": ["He was able to localize painful stimuli.", "No retinal lesions were present on dilated ophthalmologic examination.", "Laboratory tests were notable for a white blood cell count of 5000/\u03bcL with 88% polymorphonuclear leukocytes, 1% bands, 5% lymphocytes, 5% monocytes, and 0% eosinophils; hemoglobin level of 9.5 g/dL, and platelet count of 25 \u00d7103/\u03bcL.", "Sodium level was 132 mEq/L; potassium, 4.0 mEq/L; chloride, 100 mEq/L; carbon dioxide, 15 mEq/L; blood urea nitrogen, 40 mg/dL; and creatinine, 1.5 mg/dL.", "Total bilirubin level was 23.9 mg/dL; aspartate aminotransferase, 252 U/L; and alanine aminotransferase, 100 U/L.", "Venous lactate level was 49.6 mg/dL.", "A computed tomography scan of the head was unremarkable.", "A thin preparation blood smear was obtained (Figure).Thin preparation smear of blood obtained from patient (Wright-Giemsa, original magnification \u00d7100)."]}
{"Examination and Results": ["Physical examination revealed violaceous plaques, measuring 2 to 3 cm, on the extensor surface of the knees, bilaterally (Figure, B).", "Excisional biopsy specimens were obtained (Figure, C and D).A, Multiple asymptomatic erythematous nodules measuring 1.5 to 3.0 cm at presentation.", "B, Multiple violaceous plaques measuring 2 to 3 cm on the extensor surface of the knees.", "C, Excisional biopsy specimen of a calcaneal nodule (hematoxylin-eosin, original magnification \u00d720)."]}
{"Patient Personal Background": ["She reported no history of pregnancy-related complications."], "Examination and Results": ["Physical examination revealed confluent erythema with keratotic papulovesicles distributed on the face and neck (Figure, A).", "Honey-colored crusts were present on the left ear and preauricular area.", "The chest and inframammary area displayed occasional red, crusted papules.", "Laboratory tests revealed an elevated white blood cell count of 17.18\u2009\u00d7\u2009103/\u03bcL (reference range, 4.50-11.00\u2009\u00d7\u2009103/\u03bcL).", "A shave biopsy specimen and tissue culture were obtained from the center of an umbilicated papule on the neck (Figure, B and C).A, Confluent erythema with papulovesicles on the neck and face.", "B and C, Histopathological images, hematoxylin-eosin.", "B, Full-thickness epidermal necrosis with focal areas of suprabasal acantholysis with corp ronds, corp grains, and parakeratosis.", "C, Multinucleated cells with nuclear molding and margination."]}
{"Patient Personal Background": ["He reported no previous infections or family or personal medical history of autoimmune diseases or psoriasis.", "He was previously treated for rheumatoid arthritis, but various arthritis treatments showed no improvements over 1 year."], "Patient Symptoms": ["The patient exhibited no associated fever, analgesia or hypesthesia.", "A physical examination showed diffuse infiltration of the face with loss of skin creases and diminished facial hair; all joints of both hands were swollen (Figure, A); multiple asymptomatic nodules without ulceration were present on his upper arms (Figure, B); decreased sensation to pain, temperature and/or touch and neuropathic changes were not found."], "Examination and Results": ["A physical examination showed diffuse infiltration of the face with loss of skin creases and diminished facial hair; all joints of both hands were swollen (Figure, A); multiple asymptomatic nodules without ulceration were present on his upper arms (Figure, B); decreased sensation to pain, temperature and/or touch and neuropathic changes were not found.", "Laboratory test results showed a slightly elevated erythrocyte sedimentation rate (27 mm/h) and significantly elevated rheumatoid factor (70.1 IU/mL).", "Additional immunology indicators, including C-reactive protein, anticyclic citrullinated peptide, antinuclear antibodies, and globulin levels were normal.", "X-ray and joint ultrasound results suggested osteoarthritis, synovitis, flexor tendon tenosynovitis, and bone erosions.", "Ultrasound results also indicated enlarged axillary, cervical, and inguinal lymph nodes and an enlarged spleen.", "Fundus fluorescein angiography showed uveitis.A, Joints of both hands were swollen.", "C, Skin biopsy from the patient\u2019s upper arm nodule demonstrating diffuse infiltrate of foamy histiocytes in the dermis (hematoxylin-eosin stain, original magnification \u00d7100).", "D, Numerous acid-fast bacilli (acid-fast stain, original magnification \u00d7400)."], "Treatment": ["He was previously treated for rheumatoid arthritis, but various arthritis treatments showed no improvements over 1 year."], "Others": ["B, Multiple asymptomatic nodules on the upper arms."]}
{"Patient Personal Background": ["He served in the military for 4 years, including a 6-month tour in Iraq.", "He reported drinking more than 12 beers 2 to 3 times per week.", "He was prescribed a selective serotonin reuptake inhibitor (SSRI) but did not find it helpful and so he discontinued it."], "Patient Symptoms": ["He reported numerous traumatic experiences, including frequent receipt of incoming fire, multiple ambushes, and an explosion by an improvised explosive device (IED) that injured several fellow soldiers (see Theme 1, Fear Conditioning, in related Educational Review).1He denied any psychiatric issues prior to his military service, but reported that since returning home \u201cthere ain\u2019t a day that goes by that I don\u2019t think about [these experiences].\u201d The thoughts were highly distressing and he had frequent violent nightmares.", "He reported intense guilt relating to the belief that he should have detected the IED and been able to protect his colleagues.", "He reported a number of triggers (eg, walking down a city street; driving by a shooting range) that reminded him of his experiences in Iraq and induced panic-like symptoms (eg, fear, anxiety, racing heart, and feeling shaky).", "He avoided things that reminded him of these events and was reluctant to discuss his history (see Theme 1, Fear Conditioning, in related Educational Review).1He felt numb and withdrawn from others, reported difficulty sleeping, and was always \u201con guard.\u201d He startled easily and had angry outbursts.", "The patient was hopeless at times, but denied suicidal thoughts.", "He reported difficulty concentrating and had significant fluctuations in his weight."], "Treatment": ["He denied any other substance abuse history.The patient was briefly in outpatient treatment while he was still in the military.", "He was prescribed a selective serotonin reuptake inhibitor (SSRI) but did not find it helpful and so he discontinued it."], "Others": ["While in Iraq he worked as an assault vehicle operator and was involved in frequent foot patrols.", "He was referred for psychotherapy but did not keep his appointments (see the last sentence of Theme 1, Fear Conditioning, in related Educational Review).1The patient grew up in the suburb of a small city."]}
{"Patient Symptoms": ["She had 1 week of nonbilious, nonbloody emesis, and \u201cgraying out\u201d of her vision only when standing up or sitting down.", "Three months after initial presentation, she reported a 9.07-kg weight loss (height 1.57 m; body mass index dropped from 21.3 to 16.8 [calculated as weight in kilograms divided by height in meters squared]), postural lightheadedness, worsening fatigue, muscle weakness, salt cravings, loss of axillary hair, and missed periods for 2 months."], "Examination and Results": ["Examination noted normal visual acuities and swelling of both optic discs (Figure, A).", "Magnetic resonance imaging and magnetic resonance venography of the head showed no intracranial mass or venous sinus thrombosis.", "Lumbar puncture showed an opening pressure of 550 mm of water and normal cerebrospinal fluid (CSF) composition.", "Repeated ophthalmic examination showed normal visual acuities and worsening optic disc swelling.The patient presented with papilledema bilaterally (A, right eye shown) patchy tongue darkening (B), and darkening of knuckles and distal fingers (C)."], "Treatment": ["A diagnosis of idiopathic intracranial hypertension was made, and she was treated with acetazolamide."], "Diagnosis": ["Headaches initially improved but worsened during the following weeks."]}
{"Patient Personal Background": ["Surgical history consisted of a Blalock-Taussig shunt in early childhood and subsequent TOF repair at age 3 years."], "Examination and Results": ["On examination, venous pressure was visualized 4 cm above the clavicle at 45\u00b0 with a prominent a wave.", "A parasternal lift was present.", "An electrocardiogram (Figure 1A) revealed sinus rhythm with a right bundle branch block.", "Findings from a transthoracic echocardiogram (TTE) are shown in Figure 1B and Video 1.", "Right ventricular diastolic volume index, quantitated by cardiac magnetic resonance, was 161 mL/m2.A, Electrocardiogram showing sinus rhythm, right bundle branch block, right axis deviation, and premature ventricular contractions.", "B, Still frame from the transthoracic echocardiogram in parasternal long-axis orientation in diastole.", "LA indicates left atrium; LV, left ventricular; RVOT, right ventricular outflow tract."], "Others": ["Auscultatory findings at the left upper sternal border are provided in  the corresponding Audio."]}
{"Patient Symptoms": ["He also reported progressive dysphagia to solids but no dyspnea, otalgia, or weight loss."], "Examination and Results": ["Examination revealed very tender right-sided neck fullness of 6 cm.", "Laryngoscopic findings were unremarkable.", "Computed tomography (CT) with contrast demonstrated a 4.4\u2009\u00d7\u20093.6\u2009\u00d7\u20094.5-cm heterogeneously enhancing mass in the right side of the neck, splaying and completely surrounding both the internal and external carotid arteries (Figure, A).", "Scattered lymph nodes were also observed.", "On magnetic resonance imaging (MRI), the mass was hyperintense on T2 (Figure, B).", "A second 0.9-cm enhancing mass was visualized at the inferior right jugular foramen.", "Chest radiography demonstrated no suspicious pulmonary or mediastinal lesions."], "Treatment": ["He underwent excision of the mass with right-sided neck dissection.", "Cranial nerves XI, X, and XII were identified and preserved.", "Vascular surgery was performed to make an intraoperative repair, and an intraoperative angiogram demonstrated no dissections or thrombi."], "Diagnosis": ["The lesion was suspected to be benign, and the procedure was aborted."], "Others": ["During subadventitial dissection of tumor off the carotid bifurcation, a laceration of the internal carotid artery was noted.", "The patient experienced no neurologic sequelae postoperatively.", "A specimen was taken of the right-sided neck mass (Figure, C and D).A and B, Imaging of the carotid space.", "A, Computed tomographic (CT) image.", "B, Postcontrast T1 magnetic resonance image (MRI).", "C and D, Histopathologic images.", "C, Hematoxylin-eosin.", "D, Immunohistochemical staining."]}
{"Patient Personal Background": ["He was born at 37 weeks gestation via cesarean delivery and developed noisy breathing and nasal congestion shortly after birth."], "Patient Symptoms": ["On the eighth day of life, the patient returned with noisy breathing, retractions, and poor feeding.", "On the 12th day of life, he presented with worsening symptoms.", "Physical examination revealed significant distress, retractions, and cyanosis relieved by crying."], "Examination and Results": ["Otolaryngological consultation, including fiberoptic nasopharyngolaryngoscopy, was performed, and revealed a right septal deviation.", "Flexible nasopharyngolaryngoscopy revealed a large left inferior turbinate and right septal deviation.", "A mucosalized mass filling the left nasal cavity was visualized on anterior rhinoscopy, requiring nasal stenting to relieve obstruction.", "A maxillofacial computed tomographic (CT) scan demonstrated a 2.0\u2009\u00d7\u20091.6-cm mass in the left mid-nasal cavity, compressing the middle turbinate and lamina papyracea (Figure, A).", "The cribriform plate was slightly widened prompting magnetic resonance imaging (MRI), which confirmed a 2-cm heterogeneous mass, isointense on T2 with small hyperintense areas, without intracranial extension (Figure, B)."], "Treatment": ["The infant was treated with topical neosynephrine and fluticasone spray and discharged home.", "The mass was smooth, epithelialized, and pedunculated at the anterior aspect of the face of the left sphenoid sinus and medial to the middle turbinate (Figure, C).", "Transnasal delivery was performed with a deep margin achieved by resecting the periosteum of the sphenoid (Figure, D)."], "Others": ["The patient underwent urgent transnasal endoscopic excision of the mass under general anesthesia.", "Histologic examination revealed a lesion characterized by regions of cartilage admixed with irregular areas of chondromyxoid stroma containing spindle cells."]}
{"Patient Personal Background": ["She was prescribed multiple rounds of antibiotics without notable improvement."], "Examination and Results": ["Physical examination revealed a submucosal right retropharyngeal mass extending from the level of the soft palate to the postcricoid.", "Cranial nerve function and neck range of motion were normal.", "Contrast-enhanced computed tomography (CT) demonstrated a 4\u2009\u00d7\u20093\u2009\u00d7\u20093-cm right retropharyngeal mass with narrowing of the pharyngeal airway, subtle permeative destruction and cortical breakthrough of the C2 vertebral body.", "Magnetic resonance imaging (MRI) with contrast showed a T2 hyperintense, enhancing mass in the retropharyngeal and prevertebral spaces with marrow replacement of the C2 vertebral body extending to the odontoid (Figure, A).", "The patient underwent a combined otolaryngology-neurosurgical procedure with a transoral approach via an inferiorly based myomucosal flap to C1-C3 with microsurgical resection of C2 tumor and corpectomy, placement of the halo device, tracheotomy, and staged interval occiput-C6 posterior spinal fusion (Figure, B).", "Results from immunohistochemical analysis were positive for brachyury (Figure, D)."], "Treatment": ["Her postoperative course was uneventful, and she was decannulated prior to hospital discharge."]}
{"Examination and Results": ["Examination revealed a firm, immobile, and nontender mass affixed to the underlying right mandible.", "Magnetic resonance imaging (MRI) showed a 3.7\u2009\u00d7\u20093.6\u2009\u00d7\u20092.6-cm mass arising from the medial aspect of the right mandibular body with cortical destruction (Figure, A-C).", "The mass extended into the submandibular and sublingual spaces.", "Magnetic resonance imaging demonstrated a lesion isointense to muscle on T1 sequence, heterogeneously hyperintense with internal foci of decreased intensity on T2 sequence (Figure, D), and homogeneous contrast enhancement.", "Results from staging studies, including a bone survey, were negative for metastatic disease.", "Core biopsy revealed spindle cell proliferation with abundant intervening collagen but no anaplasia, mitotic activity, eosinophils, or inflammatory components.", "Incisional biopsy showed fibroblastic proliferation comprised of slender, uniform spindle cells arranged in fascicles with intervening collagenous stroma and no mitoses.", "Results from immunohistochemical analysis were positive for \u03b2-catenin and negative for CD34, desmin, and smooth muscle actin.", "No clonal abnormalities were present.", "The patient was negative for familial adenomatous polyposis (FAP) mutations on genetic testing.", "The most recent interval MRI, performed 4 years after initial presentation, showed a decrease in the size of the mass to 1.5 cm in the maximum dimension.A and B, T1 precontrast fat-saturated magnetic resonance imaging (MRI) demonstrating a mass (arrowhead) arising from right aspect of the mandible.", "C, Axial diffusion weighted imaging of the mass (arrowhead).", "D, Axial T2 MRI image demonstrating heterogeneously hyperintense mass (arrowhead)."], "Treatment": ["Chemotherapy with hydroxyurea, 20 mg/kg/d, was initiated and continued for 2 years."], "Others": ["Reconstructive surgery was considered but not pursued given the lesion size."]}
{"Patient Personal Background": ["He had a strong family history of bilateral ptosis, which included his father, grandfather, uncles, cousins, and 4 of his siblings (he had a total of 13 siblings [7 brothers and 6 sisters]).", "He had no history of trauma, crossing or drifting of the eyes, dysarthria, dyspnea, or diplopia.", "His medical history was unremarkable except for hypertension.External photograph showing bilateral blepharoptosis with dermatochalasis."], "Patient Symptoms": ["The ptosis did not worsen or fluctuate throughout the day.", "He had noticed mild lightheadedness and trouble swallowing."], "Examination and Results": ["Notice the chin-up head position that the patient has to maintain to look in the primary gaze.His visual acuity was 20/25 OU with an intraocular pressure of 11 mm Hg OU.", "He had a mild decrease in elevation and abduction in both eyes on extraocular motility testing.", "Pupil reactivity and confrontational visual fields were normal.", "The results of anterior and posterior segment examinations were normal.", "The margin to reflex distance was \u22121 mm OD and \u22123 mm OS.", "Levator function was 4 mm OD and 3 mm OS with normal orbicularis function.", "No lagophthalmos was noted.", "Goldmann perimetry showed a 30\u00b0 improvement in the right eye and a 50\u00b0 improvement in the left eye, with taping of the upper eyelids."], "Others": ["None of his children or his siblings\u2019 children were affected (the oldest being 31 years of age)."]}
{"Patient Personal Background": ["He was otherwise healthy, with no past medical or ocular history."], "Patient Symptoms": ["Despite his headaches, he denied having eye pain."], "Examination and Results": ["Prior to referral, his symptoms prompted magnetic resonance imaging of the brain, orbits, and cervical spine which were unremarkable.", "Laboratory test results for the presence of Lyme disease, rapid plasma reagin, antinuclear antibodies, angiotensin-converting enzymes, and erythrocyte sedimentation rates were normal.The best corrected visual acuity was 20/50 in the right eye and 20/200 in the left eye.", "Motility, intraocular pressures, and pupillary light reflexes were normal.", "The anterior segment examination results were normal, and the lenses were clear bilaterally.", "A fundus examination showed vitreous cells in both eyes, but the optic nerve and retinal vessels were visualized clearly.", "Also, both eyes had optic nerve hyperemia and multiple shallow serous retinal detachments."]}
{"Patient Personal Background": ["He had no history of eye problems.", "His medical history was negative for diabetes and hypertension, and review of systems was positive for recent easy bruising and progressive fatigue."], "Patient Symptoms": ["He reported flashes and progressive blurry vision in both eyes over a period of 6 days."], "Examination and Results": ["His initial best-corrected visual acuity was 20/25 OD and 20/50 OS.", "Results from examination of his pupils, motility, intraocular pressures, confrontational visual fields, and anterior segments were normal.", "A dilated fundus examination was conducted (Figure).", "He had bilateral flame-shaped and intraretinal hemorrhages in both maculae along the superior arcades and some scattered peripheral hemorrhages.", "There was no vessel tortuosity, and there were hard exudates in the left macula.", "Spectral-domain optical coherence tomography showed areas of hyperreflectivity in the middle and outer retina.", "Fluorescein angiography of both eyes showed blocking in the areas of hemorrhage, good venous filling, no leakage, and no neovascularization.Wide-field scanning laser image of the left eye showed superficial and intraretinal hemorrhages and hard exudates."]}
{"Patient Personal Background": ["Her history was significant for glaucoma and breast cancer with brain metastasis treated with CyberKnife and whole-brain radiation."], "Patient Symptoms": ["She had a left afferent pupillary defect and left superior visual field deficit."], "Examination and Results": ["At presentation, her visual acuity was 20/20 OD and 20/50 OS, and intraocular pressures were 18 and 20 mm Hg, respectively.", "Slitlamp examination of the right eye was unremarkable, while the left eye showed 1+ cell in the anterior chamber and 1+ nuclear sclerosis with pigment on the anterior lens capsule.", "Posterior examination revealed 2+ whitish vitreous deposits, a cup-disc ratio of 0.8, and inferior retinal detachment with subretinal particulate material (Figure, A).", "B-scan showed vitreous, subhyaloid, and subretinal opacities without choroidal involvement (Figure, B).", "A magnetic resonance image of the brain and orbits did not reveal any new metastatic lesions.A, Whitish vitreous deposits, inferior retinal detachment, and subretinal material seen on fundus photography of the left eye."], "Treatment": ["While abroad, she received 2 inferiorly placed periocular steroid injections and was treated with glaucoma drops for elevated pressures of 55 mm Hg."]}
{"Patient Personal Background": ["There was no history of trauma or alcohol intake."], "Patient Symptoms": ["There was guarding and tenderness in the right upper quadrant; the liver was firm, smooth, and palpable 3 cm below the right costal margin."], "Examination and Results": ["Clinical examination revealed no icterus or significant lymphadenopathy.", "Laboratory investigations were remarkable for white blood cell counts of 13\u202f200/\u03bcL (to convert to \u00d7\u2009109 per liter, multiply by 0.001) and alkaline phosphatase of 259 U/L (to convert to microkatals per liter, multiply by 0.0167).", "Ultrasonography of the abdomen revealed a large hypoechoic area in the right lobe of the liver along with gallstones.", "A contrast-enhanced computed tomography (CECT) scan was performed (Figure 1).Sections of the contrast-enhanced computed tomographic scan show a large hypodense area (blue arrowhead) measuring 16\u2009\u00d7\u200911.8\u2009\u00d7\u200912.4 cm, involving segments 4, 5, 6, 7, and 8, along with a gallstone (black arrowhead)."]}
{"Examination and Results": ["During workup, she was found to have an asymptomatic cystic lesion in the right iliac fossa.", "Fifteen months later, a contrast-enhanced computed tomographic (CT) scan of her abdomen showed a progressive 16-mm cystic lesion in close relation to the cecum (Figure 1).", "The rest of the colon and small intestine, as well as the adenexa, solid organs, and peritoneum, appeared normal.", "There was no other positive radiologic finding except for right partial nephrectomy.", "The general physical and abdominal examinations were unremarkable.", "The results of other investigations such as a hemogram, liver and kidney function tests, and serum tumor markers, including serum carcinoembryonic antigen levels (0.94 ng/mL [to convert to micrograms per liter, multiply by 1.0]), were within the prescribed normal range.", "She had good exercise tolerance, and the results of cardiopulmonary investigations, as a part of preanesthesia workup, were normal.Contrast-enhanced computed tomographic scan of the abdomen showing a cystic lesion (arrowheads) in the right iliac fossa (axial view [A] and planar reconstruction image [B])."]}
{"Examination and Results": ["A noncontrast computed tomographic (CT) scan revealed a 15\u2009\u00d7\u200913\u2009\u00d7\u200911-cm heterogeneous cystic mass that appeared to originate from the body of the pancreas and protrude into the gastric wall (Figure 1, A).", "Results of CT scan also revealed a 3-cm hypodense lesion on the left lobe of the liver, ascites, and splenomegaly.", "Further evaluation with endoscopic retrograde cholangiopancreatography and endoscopic ultrasonography revealed extrinsic compression of the gastric wall from a large mixed solid/cystic lesion with septations and well-defined margins with no clear involvement of the gastric wall.", "Analysis of the aspirate showed no tumor cells or mucinous material, and normal carcinoembryonic antigen, CA19-9, and amylase.", "A hypodense lesion in segment 3 of the liver is observed (black arrowhead) and also moderate ascites (yellow arrowhead)."], "Treatment": ["A thin, reddish-brown fluid (700 mL) was aspirated from the cystic component.", "Fine-needle aspiration was performed on the solid component of the cystic tumor (Figure 1, B-E).A, Coronal view CT scan showing a 15\u2009\u00d7\u200913\u2009\u00d7\u200911-cm complex heterogeneous mass originating from the body of the pancreas (white arrowhead) and protruding into the gastric wall."], "Others": ["B, Hematoxylin-eosin stain (original magnification \u00d720); C, \u03b1-smooth muscle actin immunostain (original magnification \u00d740); D, CD117 immunostain (original magnification \u00d740); and D, CD34 immunostain (original magnification \u00d740)."]}
{"Patient Personal Background": ["The patient works as a plumber and attributed his tender rash to a \u201cspider bite\u201d he had incurred while working in an old building."], "Patient Symptoms": ["The patient works as a plumber and attributed his tender rash to a \u201cspider bite\u201d he had incurred while working in an old building."], "Examination and Results": ["The patient was afebrile, and physical examination revealed several vesicles with purulent fluid on an erythematous base, at the base of the left thumb (Figure).", "There was no lymphadenopathy, lymphangitis, or mucous membrane involvement.", "The rash was not found elsewhere on the body."], "Treatment": ["One day prior to presentation, he went to a local emergency department, where he was prescribed clindamycin and valacyclovir."]}
{"Patient Personal Background": ["He was a former smoker with a 50\u2013pack-year history.", "He had been diagnosed with stage I low-grade prostate cancer several years previously.Lung examination showed no wheezing."], "Examination and Results": ["Cardiac examination showed a prominent pulmonary component (P2) of the second heart sound.", "Noncontrast computed tomography of the chest was unremarkable.An echocardiogram revealed dilated right atrium and ventricle.", "Spirometry showed mild airway obstruction.", "Duplex ultrasound showed a nonocclusive thrombus in the left femoral and popliteal veins.", "Catheterization of the right side of the heart showed a pulmonary arterial pressure of 79/32 mm Hg (mean, 48 mm Hg) with a normal pulmonary capillary wedge pressure.", "A ventilation-perfusion (V/Q) scan was obtained (Figure, panel A), followed by pulmonary angiography (Figure, panel B).A, Ventilation/perfusion scan, right anterior oblique view."]}
{"Patient Personal Background": ["His medical history was relevant for acute myeloid leukemia, for which he had received an allogeneic stem cell transplant that was complicated by biopsy-proven grade 3 cutaneous and grade 2 gastrointestinal graft-vs-host disease.", "As part of his posttransplant infectious prophylaxis, the patient had been prescribed valacyclovir hydrochloride, voriconazole, and trimethoprim/sulfamethoxazole.", "He was also taking tacrolimus hydrate and prednisone for treatment of his graft-vs-host disease."], "Patient Symptoms": ["The patient reported fishing outdoors on a sunny day a few days prior to the onset of these skin lesions."], "Examination and Results": ["On physical examination, the patient\u2019s skin was diffusely tan and there were flaccid bullae and erosions on the bilateral dorsal hands, elbows, and knees (Figure, A).", "A punch biopsy specimen from a bulla from the upper extremity was obtained (Figure, B).A, Flaccid bulla and erosions on the left dorsal hand at presentation."], "Others": ["B, Biopsy from the left elbow."]}
{"Patient Symptoms": ["He denied associated fevers, chills, night sweats, weight loss, joint pain, cough, difficulty breathing, or chest pain.Findings from the physical examination revealed red-brown monomorphic papules coalescing into plaques on the face, trunk, and extremities (Figure, A and B)."], "Examination and Results": ["There were thin erythematous plaques with overlying scale on bilateral extensor upper and lower extremities.", "A 4-mm punch biopsy specimen from his right upper extremity was obtained and stained with hematoxylin-eosin for histopathologic analysis.", "Periodic acid\u2013Schiff and acid-fast bacilli stains were also performed.A, Distribution of papules over the chest, abdomen, and upper extremities.", "B, Diffuse distribution of papules over the back with some papules coalescing into plaques.", "C, Hematoxylin-eosin stain (original magnification, \u00d710)."]}
{"Patient Personal Background": ["His medications included efavirenz\u2013emtricitabine\u2013tenofovir disoproxil fumarate for his HIV, with the most recent absolute CD4-positive cell count of 341 cells/mm3 (reference range, 263-2045 cells/mm3), and recent completion of an 8-month course of isoniazid treatment after being exposed to tuberculosis."], "Patient Symptoms": ["The lesion started 1 year prior as a tender red nodule on the medial aspect of his first metatarsophalangeal joint, which would enlarge and become painful approximately once a month (Figure, A).", "The patient reported that with manipulation, a clear-to-yellow material drained from the lesion.", "The patient denied any purulent drainage, additional skin lesions, fever, chills, or other systemic symptoms."], "Examination and Results": ["Physical examination demonstrated an erythematous papulonodule without warmth or drainage on the dorsal left great toe.", "No lymphadenopathy was appreciated.", "A punch biopsy was performed (Figure, B, C, and D) to help establish the diagnosis.A, Clinical photograph of slow-growing red papulonodule on the left toe dorsal foot.", "B, Biopsy with hematoxylin-eosin (H&E) staining demonstrating acral skin with acute and chronic inflammation within the deep dermis.", "C, Higher magnification highlights eosinophilic material surrounding small cocci.", "D, Gram staining of the biopsy supported the diagnosis."]}
{"Patient Personal Background": ["Review of systems was significant for heavy periods since menarche 6 months ago.", "The patient was described as a shy eighth grader who earns A\u2019s and B\u2019s in school.", "She was not physically active."], "Patient Symptoms": ["She stated that her pain worsened with walking and was minimally relieved with salicylic acid.", "It was negative for easy bruising or bleeding."], "Examination and Results": ["On physical examination, the patient was noted to be short for her age (1.3 m [4.4 ft]; height in <third percentile), weight (62.5 kg; 87th percentile), and body mass index (35 [calculated as weight in kilograms divided by height in meters squared]; 99th percentile).", "She had a relatively short, thick neck with acanthosis nigricans, dry skin, Tanner stage II breasts, and nonpitting edema of her hands (Figure 1A).", "Radiography of the hips was performed (Figure 1B), showing bilateral slipped capital femoral epiphysis (SCFE).", "B, Photograph of the patient\u2019s hand, which demonstrates nonpitting edema at time of presentation."], "Diagnosis": ["Radiography of the hips was performed (Figure 1B), showing bilateral slipped capital femoral epiphysis (SCFE)."], "Others": ["Her parents tried to schedule an outpatient appointment for evaluation of her hip pain but had difficulty owing to a lack of a primary care physician.", "The patient described normal stooling and voiding habits.", "Her family history was significant for hypothyroidism and coronary artery disease in the father, type 2 diabetes mellitus in the maternal great grandmother, and hypothyroidism in the maternal grandmother.", "Prior to undertaking definitive surgical correction of the hips, it is important to consider the potential underlying condition.A, Plain film of the hips revealing bilateral slipped capital femoral epiphysis."]}
{"Patient Personal Background": ["Her daughter had died unexpectedly a few days before presentation, and the burial service was scheduled for that day."], "Patient Symptoms": ["Except for the patient appearing struck with severe grief, the results of an initial physical examination, electrocardiography (ECG), and radiography of the chest and her initial laboratory results were all unremarkable."], "Examination and Results": ["There were no associated symptoms.", "Except for the patient appearing struck with severe grief, the results of an initial physical examination, electrocardiography (ECG), and radiography of the chest and her initial laboratory results were all unremarkable.", "Her serial troponin T levels were less than 0.01, 0.04, and 0.1 ng/mL (normal range, <0.01 ng/mL [to convert to micrograms per liter, multiply by 1.0]).", "An emergency transthoracic echocardiographic biplane volumetric assessment of left ventricular (LV) function is shown in Figure 1 (Video 1 and Video 2).", "Twelve hours after readmission, she was asymptomatic, her troponin level had increased to 2.0 ng/mL, and she again underwent ECG (Figure 1).Transthoracic echo biplane volumetric left ventricular function assessment (A-E).", "Note the systolic apical akinesis or ballooning in the 4- and 2-chamber systolic still frames (B and D, respectively).", "E, Note the extensive T-wave inversions and mild inferolateral ST elevation in the 12-lead electrocardiogram."], "Treatment": ["She received aspirin, high-intensity statin, and low-dose \u03b2-blocker and was given a therapeutic dose of low-molecular-weight heparin subcutaneously.", "Serial ECGs were unchanged, and the patient was completely asymptomatic; thus, she was permitted to briefly attend her daughter\u2019s burial service as long as she returned immediately for direct hospital admission."]}
{"Patient Symptoms": ["The patient reported 2 episodes of streptococcal tonsillitis and infectious mononucleosis over the past 8 months, as well as frequent throat soreness and associated difficulty swallowing throughout the past year."], "Examination and Results": ["Results from a review of systems were negative for weight loss, fevers, and malaise.", "On physical examination, he appeared well and had 2+ cryptic tonsils.", "A lobular mass was noted to be extending from the inferior pole of the right tonsil.", "There was no cervical lymphadenopathy.", "The right tonsil had a smooth, pedunculated, flesh-colored mass extending inferiorly.", "Both tonsils were removed without complication.", "The right tonsil with the attached mass was submitted to the pathology service fresh to allow evaluation by flow cytometry.", "Flow cytometry revealed no lymphoid abnormality.", "Grossly, the polypoid oval mass measured 2\u2009\u00d7\u20091\u2009\u00d7\u20091 cm, weighed 8.7 g, and had a narrow 0.4-cm-long stalk connecting it to the tonsil (Figure, A).", "Histologic sections revealed a polypoid structure composed of a fibrovascular core covered by stratified squamous epithelium (Figure, B).", "A subepithelial band of lymphoid tissue was noted (Figure, C) as well as lymphatic channels accentuated by D2-40 antibody (Figure, D)."], "Treatment": ["The patient was scheduled for tonsillectomy for recurrent tonsillitis and tonsillar asymmetry.", "Both tonsils were removed without complication."], "Others": ["His surgery was delayed for several months to accommodate his college schedule.", "In the operating room, the tonsils were noted to be 3+ bilaterally.", "The mass had enlarged since the prior examination."]}
{"Patient Personal Background": ["His medical history was positive for hypertension, impaired glucose tolerance, dyslipidemia, and hyperthyroidism, and negative for unusual skin pigmentation or cardiac problems."], "Patient Symptoms": ["He denied any history of trauma or surgery around the ear, and reported only a cosmetic problem without pain or discharge."], "Examination and Results": ["A laboratory examination revealed only slightly elevated thyroid-stimulating hormone levels (4.80 \u00b5U/mL).", "A physical examination showed a solitary, 1-cm, dome-shaped, glistening, flesh-colored mass adherent to the posterior groove of the concha ridge (Figure, A and B).", "There were no abnormal pigmented skin lesions on the rest of his body, including the face, trunk, and extremities.", "Neither a palpable thyroid nodule nor enlargement of hands and feet was identified."], "Treatment": ["Surgical excision was performed.", "Gross total extirpation of the mass from the surrounding tissues was enabled by meticulous dissection.", "Intraoperatively, the 1-cm mass was noted to be gelatinous and glossy with well-demarcated and smooth border.", "It was attached to the posterior surface of the concha cartilage but easily separated using blunt dissection.", "Unexpectedly, low-viscosity mucoid fluid had smeared on the surface."], "Others": ["The histopathological examination revealed the tumor to be overall hypocellular and composed of bland spindle cells with no mitotic activity in a slightly basophilic myxoid matrix (Figure, C).", "The surgical wound uneventfully healed, and no recurrence was noted during the 6-month follow-up period.A, Photograph of a protruding mass on the posterior surface of the auricle.", "B, A preoperative close-up of the solitary lesion.", "C, Histopathological image showing overall hypocellular stroma with scattered bland spindle cells in slightly basophilic myxoid matrix without mitotic activity.", "Numerous blood vessels with collapsed lumina (arrowheads) are also visible."]}
{"Patient Symptoms": ["He was highly functional and denied abdominal pain, dysuria, anxiety, lethargy, and constipation."], "Examination and Results": ["Findings from his physical examination were within normal limits.", "He did not have any palpable thyroid nodules or cervical lymphadenopathy.", "Given his elevated calcium level, parathyroid hormone (PTH) was drawn, and results returned significantly elevated at 1377 pg/mL (reference range, 10-65 pg/mL).", "Because of the extremely elevated PTH level, a technetium Tc 99m sestamibi single-photon emission computed tomographic/computed tomographic (SPECT/CT) scan was obtained, which identified a lesion in the location of the right inferior parathyroid gland, measured at 2.2 cm (Figure, A).", "In addition, CT showed associated lytic bone lesions of the left mandibular ramus, left scapula, and C5 vertebra (Figure, B).Preoperative imaging of the neck."], "Others": ["A, A technetium Tc 99m sestamibi single-photon emission computed tomographic (SPECT)/computed tomographic (CT) scan.", "B, A CT image.", "C, Postoperative CT image of the neck."]}
{"Patient Personal Background": ["No stridor or shortness of breath was reported, but he admittedly \u201chated to run\u201d and was relatively sedentary.", "He was overweight (body mass index, calculated as weight in kilograms divided by height in meters squared, 27.2); breathed comfortably at rest; and had a dysphonic, breathy voice."], "Patient Symptoms": ["His voice quality had always been husky, with recent mild exacerbation.", "His parents noted intermittent stertor while he was sleeping but no apnea."], "Examination and Results": ["Findings from an otolaryngologic examination were normal other than those from flexible laryngoscopy, which demonstrated 2 laryngeal lesions, 1 in the postcricoid interarytenoid region and 1 at the anterior commissure, the latter of which compromised vocal fold approximation.", "Vocal fold mobility otherwise appeared normal.", "Operative laryngoscopy confirmed a midline, firm, posterior cricoid mass (Figure, A), and a midline, firm, anterior subglottic mass extending into the anterior commissure (Figure, A).", "Tracheobronchoscopy revealed a distal tracheal submucosal mass partially obstructing the left mainstem bronchus (Figure, B).", "Histopathologic examination demonstrated mucosal infiltration by a monotonous population of cells with round nuclei and abundant granular cytoplasm (Figure, D), positive for S-100 and lightly positive for CD68, with occasional interspersed more darkly staining cells, consistent with histiocytes and giant cells."], "Treatment": ["Excisional biopsy of the postcricoid and subglottic masses with the carbon dioxide laser was performed (Figure, C)."], "Others": ["He had no dysphagia or aspiration manifestations.", "Sections stained negative for epithelial, muscle, endothelial, and glial cell immunohistologic markers.A, Direct laryngoscopy of the larynx.", "B, Rigid bronchoscopy of the larynx.", "C, Direct laryngoscopy of the larynx following endoscopic carbon dioxide laser ablation of the lesions.", "D, Histopathologic image (hematoxylin-eosin, original magnification \u00d7200)."]}
{"Patient Personal Background": ["Gestation was complicated by polyhydramnios and gestational diabetes."], "Patient Symptoms": ["In the NICU, choking and desaturation were noted with oral feeding.", "At 2 weeks of age, she decompensated secondary to Klebsiella pneumoniae sepsis and was intubated for persistent left lung collapse."], "Examination and Results": ["Videofluoroscopic swallow study demonstrated aspiration with all consistencies.", "At that time, computed tomographic (CT) imaging was performed, revealing the etiology of her respiratory decompensation (Figure 1).Coronal computed tomographic image of the chest with contrast."], "Diagnosis": ["Microlaryngoscopy and bronchoscopy were conducted, and the patient was diagnosed as having a type II laryngeal cleft."]}
{"Patient Personal Background": ["Her medical history was noncontributory."], "Patient Symptoms": ["She was discharged 10 days later with intravenous (IV) antibacterials, sitagliptin, insulin, and oral opiates.The patient returned to the emergency department 2 weeks later with recurrent orbital pain.", "Pain rapidly resolved, repeated MRI showed reduced enhancement, and she was discharged with a prednisone taper.Ten days later, the patient returned once again to the emergency department with pain.", "Although imaging was stable, examination revealed visual acuity of no light perception OD and new-onset right-sided third, fourth, and sixth cranial neuropathies."], "Examination and Results": ["Examination revealed a right afferent pupillary defect, visual acuity of hand motion OD and 20/30 OS, full extraocular movements, and bilateral retinal dot blot hemorrhages.", "Magnetic resonance imaging (MRI) showed enhancement along the right intracanalicular optic nerve and adjacent sinuses (Figure).", "Glycosylated hemoglobin level was elevated at 10.3% (to convert to proportion of total hemoglobin, multiply by 0.01).", "Workup results for sarcoidosis, IgG4-related disease, seropositive and seronegative arthropathies, human immunodeficiency virus, tuberculosis, syphilis, Epstein-Barr virus, and herpes simplex virus types 1 and 2 were negative.T1 fat-suppressed postgadolinium magnetic resonance imaging.", "A, Contrast enhancement centered on the right intracanalicular optic nerve (blue arrowhead), involving right orbital apex and posterior ethmoidal sinus (white arrowhead).", "B, Enhancement encircling right optic nerve (arrowhead).Orbital apex and sinus biopsy revealed acute and chronic inflammation without neoplasm or microorganisms.", "Although examination was stable, MRI showed increased apical enhancement.", "Although imaging was stable, examination revealed visual acuity of no light perception OD and new-onset right-sided third, fourth, and sixth cranial neuropathies."], "Treatment": ["The patient was diagnosed as having type 2 diabetes and MSSA sino-orbital infection.", "She was discharged 10 days later with intravenous (IV) antibacterials, sitagliptin, insulin, and oral opiates.The patient returned to the emergency department 2 weeks later with recurrent orbital pain.", "The diagnosis was revised to nonspecific orbital inflammation and the neurology department initiated a 3-day course of IV methylprednisolone.", "Pain rapidly resolved, repeated MRI showed reduced enhancement, and she was discharged with a prednisone taper.Ten days later, the patient returned once again to the emergency department with pain."], "Diagnosis": ["The patient was diagnosed as having type 2 diabetes and MSSA sino-orbital infection.", "The diagnosis was revised to nonspecific orbital inflammation and the neurology department initiated a 3-day course of IV methylprednisolone."], "Others": ["Specimen cultures grew methicillin-sensitive Staphylococcus aureus (MSSA)."]}
{"Examination and Results": ["The patient had a persistent Descemet membrane detachment at the 1-day postoperative visit (Figure).", "By the 1-week postoperative visit, the patient began to develop blood in the interface, which had not resolved by the 1-month postoperative visit with a visual acuity of 20/50 (Figure).Hemorrhagic Descemet membrane detachment after canaloplasty.", "A, At postoperative day 1, a persistent Descemet membrane detachment was observed with no blood in the detachment interface.", "B, At postoperative month 1, blood was observed in the interface, which appeared by the postoperative week 1 visit."], "Treatment": ["The patient elected to proceed with cataract extraction and a lens implant followed by canaloplasty.", "The cataract extraction and lens implant went routinely, but during the canaloplasty, a hard-stop obstruction was encountered at the 7-o\u2019clock position during the passage of the illuminated catheter.", "A viscoelastic material was injected into the Schlemm canal to attempt to break the obstruction.", "The procedure was aborted, a 50% air bubble was injected into the eye, and the physicians recommended that the patient maintain a face-up position."], "Others": ["This resulted in a large inferior nasal Descemet membrane detachment.", "A washout was not performed because of concerns of further exacerbating the detachment or inducing a hemorrhage."]}
{"Patient Personal Background": ["Her medical history included aortic repair and cervical spine abnormalities.", "The patient\u2019s family history was unknown because she was adopted.", "Her medications included oral aspirin and irbesartan.Visual acuity was counting fingers OD (without correction) and 20/30 OS (with correction)."], "Patient Symptoms": ["Her symptoms began 6 hours before presentation after she had been napping face-down on her desk for 30 minutes."], "Examination and Results": ["The right pupil was corectopic and fixed at 5 mm while the left pupil was round and reactive; no afferent pupillary defect was seen.", "Extraocular motility was normal.", "Intraocular pressures (IOPs) were 43 mm Hg OD and 14 mm Hg OS.", "Examination of the right eye revealed conjunctival injection, corneal stromal edema with Descemet folds and lenticulocorneal touch, a shallowed anterior chamber, and a lens protruding through the pupil with the superior edge in the anterior chamber (Figure 1A).", "The posterior view was limited to red reflex.", "The left eye was unremarkable except for a superotemporally subluxated lens (Figure 1B).Slitlamp photography."], "Treatment": ["Her lenses had been observed for years without intervention."], "Others": ["Her ocular history was pertinent for high myopia and contact lens wear, a posteriorly dislocated crystalline lens suspended in the vitreous cavity in her right eye, and a superotemporally subluxated crystalline lens in her left eye.", "A, Right eye demonstrates dislocation of the superior crystalline lens into the anterior chamber.", "B, Left eye shows superotemporal subluxation of the crystalline lens."]}
{"Examination and Results": ["Preoperative Snellen visual acuity was 20/40 and intraocular pressure (IOP) was 36 mm Hg; on postoperative day 1, IOP was 10 mm Hg and visual acuity fell to count fingers.", "Slitlamp examination of the left eye revealed an elevated bleb over the Ahmed plate with no leakage.", "The cornea was clear and compact, and there was a well-positioned tube overlying the iris superotemporally.", "The anterior chamber was deep with trace inflammation.", "Dilated fundus examination revealed disc edema, peripapillary hemorrhages, and diffuse intraretinal hemorrhages throughout the posterior pole and periphery (Figure 1).", "Spontaneous venous pulsations were not appreciated."]}
{"Patient Symptoms": ["Physical examination results were normal except for a nontender distended and tympanic abdomen."], "Examination and Results": ["For the past year, the patient had been investigated for hypochromic microcytic anemia.", "As part of the investigation, he underwent an esophagogastroduodenoscopy and a colonoscopy, which revealed a normal-looking bowel with no obvious source of bleeding visualized.", "The patient claimed not to have passed a bowel movement containing the capsule.", "Results of routine laboratory testing were essentially normal except for a low level of hemoglobin (8.1 g/dL [to convert to grams per liter, multiply by 10]), with no leukocytosis noted.", "Contrast-enhanced abdominopelvic computed tomography demonstrated a small-bowel obstruction, with a transition zone located at the mid-jejunum.", "An intraluminal hypodense mass was demonstrated in this area and appeared to be the cause of the obstruction.", "Adjacent to this area, the capsule was clearly demonstrated in a dilated proximal loop of the small bowel (Figure 1).Computed tomographic scan showing an intraluminal hypodense mass (pink arrowhead) causing a small-bowel obstruction.", "Adjacent to this area, the endoscopic capsule (asterisk) is demonstrated in a proximal dilated loop of the small bowel."], "Treatment": ["Further investigation involved capsule endoscopy, which was ingested 3 days prior to his emergency department admission."]}
{"Patient Personal Background": ["Although previously healthy, he reported some hospitalizations for nonspecific abdominal pain during his infancy."], "Patient Symptoms": ["Colicky abdominal pain started after eating cornflakes in the morning, then regressed spontaneously during the day.", "A relapse of the symptoms occurred the morning after and worsened during the day, with the onset of nausea as well.", "His bowel was initially open to gas and normal stools but, afterward, only to gas."], "Examination and Results": ["A physical examination revealed a soft and nondistended abdomen, with localized tenderness and guarding in the epigastric region and in the right lower quadrant.", "Hyperactive bowel sounds could be heard.", "The results of a digital rectal examination were normal.", "His vital signs were as follows: an axillary temperature of 37.3\u00b0C, a pulse rate of 71 beats per minute, and blood pressure of 120/80 mm Hg.", "The results of a urinalysis were negative; blood test results were within the normal limits, except for an elevated white blood cell count of 13\u202f000/\u03bcL (to convert to \u00d7109 per liter, multiply by 0.001), an unconjugated bilirubin level of 1.2 mg/dL (to convert to micromoles per liter, multiply by 17.104), an increased aspartate aminotransferase level of 52 U/L (to convert to microkatals per liter, multiply by 0.0167), and an alanine aminotransferase level of 136 U/L (to convert to microkatals per liter, multiply by 0.0167).", "His C-reactive protein level was 10 mg/L (to convert to nanomoles per liter, multiply by 9.524).", "A plain radiograph of his abdomen was negative for air-fluid levels and for signs of perforation.", "Further evaluation of his abdomen using ultrasonography revealed hepatic steatosis and, in the right lower quadrant, thickening of the cecal wall and a hypoechoic area 33 mm in diameter with blurred margins (Figure 1).Ultrasonographic images of the right iliac fossa (A) and the right lower quadrant of the abdomen (B) with thickened cecal wall (a) and hypoechoic area 33 mm in diameter with blurred margins (b)."], "Treatment": ["For this reason, the patient autonomously took 2 tablets of hyoscine butyl bromide without any benefit."]}
{"Patient Symptoms": ["The mass continued to enlarge and she developed progressive generalized weakness, slowed speech, and focal right-handed weakness.", "Acute onset of headache and decline in mental status prompted presentation to the ER."], "Examination and Results": ["She initially was seen by her primary care practitioner, where neurological examination was nonfocal.", "On examination an 8-cm left parietal mass was tender to palpation.", "Brain magnetic resonance imaging showed a large enhancing left frontal-parietal mass extending both extracranially and intracranially into the superior sagittal sinus (Figure).", "There was left frontal, parietal, and temporal bone involvement, and left dural thickening.", "Intracranially, there was adjacent vasogenic edema and associated mass effect.", "Computed tomographic (CT) scans of the chest, abdomen, and pelvis revealed a ground-glass sclerotic lesion of the right sacrum."], "Treatment": ["Treatment with 4 mg of dexamethasone was initiated intravenously."], "Others": ["All biochemical laboratory results were normal.", "Owing to involvement of the superior sagittal sinus and progressive growth, an ultrasound-guided core needle biopsy was performed.Large extracranial and intracranial mass extending into the superior sagittal sinus, brain, soft tissue, and bone, with left dural thickening as visualized on T1 postcontrast imaging coronal (A) and sagittal (B) views.", "Axial view of brain edema as seen on T1-weighted (C) and T2-weighted imaging without contrast (D)."]}
{"Patient Personal Background": ["His medications included amlodipine, hydrochlorothiazide, and ezetimibe.", "He worked outdoors for an oil drilling company.", "He denied recent travel out of the country."], "Patient Symptoms": ["He described the pain as akin to stepping on a sharp object and characterized it as moderately intense, sharp, continuous, and without radiation.", "After first noticing the pain, he had examined the inside of his boot but did not identify anything that would account for the tenderness."], "Examination and Results": ["Physical examination revealed 2- to 3-mm grouped vesicles on an erythematous base in a discrete area of the sole of the right foot (Figure) and no additional rashes elsewhere on the body.", "Vesicular fluid was sent for analysis.Left, Grouped vesicles on sole of patient\u2019s right foot."], "Others": ["He reported no fevers, chills, or malaise.", "He denied history of human immunodeficiency virus (HIV), hepatitis, chickenpox, or recurrent infections."]}
{"Patient Personal Background": ["He took no prescribed medications but had taken an ibuprofen pill a week prior for a mild headache; his symptoms started 3 days after that.", "He had no sick contacts or recent travel and reported no use of alcohol or tobacco.On examination, he was febrile (38.9\u00b0C) and tachycardic but normotensive."], "Patient Symptoms": ["He noticed multiple acneiform papules and pustules around the neckline that progressed to involve the face, torso, and limbs."], "Examination and Results": ["He had no sick contacts or recent travel and reported no use of alcohol or tobacco.On examination, he was febrile (38.9\u00b0C) and tachycardic but normotensive.", "Clusters of pustules, approximately 1 mm in diameter, were present over an erythematous base overlying the face, neck, chest, back, and arms (Figure).", "Laboratory analysis revealed values within normal ranges for hemoglobin (13.1 g/dL) and platelet count (186 \u00d7109/L); an elevated white blood cell count (22.3 x109/L; 82% neutrophils, 9% lymphocytes, 5% eosinophils, 4% monocytes); erythrocyte sedimentation rate of 58 mm/h (reference range, 0-20); C-reactive protein level of 232 mg/L (2210 nmol/L) (reference, <5 mg/dL [48 nmol/L]); and normal renal and hepatic function.", "Gram stain of the pustule fluid revealed no organisms, and cultures of the blood and pustule fluid were without growth."]}
{"Patient Personal Background": ["He reported smoking marijuana and denied tobacco and intravenous drug use.", "He is sexually active, with multiple male partners.On examination, he was alert and oriented, with a temperature of 36.3\u00b0C, blood pressure of 131/90 mm Hg, heart rate of 94/min, respiratory rate of 18/min with pulse oximetry of 98% on ambient air, and a body mass index of 28.1 (calculated as weight in kilograms divided by height in meters squared)."], "Patient Symptoms": ["His mother reported that he had experienced personality changes."], "Examination and Results": ["Neurologic examination was significant for hyperreflexia in all extremities, bilateral shoulder weakness, and right-sided pronator drift.", "Laboratory results showed a white blood cell count of 3600/\u03bcL (73.5% neutrophils, 16.4% lymphocytes, 7.8% monocytes, 1.4% eosinophils, 0.6% basophils); the remainder of the complete blood cell count and comprehensive metabolic profile was unremarkable.", "The result of a human immunodeficiency virus (HIV) type 1 antibody test was positive, and CD4 cell count was 73/mm3.", "Results of serologic testing for Toxoplasma gondii IgG were negative.", "Computed tomography (CT) imaging of the brain showed a left caudate nucleus and lentiform nucleus lesion with mass effect on the left lateral ventricle (Figure, left panel).", "Fluid-attenuated inversion recovery magnetic resonance imaging (MRI) of the brain confirmed the presence of an aggressive mass lesion extending through the corpus callosum (Figure, right panel).", "CT of the chest, abdomen, and pelvis and spinal MRI were unremarkable.Left, Computed tomography scan of the brain, axial view, with contrast."]}
{"Patient Personal Background": ["The patient\u2019s medications included methimazole and atenolol, which she had been taking since her diagnosis of Graves disease 1 year prior.", "She had not taken other over-the-counter medications or supplements."], "Patient Symptoms": ["She reported chills, bilateral lower extremity swelling, and several small, painful, \u201cpimple-like bumps\u201d appearing on her bilateral lower legs, which ulcerated several days later."], "Examination and Results": ["Physical examination of her bilateral lower extremities revealed pitting edema and multiple discrete, round, dry ulcers, most with central eschars, dusky gray borders, and collarettes of scale (Figure, A).", "Results from the initial laboratory workup revealed elevated levels of C-reactive protein and increased erythrocyte sedimentation rate.", "A punch biopsy specimen of an ulcer edge demonstrated a mid- and deep dermal marked lymphohistiocytic infiltrate with neutrophils and focal abscess, suggesting a nonspecific infection.", "No pathergy at the previous punch biopsy site was observed."], "Treatment": ["The ulcers progressed despite a recent course of trimethoprim-sulfamethoxazole for cultures growing methicillin-sensitive Staphylococcus aureus.", "The patient was initially treated with cephalexin, mupirocin, and conservative wound care, but the eruption later worsened, with new lesions appearing on her right leg."], "Others": ["During follow-up, an intact 4-mm papular lesion was identified on her lower right leg (Figure, B).", "A biopsy of the new intact papule was performed (Figure, C and D).A, Discrete, round, dry ulcers with central eschar and raised borders on left lateral lower leg.", "B, A new, 4-mm intact papule on right medial lower leg.", "C and D, Histopathological images from punch biopsy specimen of the papule, hematoxylin-eosin."]}
{"Patient Personal Background": ["On review of systems, he endorsed photosensitivity during childhood only.", "He denied any history of blistering, angioedema, dysphagia, hoarseness, dyspnea, or weight loss."], "Examination and Results": ["Physical examination revealed multiple skin-colored, waxy, smooth and variably verrucous papules and plaques on the dorsum of the nose and hands (Figure, A and B).A, Skin-colored, waxy, smooth papules on the dorsum of the nose.", "B, Waxy papules coalescing into verrucous-appearing plaques on the dorsal surface of the hand.", "C, Nodular deposits (hematoxylin-eosin, original magnification \u00d720).", "D, Dermal deposits (periodic acid\u2013Schiff\u2013diastase staining, original magnification \u00d74).Initial laboratory evaluation, including complete blood cell count, blood chemistry panel, liver function tests, serum/urine protein electrophoresis, and urine porphyrins, had unremarkable results.", "A punch biopsy specimen was obtained from the left dorsal hand for further evaluation (Figure, C and D)."], "Treatment": ["He had no improvement following treatment with class 1 topical corticosteroids and keratolytic emollients."]}
{"Patient Symptoms": ["He had initially developed rhinorrhea, cough, and low-grade fever 2 weeks prior.", "Over the next several days, he developed worsening fever, chills, and blisters and bullae on the arms, legs, and face."], "Examination and Results": ["Physical examination revealed numerous pink to violaceous macules, papules, and patches on the palms, dorsal hands, forearms, elbows, feet, and distal lower extremities (Figure, A and B).", "Fewer, scattered macules were on the face, neck, trunk, upper legs, upper arms, and scrotum.", "Dusky bullae were seen on the bilateral dorsal aspect of the hands, fingers, toes, and heels.", "In the oral cavity, there was 1 violaceous macule on the right buccal mucosa and a few linear, horizontal, white lines on the left buccal mucosa.", "Laboratory findings revealed a white blood cell count of 25\u202f600/\u03bcL (reference range, 3700-10\u202f500/\u03bcL) and a platelet count of 12\u202f400/\u03bcL (reference range, 15\u202f000-40\u202f000/\u03bcL).", "Results from a Tzanck smear from the initial lesion on the right dorsal aspects of the third finger were negative for multinucleated giant cells."], "Treatment": ["The patient was treated with azithromycin and subsequently developed few small, pruritic blisters on the hands and feet.", "He went to an urgent care facility and was diagnosed as having bronchitis and prescribed doxycycline and diphenhydramine."], "Diagnosis": ["He went to an urgent care facility and was diagnosed as having bronchitis and prescribed doxycycline and diphenhydramine."], "Others": ["He was admitted to the hospital, and the dermatology service was consulted.", "A punch biopsy was performed on the anterior side of the thigh (Figure, C and D)."]}
{"Patient Personal Background": ["He did not take medications, and he drank socially.", "He still worked full-time as a lawyer."], "Patient Symptoms": ["He frequently fell and had difficulty climbing the stairs.", "He stated he had hearing problems, but with further questioning, it was discovered he actually had difficulty deciphering speech.", "One month later, his condition progressed; he required a wheelchair, declined cognitively, and developed personality changes.", "He developed seizures and was admitted to a hospital.", "His mental status continued to progressively decline, and he became completely mute; he could only open his eyes and follow commands to protrude his tongue but was unable to move his eyes or any limbs."], "Examination and Results": ["His neurological examination showed mild cerebellar ataxia without myoclonus or parkinsonism.", "His Montreal Cognitive Assessment score was 28 of 30 points (2 points deducted from \u201cdelayed recall\u201d).", "Pure tone audiometry showed no conductive or sensorineural hearing loss.", "Brain magnetic resonance imaging (MRI) revealed no abnormal signal, including from the pons and cerebellum.", "A computed tomography scan of the chest, abdomen, and pelvis showed no malignancy.", "Results from cerebrospinal fluid (CSF) testing were normal without oligoclonal bands and a normal level of protein 14-3-3.", "He had no paraneoplastic antibodies in his serum or CSF.", "Results from electroencephalogram (EEG) were normal.", "Electroencephalogram showed diffuse slowing."], "Others": ["He did not have dizziness on standing nor bowel or bladder incontinence.", "He had no family history of imbalance problems."]}
{"Patient Personal Background": ["She had an ovarian cyst, but her medical history was otherwise unremarkable.", "There was no history of recreational drug use, tobacco or alcohol consumption, or sexually transmitted diseases."], "Patient Symptoms": ["A postmortem brain examination reported the presence of multitudinous corpora amylacea, but no specific neuropathological diagnosis was made.Neurologic examination of the patient during the initial consultation revealed a Mini-Mental State Examination score of 24 of 30 (points were missed on attention, calculation, and abstraction), and the patient was abulic, but it was otherwise unremarkable."], "Examination and Results": ["Her mother had died at 32 years of age, after having a chronic neuropsychiatric illness, culminating in a rapidly progressive dementia.", "Magnetic resonance imaging (MRI) of the brain showed scattered small foci of T2 hyperintensity in the white matter affecting the corpus callosum, bifrontal, and biparietal regions, associated with bifrontal and bitemporal atrophy (Figure1A).", "No lesions were identified in the cerebellum or brainstem.", "There was no abnormal enhancement.", "Laboratory investigations including complete blood cell count with differential; electrolytes; liver, renal, and thyroid function tests; vitamin B12 and folate levels; vitamin E; cholesterol and triglycerides; amino acids (serum and urine); syphilis and human immunodeficiency virus serologies; a paraneoplastic panel; and erythrocyte sedimentation rate were unrevealing.", "Cerebrospinal fluid analysis showed a slight protein elevation, but no pleocytosis, oligoclonal bands, or elevated immunoglobulin G synthesis rate.", "Arylsulfatase activity was normal.A, Axial T2 sequence showing bifrontal cerebral convexity sulcal enlargement greater than expected for patient's age, punctate bifrontal subcortical fluid-attenuated inversion recovery (FLAIR) hyperintense foci (right greater than left) are noted.", "B, Brain magnetic resonance imaging axial and coronal T2 FLAIR sequence showing more pronounced global cerebral atrophy, progression of the subcortical FLAIR hyperintense lesions in the frontal predominant distribution, and also affecting the periventricular and deep white matter into the subcortical areas."]}
{"Patient Personal Background": ["He lived with his parents, aunt, uncle, and 3-year-old cousin.", "His cousin received a diagnosis of chicken pox 6 months prior, but had persistent skin lesions and pruritus."], "Patient Symptoms": ["The dermatology department was consulted for a diffuse truncal rash concerning for a drug rash given the initiation of several antibiotics during his hospital stay.", "On admission, he was noted to have several scattered 2-mm pink papules on his trunk and extremities and a high density of blue-gray macules on his trunk.", "The duration of his skin lesions was unknown.", "His mother had several pruritic pink papules on her bilateral forearms, which she suspected were from sand fleas.A skin examination revealed a Fitzpatrick skin phototype I and numerous ill-defined 0.5- to 1-cm nonblanching blue-gray macules on his trunk, a few of which contained a central 2-mm dome-shaped pink papule (Figure)."], "Examination and Results": ["There were also several similar pink 2-mm papules and hemorrhagic punctae scattered on his trunk, extremities, and scalp.Multiple ill-defined 1-cm blue-gray macules, a few of which contain a central 2-mm dome-shaped pink papule (black arrowhead) on the chest and abdomen."], "Others": ["He was up-to-date on all of his immunizations."]}
{"Patient Personal Background": ["He had no significant medical history."], "Examination and Results": ["Results from basic laboratory testing, including serum electrolytes, troponin, and complete blood cell counts, were unremarkable.", "Routine electrocardiogram (ECG) at presentation (Figure 1A) revealed sinus rhythm with first-degree atrioventricular (AV) block, borderline right axis deviation, and right bundle branch block.", "Resting echocardiogram revealed normal left ventricular size and function, mild concentric left ventricular hypertrophy, and no significant valvular abnormalities.", "Shortly after the patient reached a peak heart rate of 130 beats per minute at 9 minutes 28 seconds of exercise (Figure 1B), his heart rate abruptly decreased to 95 beats per minute, with evidence of AV block (Figure 1C).", "Subsequent coronary angiogram revealed no obstructive epicardial coronary artery disease.A, Resting electrocardiogram (ECG) shows first-degree atrioventricular block and right bundle branch block."], "Treatment": ["The patient was sent for exercise stress echocardiography."], "Others": ["B, ECG rhythm during stage 3 of Bruce protocol.", "C, ECG during peak exercise with abrupt decrease in heart rate."]}
{"Patient Personal Background": ["His medical history was significant for an unusual gait with anterior displacement of the pelvis and hips since he began walking at 10 months of age."], "Patient Symptoms": ["Since then he had experienced intermittent episodes of limping accompanied by pain in both femurs."], "Examination and Results": ["Radiographs revealed no active fractures but did show extensive bony changes in the long bones and the skull.", "On examination, mild asymmetry of the head was noted on palpation with prominence of the right temporal and parietal area.", "On limited endoscopic examination, mucosal edema and mucopurulent discharge were observed in the left more than the right naris.", "An endoscope could not be advanced posteriorly owing to patient discomfort and right-sided sinonasal obstruction.", "Multiple macules with irregular borders were observed on the lower back, upper buttock, upper chest, upper neck, and right postauricular area.", "There was also a varus deformity of the lower extremities with mild discrepancy in leg length.", "An audiogram showed bilateral conductive hearing loss with a flat tympanogram.", "A computed tomographic (CT) scan of the head and neck revealed heterogenous opacification of the right ethmoid and maxillary sinuses with fluid accumulation within the bilateral mastoid bones and middle ears.", "His thyroid-stimulating hormone level was 0.19 mIU/mL (reference range, 0.5-2.4 mIU/mL), free thyroxine level was 1.3 ng/dL (0.9-1.6 ng/dL), and free triiodothyronine levelwas 4.6 pg/mL (3.4-5.1 pg/mL) (Figure).Computed tomographic images; bone windows."], "Treatment": ["Previous treatment with montelukast provided symptomatic relief; however, this was discontinued owing to behavioral changes."]}
{"Patient Personal Background": ["Her perinatal and medical histories were otherwise unremarkable."], "Examination and Results": ["On examination, a 1-cm mobile, well-defined, nontender mass over the nasal dorsum was noted.", "Findings from the rest of the otolaryngologic examination were normal.", "Careful inspection and palpation after excision revealed no bone involvement or intracranial extension.", "Histopathologic images of the excised nasal mass are shown in the Figure.Histopathologic images (hematoxylin-eosin) from the nasal mass, showing a disordered admixture of mature skeletal muscle, mature adipose tissue, and skin adnexal structures."], "Treatment": ["The preoperative plan was to excise the nasal dermal lesion and carefully inspect for any tracts extending intracranially, which would then warrant imaging and a revised intracranial approach.", "Intraoperatively, an incision was made above the mass and carried through the subcutaneous tissue to expose a mass with a white wall and pink tissue within.", "The 0.8\u2009\u00d7\u20090.5\u2009\u00d7\u20090.3-cm mass was freed from the surrounding tissue and excised down to the nasal bone.", "The neurosurgical team removed the superficial scalp cyst, which was found to be an epidermoid cyst."], "Diagnosis": ["Given the superficial nature of the nasal cyst on examination and in an effort to minimize radiation and anesthetic exposure for the patient, computed tomographic and magnetic resonance imaging were deferred."]}
{"Patient Personal Background": ["His medical history was notable for congestive heart failure, coronary artery disease, and gout.", "He noted a 10-pack-year smoking history and Agent Orange exposure."], "Patient Symptoms": ["Several days into his stay, he complained of having a hoarse voice for the past year.", "He denied dyspnea, dysphagia, and reported no weight loss.", "His voice was rough."], "Examination and Results": ["On examination, he had no palpable neck masses.", "The cranial nerves were grossly intact.", "He underwent a flexible laryngoscopy, which showed an exophytic yellow-white mid-membranous subepithelial lesion on the bilateral true vocal folds (Figure, A).", "On stroboscopy, there was decreased vibratory amplitude bilaterally and moderate phase asymmetry.", "Grossly, pathologic findings showed a chalky white lesion.", "Histopathologic review showed submucosal amorphous eosinophilic material (Figure, B).", "The amorphous material was negative for Congo red (Figure, C).", "Examination of an unstained slide showed needle-shaped birefringent crystals (Figure, D)."], "Treatment": ["With this nonspecific but benign diagnosis, and an inability for the patient to go to the operating room secondary to his comorbidities, he agreed to undergo office potassium titanyl phosphate laser photoangiolysis of the lesions to improve vocal fold contour and vibration.", "More of the chalky material was expressed as the overlying mucosa ablated with very little energy delivered."], "Others": ["Several weeks later, he underwent an indirect laryngoscopy and vocal fold biopsy in the office.", "On follow-up, the lesions persisted but were less bulky.A, Indirect laryngoscopy showing exophytic yellow-white mid-membranous subepithelial lesion on the bilateral true vocal folds.", "B, Amorphous eosinophilic material.", "Hematoxylin-eosin.", "C, Negative result for Congo red stain.", "D, Unstained slide showing needle-shaped birefringent crystals."]}
{"Patient Personal Background": ["He had a history of hypertension and had been prescribed a blood pressure medication (the name of which he could not remember), but he had not been taking it for weeks.", "He had no other pertinent medical history."], "Patient Symptoms": ["The swelling had been progressively increasing over the first 3 days but had remained stable over the past week.", "He denied any history of similar symptoms, pain, fever, odynophagia, or difficulty breathing.", "He complained of some difficulty swallowing owing to the swelling."], "Examination and Results": ["Physical examination revealed significant, soft, nontender swelling of the floor of mouth bilaterally causing elevation of the tongue (Figure, A).", "There was no edema of the tongue or lips.", "The neck was soft, nontender to palpation, and without palpable lymphadenopathy.", "Computed tomographic (CT) imaging of the soft tissues of the neck with intravenous contrast showed a 6.3-cm anteroposterior\u2009\u00d7\u20096.9-cm cranial caudal\u2009\u00d7\u20094.8-cm transverse cystic nonenhancing mass centered in the root of the tongue, with elevation of the oral aspect of the tongue and some downward displacement of the floor of mouth (Figure, B and C).", "The sublingual glands were compressed but otherwise appeared normal, and the sublingual spaces were effaced."], "Treatment": ["Surgical excision via an intraoral approach yielded a smooth, well-circumscribed mass."]}
{"Patient Personal Background": ["The patient recalled that the lesion was initially discovered 4 years prior to presentation at a different facility.", "He denied any previous ocular trauma and his medical and surgical histories were noncontributory."], "Examination and Results": ["Results of a complete review of systems were otherwise negative.At presentation, his visual acuity was 20/20 OU.", "Pupils and extraocular motility were intact.", "Intraocular pressures were 11 mm Hg OU.", "The anterior segment slitlamp examination was unremarkable in both eyes.", "A dilated retinal examination of the left eye revealed the findings depicted in the Figure, A.", "No retinal traction was noted.", "Spectral-domain optical coherence tomography was subsequently performed (Figure, B).", "No retinal pigment epithelium (RPE) atrophy, macular edema, retinal exudation, or subretinal fluid was noted.", "Posterior segment examination and imaging of the right eye demonstrated no abnormalities.A, Fundus photograph of the left eye demonstrating a nodular, darkly pigmented lesion with well-defined margins located inferonasal to the foveola."]}
{"Patient Personal Background": ["Aside from mild hyperopic astigmatism, there was no significant ocular, medical, or family history.", "The patient was not taking any prescription or over-the-counter medicines; however, she had recently used a short-term course of oral antibiotics for a tooth infection.On examination, Snellen visual acuity with correction was 20/20 OD and 20/25 OS."], "Patient Symptoms": ["The patient denied any change in vision, scotomas, transient visual obscurations, dimming of light, photophobia, or pain.", "She denied headache, pulsatile tinnitus, weight gain, joint pain, lethargy, decreased appetite, fever, or chills."], "Examination and Results": ["Confrontation visual fields and ocular motility were normal.", "External examination was unremarkable, and slitlamp examination revealed normal eyelids, conjunctiva, and sclera.", "There were 1+ anterior chamber white blood cells and trace anterior vitreous cells bilaterally.", "Posterior segment examination revealed 360\u00b0 nerve hyperemia with elevation of nasal disc borders bilaterally (Figure 1), without vitreous haze, snowballs, or snowbanks.", "There was no vascular sheathing, choroidal granulomas, or chorioretinal scarring in the periphery.Fundus photography from initial consultation showing 360\u00b0 nerve hyperemia with mild elevation of the nasal disc border bilaterally."]}
{"Patient Symptoms": ["He complained of right ocular irritation, redness, and discharge that had begun shortly after removal of the eyelid lesion 2 years prior.", "Eight months prior to referral, he developed a progressive right blepharoptosis followed by recurrent corneal erosions, which was treated with bandage contact lenses.On examination, he was found to have complete ptosis of the right eyelid, asymmetric erythema of the eyelid margin, and meibomian gland dysfunction, as well as papillary conjunctivitis with thickening of his medial right lower eyelid (Figure 1)."], "Examination and Results": ["His left eyelid had minimal inflammation.", "He was also noted to have right-sided subconjunctival hyperemia with a 7.2 mm\u2009\u00d7\u20092.5 mm corneal erosion and 2 mm of pannus on the right eye.A photograph of the patient demonstrating asymmetric clinical findings and scarring of the medial canthal area from previous biopsy.", "A, Fullness of the right upper eyelid with ptosis.", "B, Severe right-sided meibomian gland dysfunction, thickening of the medial lower eyelid, and subconjunctival hyperemia."], "Treatment": ["He was prescribed a treatment regimen for blepharitis, which subsequently included topical tobramycin-dexamethasone ointment, with little improvement in symptoms."]}
{"Patient Personal Background": ["Medical history included well-controlled type 2 diabetes treated with metformin and sitagliptin.Best-corrected visual acuity was 20/20 OU."], "Patient Symptoms": ["Review of systems was positive for a skin rash on the upper arms and trunk, which he noticed 2 months earlier."], "Examination and Results": ["There was a barely perceptible right relative afferent pupillary defect.", "Anterior segment examination was normal.", "On ophthalmoscopy, there were few vitreous cells with no detectable haze and optic nerve head edema grade IV on the Fris\u00e9n scale, with peripapillary flame hemorrhages in the right eye (Figure); the optic nerve was normal on the left.", "Automated perimetry using the 24-2 pattern and Swedish interactive threshold algorithm strategy (Humphrey Field Analyzer; Carl Zeiss Meditec) was normal in each eye and optical coherence tomography showed marked elevation of the peripapillary retinal nerve fiber layer on the right."]}
{"Patient Personal Background": ["The patient reported undergoing an appendectomy when he was 10 years old."], "Examination and Results": ["The patient did not have a fever and he was hemodynamically normal.", "Laboratory workup revealed leukocytosis with a white blood cell count of 11\u202f600/\u03bcL (to convert to \u00d7109/L, multiply by 0.001).", "Physical examination revealed tenderness in the right lower quadrant without overt signs of peritonitis.", "Abdominal computed tomography was obtained (Figure 1).Coronal computed tomography scan showing calcification in the terminal ileum with surrounding enteritis (arrowhead)."]}
{"Patient Symptoms": ["Intriguingly, the heartburn was most severe while she was sitting up but lying supine relieved the symptoms.", "Paradoxically, dysphagia was worse while she was reclining and partially resolved in the upright position."], "Examination and Results": ["The physical examination was normal while laboratory workup revealed mild anemia.", "Subsequently, further workup with an esophagram revealed a 2.7-cm filling defect at the gastroesophageal junction, suggestive of extrinsic compression.", "Computed tomography demonstrated a 2.5-cm low-attenuation ovoid lesion at the gastroesophageal junction (Figure 1A).", "Considering a diagnosis of gastric tumor, she then underwent upper endoscopy that showed a mobile smooth-surfaced polypoid subepithelial lesion at the posterolateral wall of the gastroesophageal junction.", "Mucosal biopsies were performed, which were consistent with normal squamous mucosal epithelium.", "Following this, endoscopic ultrasonography was performed, which demonstrated an anechoic, loculated, subepithelial lesion located within the submucosa of the distal esophagus (Figure 1B).", "The endosonographic borders were well defined without invasion into the nearby structures.", "Manometry and 24-hour pH testing revealed preserved motility but abnormal acid exposure of the distal esophagus.", "Ultrasonography of the liver, gallbladder, and pancreas revealed no abnormalities.Diagnostic imaging for the patient.", "A, Contrast computed tomogram (CT) revealing a mass at the gastroesophageal junction protruding into the cardia of the stomach.", "B, Endoscopic ultrasonography demonstrated a cystic lesion originating and localized to the wall of the esophagus but not invading local structures."], "Treatment": ["She was administered a trial of acid-suppression therapy for 6 weeks, which transiently alleviated heartburn but the dysphagia persisted."], "Others": ["The mass flopped back and forth into the gastroesophageal junction."]}
{"Patient Symptoms": ["She reported pain with chewing, which led to a 5-kg weight loss, but denied trismus."], "Examination and Results": ["On examination, there was craniofacial deformity with left facial preauricular swelling.", "The left parotid was firm and a fixed mass was felt throughout the left preauricular space, expanding into the temporomandibular joint area and zygoma.", "Soft-mobile lymphadenopathy was palpable in the left neck, and a firm, adherent, immobile right supraclavicular mass extended under the clavicle.", "Cranial nerve examination findings were normal.Magnetic resonance imaging and computed tomography of the neck showed a 3.2\u2009\u00d7\u20094.4\u2009\u00d7\u20092.8-cm lobulated enhancing paramandibular mass extending into the left masticator space and infratemporal fossa, with frank erosion of the left mandibular condyle (Figure).", "Several enlarged lymph nodes were noted.", "Computed tomography of the chest showed a 4.6\u2009\u00d7\u20093.2\u2009\u00d7\u20093.5-cm supraclavicular mass with infiltration of the surrounding fat and scalene muscle and extension into the chest wall and axilla.", "Positron emission tomography showed a large metabolically active left masticator space mass (standardized uptake value for body weight at maximum counts per pixel [SUVmax], 18.2) and previously mentioned pathologic nodes.", "The right supraclavicular mass was also metabolically active (SUVmax, 19.4), and metabolically active right axillary, left mediastinal, and intra-abdominal lymphadenopathy was also noted.A, Axial computed tomography of the head and neck showing a lobulated paramandibular mass (arrowhead).", "B, Magnetic resonance imaging of the brain showing a lobulated paramandibular mass (arrowhead).", "C, Coronal computed tomography of the chest demonstrating a paramandibular mass (arrowhead).", "D, Coronal computed tomography of the chest demonstrating a supraclavicular mass (arrowhead)."]}
{"Patient Personal Background": ["He had no other symptoms and reported taking no medications."], "Examination and Results": ["Findings on skin examination included near-complete loss of eyebrows and eyelashes, a scaly plaque on the right shin, and mild bilateral erythema of the earlobes, distal fingers, and toes (Figure)."]}
{"Patient Personal Background": ["She was a nonsmoker and took no medications.", "A review of her social history revealed that she was working at a horse stable and rode for many hours a day."], "Patient Symptoms": ["She reported that the eruption was worsening during the winter months.", "She had not experienced any fevers, chills, joint pains, recent weight loss, or any other constitutional symptoms."], "Examination and Results": ["On physical examination, distributed over the bilateral posterior lateral thighs, there were several arcuate to circinate erythematous to violaceous plaques.", "There were also several focal areas of ulceration with overlying scale-crust (Figure, A and B).", "A biopsy was performed during this initial visit (Figure, C and D)."]}
{"Patient Personal Background": ["He reported a medical history of rheumatoid arthritis (RA), chronic obstructive pulmonary disease, chronic kidney disease, and heavy tobacco use.", "The patient denied any recent changes to his medications or recent travel."], "Patient Symptoms": ["The lesions started spontaneously as erythematous tender papules with white purulent discharge."], "Examination and Results": ["No other household members were affected.Physical examination of the left lower extremity revealed a 2.5-cm keratotic plaque with central ulceration that expressed a straw-colored fluid.", "The limb was dusky with scattered hyperpigmented patches and surrounding erythema (Figure, A and B).", "Both lower limbs exhibited pitting edema of 1+ severity, and negative Homans sign bilaterally for deep vein thrombosis.", "Fungal and bacterial culture samples were negative.", "Rheumatoid factor was elevated at 198 IU/mL, and other laboratory data were noncontributory.", "A punch biopsy specimen was obtained from the edge of the lesion (Figure, C and D).A, Left pretibia on initial visit."], "Treatment": ["He recently failed a course of amoxicillin and trimethoprim-sulfamethaxazole initiated by his primary care physician."], "Others": ["B, Left pretibia at 7-day follow-up.", "C, Periodic acid\u2013Schiff stain (original magnification \u00d74).", "D, Hematoxylin-eosin stain (original magnification \u00d720)."]}
{"Patient Personal Background": ["The patient had occasional numbness in both legs in stocking distribution, attributed to diabetic neuropathy."], "Patient Symptoms": ["The patient reported no fevers, chills, weight loss, or night sweats.", "He had long-standing, intermittent dyspnea on exertion, but no baseline shortness of breath, orthopnea, or bilateral lower extremity edema."], "Examination and Results": ["Physical examination revealed a 4.5 cm waxy, nontender, smooth-surfaced, cobblestoned plaque located in the sulcus between the second and fourth toes (Figure, A).", "A biopsy specimen obtained by the patient\u2019s podiatrist was sent to the dermatopathology laboratory for review.A, Clinical presentation revealed smooth-surfaced cobblestoned plaque that was asymptomatic.", "B, Hemotoxylin-eosin stain (original magnification \u00d7100) results show a diffuse infiltrate of pale eosinophilic material with prominent clefts.", "C, Congo red stain (original magnification \u00d7200)."], "Treatment": ["The patient was then referred to a dermatology specialist for further treatment."], "Others": []}
{"Patient Personal Background": ["His medical history was significant for seizures and behavioral disturbances managed with stable doses of lamotrigine and chlorpromazine."], "Patient Symptoms": ["Associated symptoms included fatigue, decreased appetite, abdominal discomfort, and intermittent scleral icterus noted by his mother.", "His lower extremities were tender to palpation and he resisted passive ranging of his joints.A, Markedly edematous and friable gingiva."], "Examination and Results": ["On physical examination, he was nonverbal but in no visible distress.", "There was hemorrhagic gingivitis (Figure, A) without cervical lymphadenopathy, and the bilateral lower extremities had marked asymmetric pitting edema, large ecchymoses on the thighs, ankles, and feet (Figure, B), and scattered petechiae (Figure, C).", "C, On the lower leg, perifollicular hemorrhage and corkscrew hairs (arrowhead) are present.Initial laboratory workup revealed microcytic anemia with hematocrit level of 22.8% (to convert to proportion of 1.0, multiply by 0.01), mean corpuscular volume of 75.9 \u00b5m3 (to convert to femtoliters, multiply by 1), white blood cell count of 5.9/\u00b5L (to convert to \u00d7109 per liter, multiply by 0.001), platelet count of 248 \u00d7103/\u00b5L (to convert to \u00d7109 per liter, multiply by 1), elevated erythrocyte sedimentation rate of 52 mm/h (to convert to millimeters per hour, multiply by 1), and C-reactive protein level of 5.5 mg/L (to convert to nanomoles per liter, multiply by 9.524), with hypoalbuminemia of 3.4 g/dL (to convert albumin to grams per liter, multiply by 10), but normal creatine kinase level of 83 U/L (to convert to microkatals per liter, multiply by 0.0167), and unremarkable activated partial thromboplastin time and international normalized ratio.", "Ultrasonography of the lower extremities showed soft tissue swelling without thrombosis.", "Lower extremity magnetic resonance imaging/magnetic resonance angiography showed diffuse round mildly enhancing bone marrow lesions without vascular changes."], "Treatment": ["One week prior, a dentist diagnosed acute necrotizing gingivostomatitis based on gum inflammation and bleeding, prompting treatment with metronidazole and penicillin."], "Others": ["There was no history of trauma, fevers, hematuria, or hematochezia or family history of coagulation disorders.", "B, Ecchymoses on the lateral ankle."]}
{"Patient Personal Background": ["He denied substance abuse or addiction.The abdomen was soft with hypogastric tenderness."], "Patient Symptoms": ["The pain was constant in the hypogastric region, with no radiation.", "He did not have bowel movements for 5 days but passed gas normally.", "He did not complain of nausea or vomiting."], "Examination and Results": ["He denied substance abuse or addiction.The abdomen was soft with hypogastric tenderness.", "There was no abdominal distension, guarding, or rebound tenderness.", "Neither hernia nor surgical scars were seen on examination, and vital signs and results from laboratory tests were normal.", "An axial contrast computed tomography (CT) scan of the abdomen was performed (Figure 1).A, A computed tomography scan of the abdomen did not show abnormal intestinal air-fluid levels nor free peritoneal air.", "B, A computed tomography scan revealed that the rectum was not empty."]}
{"Patient Symptoms": ["It grew rapidly throughout the past year, becoming increasingly painful and bleeding easily with light contact."], "Examination and Results": ["Clinical examination revealed an 8\u2009\u00d7\u20096\u2009\u00d7\u20094-cm multilobulated, purplish lesion that was fungating and friable (Figure 1).", "He also had a palpable, hard mass in the left axilla.", "A punch biopsy of the back mass revealed immunohistochemistry strongly positive for S-100, MART-1, and HMB-45.", "Computed tomographic and positron emission tomographic scans demonstrated a fludeoxyglucose-avid lesion on the back extending into the subcutaneous fat and fludeoxyglucose-avid uptake in the left axilla.An 8 \u00d7 6 \u00d7 4-cm multilobulated, purplish lesion on the back that was fungating and friable."], "Others": ["He had no other lesions elsewhere on his body."]}
{"Patient Symptoms": ["The patient then developed deep ST-segment depressions associated with chest and throat pain."], "Examination and Results": ["Transthoracic echocardiography showed an atrial septal defect, and transesophageal echocardiography confirmed a 1.2-cm secundum atrial septal defect with bidirectional shunting without a clear superior rim.", "A computed tomographic (CT) pulmonary angiogram showed a dilated pulmonary artery consistent with pulmonary hypertension (Figure 1A).A, Computed tomographic (CT) pulmonary angiogram showing a dilated pulmonary artery size in compare to the aorta size.", "B, Coronary angiogram revealing diffuse narrowing of the left main coronary artery at its origin.Right and left heart cardiac catheterization was performed.", "During coronary angiography, the patient was noted to have diffuse 90% to 95% narrowing of the left main coronary artery at its origin (Figure 1B; Video).", "The left anterior descending and left circumflex arteries were normal in caliber and appearance.The question arose whether the left main coronary artery stenosis represented an anatomic anomaly, a spasm, or a combination."], "Treatment": ["Intracoronary nitroglycerine was administered with no change in angiographic appearance of the left main coronary artery.", "The catheter was re-engaged, and additional intracoronary nitroglycerine was administered with the resolution of ST-segment depression and pain.The patient then developed ventricular tachycardia requiring cardioversion and intravenous amiodarone and lidocaine.", "The patient became unstable with recurrent episodes of ventricular tachycardia/fibrillation requiring cardiopulmonary resuscitation."]}
{"Patient Personal Background": ["He had no history of trauma, surgery, or intubation."], "Patient Symptoms": ["He experienced a popping sensation during the sneeze followed by neck stiffness 15 minutes later.", "He did not have associated shortness of breath, hemoptysis, or other pertinent medical history.", "Anterior neck examination revealed tenderness over the thyroid notch and left side of the laryngotracheal complex."], "Examination and Results": ["On physical examination, his vital signs were stable with normal oxygen saturation on room air.", "His voice was rough and without stridor.", "There was no palpable crepitus.", "Flexible laryngoscopy was performed, which showed hematoma of the left true vocal fold and laryngeal surface of the epiglottis with normal vocal fold movement and complete glottic closure (Figure, A).Hematoma of the left true vocal fold and laryngeal surface of the epiglottis."], "Others": ["B, CT indicates computed tomography."]}
{"Patient Symptoms": ["He reported no perceived association between these episodes and breathing and head position, and denied precipitation of symptoms with exposure to loud sound or pressure change.", "He had not experienced hearing loss, aural fullness, autophony, or headache."], "Examination and Results": ["On physical examination, objective, intermittent, clicking tinnitus at a frequency of 1 click per second was noted on placement of a stethoscope in close proximity to the right ear.", "The tinnitus coincided temporally with the patient\u2019s complaints but was nonsynchronous with pulse.", "Results from prior imaging including a computed tomographic (CT) scan of the head with multiplanar reconstruction (Figure, A, C, and D), were normal.", "Steady state tympanometry showed mildly decreased compliance of the tympanic membrane when the patient reported hearing the clicking sensation."], "Treatment": ["The patient was tentatively diagnosed as having tensor tympani and stapedius myoclonus and after discussion of treatment options, he decided to undergo middle ear exploration for muscle sectioning."], "Diagnosis": ["The patient was tentatively diagnosed as having tensor tympani and stapedius myoclonus and after discussion of treatment options, he decided to undergo middle ear exploration for muscle sectioning."], "Others": ["The incidental findings observed during middle ear exploration are shown in the Figure, B.A, Computed tomographic (CT) image of the head using bone window.", "B, Intraoperative photograph of incidental surgical findings.", "C, Multiplanar oblique coronal reconstruction of computed tomographic image.", "The inset shows the plane of reconstruction in an oblique coronal view longitudinal with the petrous pyramid.", "D, Computed tomographic image of the head using bone window."]}
{"Patient Symptoms": ["She had not experienced dyspnea, hoarseness, dysphagia, hemoptysis, or chest pain."], "Examination and Results": ["Flexible fiber-optic nasolaryngoscopy demonstrated a smooth hypervascular mass arising from the posterior membranous trachea (Figure, A)."], "Treatment": ["The patient underwent tracheostomy and complete excision via a transtracheal approach.", "The patient was decannulated on postoperative day 5."]}
{"Patient Symptoms": ["His appetite was intact; he had not lost weight; and no dysphagia, stomach pain, or stool irregularity was reported."], "Examination and Results": ["Blood tests revealed serious iron deficiency anemia (hemoglobin level, 8.6 g/d [86 g/L]) and a positive result for a fecal occult blood test.", "Initially, we performed an upper endoscopy that revealed normal esophageal mucosa with folding of the posterior esophageal wall through the entire length of the esophagus.", "Distal ending of the folding was not clearly seen in forward viewing, but in retroflexion, a necrotic polypoid lesion was observed protruding from the esophagogastric junction.", "A computed tomographic scan of the chest with oral contrast revealed an esophageal intraluminal tubular mass of soft-tissue density, about 15 mm in diameter originating just below the pyriform recessus and extending through the esophagus in the stomach lumen for about 20 mm (Figure 1).", "The patient was referred to an ear, nose, and throat specialist who performed esophagoscopy of the hypopharynx with the patient under endotracheal anesthesia.Intraluminal tubular mass extending through the entire esophagus."], "Others": ["CT indicates computed tomographic."]}
{"Patient Personal Background": ["He had experienced blurred vision of the right eye for 2 months; medical history included hypercholesterolemia."], "Patient Symptoms": ["He had experienced blurred vision of the right eye for 2 months; medical history included hypercholesterolemia."], "Examination and Results": ["Best-corrected visual acuity was 20/80 OD and 20/20 OS.", "The anterior segment was normal and intraocular pressure was 16 mm Hg in both eyes.", "Dilated fundus examination of the right eye revealed a normal optic disc, mild venous engorgement, and widespread peripheral dot-blot retinal hemorrhages mainly located in the temporal midperiphery (Figure 1A).", "No spontaneous retinal arterial pulsation was noted.", "Examination findings of the left eye were unremarkable.", "Fluorescein angiography in the right eye showed delayed venous filling, mild perifoveal leakage, and scattered microaneurysms in the temporal sector (Figure 1B).A, Montage color fundus photograph of the right eye at presentation shows mild venous dilation and midperipheral dot and blot hemorrhages mostly located in the temporal sectors.", "B, Fluorescein angiography frame (2 minutes, 3 seconds) shows multiple microaneurysms in correspondence of the dot-blot retinal hemorrhages and a barely visible perifoveal vascular leakage."]}
{"Patient Personal Background": ["Her medical history was significant for hypertension, asthma, hepatitis C, and essential tremor.", "Her medications include lisinopril, albuterol sulfate, and amantadine hydrochloride.", "She denied any previous ocular surgical procedures or trauma."], "Patient Symptoms": ["She endorsed mild photophobia but denied pain, redness, tearing, or discharge."], "Examination and Results": ["Her central corneal thickness at that time was recorded at 798 \u03bcm OD and 827 \u03bcm OS.Her best-corrected visual acuity at presentation was 20/70 OD and 20/50 OS.", "Her extraocular motility, pupils, and confrontation visual fields were normal.", "Intraocular pressures were 7 and 9 mm Hg OD and OS, respectively.", "An anterior segment slitlamp examination was significant for central bilateral stromal edema, Descemet folds, microcystic edema, and endothelial guttae in both eyes (Figure).", "There were no keratic precipitates, and the anterior chamber did not show cells or flare.", "Conjunctiva was white and quiet.", "No abnormalities were noted during an ophthalmoscopic examination.", "Her central corneal thickness was found to be 833 \u03bcm OD and 925 \u03bcm OS.Slitlamp photograph at presentation showing corneal edema in the left eye.", "Corneal edema was similar in both eyes."], "Treatment": ["She was seen 2 weeks prior and was treated with 400 mg of oral acyclovir sodium 5 times a day and sodium chloride, 5%, ointment 4 times a day."], "Others": ["There was no history of oral/genital ulcers, rashes, or atopy."]}
{"Patient Personal Background": ["Her medical history included sarcoidosis, type 2 diabetes, hypertension, and coronary artery disease.", "Her ocular history included pseudophakia and proliferative diabetic retinopathy in both eyes; she had also undergone pars plana vitrectomy and panretinal photocoagulation in both eyes."], "Patient Symptoms": ["However, her symptoms persisted and eventually worsened.", "She reported increasing swelling and pain in the affected region.", "She denied changes in vision, eye pain, or pain with eye movements."], "Examination and Results": ["The patient\u2019s best-corrected visual acuity was 20/60 OD and 20/50 OS, her pupils were reactive, extraocular motility was full and painless, and intraocular pressures were 18 mm Hg in both eyes.", "External examination revealed an erythematous, tender, firm mass in the medial periorbital area (Figure, A).", "Results of anterior slitlamp examination and dilated fundus examination were unremarkable.", "Contrast-enhanced computed tomographic imaging of the maxillofacial region was performed and showed a peripherally enhancing mass in the affected area (Figure, B).A, External photograph demonstrating a firm, tender, erythematous mass located in the medial periorbital area."], "Treatment": ["Seven days prior to presentation, an ophthalmologist prescribed the patient oral amoxicillin-clavulanate, 500 mg 3 times daily, and topical antibiotics."]}
{"Patient Personal Background": ["The patient had a concussion 1 year prior after becoming dehydrated during marching band practice, fainting, and hitting her head on pavement.", "Her postconcussion symptoms included headaches, dizziness, and dysarthria.", "The headaches and dizziness resolved but the dysarthria remained.", "Brain magnetic resonance imaging (MRI) within the last year was normal.", "Family history was unremarkable for vision loss, glaucoma, inherited retinal degeneration, and autoimmune disease.Best-corrected visual acuity was 20/80 OU."], "Patient Symptoms": ["She complained of progressively declining, blurred vision for 2 years.", "She denied floaters, flashes of light, headaches, and eye pain.", "The headaches and dizziness resolved but the dysarthria remained.", "Family history was unremarkable for vision loss, glaucoma, inherited retinal degeneration, and autoimmune disease.Best-corrected visual acuity was 20/80 OU.", "Goldmann visual field testing showed mild bilateral nasal constriction.Two months after presentation, the patient returned with new balance difficulties and worsening dysarthria.", "Horizontal and vertical saccades were markedly slowed bilaterally."], "Examination and Results": ["Ishihara testing revealed red-green color deficiency bilaterally.", "Intraocular pressures, extraocular motility, confrontational visual fields, and pupils were normal.", "Anterior segment examination was unremarkable.", "Ophthalmoscopic examination demonstrated mild mottled retinal pigment epithelial abnormalities bilaterally (Figure, A).Right eye multicolor fundus image and retinal spectral-domain optical coherence tomography (SD-OCT).", "A, Multicolor fundus image demonstrates mild macular mottling.", "The optic disc and retinal vessels are unremarkable.", "B, Retinal SD-OCT shows normal foveal contour with disruption and loss of the interdigitation and ellipsoid zones subfoveally.Fundus autofluorescence showed bilateral mild macular hyperautofluorescence likely within normal range without evidence of flecks.", "Retinal spectral-domain optical coherence tomography demonstrated bilateral disruption of the interdigitation and ellipsoid zones subfoveally (Figure, B).", "Electroretinogram (ERG) revealed delayed and decreased amplitude responses to 30-Hz flicker with normal dark-adapted responses.", "Goldmann visual field testing showed mild bilateral nasal constriction.Two months after presentation, the patient returned with new balance difficulties and worsening dysarthria."]}
{"Patient Symptoms": ["Three months into treatment, she developed multiple thick, mildly pruritic, yellow hyperkeratotic plaques on her lower extremities (Figure, A)."], "Examination and Results": ["B, Shave biopsy of skin (hematoxylin-eosin; original magnification \u00d710).", "C, Deeper biopsy demonstrating bandlike lymphocytic infiltration (hematoxylin-eosin; original magnification \u00d720)."], "Treatment": ["Biopsy results demonstrated a squamous cell carcinoma (SCC) of the lung, and chemoradiotherapy with carboplatin and paclitaxel for stage 3A disease was initiated.", "An allergic reaction prompted a change to cisplatin-etoposide, which continued as adjuvant chemotherapy after the radiation was complete.", "At first restaging, a recurrence of disease in the lung was detected, which was treated with cisplatin and gemcitabine for 4 months before she enrolled in a clinical trial (NCT02009449) in which she received combination therapy with pembrolizumab, 2 mg/kg intravenously for 21 days, and an investigational agent, AM0010 (pegylated recombinant human interleukin-10), 10 \u03bcg/kg subcutaneously on days 1 through 14 of the 21-day cycle."], "Diagnosis": ["Biopsy results demonstrated a squamous cell carcinoma (SCC) of the lung, and chemoradiotherapy with carboplatin and paclitaxel for stage 3A disease was initiated."], "Others": ["A referral to a dermatology expert was initiated.A, Clinical image showing representative plaque on left leg of patient on initial presentation."]}
{"Patient Symptoms": ["Six weeks later, he presented with abdominal discomfort for 3 weeks relieved by bowel movements associated with increased stool frequency (4-5 Bristol type 4 stools per day)."], "Examination and Results": ["He was diagnosed with Clostridium difficile infection (CDI) with a positive stool polymerase chain reaction (PCR) for the toxin B (tcdB) gene.", "Laboratory studies showed unremarkable results (Table 1).", "Vital signs and physical examination were unremarkable and a repeat stool test for C difficile toxin PCR was positive.Diagnose recurrent Clostridium difficile infection (CDI) and prescribe metronidazole.Diagnose postinfectious altered bowel habits with C difficile colonization and recommend a high-fiber diet.Diagnose refractory CDI and consider fecal microbiota transplantation."], "Treatment": ["He was successfully treated with a 10-day course of oral metronidazole, and his bowel movement pattern returned to its baseline of 2 to 3 Bristol type 4 stools per day."]}
{"Patient Personal Background": ["Her medical and family histories were unremarkable."], "Patient Symptoms": ["The lesions had been present since childhood, but the size of the lesions and the intensity of pain associated with them had recently increased with even light touch causing paroxysms of pain.", "The pain associated with these papules worsened as the day progressed, and she could not tolerate elastic compression due to excessive pain on compression."], "Examination and Results": ["Physical examination revealed multiple discrete and agminated blue papules on the face, arms, hands, and thighs with a cobblestoned appearance (Figure 1).", "On palpation, the papules were exquisitely tender and partially compressible.", "The patient underwent duplex ultrasonography of representative papules on the thigh, and a skin biopsy specimen of a papule on the thigh was obtained for histopathologic evaluation.Clinically, multiple discrete and agminated blue papules are apparent, nodular, blue cutaneous lesions cobblestone-like in appearance, on the thigh (A) and hand and thigh (B)."]}
{"Patient Symptoms": ["The lesions were present since childhood, progressively increasing in number.", "They involved primarily her face, and, less so, her extremities and trunk.", "The papules were present in childhood and were increasing in number."], "Examination and Results": ["Previous studies and imaging of the 2 siblings had failed to reveal any systemic findings.Physical examination revealed multiple smooth skin-colored and erythematous papules of various size, some with telangiectasia, with a medial but asymmetrical distribution on the face (Figure, A).", "Identical, less numerous lesions were also present on her hands and back.", "Three biopsy samples were taken and showed similar findings (Figure, B-D).", "B, Hematoxylin-eosin stain (original magnification \u00d720).", "C, Hematoxylin-eosin stain (original magnification \u00d740).", "D, Alcian blue stain (original magnification \u00d710)."], "Others": ["There was no medical history of spontaneous regression.", "She had a young brother, who had the same papular lesions that had followed the same natural history, displaying a similar bodily distribution although fewer in number.", "A, Multiple skin-colored to erythematous asymptomatic facial papules in a woman in her 20s."]}
{"Patient Symptoms": ["Two ulcers developed at the surgical site, and 2 similar ulcers developed on his back shortly after cyst excision.", "A few days after establishing care, he presented to the emergency department with extreme weakness and intolerable pain related to his ulcers."], "Examination and Results": ["Physical examination revealed an ill-appearing man.", "In the right upper lobe, there were decreased breath sounds with clear auscultation in the remaining chest.", "On the right anterior neck were two, 3- to 4-cm tender ulcers extending to the deep subcutaneous fat with erythematous, friable borders (Figure).", "On his back were 2 similar 2- to 2.5-cm ulcers.", "Inflammatory markers were notably elevated.", "A complete autoimmune panel, indirect immunofluorescence assays, enzyme immunoassays for antineutrophil cytoplasmic antibodies (c-ANCA)/proteinase 3, antineutrophil cytoplasmic antibody/myeloperoxidase, a quantiferon gold test, cultures of blood, broncheoalveolar washings, and tissue analysis were performed.", "Only c-ANCA testing revealed positive results.", "A CT scan of the sinus showed multiple bony defects and acute and chronic sinusitis."], "Treatment": ["A transbronchial biopsy of the lung and excisional biopsy of the skin bridge between back ulcers were performed.A, Two deep ulcers of the right mid-lower back with erythematous borders."], "Diagnosis": ["He had been recently diagnosed with lung cancer based on computed tomographic (CT) and positron emission tomographic imaging showing an enhancing, hypermetabolic, 7-cm cavitary right upper lobe mass with mediastinal adenopathy."], "Others": ["A chest x-ray 6 months prior revealed negative results.", "B, Hematoxylin and eosin stain (original magnification \u00d7 5).", "C, Hematoxylin and eosin stain (original magnification \u00d7 200).", "D, Hematoxylin and eosin stain (original magnification \u00d7 200)."]}
{"Patient Personal Background": ["Until 18 months ago, he had worked as a clerk, but he retired because of a history of hypertension and diabetes.", "His family history revealed no neurological disorders, except for a brother who had a brain lesion excised."], "Patient Symptoms": ["Four days before presentation, he experienced sudden, severe neck pain that swiftly progressed to neck stiffness and bilateral shoulder pain.", "The next day, he noticed weakness in the right arm and leg.", "The day before hospitalization, the weakness progressed, and he lost the ability to ambulate."], "Examination and Results": ["On examination, he was afebrile, and his vital signs were normal.", "He was fully alert but had weakness in the right distal arm (medical research council [MRC] grade 3/5) and the right leg (MRC grade 4/5) with sensory impairment to pinprick and temperature in the left leg.", "Laboratory values revealed an elevated \u03b3-glutamyltransferase level of 615 U/L (reference range, 10-71 U/L).", "Analysis of the cerebrospinal fluid indicated xanthochromia; normal white blood cell count, 1 cell/\u00b5L; red blood cell count, 2.19\u2009\u00d7\u200910/\u03bcL; increased glucose level at 133 mg/dL (reference range, 40-80 mg/dL); increased total protein level at 0.10 g/dL (reference range, 0.03-0.05 mg/dL); and increased lactate level at 28.8 mg/dL (reference range, 9.9-21.6 mg/dL).", "Magnetic resonance imaging (MRI) of the brain and the entire spinal cord revealed patency of the intracranial vessels and multiple abnormal signals throughout the brain on T1-, T2-, and susceptibility-weighted sequences (SWIs) and 1 lesion at the level of the fifth cervical vertebra (Figure).A, Susceptibility-weighted magnetic resonance image (MRI) showing numerous intraparenchymal hypointensities (red arrowheads)."]}
{"Patient Symptoms": ["The rash did not bleed, ulcerate, weep, or appear itchy or painful, though the patient did seem uncomfortable when getting dressed.", "The lesions were nontender."], "Examination and Results": ["The eruption continued to spread down his left thigh over the next 2 days, at which point the pediatrician advised the family to go to the emergency department.On examination, the boy was afebrile and well-appearing.", "There were multiple discrete clusters of monomorphic pink to violaceous papulovesicles with surrounding erythema scattered across the left buttock, thigh, and upper calf, some with central punctate hemorrhagic crust (Figure).", "There were no skin lesions elsewhere."], "Treatment": ["His pediatrician prescribed cephalexin and mupirocin for a presumed cutaneous bacterial infection."], "Others": ["He was fully vaccinated, with routine vaccines at 12 months of age administered in the left thigh.", "The influenza vaccine was administered 1 week prior to presentation in the left buttock, after which his parents noted a red patch near the site of vaccination.", "The patch became raised and spread down the left thigh over the course of several days.", "He had no known sick contacts at day care, exposure to  herpes simplex virus, or exposure to new topical products or clothing.", "A test was performed.Discrete clusters of monomorphic pink to violaceous papulovesicles with surrounding erythema."]}
{"Patient Personal Background": ["His medical history was unremarkable.", "His social history was notable for a 15-pack-year smoking history and consumption of 6 to 8 beers per night.", "He had no family history of malignant disease."], "Patient Symptoms": ["He described early satiety but had no nausea or vomiting.", "He reported night sweats and a 9.1-kg weight loss over the prior 6 months."], "Examination and Results": ["On examination he had no fever, a reducible umbilical hernia, a palpable left-sided abdominal mass, and significant bilateral lower extremity edema.", "Laboratory evaluation revealed anemia for which the patient received several blood transfusions, leukocytosis (white blood cell count, 57\u202f000/\u03bcL), and hyponatremia (sodium level, 128 mEq/L).", "He was first referred to the hematology service, and a blood smear showed 74% neutrophils.", "A bone marrow biopsy specimen showed a hypercellular marrow with a myeloid left shift but no increase in blasts or dyspoiesis.", "Tests for BCR/ABL and peripheral blood JAK2 mutation were negative.", "Computed tomography revealed splenomegaly, hydronephrosis, and a 25-cm left-sided retroperitoneal mass (Figure).", "A, A large retroperitoneal mass extending from the upper abdomen into the pelvis.", "B, A mass encasement of the left kidney."], "Others": ["Surgical consultation was requested.Computed tomographic images."]}
{"Patient Personal Background": ["She had no significant medical history and no prior abdominal surgery."], "Patient Symptoms": ["Results of her abdominal examination revealed a slight distension and diffuse tenderness to palpation, particularly in the epigastrium and right upper quadrant, but no peritoneal signs."], "Examination and Results": ["In the emergency department, she was afebrile with stable vital signs.", "Results of laboratory tests were unremarkable except for mild leukocytosis.", "Abdominopelvic computed tomography revealed a distended cecum in the left upper quadrant (Figure 1).Computed tomographic images of a dilated cecum in the left upper quadrant (arrowhead)."]}
{"Patient Personal Background": ["A review of systems as well as her medical, family, and social history were unremarkable.", "She was not taking any medications and did not have any allergies."], "Patient Symptoms": ["She had no specific chief complaint other than intermittent floaters."], "Examination and Results": ["Best-corrected visual acuity was measured 20/25 OD and 20/20 OS.", "Extraocular movements were intact and pupils were round and reactive with no afferent pupillary defect.", "Intraocular pressure by applanation was 18 mm Hg OU.", "Her anterior segment examination was within normal limits.", "Examination of her fundus revealed the optic nerves seen in Figure 1."]}
{"Patient Personal Background": ["The patient had no ocular history.", "His medical history was significant for 8 months of bilateral recurrent gingivitis with persistent reactive lymphadenopathy of the head and neck unresponsive to treatment with systemic antibiotics."], "Patient Symptoms": ["He was referred to our clinic for worsening uveitis and ocular hypertension.", "He denied any constitutional symptoms.", "Gram stain and culture of aqueous and vitreous biopsy sample results were negative for infectious and cytologic studies, as were serum human leukocyte antigen B27, tuberculosis, syphilis, and sarcoidosis test results (Figure, C).Slitlamp examination findings of the left eye with hypopyon (A) and iris nodules (B)."], "Examination and Results": ["His visual acuity was 20/40 OD and 20/200 OS, and intraocular pressures were 17 and 32 mm Hg, respectively.", "On slitlamp examination, both eyes were markedly hyperemic with diffuse corneal stromal edema, and his anterior chambers were deep with 3+ OD and 4+ OS cell and mixed hypopyon and hyphema in each eye (Figure, A and B).", "His dilated fundus examination findings were remarkable only for an area of retinal pigment epithelial stippling inferonasal to the macula in the left eye, without any vitritis in either eye.", "He did not have any skin or mucocutaneous lesions, but he had extensive bilateral preauricular, submental, posterior occipital, and supraclavicular lymphadenopathy.", "C, Aqueous cytology (Wright stain).", "Note the scant cytoplasm containing small, irregular nuclei with inconspicuous nucleoli."]}
{"Patient Personal Background": ["In 1998, he underwent mitral valve replacement with a St Jude mechanical prosthesis for severe mitral regurgitation owing to a flail leaflet, with 2-vessel coronary artery bypass grafting.", "He reported compliance with warfarin therapy for many years.One year ago, he noted the onset of exertional dyspnea that culminated in multiple recurrent admissions for decompensated heart failure requiring intravenous diuretics."], "Patient Symptoms": ["He reported compliance with warfarin therapy for many years.One year ago, he noted the onset of exertional dyspnea that culminated in multiple recurrent admissions for decompensated heart failure requiring intravenous diuretics."], "Examination and Results": ["While hospitalized, he underwent a cardiac catheterization that demonstrated patent bypass grafts but a profoundly low cardiac output and elevated pulmonary capillary wedge pressure.", "A transthoracic echocardiogram was performed that suggested the presence of a significantly elevated gradient across his mitral prosthesis.", "A plain radiography of the chest demonstrated a mechanical prosthesis (Figure 1A).", "A transesophageal echocardiogram was then performed that demonstrated complete immobilization of 1 mechanical leaflet and impaired excursion of the other leaflet (Figure 1B), with subsequent severe mitral stenosis (Figure 1C) at a baseline heart rate of 82 bpm.", "B, Transesophageal echocardiogram midesophageal view (90\u00b0) demonstrating bileaflet mechanical mitral valve prosthesis with immobilized leaflet (left) in systole and diastole."], "Treatment": ["He developed worsening hemodynamic instability and refractory pulmonary edema, and a TandemHeart left ventricular assist device was placed for cardiogenic shock.A, Chest radiograph with zoom of the mitral valve prosthesis, demonstrating opening of 1 leaflet from en face view and other leaflet not seen."], "Diagnosis": ["A transesophageal echocardiogram was then performed that demonstrated complete immobilization of 1 mechanical leaflet and impaired excursion of the other leaflet (Figure 1B), with subsequent severe mitral stenosis (Figure 1C) at a baseline heart rate of 82 bpm."]}
{"Patient Personal Background": ["Her history of end-stage renal disease precluded postoperative radioactive iodine treatment."], "Patient Symptoms": ["Her compressive symptoms had also resolved."], "Examination and Results": ["Ultrasonography performed at her 3-month follow-up showed no evidence of disease recurrence or local metastasis.", "Ultrasonography revealed a 1.3\u2009\u00d7\u20091.1\u2009\u00d7\u20091.0-cm hypoechoic mass in the right central compartment and a suspicious lymph node in the right carotid sheath.", "Fine-needle aspiration confirmed recurrence of a malignant neoplasm in the central compartment; however, the lymph node was not amenable to sampling based on its anatomic location.", "C and D, Histopathologic images of resected tissue specimen, hematoxylin-eosin."], "Treatment": ["The procedure was uneventful and well tolerated.", "The patient decided to undergo a right central (level VI) lymph node dissection.", "In the right central compartment several prelaryngeal and pretracheal nodes were identified and excised.", "The expansile mass was excised."], "Diagnosis": ["Intraoperatively, insular carcinoma was dissected away from the cricothyroid membrane and recurrent laryngeal nerve.", "Histopathologic analysis revealed a cystic mass composed primarily of mucosal cells and sparse fibroconnective tissue (Figure, C and D).A, A large heterogeneously enhancing mass with central necrosis arising from the right thyroid fossa with leftward displacement of the trachea (t)."], "Others": ["After removal of the most distal of these nodes, a separate pale tan mass 2 cm in diameter was visualized at the level of the thoracic inlet.", "The mass demonstrated respiratory expansion and retraction.", "Large air-filled cavity (yellow arrowhead) measuring 20\u2009\u00d7\u200918\u2009\u00d7\u200915 mm and communicating with the right posterolateral aspect of the trachea.", "Incidental small esophageal diverticulae noted (e).", "B, Large air-filled cavity (red arrowhead) measuring 20\u2009\u00d7\u200918\u2009\u00d7\u200915 mm and communicating with the right posterolateral aspect of the trachea (t).", "C, Respiratory epithelial lined cyst.", "Respiratory mucosa with absence of thyroid, lung, smooth muscle, and cartilaginous tissues."]}
{"Patient Personal Background": ["Her birth had been uncomplicated after a term pregnancy."], "Patient Symptoms": ["Her parents also reported loud snoring and some retractions during sleep."], "Examination and Results": ["Physical examination revealed mild inspiratory stridor and several light-brown macules approximately 1 cm in size on the patient\u2019s skin.", "On flexible fiberoptic laryngoscopy (Figure), a supraglottic mass could be seen, but visualization of the full extent of the larynx or the mass was difficult owing to lack of cooperation by this very young patient.", "A submucosal lesion of the left aryepiglottic fold extending inferiorly to the level of the arytenoid, and displacing the epiglottis medially, was found.", "C, T1-weighted sagittal magnetic resonance image (MRI) showing laryngeal lesion.", "D, Bundles of spindle cells with angulated nuclei in a stroma of variable coarse collagen and loose myxoid matrix (hematoxylin-eosin, original magnification \u00d74)."], "Treatment": ["The decision was made to obtain a better view under direct laryngoscopy in the operating room.", "An incision was made through the mucosa, where a firm, whitish mass that bled minimally was noted, and a biopsy specimen was sent for permanent pathologic analysis."], "Others": ["There was no clinically significant medical or family history.", "A magnetic resonance image was then obtained to assess the full extent of the mass and whether surrounding tissues were involved.A, View of lesion at the level of the epiglottis on direct laryngoscopy.", "B, View of the vocal folds on direct laryngoscopy."]}
{"Patient Symptoms": ["Four months after SMG excision, she developed a right floor of mouth lesion after \u201cburning her mouth\u201d with high-temperature food."], "Examination and Results": ["No saliva was expressed on examination.", "Computed tomography (CT) and ultrasonography showed normal-appearing submandibular glands and neck soft tissues.", "A sialogram showed high-grade stricture approximately 3 to 4 cm into the right submandibular duct orifice.", "Complete stricture prevented evaluation of the proximal duct and intraglandular portions.", "Sialendoscopy showed a widely patent right submandibular duct proximally with a segmental takeoff, consistent with the Bartholin duct draining into the Wharton duct distal to a blind pouch identified 2.5 cm from the intraoral duct orifice (Figure, A).", "Magnetic resonance imaging demonstrated a cystic lesion in the right sublingual space following the Wharton duct (Figure, B).", "Recurrent floor of mouth swelling (Figure, C) was addressed by repeated marsupialization and eventual sublingual gland excision.", "Pathologic analysis identified fragments of squamous mucosa with inflammation, cystic space, and compressed granulation tissues consistent with mucous extravasation (Figure, D)."], "Treatment": ["Despite a Wharton ductoplasty to improve sublingual gland drainage through the Bartholin duct, the degree of scarring at the hilum and inability to further dilate warranted submandibular gland (SMG) excision.", "Recurrent floor of mouth swelling (Figure, C) was addressed by repeated marsupialization and eventual sublingual gland excision."]}
{"Patient Personal Background": ["Her medical history included ulcerative colitis (UC) controlled by oral azathioprine for 2 years.", "She was a nonsmoker."], "Patient Symptoms": ["Initially, she had been treated with oral amoxicillin\u2013clavulanic acid with no improvement.", "Initial clinical evaluation revealed respiratory distress with respiratory rate of 21 breaths per minute, with oxygen saturation 95% on room air."], "Examination and Results": ["Her heart rate was 95 beats per minute, her blood pressure was 135/91 mm Hg, and she was pyretic.", "Further examination with flexible fiberoptic laryngoscopy (Figure, A) showed considerable erythema and edema of the epiglottitis with patchy necrosis partially obstructing the glottis and saliva pooling in the supraglottis.", "Findings from the remainder of the otolaryngology examination and chest auscultation were normal.", "Subsequently, oxygen saturation improved to 100% with 3 L per minute of oxygen via nasal prongs.", "Her initial laboratory findings revealed a white blood cell count of 12\u202f000/\u03bcL, absolute neutrophil count of 46%, hemoglobin count of 12.8\u2009g/dL, and a platelet count of 175\u202f000/\u03bcL.", "Her C-reactive protein level was 5 mg/dL (normal level, <0.5 mg/dL).", "Results from liver function tests and chest radiograph were normal."]}
{"Patient Personal Background": ["He had a history of renal cell carcinoma and had undergone left nephrectomy 1 year prior with no recurrence."], "Examination and Results": ["Prior to presentation, his evaluation included brain magnetic resonance imaging and neurologic evaluation with unremarkable results, and he was scheduled to undergo neuropsychological testing.Visual acuity was counting fingers OD, and 20/100 OS.", "Motility and intraocular pressures were normal.", "There was a right afferent pupillary defect.", "Examination of the right eye revealed rubeosis iridis, a clear lens, neovascularization of the optic disc, retinal vasculitis, venous sheathing, and a dusky-appearing peripheral retina.", "The left eye had a clear lens and a normal fundus on clinical examination.", "Fluorescein angiography demonstrated a mixed retinal arteritis and phlebitis with extensive retinal and choroidal nonperfusion of the right eye with both retinal and optic nerve neovascularization.", "The left eye demonstrated patches of active arteritis peripherally with a minimally affected posterior pole (Figure).Fluorescein angiogram at 1 minute demonstrating a mixed occlusive arteritis and phlebitis (yellow arrowhead) with extensive areas of retinal and choroidal nonperfusion (white arrowhead) in the right eye."]}
{"Patient Personal Background": ["She had a history of \u201cmultiple lasers\u201d of her right eye and blindness of her left eye from an unrepaired retinal detachment.", "Her medical history included a pheochromocytoma, bilateral adrenal gland resection, and a pancreatic cyst.", "Her father had a history of retinal detachment in his right eye; her 2 siblings did not have any medical or ocular issues.Visual acuity was 20/200 OD and no light perception OS."], "Patient Symptoms": ["She had daily frontal headaches without any associated visual aura, numbness, or weakness."], "Examination and Results": ["Anterior segment examination was unremarkable in the right eye and revealed phthisis bulbi of the left eye.", "Dilated fundus examination of the right eye revealed prominent, engorged, and tortuous vessels with traction extending from the optic disc to the superior peripheral retina.", "There was an associated thick fibrotic epiretinal membrane extending from the macula to the superior peripheral retina.", "The retinal arterioles were attenuated and there was thickening of the macula with subretinal fluid found on optical coherence tomography.", "In the superior retinal periphery, there was an orange, round, circumscribed mass with overlying tractional retinal detachment and numerous other smaller orange masses (Figure 1A).", "Fluorescein angiography of her right eye showed early hyperfluorescence of the lesions with late leakage (Figure 1B).A, Wide-field scanning laser image of right fundus showing a round mass with an overlying tractional retinal detachment.", "Associated engorged and tortuous vessels emanate from the optic disc.", "B, Wide-field scanning laser fluorescein angiographic late-phase frame of right fundus demonstrating late leakage of engorged vessels."]}
{"Patient Personal Background": ["Her disease recurred 1 year later, and she underwent haplotype-matched allogeneic SCT 8 months prior to admission.", "The patient lived with her family, including her son who recently had a cough.", "She was born in the Philippines and immigrated to the United States 3 decades prior."], "Patient Symptoms": ["She denied recent travel.On examination, her temperature was 38.3\u00b0 C, pulse of 115 beats/min, blood pressure of 110/50 mm Hg, respiratory rate of 24 breaths/min, and an oxygen saturation of 90% on room air.", "Cardiopulmonary examination revealed tachycardia, increased work of breathing and bibasilar crackles without wheezes."], "Examination and Results": ["Cardiopulmonary examination revealed tachycardia, increased work of breathing and bibasilar crackles without wheezes.", "Her laboratory studies revealed a white blood cell count of 4.2\u2009\u00d7\u2009106/mL (normal range, 3.4-10\u2009\u00d7\u2009106/mL), hemoglobin of 10.3 g/dL (normal range, 12-15.5 g/dL [to convert g/dL to g/L, multiply by 10]), platelets of 45\u2009\u00d7\u2009106/mL (normal range, 140-450\u2009\u00d7\u2009106/mL), and creatinine of 1.2 mg/dL (normal range, 0.5-1.0 mg/dL [to convert mg/dL to \u03bcmol/L, multiply by 88.4]).", "A chest radiograph demonstrated bilateral opacities without pleural effusion or pneumothorax."], "Treatment": ["Two months prior to admission, she developed graft-vs-host disease requiring high-dose prednisone, rituximab, and intravenous immunoglobulin.", "At the time of admission, she was receiving prednisone (40 mg/d) and tacrolimus for graft-vs-host disease and prophylaxis of infection with levofloxacin, valacyclovir, posaconazole, and thrice weekly dapsone.", "On hospital day 2, she was intubated for hypoxemic respiratory failure."], "Others": ["Initial empirical treatment included vancomycin, cefepime, azithromycin, and oseltamivir."]}
{"Patient Personal Background": ["His home medications included acyclovir, fluconazole, and cyclosporine."], "Patient Symptoms": ["Temperature on admission was 103.1\u00b0 F, and other vital signs were unremarkable.", "Thereafter, he had 2 more emergency department visits and was readmitted for recurrent fever.", "A thorough physical examination revealed 2 nonpruritic skin bumps on the right forearm and left calf that both measured 1.0 cm\u2009\u00d7\u20091.5 cm."], "Examination and Results": ["Post-SCT bone marrow biopsy specimen analysis at day 30 showed no evidence of leukemic cells and 99.5% donor cells.", "Complete blood cell counts with differential counts showed no evidence of peripheral blasts.", "Laboratory and imaging work-up\u2014including chest radiographs, blood culture, fungal culture, urinalysis, sputum culture, respiratory viral panel, fungitell and galactomannan assay, coccidioidomycosis serology, and cytomegalovirus and human herpesvirus 6 polymerase chain reaction assays\u2014were all negative.", "Both bumps were soft without pigmentation or ulceration.", "Pathologic sampling of the respective lesions revealed a diffuse infiltration of large mononuclear cells with high nuclear-to-cytoplasmic ratio (Figure, A and B).", "Immunohistochemistry staining was positive for CD4 cells and myeloperoxidase (Figure, C and D)A and B, Histologic evaluation of the skin biopsy specimens."], "Treatment": ["Vancomycin and cefepime were started for possible infection.", "The patient was discharged with oral antibiotics after being afebrile for 72 hours."]}
{"Patient Personal Background": ["She did not have any history of bleeding disorders, preceding trauma, or other precipitating factors such as recent heparin exposure, surgical procedures, underlying liver disease, or receipt of anticoagulation agents.", "There was no family history of hematologic disorders.Her vital signs were normal."], "Patient Symptoms": ["Physical examination showed large ecchymoses on the left arm, right shoulder, left anterior chest wall, and flank."], "Examination and Results": ["There was no family history of hematologic disorders.Her vital signs were normal.", "Initial laboratory results showed isolated severe anemia.", "Computed tomographic imaging showed a large soft-tissue hematoma in the left chest wall without evidence of internal hemorrhage.", "Test results for other causes of anemia were unremarkable.", "Laboratory values and mixing study results are shown in the Table.The patient has a common clotting factor inhibitor.The patient has an extrinsic clotting factor inhibitor.The patient has an intrinsic clotting factor inhibitor.The patient does not have a clotting factor inhibitor."]}
{"Patient Personal Background": ["Her medical history was significant for asthma, but she had been symptom free for more than 7 years without medications.", "The patient, a stay-at-home mother, denied prior toenail trauma, frequent sports activities, or hyperhidrosis of the feet.", "She had undergone no previous diagnostic tests or treatment for her toenails."], "Patient Symptoms": ["She had used an over-the-counter antifungal cream intermittently to treat pruritus of her feet.", "She reported no pain in the nails or difficulty ambulating."], "Examination and Results": ["Physical examination revealed thickening, yellow discoloration, and subungual hyperkeratosis of all 10 toenails (Figure, panel A).", "Scale was present on the plantar surface skin and in the web spaces (Figure, panel B).", "Examination of the fingernails, scalp, and skin was normal.A, Appearance of toenails on left and right feet."], "Others": ["Her father and sister had similar, but less severe, toenail problems.", "She had no history of dandruff, skin problems, or joint pains."]}
{"Patient Personal Background": ["He fractured the digit more than 30 years earlier."], "Patient Symptoms": ["He reported paroxysmal, intermittent pain that was exacerbated by cold weather."], "Examination and Results": ["Physical examination revealed distal nail plate splitting with accompanying longitudinal erythronychia (Figure, A) and tenderness on palpation of the nail unit.", "Magnetic resonance imaging revealed a nail matrix lesion (Figure, B), which was excised using a transungual approach with partial nail avulsion."], "Treatment": ["Magnetic resonance imaging revealed a nail matrix lesion (Figure, B), which was excised using a transungual approach with partial nail avulsion."]}
{"Patient Personal Background": ["She was taking no medications and these lesions were unchanged throughout an uncomplicated pregnancy.", "There was no personal or family history of melanoma or eruptive nevi."], "Patient Symptoms": ["The patient noted that the lesions initially began on her thighs and rapidly multiplied throughout her skin.", "Some of the lesions were pruritic and when scratched could be removed, leaving behind a hyperpigmented macule."], "Examination and Results": ["On physical examination, she had hundreds of 1- to 2-mm dark brown-black monomorphic papules throughout her trunk, extremities, palms, face, tongue, and sclera (Figure, A).", "No lymphadenopathy was present.", "Findings from laboratory tests, including a complete blood cell count, comprehensive metabolic panel, and computed tomography of the chest, were unremarkable.", "A punch biopsy was performed for histopathologic examination (Figure, B-D).A, Photograph of left thigh shows diffuse 1- to 2-mm dark brown-black macules and papules.", "B and C, Punch biopsy of right arm shows a circumscribed proliferation of pigmented epithelioid melanocytic nests, located primarily at tips of rete ridges.", "Moderate cytologic atypia is present.", "Superficial papillary dermis shows prominent pigment incontinence.", "No mitotic figures are seen.", "Kamino bodies were not visualized.", "D, Melan-A immunostain shows low pagetoid migration of melanocytes with a lack of melanocytic confluence at the dermal-epidermal junction."], "Others": ["The patient described a sunburn several weeks prior to the initial eruption."]}
{"Patient Symptoms": ["The lesion initially appeared as a small, bluish plaque at a young age and had gradually increased in size with subsequent development of wartlike features.", "Aside from minor local pain and pruritus, the patient reported history of recurrent infections as well as oozing and bleeding after minimal trauma."], "Examination and Results": ["Physical examination revealed soft, compressible nodules overlying a friable verrucous plaque in a linear distribution involving the length of the right calf with minimal tenderness on palpation.", "No other lesions were found on the body.", "B, Biopsy specimen demonstrating epidermal verrucous hyperplasia, acanthosis, papillomatosis, and hyperkeratosis overlying dilated vessels in the dermis (hematoxylin-eosin, original magnification \u00d74).", "C, Deeper section showing similarly dilated vessels in the deep dermis to the base of the specimen, indicating the probability of deeper extension (hematoxylin-eosin, original magnification \u00d74).", "D, Negative D2-40 stain."], "Others": ["A deep punch biopsy specimen was obtained and sent for histopathological examination (Figure, B and C).A, Clinical photograph of extensive verrucous plaque on the right calf."]}
{"Patient Personal Background": ["He had previously been referred to orthopedics by his pediatrician owing to multiple presentations for the same complaint.", "He was born in the United States with no recent travel."], "Patient Symptoms": ["His pain was mild to moderate, woke him from sleep, and limited his physical activity."], "Examination and Results": ["According to outpatient records, his height had been unchanged for the last 2 years.A physical examination showed a well-appearing young boy with unremarkable heart, lung, and abdominal findings.", "There was mild tenderness to palpation of the lumbar spine, and mild pain elicited with flexion and extension of his back.", "His strength was 4/5 in bilateral lower extremities, with otherwise normal neurological examination findings.He had a white blood cell count of 6.2\u2009\u00d7\u2009103/\u00b5L (to convert to \u00d7109 per liter, multiply by 0.001), a hemoglobin level of 10.9 g/dL (to convert to grams per liter, multiply by 10.0), and a platelet count of 611\u2009\u00d7\u2009103/\u00b5L (to convert to \u00d7109 per liter, multiply by 1.0), with a normal peripheral smear result.", "The results of a complete metabolic panel were unremarkable, and so were his lactate dehydrogenase and uric acid levels.", "He had an erythrocyte sedimentation rate of 80 mm/h and a C-reactive protein level of 20 mg/L (to convert to nanomoles per liter, multiply by 9.524).In the emergency department, a radiograph of his chest (Figure, A) revealed a right paravertebral mass, destruction of left seventh rib, a compression fracture of T8, and bony erosion of L1 vertebra.", "A computed tomographic (CT) scan (Figure, B) revealed paravertebral abscesses with T8 compression and destruction.", "Mediastinal and hilar lymphadenopathy was noted on imaging but are not shown.A, Radiograph of the chest reveals a right paravertebral mass (left arrowhead), destruction of the left seventh rib (top right arrowhead), a compression fracture of T8 (middle right arrowhead), and bony erosion of L1 vertebra (bottom right arrowhead)."], "Others": ["The patient denied recent trauma, fevers, weight loss, cough, rash, or sick contacts."]}
{"Patient Personal Background": ["His medical and family history as well as review of other systems were unremarkable."], "Examination and Results": ["Physical examination revealed a positive Kussmaul sign and pulsus paradoxus but no cardiac murmurs.", "An electrocardiogram demonstrated sinus tachycardia.", "Results of a complete blood cell count and biochemical panel were within reference ranges.", "A chest radiograph revealed convexity on the right heart border suggestive of cardiomegaly (Figure 1A).", "Echocardiography demonstrated normal cardiac chambers and valves.", "However, an echogenicity was noted compressing the superior vena cava and right ventricle.", "The patient subsequently underwent computed tomographic imaging of the chest that revealed a large, 16.2\u2009\u00d7\u20096.8\u2009\u00d7\u20095.6-cm anterior mediastinal mass compressing the right cardiac structures, particularly the superior vena cava.", "The mass consisted mostly of fat attenuation, but was interspersed with nodular densities (Figure 1B).", "Tumor marker levels, including \u03b1-fetoprotein, lactate dehydrogenase, and \u03b2-human chorionic gonadotropin, were within reference ranges."], "Others": ["Chest imaging.", "A, Radiograph showed a convexity on the right heart border and cardiomegaly.", "B, Tomographic examination revealed a large, anterior mediastinal mass with fat attenuation interspersed with nodular soft tissue elements (asterisk)."]}
{"Patient Symptoms": ["He had been transferred from an outside institution with rectal bleeding requiring blood transfusion.", "Twenty hours after the procedure, he reported abdominal pain."], "Examination and Results": ["The result of an upper gastrointestinal endoscopy performed at the referring institution was normal.", "A colonoscopy had been performed at the referring institution, but visualization was poor, with fresh blood and clots noted in the ascending colon.", "At angiography, no blush or bleeding vessel was evident.", "Findings from computed tomographic scan of the abdomen and pelvis obtained at this time were unremarkable."], "Treatment": ["Endoscopic treatment of a right colon arteriovenous malformation with active bleeding was attempted.", "The patient underwent urgent angiography and embolization of a right colic artery branch (Figure 1B).", "The decision to embolize the right colic branch was based on the endoscopic findings and the presence of pooling contrast in the cecum noted on a computed tomographic angiogram (Figure 1A) performed at the referring institution.", "He was treated with antibiotics and observed."], "Others": ["This was unsuccessful and bleeding persisted.", "He had no further bleeding episodes."]}
{"Patient Personal Background": ["His medical history was significant for diabetes without retinopathy and radial keratotomy in both eyes for moderate myopia."], "Patient Symptoms": ["In the ensuing days to weeks after these urologic procedures, the patient reported fever, weakness, and decreased appetite, which resolved spontaneously after several days but resulted in persistent weight loss of\u2009approximately\u200915 lb.", "Three months following this episode, visual symptoms developed.On examination, visual acuity was 20/400 OD and 20/20 OS."], "Examination and Results": ["Intraocular pressure, pupils, visual fields, and ocular motility were normal.", "On slitlamp examination of the right eye, trace conjunctival hyperemia was present, the anterior chamber had occasional cells, the lens had mild nuclear/cortical cataract, and the anterior vitreous had 2+ cells.", "Dilated fundus examination of the right eye showed grade 2 vitreous haze, mild optic disc edema, scattered elevated white chorioretinal lesions\u2014some with mild surrounding intraretinal and subretinal hemorrhage\u2014and a prominent macular lesion (Figure 1)."], "Treatment": ["The patient had undergone 2 ureterorenoscopies over a 2-week period with laser fragmentation for nephrolithiasis.", "A ureteral stent was placed followed by systemic ciprofloxacin.", "The patient\u2019s urinary symptoms subsequently improved."]}
{"Patient Personal Background": ["His mother, also hyperopic, previously underwent prophylactic laser iridotomy for anatomically narrow, occludable angles.Best corrected visual acuity was 20/20 OU, with a manifest refraction of +7.75 \u22121.00\u2009\u00d7\u2009170 OD and +7.75 \u22121.25\u2009\u00d7\u2009010 OS."], "Patient Symptoms": ["He had a high hyperopic refractive error, and the magnification of his spectacle lenses highlighted the eccentric pupil.", "He had no associated symptoms of decreased vision, ocular pain, diplopia, glare, or haloes and had no history of ocular infection, surgical procedure, or trauma."], "Examination and Results": ["Slitlamp examination confirmed mild corectopia in the right eye, along with 4 clock hours of iridocorneal touch nasally and a \u201chammered silver\u201d appearance to the involved cornea (Figure 1).", "On examination via gonioscopy, there were high peripheral anterior synechiae (PAS) above the Schwalbe line in this area, while the remaining angle was deep without PAS.", "The left eye was normal.", "Intraocular pressures were 15 mm Hg OD and 14 mm Hg OS.", "Pachymetry testing revealed symmetric central corneal thicknesses of 577 \u03bcm OD and 582 \u03bcm OS.", "Both optic discs appeared healthy, with a cup-disc ratio of 0.2."]}
{"Patient Symptoms": ["She also reported intermittent, binocular diplopia."], "Examination and Results": ["Results from a review of systems were otherwise negative, and she had not experienced recent trauma.", "On examination, visual acuity was 20/20 in both eyes with subjective red desaturation OD.", "Pupils were equal and without afferent pupillary defect.", "Confrontation visual fields were full.", "Intraocular pressures were 24 mm Hg OD and 12 mm Hg OS.", "Hertel exophthalmometry showed 4.5 mm of relative proptosis OD.", "She had limitation of her extraocular muscles in nearly all fields of gaze OD, with the most obvious limitation occurring in abduction.", "She had decreased sensation to light touch in the right cheek (cranial nerve V2).", "There were no orbital bruits.", "Ocular examination revealed diffuse conjunctival injection OD with tortuous, dilated, corkscrew-shaped blood vessels (Figure, A).", "Dilated fundus examination revealed mild optic nerve hyperemia and mild vascular tortuosity OD.", "Vital signs and results from complete blood cell count and thyroid function tests were normal.", "Computed tomography and magnetic resonance imaging, angiography, and venography of the brain and orbits revealed extraocular muscle enlargement and enhancement and a dilated superior ophthalmic vein OD."], "Treatment": ["She was started on topical antihypertensive drugs for elevated intraocular pressure (IOP) in the affected eye (30 mm Hg) and referred to our institution."]}
{"Patient Symptoms": ["The patient reported the acute onset of foreign body sensation in his left eye while splitting wood 1 year prior.", "He stated that his vision initially returned to normal after treatment, but had subsequently worsened.", "He complained of tearing, photophobia, and burning in the left eye.The visual acuity was hand motions OS with a grossly constricted visual field by confrontation."], "Examination and Results": ["The intraocular pressure was normal.", "The anterior segment examination revealed mild edema of the cornea, a shallow anterior chamber, iris heterochromia (Figure 1A), and an intumescent white cataract with pigment deposition on the anterior lens capsule.", "The cataract precluded visualization of the fundus.", "B-scan ultrasonography did not reveal masses, retinal detachment, or foreign body (Figure 1B).Heterochromia iridis."], "Treatment": ["He attended a hospital emergency department at that time and was diagnosed with a corneal abrasion and treated with topical antibiotics."], "Diagnosis": ["He attended a hospital emergency department at that time and was diagnosed with a corneal abrasion and treated with topical antibiotics."]}
{"Patient Symptoms": ["On postoperative day 10, she developed seizures when walking and was immediately intubated.", "Subsequently, she developed hypoxemia and hypotension associated with acute pulmonary edema and new cardiomegaly (Figure 1A)."], "Examination and Results": ["Brain imaging revealed a new intracerebral hemorrhage in the right frontal and left occipital lobes, with narrowing of the internal carotid, basilar, posterior cerebral, and right posterior communicating arteries, suggestive of vasospasm or vasculopathy.", "An electrocardiogram showed nonspecific ST changes with T-wave inversion (Figure 1B), and serum levels of troponin and creatine phosphokinase were negative.", "Transesophageal echocardiography revealed new dilation of the left ventricle (LV), with an ejection fraction of 10%, functional mitral regurgitation, anterior and apical akinesis, and basal hypokinesis (Video 1, Video 2, and Video 3).", "The right ventricle (RV) was distended, with moderate tricuspid regurgitation.", "Recent pretransplantation coronary angiography did not reveal atherosclerosis.", "Her cardiopulmonary status rapidly worsened, with cardiogenic shock and refractory hypoxemia (arterial blood pH, 7.12; arterial partial pressure of oxygen, 43 mm Hg; and partial pressure of carbon dioxide, 56 mm Hg), despite mechanical ventilation (rate, 24/min; tidal volume, 6 mL/kg; fraction of inspired oxygen, 100%; and positive end-expiratory pressure, 15 cm H2O), neuromuscular blockade, and administration of inotropes.Patient workup.", "A, Chest radiographs were obtained on the morning of postoperative day 10 before (left) and after (right) the onset of pulmonary edema.", "B, An electrocardiogram shows nonspecific ST changes and T-wave inversion."], "Treatment": ["On postoperative day 10, she developed seizures when walking and was immediately intubated.", "A, Chest radiographs were obtained on the morning of postoperative day 10 before (left) and after (right) the onset of pulmonary edema."]}
{"Patient Symptoms": ["Neurologic examination showed incomplete left eye closure with a grade 5 of 6 on the House-Brackmann scale."], "Examination and Results": ["Physical examination revealed no palpable parotid mass and no overlying skin changes.", "Magnetic resonance imaging showed subcutaneous nodules focally infiltrating the superficial parotid gland with evidence of perineural spread along the labyrinthine segment of CN VII.", "Fine-needle aspiration (FNA) with ultrasonographic guidance was nondiagnostic.", "An open excisional biopsy demonstrated dense subcutaneous tissue overlying and invading the parotid gland.", "Intraoperative frozen section revealed a spindle cell tumor.", "Histopathologic examination revealed a subcutaneous mass with stellate extension into and around the parotid gland.", "The tumor consisted of bland fusiform tumor cells in a storiform pattern near inconspicuous hyalinized vessels (Figure, A and B).", "Immunohistochemical staining demonstrated diffuse positivity for CD34 (Figure, C), positivity for bcl-2, and negativity for CD99 and S-100.", "Fluorescent in situ hybridization (FISH) further characterized the tumor with a translocation t(17;22)(q21;q13) and corresponding COL1A1/PDGFB fusion protein (Figure, D).A-C, Histopathologic images."], "Treatment": ["Treatment with steroids and antiviral agents marginally improved facial strength and allowed eye closure.", "A superficial parotidectomy with facial nerve dissection and preservation was performed."], "Others": ["A, Tumor infiltrating around and within the parotid gland.", "B, Fusiform tumor cells arranged in a storiform pattern.", "C, Tumor cells strongly positive for CD34.", "D, Image from FISH studies."]}
{"Examination and Results": ["Examination revealed normal otoscopic findings, and an audiogram demonstrated moderate low-frequency CHL of 45 dB in the right ear and mild 30-dB CHL in the left ear with a normal tympanogram (Figure, A).", "An axial computed tomographic (CT) scan performed at that time was interpreted as normal.", "Owing to concerns of visual changes and possible associated genetic cause for hearing loss (HL), magnetic resonance imaging (MRI) was ordered 1 year after initial presentation and showed no central or peripheral otologic abnormalities.", "Follow-up audiograms at 3 and 6 months showed similar persistent CHL despite normal otoscopy results.", "After 30 months of persistent CHL with an unknown etiology, a repeated CT scan of the temporal bones was performed (Figure, B and C)."], "Treatment": ["Two sets of tympanostomy tubes were placed the year before his initial visit for presumed otitis media\u2013related CHL, but his hearing did not improve.", "The patient and family decided to treat the CHL with bilateral hearing aid amplification and a frequency modulation (FM) system at school.", "Operative intervention vs amplification was discussed, and the patient and family decided to continue with hearing aids because he had improved performance in school."], "Others": ["Surgical treatment will be considered in the future if there is a decline in hearing.A, Right-sided (45-db) and left-sided (30-db) conductive hearing loss in low frequencies (arrows).", "O and X indicate right and left air conduction, respectively; opening and closing brackets, right and left bone conduction, respectively.", "B and C, Axial computed tomographic (CT) scans of the temporal bones."]}
{"Patient Personal Background": ["His medical history included hypertension and chronic rhinosinusitis."], "Examination and Results": ["On oral endoscopic examination, mild bilateral hyperemia of the tonsillar area and posterior pharyngeal wall were noted.", "The base of tongue was normal.", "Fiber-optic laryngoscopy revealed a reddish, 2-cm supraglottic lesion involving medially the free margin of the suprahyoid epiglottis (Figure, A).", "The neoplasm appeared highly vascularized on narrowband imaging (Figure, B).", "For this reason, before attempting an incisional biopsy, contrast magnetic resonance imaging (MRI) was performed.", "The MRI scan revealed an oval, 2.2-cm hypervascular mass arising from the free border of the suprahyoid epiglottis, which extended along the right aryepiglottic fold.", "The mass appeared to be capsulated, with regular margins, and did not show laryngeal deep tissues invasion."], "Treatment": ["We proposed to the patient a surgical excision that could have been transoral or open according to the quality of exposure (which would be evaluated in general anesthesia).", "After evaluating the optimal exposure using a Crowe-Davis retractor, a transoral excision using the da Vinci robotic system was performed.", "The postoperative course was uneventful, and patient did not develop complications.", "On the second postoperative day, pain was fully controlled with oral medications, and the patient tolerated oral intake.", "He was discharged on the second postoperative day.A, Endoscopic examination of the supraglottic larynx revealing reddish supraglottic neoplasm arising from the free epiglottic border."], "Others": ["B, Narrowband imaging of highly vascularized supraglottic neoplasm."]}
{"Patient Symptoms": ["He had a several-year history of joint, back, and abdominal pain; constipation; fatigue; and depression."], "Examination and Results": ["Laboratory workup revealed a normal intact parathyroid hormone (PTH) level (50 pg/mL; reference range, 13-88 pg/mL) and a slightly elevated 24-hour urinary calcium level (314 mg/d; reference range, 25-300 mg/d).", "A technetium Tc-99m sestamibi scan showed no definitive lesion but demonstrated a small focus of possible increased tracer uptake near the mid-pole of the left thyroid lobe (Figure, A, arrowheads).", "No abnormal masses were readily identifiable by ultrasonography or contrast-enhanced computed tomography (CT) of the neck.", "Histological examination of permanent sections showed a thinly encapsulated parathyroid tissue (Figure, B) with approximately 30% displaying myxoid stromal change and focal presence of interspersed adipocytes (Figure, C, yellow arrowhead) bordered by a rim of compressed gland containing abundant stromal fat (Figure, C, blue arrowhead).", "Examination at higher power showed chief cells in lobules, nests, and focal trabeculae with occasional clusters of clear and oxyphil cells (Figure, C and D).A, Technetium Tc-99m sestamibi scan with sodium iodide I-123 subtraction."], "Treatment": ["He underwent a parathyroid exploration and excision of a soft, ovoid tissue, believed to be a slightly enlarged left inferior parathyroid gland (120 mg; 1.0\u2009\u00d7\u20090.6\u2009\u00d7\u20090.3 cm)."], "Others": ["Intracytoplasmic fat vacuoles were evident on intraoperative touch preparation.", "Columns 2 to 4 show delayed images at 30 minutes, 1 hour, and 2 hours.", "B-D, Histopathologic images (hematoxylin-eosin) of thinly encapsulated parathyroid tissue."]}
{"Patient Personal Background": ["He was initially evaluated by an infectious disease physician and a local dermatologist, who had intermittently prescribed empirical antibiotics (clindamycin hydrochloride and doxycycline calcium) for a presumptive clinical diagnosis of methicillin-resistant Staphylococcus aureus (MRSA) infection for more than 1 year with minimal response.", "Because no objective data including wound culture or biopsy were obtained during his prior evaluations, he sought an alternate clinical consultation given the appearance of new violaceous ulcerated lesions over his right lateral proximal calf (Figure, A) despite his actively taking doxycycline."], "Patient Symptoms": ["Because no objective data including wound culture or biopsy were obtained during his prior evaluations, he sought an alternate clinical consultation given the appearance of new violaceous ulcerated lesions over his right lateral proximal calf (Figure, A) despite his actively taking doxycycline.", "He endorsed spontaneous healing of previously involved sites despite the absence of antibiotic exposure but denied constitutional complaints, recent travel, or high-risk behavior."], "Examination and Results": ["His physical examination was unremarkable for hepatosplenomegaly or systemic adenopathy.", "Laboratory evaluation including complete blood cell count, peripheral blood cultures, MRSA swab, human immunodeficiency virus/human T-cell lymphotropic virus testing, flow cytometry, and Lyme disease titers had unremarkable results.", "Pathologic sampling of the lesions revealed V-shaped perifascicular infiltrative large lymphocytes with abundant amphophilic cytoplasm and prominent nucleoli (Figure, B and C).", "Lesional cells exclusively involving the dermis stained positive for CD30, leukocyte common antigen, CD2, TIA-1, and CD4 and negative for CD7, CD8, CD43, CD56, and programmed cell death protein 1.", "Scattered B lymphocytes were PAX5 positive and CD20 positive.", "Ki-67 level was 87%.", "Scattered dermal dendritic and Langerhans cells were S100 positive.", "T-cell receptor (TCR) gene rearrangement testing had negative results.", "Systemic imaging did not reveal extracutaneous involvement, and screening endoscopy for upper and lower gastrointestinal involvement had unremarkable results.A, Photograph of right lateral proximal calf shows violaceous ulcerated nodule."], "Treatment": ["He was initially evaluated by an infectious disease physician and a local dermatologist, who had intermittently prescribed empirical antibiotics (clindamycin hydrochloride and doxycycline calcium) for a presumptive clinical diagnosis of methicillin-resistant Staphylococcus aureus (MRSA) infection for more than 1 year with minimal response.", "Because no objective data including wound culture or biopsy were obtained during his prior evaluations, he sought an alternate clinical consultation given the appearance of new violaceous ulcerated lesions over his right lateral proximal calf (Figure, A) despite his actively taking doxycycline."]}
{"Patient Personal Background": ["She had hyperlipidemia for which she took fish oil and red yeast rice extract."], "Patient Symptoms": ["She reported no fatigue, depression, memory problems, dry skin, or constipation."], "Examination and Results": ["Heart rate was 80/min and body mass index was 31 (calculated as weight in kilograms divided by height in meters squared).", "Physical examination demonstrated a thyroid gland of normal size and consistency without palpable nodules.", "Deep tendon reflexes were normal."], "Diagnosis": ["Her laboratory values are reported in the Table.The patient has subclinical hyperthyroidism and does not need a repeat testing of a thyroid-stimulating hormone (TSH) level.The patient has subclinical hypothyroidism and does not need a repeat testing of a TSH level.The patient has subclinical hypothyroidism and should have the TSH level repeated in 1 to 3 months."]}
{"Patient Symptoms": ["He experienced nausea and vomiting in the 2 weeks prior to surgery.", "One week after the second operation, he reported an \u201cinability to visually focus on objects\u201d and excruciating, burning pain in the lower limbs, both proximally and distally."], "Examination and Results": ["On evaluation, the patient was alert and interactive, afebrile, and had no neck rigidity.", "A primary gaze upbeat nystagmus was present, with superimposed gaze-evoked nystagmus in all directions (Video).", "The remainder of the cranial nerve examination was normal.", "He had neither motor deficits nor coordination problems.", "Sensory examination revealed hyperalgesia and allodynia in the lower extremities.", "Bilateral ankle reflexes were diminished.", "He could not recall 3 items after a 5-minute delay.", "The results of laboratory tests, including a complete blood cell count and comprehensive metabolic panel, were all within reference ranges.", "Magnetic resonance imaging (MRI) of the brain showed abnormal signals of both medial thalami (Figure).Axial fluid-attenuated inversion recovery magnetic resonance imaging of the brain showing bilateral medial thalamic hyperintensity.", "These areas demonstrated restricted diffusion on diffusion-weighted imaging (not shown)."], "Treatment": ["Although the surgical procedure was uneventful, the postoperative period was complicated by an enterocutaneous fistula that required further surgical intervention."]}
{"Patient Symptoms": ["The lesions were round, hypopigmented macules and were symmetrically distributed in the affected area.", "The patient reported that the macules had appeared on his cheeks 2 years earlier and had gradually coalesced (Figure).", "There was no hair growth at the site of the lesions, and the patient reported no symptoms."], "Examination and Results": ["The size of the lesions ranged from approximately 2 to 3 mm to 25 mm in diameter.", "A skin biopsy was performed to rule out some kind of morphea.A, Hypopigmented macules on the face and neck.", "B, Absence of hair growth in the affected area."], "Treatment": ["He was treated for tinea versicolor, without success."], "Others": ["C, Hematoxylin-eosin staining (original magnification \u00d710).", "D, Hematoxylin-eosin staining (original magnification \u00d720)."]}
{"Patient Personal Background": ["He had been hospitalized 6 months prior for hypoxia."], "Patient Symptoms": ["The patient was referred for a second opinion.On presentation he had symmetric swelling of metacarpophalangeal joints (MCPs) and interphalangeal joints (IPs), preventing fist formation.", "Dorsal MCPs had ulcers distal fingers were dyspigmented and atrophic, capillaroscopy was normal, and palmar IP creases had ulcerated lichenoid papules (Figure, A and B)."], "Examination and Results": ["Chest computed tomography (CT) showed hilar lymphadenopathy, interstitial thickening, and perilymphatic ground glass opacities.", "Bronchoscopy revealed plaquelike lesions, and transbronchial nodal aspiration of mediastinal nodes was negative for carcinomas and/or granulomas.", "Auscultation revealed bibasilar rales.", "He had normal aldolase levels (4.5 U/L [to convert to \u03bckat/L, multiply by 0.0167]), depressed creatine kinase (32 U/L), hyperferritinemia (1543 ng/mL), and T lymphocytopenia (absolute CD3, CD4, and CD8 counts, 328 \u03bcL, 233 \u03bcL, and 85 \u03bcL, respectively); the patient also had anti-SSA (Ro) antibodies, and immunoglobulin G anticardiolipin antibodies (19.5 units).", "The patient tested negative for HIV, anti\u2013Scl-70 antibodies, anti\u2013\u03b22-glycoprotein 1 antibodies, lupus anticoagulant, cryoglobulins, and anti\u2013Mi-2 antibodies; prothrombin time, partial thromboplastin time, and tissue thromboplastin were normal.A, Edematous hands with crusted ulcers and surrounding hyperpigmentation overlying dorsal metacarpophalangeal joints and interphalangeal joints."], "Treatment": ["Prednisone was initiated for presumed sarcoidosis."], "Others": ["B, Ulcerating papules with crust located in the palmar creases of the priximal interphalangeal joints and distal interphalangeal joints.", "C, Histopathology."]}
{"Patient Personal Background": ["In addition, the patient suffered from a splenic marginal zone lymphoma with bone marrow infiltration, had a history of splenectomy, and an IgM-\u03ba paraproteinemia.", "His hematologic condition was considered stable by his physician, who had also been treating the patient for hepatitis C with ledipasvir-sofosbuvir for 3 months."], "Patient Symptoms": ["On examination, there was a warm erythema on most of the abdomen, which appeared distended owing to hepatitis-induced ascites (Figure, A)."], "Examination and Results": ["On examination, there was a warm erythema on most of the abdomen, which appeared distended owing to hepatitis-induced ascites (Figure, A).", "Laboratory results showed an elevated but stable white blood cell count of 19.04\u2009\u00d7\u2009103\u00b5L (reference range, 3.6-10.5\u2009\u00d7\u2009103\u00b5L), a recent rise of C-reactive protein levels to 179 mg/L (reference range, 0-5 mg/L), as well as a rise of IgM levels from 1060 mg/dL to 2220 mg/dL (reference range, 34-248 mg/dL) within the past year.", "A biopsy procedure was performed on the abdomen (Figure, B-D).A, Light red erythema on most of the abdomen.", "B, Interstitial infiltrate of deeply eosinophilic cells in the entire dermis and adjacent subcutis."], "Treatment": ["His hematologic condition was considered stable by his physician, who had also been treating the patient for hepatitis C with ledipasvir-sofosbuvir for 3 months."], "Others": ["Hematoxylin-eosin staining (original magnification \u00d72).", "C, Hematoxylin-eosin staining (original magnification \u00d740).", "D, Original magnification \u00d710."]}
{"Patient Personal Background": ["Two years prior, he was hospitalized with coma with no identifiable precipitant and an extensive workup done at that time only revealed an elevated ammonia level of 233 \u00b5g/dL (to convert to \u00b5mol/L, multiply by 0.714); etiology remained unclear but he improved with lactulose.", "Prior to this admission, he was working in a restaurant, did not ingest any drugs or mushrooms, and had no operations and no family history of similar problems."], "Patient Symptoms": ["His mental status rapidly declined despite treatment with lactulose, necessitating intubation.", "Within a few hours of transfer, his ammonia level peaked to 1960 \u00b5g/dL and he lost all brainstem activity due to diffuse cerebral edema (Figure 1B).A, Electroencephalography (EEG) showing diffuse polyspike complexes consistent with myoclonic seizures."], "Examination and Results": ["He was found to have hyperammonemia to 239.5 \u00b5g/dL and respiratory alkalosis (pH level, 7.482; partial pressure of carbon dioxide, 27.3 mm Hg, and partial pressure of oxygen, 109 mm Hg [to convert to kPa, multiply by 0.133]; and bicarbonate, 20.2 mEq/L [to convert to mmol/L, multiply by 1]).", "Liver and kidney function were normal (protein, 6.4 g/dL, and albumin, 3.4 g/dL [to convert to g/L, multiply by 10]; direct bilirubin, 0.1 mg/dL, and indirect bilirubin, 0.8 mg/dL [to convert to \u00b5mol/L, multiply by 17.104]; alkaline phosphatase, 38 U/L, aspartate aminotransferase, 22 U/L, and alanine aminotransferase, 42 U/L [to convert to \u00b5kat/L, mutiply by 0.0167]).", "Head computed tomography and cerebrospinal fluid analysis were unrevealing.", "Ammonia levels progressively increased to 1120.5 \u00b5g/dL, requiring hemodialysis and sodium phenylbutyrate, which did not lead to significant clinical improvement.", "On hospital day 6, he developed continuous myoclonus due to status epilepticus (Figure 1A), which was refractory to treatment with lorazepam and levetiracetam as well as continuous midazolam, lorazepam, and propofol infusions.", "B, Head computed tomography showing diffuse cerebral edema, obliteration of basal cisterns, and transtentorial and tonsillar herniation."], "Treatment": ["Two years prior, he was hospitalized with coma with no identifiable precipitant and an extensive workup done at that time only revealed an elevated ammonia level of 233 \u00b5g/dL (to convert to \u00b5mol/L, multiply by 0.714); etiology remained unclear but he improved with lactulose.", "His mental status rapidly declined despite treatment with lactulose, necessitating intubation.", "Ammonia levels progressively increased to 1120.5 \u00b5g/dL, requiring hemodialysis and sodium phenylbutyrate, which did not lead to significant clinical improvement.", "Plasma amino acids and urine organic acids were requested.", "Continuous venovenous filtration hemodialysis and carnitine treatment were started because of concern for inborn errors of metabolism."]}
{"Patient Personal Background": ["A throat culture grew group A Streptococcus."], "Patient Symptoms": ["The illness began 1 week prior with low-grade fever and back pain.", "The following day, she developed periorbital swelling and subjective high fever.", "The back pain resolved, but she complained of fatigue, stiffness in her limbs, and sore throat.", "She presented for reevaluation when she developed eyelid ecchymoses and conjunctival hemorrhage."], "Examination and Results": ["Four days prior to the onset of illness, she had completed a 10-day course of amoxicillin for acute otitis media.A 7-year-old girl with periorbital edema, ecchymosis, and bilateral conjunctival hemorrhage.A physical examination revealed a febrile patient with bilateral conjunctival hemorrhages, periorbital edema, and eyelid ecchymoses.", "She had tonsillar hypertrophy with erythema and exudates.", "Her liver and spleen were mildly enlarged.", "Laboratory tests showed leukocytosis with a white blood cell count of 16.7\u202f000/\u03bcL (to convert to \u00d7109 per liter, multiply by 0.001) with a predominance of lymphocytes, mild thrombocytopenia (platelet count, 108\u2009\u00d7\u2009103/\u03bcL [to convert to \u00d7109 per liter, multiply by 1.0]), elevated aminotransferases (alanine aminotransferase, 232 U/L [to convert to microkatals per liter, multiply by 0.0167]; aspartate aminotransferase, 261 U/L [to convert to microkatals per liter, multiply by 0.0167]), \u03b3-glutamyltransferase (265 U/L), conjugated bilirubin (2.3 mg/dL [to convert to microkatals per liter, multiply by 0.0167]), and lactate dehydrogenase (2116 U/L [to convert to microkatals per liter, multiply by 0.0167])."], "Treatment": ["A rapid antigen detection test from a throat swab was positive for group A Streptococcus, so she was given an \u201cantibiotic shot,\u201d presumably penicillin."]}
{"Patient Personal Background": ["The only medical history reported was a previous umbilical hernia repair.", "On further discussion, it was discovered that he was involved in a motorcycle crash many years ago.", "Other than a brief loss of consciousness, no significant injuries were sustained per the patient\u2019s report.", "He did undergo a formal trauma evaluation at that time; however, the radiographic images and medical records were no longer available.", "In addition to complaints of dyspnea and chest discomfort, the patient reported 5 to 6 episodes of small-volume emesis over the last 6 months."], "Patient Symptoms": ["He denied any other gastrointestinal symptoms, such as heartburn, dyspnea, or constipation."], "Examination and Results": ["A large air-fluid level was seen on a recent chest roentgenogram, and subsequent computed tomographic scans of his chest were obtained (Figure 1).", "The results of his examination were unremarkable, with the exception of bowel sounds being heard on auscultation of the left chest."]}
{"Patient Personal Background": ["He was diagnosed with myocardial infarction 1 month earlier at another hospital and a coronary intervention was performed with 1 drug-eluted stent put in the left anterior descending artery."], "Patient Symptoms": ["Progressive dyspnea at rest was noted in recent days."], "Examination and Results": ["Physical examination revealed tachycardia and tachypnea.", "His heart rate was 138 beats/min and respiratory rate, 25 breaths/min.", "Blood pressure was 92/58 mm Hg.", "Chest auscultation revealed bilateral rales.", "Heartbeat was regular, but with faint S1 and S2.", "The extremities were cold, while no pitting edema was found.", "Twelve-lead electrocardiography demonstrated persistent ST-T segment elevation in V2 to V6 leads.", "Transthoracic echocardiography showed a hypoechoic mass around the apical region (Figure 1A).", "Computed tomography of the chest revealed a large crescentic hypodense lesion surrounding the anterolateral wall of the left ventricle and apex (Figure 1B).A, Transthoracic echocardiography, apical 4-chamber view, showing a hypoechoic mass (arrowhead)."], "Others": ["Review of systems and family history were unremarkable.", "Laboratory findings were within normal limits.", "LA indicates left atrium; LV, left ventricle; RA, right atrium; RV, right ventricle.", "B, Computed tomography of the chest, axial view, showing a hypodense lesion surrounding the anterolateral wall of the left ventricle and apex (arrowhead)."]}
{"Patient Personal Background": ["He was not taking any regular medication."], "Patient Symptoms": ["The rash caused a burning sensation; otherwise, he was feeling well.", "He had a tender right submandibular lymphadenopathy but was apyrexial.A healthy teenaged boy presented with multiple target lesions and erythema on his right eyelids."], "Examination and Results": ["His visual acuity was 20/20 OU.", "Examination revealed clusters of target lesions on the right upper and lower eyelids.", "There were papillae in the upper palpebral conjunctiva and follicles and a few pustules in the lower palpebral conjunctiva.", "The cornea was unremarkable with no staining, and results of a dilated ophthalmoscopy examination were normal.", "Ocular movements were full, and there was no proptosis.", "A few solitary lesions were found scattered on his nose and right cheek; however, his body was not affected."], "Others": []}
{"Patient Symptoms": ["During the office evaluation, the patient had an uncorrected visual acuity of 20/30 OD and 20/25 OS but was extremely photophobic and would not cooperate with any additional examination."], "Examination and Results": ["An examination under anesthesia was performed.", "Intraocular pressures by Tono-Pen XL (Reichert) under light sedation were 13 mm Hg OD and 12 mm Hg OS.", "Axial lengths by echography were 23.7 mm OD and 23.9 mm OS.", "Retinoscopy showed bright reflexes in both eyes.", "Anterior segment examination of each eye showed normal eyelids and lashes, conjunctiva, anterior chamber, iris, and lens.", "The examination of the cornea of each eye was significant for punctate keratitis in the epithelial and subepithelial layers that stained lightly with fluorescein (Figure).", "The corneal diameters were normal, and there was no evidence of Haab striae or stromal scarring.", "The ophthalmoscopic examination was unremarkable.RetCam photograph demonstrating punctate keratitis in the epithelial and subepithelial layers of the cornea."]}
{"Patient Symptoms": ["She also noticed subjective fevers, weakness, and spasticity in her left upper and lower limbs, along with right ear pain and decreased hearing."], "Examination and Results": ["Her postoperative course had initially been complicated by the development of a transverse sinus thrombosis on postoperative day 4, for which she was treated with anticoagulation.Over the next several days, she experienced marked worsening of her headaches, nausea, and blurred vision.", "Repeated magnetic resonance imaging and venography of the head and neck demonstrated worsening of the cerebral venous sinus thrombosis, now extending into the right sigmoid sinus and jugular vein.", "Additionally, opacification of the mastoid air cells on the right side was noted, consistent with mastoiditis.", "Physical examination revealed otitis media on the right side.Ophthalmologic examination showed a visual acuity of 20/30 OD and 20/20 OS; color plates were 8 of 8 bilaterally, and there was no afferent pupillary defect.", "Motility and confrontational visual fields were without abnormality.", "Dilated fundus examination showed edema of the optic nerves bilaterally."], "Treatment": ["Her postoperative course had initially been complicated by the development of a transverse sinus thrombosis on postoperative day 4, for which she was treated with anticoagulation.Over the next several days, she experienced marked worsening of her headaches, nausea, and blurred vision."], "Others": ["Spectralis MultiColor fundus images were obtained (Figure, A), as well as traditional spectral-domain optical coherence tomography images (Figure, B).Optical coherence tomography (OCT) of the patient\u2019s optic nerves prior to lumbar puncture."]}
{"Patient Symptoms": ["He also reported a single episode of binocular diplopia that lasted for 1 day and resolved spontaneously.", "Otherwise, his medical history was unremarkable.On physical examination, there was mild right-sided ptosis and miosis."], "Examination and Results": ["Otherwise, his medical history was unremarkable.On physical examination, there was mild right-sided ptosis and miosis.", "After instilling 10% topical cocaine eyedrops, the right pupil did not change its size whereas the left pupil dilated by 2 mm, supporting a diagnosis of right-sided Horner syndrome."], "Diagnosis": ["After instilling 10% topical cocaine eyedrops, the right pupil did not change its size whereas the left pupil dilated by 2 mm, supporting a diagnosis of right-sided Horner syndrome."], "Others": ["Pain and temperature sensation were not evaluated."]}
{"Examination and Results": ["No history of clinically significant fever was noted.", "The electrocardiogram showed ST-segment elevation in leads I, aVL, II, III, aVF, and V3-6 (Figure 1A), which was accompanied by fluctuating elevation of troponin-T levels (1.2-12.0 ng/mL).", "Angiography showed no evidence of coronary artery disease.", "Transthoracic echocardiography demonstrated restricted diastolic filling with a low left ventricular ejection fraction (40%).", "Late delayed enhancement images showed a striking sawtooth pattern of hyperenhancement in the left ventricular epicardium (Figure 1B) and right-sided enhancement of the anteroseptum.", "Extensive myocardial edema was noted in the left ventricle via T2-weighted short tau inversion recovery imaging (Figure 1C).", "Chest and abdominal computed tomography (CT) showed no inflammatory changes or lymphadenopathy.", "Serum angiotensin-converting enzyme (ACE) levels were not elevated.", "The brain natriuretic peptide level was elevated (1550 pg/mL).A, Electrocardiogram with ST-segment elevation in leads I, aVL, II, III, aVF, and V3-6."], "Treatment": ["Treatment for heart failure was initiated."], "Others": ["Cardiac magnetic resonance (CMR) imaging was then scheduled."]}
{"Patient Personal Background": ["She did have a history of recent pericoronitis, but several courses of antibiotics were unhelpful."], "Patient Symptoms": ["The growth also caused malocclusion and ipsilateral upper lip numbness.", "She reported no recent trauma; no difficulty speaking, breathing, or swallowing; no epistaxis, nasal congestion or nasal drainage; and no recent fevers."], "Examination and Results": ["Physical examination revealed a submucosal growth centered on the mesial aspect of the left maxillary alveolus.", "Transnasal endoscopy was unremarkable.", "Contrasted computed tomographic and magnetic resonance imaging showed a heterogeneously ossified lesion filling the left maxillary sinus, with local destruction of hard palate and alveolar bone (Figure, A and B).", "Positron emission tomographic scans highlighted the fluorodeoxyglucose-avid nature of both the tumor and associated cervical lymphadenopathy.", "A biopsy showed a tumor with lobular architecture, an incomplete peripheral ossified rim (Figure, C), and focal areas of osteoid matrix.", "Higher power showed atypical cells with increased mitotic activity in a myxoid stroma (Figure, D).", "Immunostains were negative for S100, pankeratin AE1/AE3, SMSA, and GFAP.A, Computed tomographic (CT) image of the head, coronal view."], "Others": ["B, Magnetic resonance image (MRI) of the face, coronal view with contrast.", "C, Histopathologic image.", "D, Histopathologic image.", "Arrows indicate mitotic figures."]}
{"Patient Symptoms": ["He described the need to cough to clear the airway, but coughing provided no relief.", "He noted some relief when bending at the waist or lying prone."], "Examination and Results": ["Flexible fiber-optic laryngoscopy revealed a large, irregular pedunculated mass on the left anterior false vocal fold (Figure, A and B).", "The mass was seen to ball-valve in and out of the glottis with respiration.", "It was removed with microscissors.", "Pathologic examination (Figure, C and D) revealed a 1.7\u2009\u00d7\u20091.3\u2009\u00d7\u20091.0-cm mass with a papillary-like architecture, expansion of the submucosa by benign mature adipose tissue, and variable amount of fibrous tissue."], "Treatment": ["Preparations for emergency tracheotomy were made.", "In the operating room, with the patient, the anesthesia unit performed flexible fiber-optic laryngoscopy and advanced the endotracheal tube into the trachea over the flexible bronchoscope.", "The patient was turned supine, and microdirect laryngoscopy was performed.", "The mass originated from a stalk in the left anterior ventricle."], "Others": ["The position of the mass was discussed with the anesthesiology team, who felt comfortable performing prone intubation.", "A video laryngoscope was used to ensure that advancing the tube would not shear the mass.", "There was mild chronic submucosal inflammation without squamous epithelial proliferation.A, Direct laryngoscopic image of mass.", "B, Direct laryngoscopy with retraction of mass to view stalk.", "C, Hematoxylin-eosin, original magnification \u00d740.", "D, Hematoxylin-eosin, original magnification \u00d7200."]}
{"Patient Personal Background": ["She referred only to minor head trauma 15 years earlier."], "Examination and Results": ["Findings from a physical examination were negative, while nasal endoscopy showed diffuse mucous rhinorrhea.", "A CT scan of the paranasal sinuses showed complete opacification of the left sphenoid sinus, a double-lined appearance of the sinus walls (an inner bony sclerotic layer and a thin external one) (Figure, A), and 2 bony defects of the sphenoid sinus walls next to the cavernous sinus along the floor (Figure, B).", "An MRI scan showed a concentric multistratified appearance of the sinus content.", "On T2-weighted images (Figure, C), a hyperintense line peripheral layer consistent with fluid retention, an irregularly thick hypointense line, consistent with the sclerotic bone visible on CT, a crescent-shaped heterogeneous material in the lower part, and a black oval area in the upper part of the sinus were identified.", "After gadolinium administration, volumetric interpolated breath-hold examination (VIBE) sequences revealed very intense enhancement of the oval black area in the upper part of the sinus, with no contrast enhancement of the remainder of the sinus (Figure, D)."]}
{"Patient Personal Background": ["His medical history was significant for atopic dermatitis.", "He had no previous treatment with radiation or immunosuppressive medications."], "Examination and Results": ["On examination, he had a surgical scar, an indurated malformed auricle, a superficial right parotid mass infiltrating the overlying skin, and a 1.5-cm postauricular node.", "Facial nerve function was normal.", "Postgadolinium magnetic resonance imaging (MRI) showed infiltration into the cartilaginous tissue of the external auditory canal and ipsilateral cervical adenopathy (Figure, A).", "Serum laboratory test results revealed an eosinophil count of 1109 cells/\u03bcL (reference range, 50-350 cells/\u03bcL), and an IgE level of 5.44 \u03bcg/mL (reference range, <0.27 \u03bcg/mL).", "Flow cytometry was negative for signs of leukemia or lymphoma.", "Fine-needle aspiration (FNA) revealed a mixed leukocyte population and was negative for malignant neoplasm, necrosis, and granulomatous disease.", "Within the lymphoid tissue there was prominent follicular hyperplasia and a diffuse infiltrate of eosinophils (Figure, B).", "There was an increase in small blood vessels within the germinal centers.", "While some follicles had well-defined mantle zones, others demonstrated a spectrum of lytic changes accompanied by intrafollicular infiltrates of eosinophils (Figure, C).", "The stroma was densely fibrotic with perivascular sclerosis (Figure, D).A, Magnetic resonance image (MRI) of a right parotid mass and pathologic preauricular and retroauricular lymph nodes."], "Treatment": ["An excisional biopsy of the postauricular node was performed."], "Others": ["B-D, Histopathologic images, hematoxylin-eosin."]}
{"Patient Personal Background": ["He had no clinically significant medical, surgical, or social history."], "Patient Symptoms": ["His voice was breathy and raspy, and he projected his voice poorly."], "Examination and Results": ["Flexible Lindholm laryngoscopy revealed a large, right-sided, supraglottic, submucosal mass expanding the aryepiglottic fold and false vocal fold with hypomobility of the right vocal fold (Figure, A).", "The lesion extended posterolaterally to the aryepiglottic fold and obscured visualization of the glottis.", "The right laryngeal ventricle was effaced, but the mucosal surface of both true vocal cords appeared normal.", "A computed tomographic (CT) scan to determine the extent of the lesion revealed a cystic mass with no protrusion out of the thyrohyoid space or into the subglottic airway (Figure, B and C)."], "Treatment": ["The mass was completely removed using a pulsed potassium titanyl phosphate laser to make mucosal incisions just lateral to the aryepiglottic fold and cold instrumentation to manipulate and remove the mass.", "Strategic needle decompression and angled endoscopes facilitated complete visualization and removal of the mass.", "The paraglottic space was closed via endoscopic suturing."], "Others": ["He denied dyspnea, dysphagia, odynophagia, weight loss, and lymphadenopathy.", "Intraoperatively, the lesion was fully visualized with a Lindholm laryngoscope (Figure, A).", "The patient tolerated oral intake and was discharged home within 24 hours.", "Pathologic findings were benign.", "Considerable voice improvement and vocal fold mobility was noted at 6 weeks, with normal vocal fold movement, normal mucosal pliability, and complete glottic closure achieved at 1 year (Figure, D)."]}
{"Patient Personal Background": ["She reported no sick contacts, recent travel, recent antibiotic exposure, or nutritional supplement intake.", "She denied use of tobacco, alcohol, or illicit drugs."], "Patient Symptoms": ["She initially had 10 to 12 watery bowel movements a day, which progressed to passage of bright red blood per rectum."], "Examination and Results": ["Vital signs were notable for elevated temperature (37.9\u00b0C), tachycardia (heart rate, 112/min), respiratory rate of 16/min, and blood pressure of 105/60 mm Hg.", "Physical examination showed a soft nondistended abdomen without organomegaly and normal bowel sounds.", "She had diffuse tenderness to deep palpation.", "Laboratory evaluation revealed normal hematological indices, renal function, and hepatic function.", "Computed tomography of the abdomen and pelvis demonstrated colonic wall thickening without perforation and stable prior pelvic lymphadenopathy.", "No pathogenic organisms or parasitic ova were detected on stool culture.", "Results of a stool Clostridium difficile toxin assay were negative.", "Flexible sigmoidoscopy demonstrated grossly congested and erythematous mucosa in the rectosigmoid and descending colon.", "Histopathology from the biopsies of one of the affected areas is shown in the Figure."]}
{"Patient Personal Background": ["His medical history includes hypertension, benign prostatic hyperplasia, hypothyroidism, and chronic obstructive pulmonary disease, for which he takes finasteride, tamsulosin, levothyroxine, lisinopril, pantoprazole, and trospium.", "He recently quit smoking and reduced his alcohol intake to 2 drinks daily but has an approximately 50 pack-year smoking history and a history of heavy alcohol consumption.", "He works outdoors.", "Family history and review of systems were unremarkable."], "Patient Symptoms": ["He denied pruritus, trauma, or contact with allergens or irritants."], "Examination and Results": ["Examination of the dorsal surfaces of the hands revealed five 0.2-cm to 0.6-cm tense, mildly hemorrhagic vesicles, a few 0.4-cm to 0.6-cm erosions with hemorrhagic crusting, scattered 0.5-cm pink scars, and milia (Figure).", "The palms were spared.", "No mucosal changes were noted.", "Results of a basic metabolic panel, complete blood cell count, and urinalysis were normal.", "Liver function tests revealed a total bilirubin level of 1.37 mg/dL (23.43 \u03bcmol/L), direct bilirubin level of 0.69 mg/dL (11.80 \u03bcmol/L), aspartate aminotransferase level of 100 U/L (1.67 \u03bckat/L), and alanine aminotransferase level of 46 U/L (0.77 \u03bckat/L)."], "Others": ["He denied use of illicit substances.", "Results of viral hepatitis and human immunodeficiency virus testing were negative.Dorsal surfaces of hands showing hemorrhagic vesicles, erosions with hemorrhagic crust, postinflammatory erythema and collarettes of scale, and milia."]}
{"Patient Symptoms": ["She reported no occurrence of fever, rashes, oral ulcers, Raynaud phenomenon, chest pain, dyspnea on exertion, paresthesia, or joint concerns."], "Examination and Results": ["On examination, her temperature was 36.9\u00b0 C, blood pressure was 134/81 mm Hg, pulse was 110/min, and oxygen saturation level was 91% breathing room air.", "She appeared dyspneic, had no heart murmur, and had diffuse crackles especially at the lung bases and 2+ pitting edema of the legs without jugular venous distension.", "No rashes, synovitis, or focal neurological deficits were found.", "Laboratory evaluation showed a hemoglobin level of 7.5 g/dL from a baseline of 10.4 g/dL (reference range, 11.6-15.2 g/dL); a creatinine level of 6.5 mg/dL from a baseline of 1.2 mg/dL (reference range, 0.6-1.2; SI conversion to \u03bcmol/L, multiply by 88.4); and normal white blood cell count, platelets, and lactate.", "Urinalysis showed the presence of red blood cells but no protein.", "Chest x-ray showed new bilateral opacities.", "Computed tomographic imaging of the chest showed moderate stable fibrosis with multiple ground-glass opacities in the left lung."], "Diagnosis": ["Based on these results, additional studies were performed (Table).The patient has antiglomerular basement membrane disease (Goodpasture syndrome)."]}
{"Patient Personal Background": ["She had a history of basal cell skin cancer but denied a history of internal cancer, as well as new medications.", "Pertinent daily medications included metformin hydrochloride, sitagliptin phosphate, insulin glargine, somatostatin, and antihypertensives."], "Patient Symptoms": ["The lesions were mildly pruritic and would typically occur in crops of 3 to 4 on the arms, legs, trunk, and buttocks.", "Individual lesions would last a few months before spontaneously resolving without scarring.", "The patient denied new or progressively worsening systemic symptoms, including fevers, chills, night sweats, or rapid unexpected weight loss."], "Examination and Results": ["Physical examination revealed an obese but otherwise healthy-appearing white woman with multiple small 1.5-cm monomorphic and somewhat octagonal groupings of folliculocentric, erythematous, scaly, and hyperkeratotic papules at different stages of development distributed across arms, legs (Figure, A and B), trunk, and buttocks.", "Skin examination otherwise had unremarkable results, including normal scalp, palms, soles, and nails, as well as no palpable cervical, axillary, or inguinal lymphadenopathy."], "Treatment": ["Two scoop shave biopsies of representative lesions were performed (Figure, C and D).Folliculocentric, octagonal, erythematous, and scaly papules on the left thigh."], "Others": ["A and B, Clinical photographs.", "C and D, Shave biopsy specimen (hematoxylin-eosin)."]}
{"Patient Personal Background": ["Her medical history included seasonal allergies, and she did not take any prescription medications."], "Patient Symptoms": ["She felt well and denied weight loss, night sweats, and any other systemic symptoms.Physical examination revealed scattered skin-colored papules on the right neck, a solitary 8-mm skin-colored nodule on the right jawline, and three 2- to 3-cm pink firm nodules on the right thigh (Figure, A and B)."], "Examination and Results": ["She felt well and denied weight loss, night sweats, and any other systemic symptoms.Physical examination revealed scattered skin-colored papules on the right neck, a solitary 8-mm skin-colored nodule on the right jawline, and three 2- to 3-cm pink firm nodules on the right thigh (Figure, A and B)."], "Treatment": ["A shave biopsy was obtained from the nodule on the right jawline (Figure, C), and the thigh nodules were excised."]}
{"Patient Personal Background": ["She had consulted a dermatologist 18 months prior, who performed a biopsy of the lesion that was inconclusive.", "Her medical history was relevant for multiple consultations with several neurologists in the past 2 years for intermittent moderate-to-severe unilateral headache with an unsatisfactory response to nonsteroidal antiinflammatory drugs and amitriptyline.", "She was not taking any medication at the time of consultation."], "Patient Symptoms": ["Her medical history was relevant for multiple consultations with several neurologists in the past 2 years for intermittent moderate-to-severe unilateral headache with an unsatisfactory response to nonsteroidal antiinflammatory drugs and amitriptyline."], "Examination and Results": ["Clinical examination revealed a 12-cm-wide, soft, nontender plaque with a raised, nodular, and slightly desquamative erythematoviolaceous border and a clear, atrophic center with an increase in wrinkle depth on her upper right arm (Figure, A).", "Her neurological and mental state examination showed no abnormalities.", "A biopsy specimen that included the border of the lesion was obtained (Figure, B and C).A, Annular plaque with raised borders and an atrophic and wrinkled center on the right arm."], "Others": ["No treatment was prescribed at the time.", "She denied any systemic symptoms.", "There were no other mucosal or skin lesions.", "No physical examination was performed specifically to the head and neck.", "B, Hematoxylin-eosin stain (original magnification x20).", "C, Orcein stain (original magnification x40)."]}
{"Patient Personal Background": ["The patient was born at full term via spontaneous vaginal delivery after an uncomplicated pregnancy with APGAR scores of 8 and 9 at 1 and 5 minutes, respectively.", "His mother was varicella nonimmune and had no active rashes including in the perineal area."], "Patient Symptoms": ["Physical examination of the patient revealed widespread papulovesicular, crusted lesions on the arms, legs, face, scalp, and trunk (Figure 1)."], "Examination and Results": ["Physical examination of the patient revealed widespread papulovesicular, crusted lesions on the arms, legs, face, scalp, and trunk (Figure 1).", "The palms, soles, and oral mucosa were spared.", "The patient was afebrile.Further workup included Tzanck smear, direct fluorescent antibody test for varicella, herpes virus culture, syphilis IgG antibody test, fungal culture, and bacterial culture."], "Treatment": ["While results were pending, the patient started empirical treatment with ampicillin, gentamicin, and acyclovir."]}
{"Patient Symptoms": ["Two weeks after surgery, he was evaluated for persistent mild abdominal pain in clinic.", "He returned to the emergency department 1 month later with a 2-day history of progressive abdominal pain, nausea, and vomiting.", "He denied fever and chills.", "Laboratory findings were unremarkable."], "Examination and Results": ["Ultrasonography of the abdomen\u2019s right upper quadrant showed gallbladder wall thickening with gallstones in the neck of the gallbladder consistent with acute calculous cholecystitis.", "Computed tomography (CT) of the abdomen showed a 2.5-cm calcified mass with adjacent inflammatory changes in the left hemiabdomen that was most consistent with a lost gallstone (Figure 1A).", "Results of a physical examination revealed mild abdominal tenderness in the left lower quadrant.", "A second abdominal CT was performed (Figure 1B).A, Postoperative computed tomography (CT) of the abdomen demonstrating a lost gallstone in the left hemiabdomen (arrowhead)."], "Treatment": ["He subsequently underwent a laparoscopic cholecystectomy.", "The critical view of safety1 was obtained, and the gallbladder was removed from the fossa without difficulty.", "On extraction of the gallbladder through the umbilical incision, a large stone in the gallbladder could be palpated.", "After several attempts of extraction, the retrieval bag perforated and stones spilled into the abdomen.", "Not all the spilled stones could be retrieved."], "Diagnosis": ["Ultrasonography of the abdomen\u2019s right upper quadrant showed gallbladder wall thickening with gallstones in the neck of the gallbladder consistent with acute calculous cholecystitis."], "Others": ["The patient had an uncomplicated postoperative course and was discharged to home on postoperative day 2."]}
{"Patient Personal Background": ["He had a history of prolonged alcohol abuse."], "Examination and Results": ["A physical examination revealed stable vital signs and a normothermic, nontender, nonpulsatile, fixed lump in his upper abdomen (Figure, A).", "A routine blood test revealed leukocytosis (white blood cell count of 12\u202f000/\u03bcL[to convert to \u00d7109 per liter, multiply by 0.001]), and his liver and kidney function test results were unremarkable.", "His serum amylase level was 487 U/L (normal range, 28-100 U/L [to convert to microkatals per liter, multiply by 0.0167]).", "A contrast-enhanced computed tomography (CT) scan of his abdomen was performed (Figure, B).Fixed and nonpulsatile abdominal lump (A) and contrast-enhanced computed tomography (CT) scan of the abdomen (B) (axial view).", "The scan reveals a homogeneous collection of fluid (black arrowhead) encysted by a well-defined enhancing wall (yellow arrowhead)."], "Treatment": ["Ten weeks previously, he was hospitalized and conservatively managed for acute pancreatitis."]}
{"Patient Symptoms": ["Soon after the procedure, the patient began complaining of a large, linear \u201cfloater\u201d in his central vision, which was very disturbing to him."], "Examination and Results": ["On examination, the implant was seen in the middle of the vitreous cavity in a vertical orientation and in the visual axis (Figure 1).", "The patient was observed for 2 weeks with the hope the implant would settle down or move out of the visual axis, but this did not happen.Optos image of the patient\u2019s right eye.", "The fluocinolone acetonide intravitreal implant can be seen in the middle of the vitreous cavity, very close to the visual axis."], "Treatment": ["The left eye had undergone pars plana vitrectomy for the repair of a macula-involving tractional retinal detachment, but despite anatomical success, visual acuity remained count fingers, presumably due to a loss of retinal tissue from macular ischemia.", "The right eye had undergone cataract extraction with intraocular lens implantation and a pars plana vitrectomy for nonclearing vitreous hemorrhage.", "After this surgery, the patient was treated for persistent DME and received multiple intravitreous injections of bevacizumab, ranibizumab, triamcinolone acetonide, and a dexamethasone intravitreal implant, but the DME persisted, and visual acuity was 20/70 OU.", "Therefore, a fluocinolone acetonide intravitreal implant (ILUVIEN; Alimera Sciences Inc) was injected."]}
{"Patient Personal Background": ["She had a history of high myopia, astigmatism, and mild cataracts, as well as narrow angles, for which she had undergone laser peripheral iridotomy in both eyes a number of years earlier.", "Her review of systems was normal, and she had no relevant family history of ocular disease."], "Examination and Results": ["The best-corrected visual acuity measured 20/100 OD and 20/200 OS, with manifest refractions of \u22129.00 \u22121.25\u2009\u00d7\u2009090 OD and \u22128.50 \u22120.75\u2009\u00d7\u2009086 OS.", "Intraocular pressure measured 12 mm Hg OU.", "The pupils were middilated and poorly reactive.", "There were patent peripheral iridotomies bilaterally.", "The lenses were displaced into the anterior chambers without any lenticular zonules visible.", "There was central lenticulocorneal touch bilaterally with trace Descemet membrane folds at the points of contact (Figure).", "The posterior segment examination results were unremarkable."]}
{"Patient Symptoms": ["His vision was central, steady, and unmaintained in the left eye."], "Examination and Results": ["His visual acuity was 20/30 OD but the child was unable to read the distance chart with his left eye.", "Worth 4-dot testing showed evidence of suppression in the left eye.", "There was a relative afferent pupillary defect in the left eye.", "Intraocular pressure was soft by palpation in both eyes.", "The eyelids, conjunctiva, sclera, cornea, anterior chamber, iris, and lens were unremarkable in both eyes.", "Fundus examination of the right eye was normal.", "The fundus examination of the left eye revealed the findings shown in Figure 1.Fundus photograph of the left eye on initial presentation."]}
{"Patient Personal Background": ["She did not report trauma, changes in vision, or foreign travel and did not take any topical ophthalmic medications.", "Her medical history was unremarkable."], "Examination and Results": ["Her best-corrected visual acuity was 20/25 OD and 20/20 OS.", "Her pupils were round with no afferent pupillary defect, although the circular lesion did move in concert with the pupillary constriction and dilation.", "The intraocular pressure was 14 mm Hg OU.", "Extraocular movements were normal.", "Slitlamp examination of the anterior segment showed a 2 mm\u2009\u00d7\u20092\u2013mm circular iris lesion at the inferotemporal border of the iris.", "The mass appeared to have a fluid-debris level (Figure 1A).", "When the anterior segment was visualized with a goniolens (Figure 1B), we saw that the irideocorneal angle was open, that no neovascularization was present, and that a spherical mass about 2 mm in height arose from the pupillary margin.", "Its nasal surface appeared white with speckled-brown pigmentation, while the remainder of the lesion had brown pigment (Figure 1B).", "The anterior segment of the left eye and posterior segment of both eyes were unremarkable.A, Slitlamp photograph of anterior segment showed an iris lesion with a fluid-debris level (black arrowhead) inferotemporal to the pupillary border (white arrowhead)."]}
{"Patient Symptoms": ["After the PCI, the chest pain resolved, but the patient\u2019s blood pressure was 90/60 mm Hg."], "Examination and Results": ["The electrocardiogram (ECG) at presentation revealed atrial fibrillation: concave upward ST-segment elevations of more than 1 mm in the inferior leads, more prominent in lead III than lead II, along with reciprocal ST-segment depressions in the anterior precordial leads.", "The coronary angiogram (Figure 1A) confirmed this finding.", "The left main, the left anterior descending, and the left circumflex coronary arteries were normal.", "Another ECG (Figure 1B) demonstrated resolution of the ST-segment elevations in the inferior leads with a new rSR\u2032 pattern with concave upward ST-segment elevations in leads V1 to V3.A, Coronary angiogram revealing complete occlusion of the mid-right coronary artery (black arrowhead) distal to a large right ventricular branch (white arrowhead).", "B, Electrocardiogram (ECG) after a percutaneous coronary intervention reveals resolution of ST-segment elevations in inferior leads and a new rSR\u2032 pattern with concave upward ST-segment elevations in leads V1 to V3."], "Treatment": ["A percutaneous coronary intervention (PCI) of the mid-RCA occlusion just distal to the right ventricular branch was performed."], "Diagnosis": ["This was suggestive of an acute inferoposterior myocardial infarction (MI), likely from complete occlusion of the right coronary artery (RCA)."]}
{"Examination and Results": ["Initial laryngoscopy with a Parsons laryngoscope identified airway deviation secondary to mass effect, with intubation ultimately achieved with assistance of a bronchoscope.", "Examination revealed a large neck mass extending from the mandible to the clavicles, with mass effect causing neck extension and rotation.", "The mass was multicystic, with prominent vasculature, and a small area of skin necrosis.", "The patient underwent a magnetic resonance image (MRI) on day of life 3 which showed a 15.7\u2009\u00d7\u200910.0\u2009\u00d7\u200914.4-cm midline neck mass with solid and cystic components.", "Flow voids were present throughout the mass.", "The mass was isointense to hypointense on T1, and isointense to hyperintense on T2.", "The patient also underwent a computed tomographic (CT) scan, which demonstrated calcifications present within the multicystic neck mass."], "Treatment": ["Owing to continued growth and risk of airway compromise, the patient was taken to the operating room on day 5 of life for resection of the mass and tracheostomy."], "Others": ["Following birth, the mass continued to grow, with inability to palpate the sternal notch by day of life 4 (Figure, A).", "Pathologic results showed a multinodular 19-cm mass, 80% solid and 20% cystic, with multiple tissue types present (Figure, B-D)."]}
{"Patient Symptoms": ["Examination revealed a 5-cm, minimally tender mass deep to the left parotid gland."], "Examination and Results": ["Fine-needle aspiration was interpreted as a \u201cwell-differentiated squamous cyst.\u201d Routine laboratory test results and hematologic markers were normal.", "Cranial nerve examination findings were normal, and no overlying skin or mucosal changes were noted.", "CT imaging (Figure, A and B) revealed a well-defined hypodense mass within the left masticator space measuring 5.0\u2009\u00d7\u20093.5 cm, resulting in smooth remodeling of the left mandibular ramus.", "The second left mandibular molar appeared to be missing.", "On magnetic resonance imaging (MRI), the lesion was T2 hyperintense, mildly T1 hyperintense, without enhancement, with remodeling of left mandibular alveolar ridge.", "No definite site of mandibular or maxillary attachment was noted (Figure, C and D)."], "Treatment": ["He underwent resection via a combined transoral and transantral (Caldwell-Luc) approach."], "Diagnosis": ["Pathologic assessment demonstrated a squamous lined cyst with parakeratosis.Imaging of the face of a patient with a left jaw mass."], "Others": ["The mass was noted to be associated with an empty socket of the second mandibular molar, was not well circumscribed, and was notably adherent to some surrounding tissues, requiring meticulous dissection from the inferior alveolar nerve, temporomandibular joint capsule, and skull base.", "A and B, Computed tomographic (CT) images.", "C and D, Magnetic resonance images."]}
{"Patient Personal Background": ["Her medical history was significant for extensive craniofacial polyostotic fibrous dysplasia (FD), breast adenocarcinoma, and stage IV clear cell renal cell carcinoma with metastasis to the ipsilateral adrenal gland treated with radical nephrectomy."], "Patient Symptoms": ["Physical examination was remarkable for soft, tender nodules at the forehead and right orbit with right proptosis."], "Examination and Results": ["Neurologic examination results were normal, except for hypesthesia in a V1 distribution.", "Sinus computed tomography showed a soft-tissue mass with involvement of multiple craniofacial bones with orbital, anterior, and posterior table defects.", "Magnetic resonance imaging with contrast (Figure, B) showed interval growth at the frontal bones in the region of previously diagnosed FD.", "Romanowsky-stained direct smears (Figure, C) showed loose billowing clusters of epithelial cells involved by strands of magenta extracellular tissue (black arrowhead).", "Cytoplasm was abundant with coarse and fine textures.", "Nuclei were large and round, occasionally with conspicuous nucleoli (blue arrowheads).", "Hematoxylin-eosin staining (Figure, D) showed cells with abundant clear cytoplasm and nuclei with varying nucleolar prominence (blue arrowheads).", "Immunohistochemical stains were positive for pancytokeratin, vimentin, CD10 and PAX-8."], "Diagnosis": ["A fine-needle aspiration (FNA) biopsy established the diagnosis."], "Others": ["A carbonic anhydrase IX (CA-IX) stain was noncontributory.A.", "Multiple forehead nodules, oblique view.", "B, Magnetic resonance image (MRI).", "C and D, Histopathologic images.", "C, Original magnification \u00d7400."]}
{"Patient Personal Background": ["His medical history was significant for emphysema but no previous skin cancers or surgery."], "Patient Symptoms": ["The lesion was growing in size and had begun to drain.", "Prior to the visit, he had been evaluated in emergency care for the same complaint and was given a prescription of oral antibiotics; however, the lesion persisted."], "Examination and Results": ["On physical examination, the patient had a 2.5\u2009\u00d7\u20092-cm, singular, umbilicated, ulcerated papular lesion of the left temple with overlying crusts and surrounding erythema and induration (Figure, A).", "Computed tomography with contrast of the soft tissue revealed an abnormal mass in the site of the left temporal scalp lesion.", "The mass appeared homogenous and was not particularly enhanced by contrast (Figure, B).", "There was no accompanying surrounding lymphadenopathy.", "A preoperative biopsy and low-power histological analysis revealed an epidermal proliferative process; vertically oriented anastomosing strands of basaloid epithelium were seen arising from multiple points along the epidermis (Figure, C).", "In this case, there was concurrent well-differentiated carcinoma (Figure, C)."], "Treatment": ["Prior to the visit, he had been evaluated in emergency care for the same complaint and was given a prescription of oral antibiotics; however, the lesion persisted.", "Afterward he was referred to a local dermatologist, who performed a biopsy of the lesion."], "Others": ["Ductal differentiation was observed on high power, and the mass had an intervening fibrovascular stroma (Figure, D).A, Left temple lesion.", "B, Computed tomographic image with contrast, soft-tissue window.", "C and D, Micrographs of tissue biopsy, hematoxylin-eosin.", "C, Original magnification \u00d74.", "D, Original magnification \u00d740."]}
{"Patient Personal Background": ["He reported poor dental health and no exposure to tuberculosis.", "He smoked cigarettes daily and consumed alcohol socially.", "Significant medical history included excision of a mass at the ulcer site 8 years before that healed uneventfully.", "Surgical pathologic examination revealed areas of histiocytes surrounded by lymphocytes and a focus of central necrosis."], "Patient Symptoms": ["The area bled, expressed serosanguineous drainage, and was prone to crust formation.", "It was nontender, bled with manipulation, and appeared to be fixed to the underlying mandible."], "Examination and Results": ["Acid fast bacilli and fungal stains and cultures were negative.", "There was a 1.5\u2009\u00d7\u20091.5-cm ulcerated, submental lesion within the mid-portion of a scar.", "Examination of the oral cavity revealed caries and periodontal disease.", "There was no palpable cervical adenopathy.", "Because the biopsy was concerning for malignancy, an excision with frozen section margins was then performed.", "The lesion was present within old scar tissue and had an infiltrative growth pattern.", "Microscopically there were epithelioid or spindle-shaped tumor cells with atypical vesicular nuclei and pale eosinophilic cytoplasm with areas of necrosis (Figure, A).", "Tumor cells stained strongly positive for EMA, CD34, and pankeratin and demonstrated loss of INI-1 immunostaining (Figure, B and C).Histopathologic images.", "A, Hematoxylin-eosin.", "B, Strong cytoplasmic staining with cytokeratin AE1/AE3 immunostain.", "C, Loss of INI-1 immunostaining."], "Treatment": ["The patient received a course of antibiotic therapy.", "When symptoms persisted, he underwent a biopsy.", "Because the biopsy was concerning for malignancy, an excision with frozen section margins was then performed."]}
{"Patient Personal Background": ["She had no history of infections or recent travel."], "Examination and Results": ["Physical examination revealed a body mass index of 20 (calculated as weight in kilograms divided by height in meters squared), normal vital signs, and darkening of the palmar creases and buccal mucosa.", "Morning laboratory tests were performed and are reported in the Table.Evaluate for congenital adrenal hyperplasia with serum 17-hydroxyprogesterone.Evaluate for primary adrenal insufficiency with a 250-\u03bcg corticotropin stimulation test.Evaluate for a pituitary adenoma with magnetic resonance imaging.Evaluate for a laboratory error by repeating tests for serum adrenocorticotropic hormone and cortisol."], "Others": []}
{"Patient Personal Background": ["She had a history of similar yet milder skin eruptions with sun exposure over the prior 2 years.", "No other family members were similarly affected."], "Examination and Results": ["The physical examination findings were notable for acral edema and well-demarcated, tender petechial patches on the dorsal surface of the hands and feet (Figure, A and B).", "No vesicles were noted.", "A punch biopsy specimen from the affected area of her hand was obtained (Figure, C and D).In the clinical images, edema with petechial eruption is evident on the hands (A) and feet (B).", "In the pathologic images, the hematoxylin-eosin\u2013stained specimens from affected areas of the dorsal aspect of the hands show subtle thickening of vessel walls (C), in addition to extravasation of erythrocytes and fibrin thrombus formation (D)."]}
{"Patient Symptoms": ["The patient had a marfanoid habitus, disproportion of limbs, and an enlarged face.", "Both lips were enlarged and felt nodular (Figure, A).", "Multiple pink-whitish and translucent nodules were observed on the lateral and anterior surface of the tongue (Figure, B)."], "Examination and Results": ["The rest of her physical examination did not reveal other cutaneous abnormalities, except for mild acne.", "Biopsy results from tongue tissue are shown in the Figure, C and D.A, Both upper and lower lips were enlarged and felt nodular.", "B, Oral examination revealed the presence of multiple small nodules located on the anterior and lateral surface of the tongue."]}
{"Patient Symptoms": ["He reported that the lesions began on his face, then spread to his thighs and were mildly pruritic.", "He did not have any other involvement and was in no pain."], "Examination and Results": ["On physical exam, multiple 1 to 3 cm purple papules with central black and hemorrhagic crusting were noted on his forehead, bilateral cheeks, and anterior thighs (Figure 1, A and B).", "On his left flank, he had a large polycyclic, atrophic hyperpigmented plaque with a slightly erythematous and scaly border (Figure 1C).", "The scalp, oral mucosa, back, chest, abdomen, arms, palms and soles were all spared.", "Multiple toenails were noted to be dystrophic with hyperkeratotic subungual debris.", "Over the next few days, the crusted papules and nodules eroded leaving smooth erythematous plaques with punched-out centers.", "Testing for the human immunodeficiency virus (HIV) and hepatitis was negative.", "Punch biopsy specimens from the left anterior thigh were taken for histopathologic analysis and fungal, bacterial, and atypical mycobacterial tissue cultures.", "A skin culture was obtained of the polycyclic plaque on his left flank.A, Discrete and coalescing papules and nodules on the forehead and cheeks with central black and hemorrhagic crust.", "B, Morphology on the thighs was similar to the face with friable, firm purple crusts overlying smoother dermal plaques.", "C, Left flank with a large polycyclic, atrophic hyperpigmented plaque with a slightly erythematous and scaly border."]}
{"Patient Personal Background": ["His medical history was significant for hypertension, hyperlipidemia, coronary artery disease after placement of a stent 7 years prior, right-lung empyema with decortication 8 years prior, and chronic obstructive pulmonary disease.", "His family history was negative for neurological disease but positive for myocardial infarction and colon cancer.", "He had a remote smoking history of 10 pack-years and no history of alcohol or illicit drug use."], "Patient Symptoms": ["Sixteen days later, the patient presented to the hospital again with a 2-day history of numbness and weakness in his left arm.", "Significant neurological examination findings included fluent but dysarthric speech, dysphagia, marked left facial droop, and difficulty with multistep commands.", "A motor examination revealed decreased left upper extremity strength (3/5 proximally and 4/5 distally), conspicuous loss of fine motor coordination, dysmetria, and dysdiadochokinesis."], "Examination and Results": ["Magnetic resonance imaging scans of the head were visually interpreted to show an acute infarct involving the posterior right frontal lobe (Figure 1).", "An echocardiogram did not reveal evidence of an embolic source.", "Hemogram and inflammatory markers were within normal limits (white blood cell count of 5600/\u03bcL [to convert to \u00d7109 per liter, multiply by 0.001], erythrocyte sedimentation rate of 0 mm/h, and C-reactive protein level of 5 mg/L [to convert to nanomoles per liter, multiply by 9.524]).", "Carotid arteries were unremarkable via ultrasonography.", "Magnetic resonance imaging of the brain demonstrated an intra-axial necrotic lesion with adjacent vasculogenic edema primarily involving the right posterior frontal and anterior parietal lobes.Magnetic resonance imaging (MRI) of the brain at the time of initial presentation revealing hyperintensity in the right posterior frontal lobe (A) and hypointensity involving the right posterior frontal lobe (B)."], "Treatment": ["The patient was discharged from the hospital 2 days later and was treated with aspirin and clopidogrel bisulfate."]}
{"Patient Personal Background": ["Her medical history was unremarkable, except for hypertension, and she denied having any abdominal operations.Her laboratory results indicated the following: white blood cell count, 11670/\u03bcL (to convert to \u00d7109/L, multiply by 0.001); sodium level, 132 mEq/L (to convert to mmol/L, multiply by 1); and creatinine, 0.6 mg/dL (to convert to \u00b5mol/L, multiply by 88.4)."], "Patient Symptoms": ["She also had anorexia, and she had crampy abdominal pain during the past few days.", "Similar symptoms occurred previously but were self-relieved.", "She reported dull pain below the pelvic bone as we palpated gently over the abdomen."], "Examination and Results": ["In triage, her body temperature was 37.3\u00b0C, and she had a normal heart rate.", "Physical examinations were notable for distended abdomen and hyperactive bowel sounds but negative for the peritoneal sign.", "No gross abnormalities were present in the perineal area.", "Abdominal radiography revealed segmental dilatation of the small bowel.", "Further evaluation with computed tomography of the abdomen and pelvis was performed (Figure 1).A, Computed tomographic scan showing small-bowel ileus.", "B, Computed tomographic scan showing a mass lesion in the right lower pelvic wall."], "Treatment": ["She was kept in the emergency department for observation."], "Diagnosis": ["Further evaluation with computed tomography of the abdomen and pelvis was performed (Figure 1).A, Computed tomographic scan showing small-bowel ileus."], "Others": ["However, she experienced little improvement in her primary symptoms."]}
{"Patient Symptoms": ["Physical examination revealed at least 4 lower extremity edemas and an abdomen that was large, taut, and distended (Figure 1A)."], "Examination and Results": ["A computed tomographic scan of the chest, abdomen, and pelvis was obtained (Figure 1B).A, In addition to lower extremity edemas, the abdomen of the patient was markedly taut and distended.", "B, Representative computed tomography images with intravenous and oral contrast.", "Note the patient\u2019s descending colon was severely displaced by the retroperitoneal mass and was located on the patient\u2019s right side.", "The mass enveloped the left kidney without evidence of hydronephrosis."]}
{"Patient Symptoms": ["Visual acuity was hand motion, and intraocular pressure was 17 mm Hg."], "Examination and Results": ["On examination, visual acuity  was counting fingers OD and 20/200 OS.", "Anterior segment examination was unremarkable.", "Dense vitreous hemorrhage precluded fundus examination of the right eye, and B-scan ultrasonography did not reveal any additional pathology.", "The left fundus examination exhibited diabetic macular edema with central subfield thickness of 425 \u03bcm on optical coherence tomography and severe nonproliferative diabetic retinopathy, for which he had laser surgery for diabetic macular edema and panretinal photocoagulation.", "On postoperative day 1, visual acuity was 20/200 and intraocular pressure was elevated to 35 mm Hg.", "The conjunctiva had mild hyperemia with foci of subconjunctival hemorrhage, the anterior chamber was deep and quiet, the anterior vitreous contained no cells, and a few cobweblike, tan strands were present throughout the vitreous cavity.", "The anterior chamber had minimal inflammation.", "Extensive strands and veils were noted throughout the vitreous cavity (Figure 1).Anterior vitreous cavity (A) and wide-field fundus photograph (B) of the left eye demonstrating extensive transvitreal strands and sheets."], "Treatment": ["He subsequently underwent vitrectomy in the right eye for nonclearing vitreous hemorrhage with an uneventful postoperative course and improvement of his visual acuity to 20/100.", "The patient was lost to follow-up and returned 4 months later with visual acuity 20/125 OD and counting fingers OS, with a vitreous hemorrhage in the left eye for which he underwent vitrectomy with thorough panretinal photocoagulation (1200 spots).", "Topical timolol/acetazolamide and brimonidine were started twice daily, together with prednisolone acetate and moxifloxacin every 6 hours."], "Others": ["On postoperative day 3, the patient noted decreased visual acuity OS but he denied pain or discharge."]}
{"Patient Symptoms": ["Three years prior to presentation, she reported difficulties with her vision.", "She had difficulty comprehending some words while reading and also reported the feeling of a \u201cblind spot\u201d in her vision and a \u201cpart of her vision\u201d that she could not see.", "On further questioning, she had developed some recent difficulties with short-term memory and reported easily getting lost when driving."], "Examination and Results": ["She was found to have a left homonymous visual field defect.", "She underwent repeated visual field examination every 6 months, showing progression of the visual field defect along with an increase in false-negative results.", "She underwent 3 magnetic resonance imaging (MRI) scans of the brain, showing no neoplasm or stroke, and also underwent a stroke workup with negative results.", "Review of the most recent MRI showed profound cortical atrophy of the parieto-occipital lobes with a slight predilection to the right side compared with the left.", "Her best-corrected visual acuity was 20/20 OU, and color plate results were severely reduced in both eyes.", "Dilated fundus examination findings were unremarkable.", "Automated visual fields again showed a left homonymous visual field defect with high false-negative results (Figure, A).", "She was unable to draw a clock and had simultanagnosia (Figure, B).A, Automated visual field testing (Swedish interactive thresholding algorithm [SITA]) showed a dense left homonymous visual field defect with high false-negative results."]}
{"Patient Personal Background": ["His ocular history was significant for a motor vehicle crash resulting in likely left optic neuropathy (18 years ago), a procedure performed to change the color of his eyes from brown to blue (4 years ago), and bilateral laser in situ karatomileusis surgery (2 years ago).", "He did not wear contact lenses."], "Examination and Results": ["His best-corrected visual acuity was 20/20 OD and 20/30 OS.", "Anterior slitlamp examination of both eyes revealed the finding shown in Figure 1.", "His anterior segment was deep and quiet, and his dilated fundus examination was unremarkable.", "His intraocular pressure (IOP) was reproducibly higher in the right eye on 3 separate visits, averaging 20 mm Hg OD and 13 mm Hg OS.", "His central corneal thickness was 496 \u03bcm OD and 480 \u03bcm OS."], "Treatment": ["He was being treated by outside ophthalmologists with loteprednol, nepafenac, timolol, and artificial tears."]}
{"Patient Personal Background": ["Fourteen years earlier, the patient underwent a pituitary adenoma resection and external beam radiation.", "Immediately after the resection, she developed slight ptosis and an adduction deficit of the right eye, presumed to be secondary to partial oculomotor nerve III (CNIII) damage.", "Four years earlier, she developed intermittent esotropia of the right eye, presumed secondary to cranial nerve VI palsy."], "Patient Symptoms": ["At the present clinic visit, the patient reported the persistence of intermittent diplopia, which had remained unchanged for years, and denied other ocular or systemic complaints.", "These episodes occurred more commonly following voluntary adduction.", "On infraduction, the right upper eyelid simultaneously retracted, exposing 3 mm of superior sclera (Figure, B).", "On adduction, the right pupil constricted slightly."], "Examination and Results": ["Visual acuity measured 20/20 OU.", "We noted 3 mm of relative right upper eyelid ptosis and anisocoria (3 mm OD and 4.5 mm OS in ambient lighting).", "Pupils were round and reactive with no afferent pupillary defect.", "The degree of anisocoria was the same in ambient and dim lighting.", "Extraocular movements were initially intact; however, a few minutes later, the patient developed an intermittent esotropia of the right eye, with episodes of sustained adduction lasting up to 30 seconds followed by normalization of ductions and alignment (Video; Figure, A).", "A magnetic resonance imaging (MRI) from 1 year prior showed a small amount of residual tumor within the right cavernous sinus, stable over years (Figure, C).A, Right eye esotropia after voluntary leftward gaze."], "Others": ["The remainder of the examination was within normal limits.", "B, Right upper eyelid retraction after downward gaze.", "C, Magnetic resonance imaging of the brain showing a very small amount of residual tumor (arrowhead) in the right cavernous sinus, creating a slight convexity of the lateral wall."]}
{"Patient Symptoms": ["Although his right ankle pain and swelling initially improved, he presented 1 week later with left ankle and right knee pain and swelling.", "He remained afebrile but continued to complain of persistent left ankle and right knee pain.On examination, he had a multitude of skin lesions, including a raised follicular rash on both shins; painful flesh-colored raised nodules on the right knee, left index finger, and elbows; and painful raised circular violaceous papulonecrotic lesions with surrounding erythema and induration on the bilateral shins, left knee, right upper arm (Figure, A), and bilateral buttocks."], "Examination and Results": ["He had a tender, nonerythematous, subcutaneous 1-cm nodule above the right olecranon.", "Laboratory results were notable for an elevated erythrocyte sedimentation rate of 44 mm/h, a C-reactive protein level of 0.84 mg/L (to convert to nanomoles per liter, multiply by 9.524), an antistreptolysin O titer of 1150 IU/mL, and an anti-DNase B titer of 961 U/mL.", "Admission laboratory results included a hemoglobin concentration of 9.3 g/dL (to convert to grams per liter, multiply by 10), indicating normocytic anemia; a white blood cell count of 11\u202f500/\u03bcL (to convert to \u00d7\u2009109/L, multiply by 0.001), with 64% neutrophils; an elevated erythrocyte sedimentation rate of 46 mm/h; and a C-reactive protein level of 0.57 mg/L.", "Punch biopsy was obtained from a lesion (Figure, B), which showed a dermal neutrophilic infiltrate with normal Gram and Grocott methenamine silver stains.A, Painful raised circular violaceous papulonecrotic lesion with surrounding erythema on child\u2019s right upper arm."], "Treatment": ["He was diagnosed with cellulitis and prescribed 10 days of sulfamethoxazole and trimethoprim.", "Echocardiogram and electrocardiogram were normal, and he was treated with amoxicillin."], "Diagnosis": ["The results of the rapid strep test and throat culture were normal, but given his constellation of symptoms, he was diagnosed with acute rheumatic fever."], "Others": ["Four days after discharge, he developed new painful skin lesions on his elbows, forearms, and legs.", "B, Punch biopsy of lesion.", "Hematoxylin-eosin stain reveals dense neutrophilic infiltrate in the dermis as well as papillary dermal edema (original magnification\u2009\u00d7\u200940)."]}
{"Patient Personal Background": ["She had reported intermittent chest pain without precipitating factors since the age of 8 years.", "This had been evaluated by a pediatric cardiologist and was felt to be noncardiac in nature.", "Persistence of pain and associated distress eventually prompted referral to adolescent psychiatry.", "An electrophysiologist commenced treatment with flecainide and warfarin.", "Warfarin was stopped after 6 months arrhythmia-free."], "Patient Symptoms": ["At our clinic, she reported intermittent, nonexertional, atypical chest pain and exertional dyspnea with a gradual decline in exercise capacity, confirmed by cardiopulmonary exercise test (oxygen consumption peak 65% predicted)."], "Examination and Results": ["Electrocardiogram demonstrated sinus rhythm, a prominent biphasic p-wave, and occasionally prolonged interval between the beginning of the electrocardiographic wave representing ventricular depolarization and the end of the T-wave (QT, QTc up to 594 milliseconds) (Figure 1A).", "Transthoracic echocardiogram revealed normal ventricular dimensions and systolic function with biatrial dilatation (left\u2009>\u2009right) (Figure 1B), dilated pulmonary veins, and abnormal diastolic filling.", "Cardiac magnetic resonance imaging with gadolinium confirmed dilatation of the atria, pulmonary veins, and inferior vena cava with normal ventricular size, mass, and ejection fraction without enhancement suggestive of infarction, inflammation, or fibrosis.", "Pericardium was of normal thickness.A, Electrocardiogram demonstrating prominent and biphasic P-wave and ST-T segment abnormalities."], "Treatment": ["At age 17 years she experienced 3 episodes of AF, each treated with direct-current cardioversion."], "Others": ["B, Four-chamber view of transthoracic echocardiogram."]}
{"Patient Personal Background": ["Her family history was positive for breast cancer in her mother, and the patient was a lifelong nonsmoker."], "Patient Symptoms": ["She had a cough and fatigue at the time, but no other symptoms of upper respiratory tract infection at onset.", "She attributed her fatigue to staying up late studying and had not tried any treatments, including antibiotics.", "She denied any trauma, night sweats, fever, chills, weight loss, generalized pruritus or lymphadenopathy in other areas of her body, any voice change, dysphagia, odynophagia, hoarseness, hemoptysis, hematemesis, or weight loss."], "Examination and Results": ["Physical examination revealed palpable nontender, freely movable mass in the right supraclavicular region.", "Palpation of the parotid, submandibular glands, and thyroid gland did not reveal any suspicious masses or tenderness.", "No mucosal lesions, scars, or masses were found on intraoral examination, with clear oropharynx.", "Computed tomography revealed a 2.0-cm, right-sided supraclavicular mass just anterior and superior to the right subclavian vein with central patches of hypoattenuation (Figure, A).", "Results from initial ultrasonography-guided fine-needle aspiration were nondiagnostic.", "Subsequent ultrasonography-guided core needle biopsy on supraclavicular aspirate showed a benign spindle cell proliferation arranged in a tissue-culture\u2013like pattern with a myxoid to collagenous stroma (Figures, B and C).", "Immunohistochemical stains demonstrated the cells to be positive for actin and negative for cytokeratin and S100 protein."]}
{"Patient Symptoms": ["The swelling persisted despite a course of oral antibiotics prescribed by the primary care team.", "His parents denied any recent fevers, night sweats, weight loss, pain, respiratory distress, nasal bleeding, or significant rhinorrhea."], "Examination and Results": ["The physical examination revealed a right infraorbital and maxillary swelling, with deformity of the right lateral nasal dorsum.", "The remainder of the physical examination was unremarkable.", "Flexible fiber-optic sinonasal endoscopy revealed a normal appearance of the nasal mucosa with no obvious obstruction, mass lesion, rhinorrhea, or bleeding.", "Vision was grossly normal with no diplopia, and sensation of the right cheek was intact.", "A contrasted maxillofacial computed tomographic (CT) scan and magnetic resonance imaging (MRI) were performed, revealing an expansile right maxillary mass, associated with roots of the upper molar and premolar teeth, with erosion through the anterior maxillary wall and some thinning and displacement of the inferior orbital wall (Figure, A)."], "Treatment": ["The lesion was excised via a sublabial approach using both open and endoscopic techniques for better visualization."], "Others": ["Histopathologic analysis revealed a bland, monotonous proliferation of stellate spindled cells with a variable extracellular matrix ranging from loose myxoid (Figure, B) to fibromyxoid and collagenous (Figure, C).", "There was also permeation of adjacent bone marrow spaces (Figure, D).A, Coronal view.", "B-D, Histopathologic images (hematoxylin-eosin, original magnification \u00d74)."]}
{"Patient Symptoms": ["Results from a rapid strep test were negative, and observation was initiated for presumed viral pharyngitis.", "Progression of neck swelling led to empirical treatment for bacterial pharyngitis.", "Necrotic skin changes and persistent purulent neck drainage through the needle biopsy site required incision and drainage as well as incisional biopsy of the left side of her neck."], "Examination and Results": ["A neck computed tomographic scan with contrast revealed large bilateral asymmetric conglomerations of necrotic cervical lymph nodes measuring up to 9 cm in the greatest dimension (Figure, A).", "Initial evaluation, including fiber-optic laryngoscopy, revealed the presence of significant bilateral tender lymphadenopathy in the absence of any lesions in the upper aerodigestive tract.", "A core biopsy specimen yielded negative gram stain and aerobic and anaerobic bacterial, fungal, and acid-fast bacillus cultures.", "Polymerase chain reaction (PCR) of nodal contents was negative for Bartonella henselae.", "A chest radiograph was normal.", "All the cultures once again returned with no growth.", "Final pathologic examination showed necrotizing granulomatous inflammation (Figure, B) with no monoclonal lymphocyte population on flow cytometry.", "Results from a test for human immunodeficiency virus and angiotensin-converting enzyme testing were negative."], "Treatment": ["Progression of neck swelling led to empirical treatment for bacterial pharyngitis.", "Operative findings included abundant purulent debris and considerable necrosis of skin and neck musculature."], "Others": ["Four weeks after symptom onset, the patient was referred to the otolaryngology service."]}
{"Patient Personal Background": ["His medical history was significant for chronic rhinosinusitis, allergic rhinitis, and asthma, for which he took fluticasone propionate and salmeterol (Advair) and albuterol."], "Patient Symptoms": ["A review of systems revealed epiphora and ocular crusting for 4 months.", "The patient was lost to follow-up but returned several months later with 6 weeks of progressive bilateral parotid swelling (Figure, B).", "A history of recent tuberculosis exposure was obtained."], "Examination and Results": ["Findings on nasal endoscopy included bilateral turbinate hypertrophy and significant nasal crusting.", "A computed tomographic (CT) scan of the sinuses revealed diffuse mucosal thickening consistent with pansinusitis (Figure, A).", "All laboratory results from an autoimmune workup were normal for angiotensin-converting enzyme (ACE) level, antineutrophil cytoplasmic antibodies, antinuclear antibody, and immunoglobulin levels.", "He had a normal chest radiograph.", "His parotid glands were diffusely enlarged and tender, and his facial function was normal.", "Radiologically, no masses or sialoliths were seen (Figure, C).", "Test results for SSa/SSb levels, human immunodeficiency virus (HIV), polymerase chain reaction (PCR), mumps titers, rapid plasma reagin, amylase, cytomegalovirus PCR, and quantiferon testing were negative.", "A superficial parotid biopsy revealed noncaseating granulomatous inflammation (Figure, D)."], "Others": ["His only associated symptoms were fevers and fatigue."]}
{"Patient Symptoms": ["There was no associated pain, facial numbness, or weakness."], "Examination and Results": ["On examination, the mass was freely mobile, the facial nerve was intact bilaterally, and there was no palpable lymphadenopathy.", "Results from fine-needle aspiration 6 months prior to presentation were consistent with a cystic oncocytic neoplasm, and computed tomography revealed a 1.9\u2009\u00d7\u20091.5\u2009\u00d7\u20092.1-cm, well-circumscribed ovoid lesion in the anterior aspect of the superficial lobe of the left parotid gland (Figure, A).", "Postoperative pathological analysis revealed a cystic, cribriform, papillary neoplastic growth with low-grade cytologic features and nearly complete myoepithelial rims (Figure, B and C).", "Calponin and p63 staining were positive in the myoepithelium surrounding the tumor nests (Figure, D), S-100 was positive within the tumor, and the Ki-67 rate was approximately 5%.", "Extracellular mucin and occasional mucous cells were also noted.", "Margins were clear, and there was no evidence of perineural spread or lymphovascular invasion."], "Treatment": ["Multiple aspirations of the mass had been performed, which would temporarily decrease the size.", "A left superficial parotidectomy was performed under general anesthesia with facial nerve dissection and facial nerve monitoring."], "Diagnosis": ["Results from fine-needle aspiration 6 months prior to presentation were consistent with a cystic oncocytic neoplasm, and computed tomography revealed a 1.9\u2009\u00d7\u20091.5\u2009\u00d7\u20092.1-cm, well-circumscribed ovoid lesion in the anterior aspect of the superficial lobe of the left parotid gland (Figure, A)."], "Others": ["No complications were encountered.", "The patient tolerated the procedure well, recovered appropriately, and was free of complications at his first follow-up appointment."]}
{"Patient Personal Background": ["She also reported no recent sick contacts, travel, illicit drug use, or use of oral contraceptive pills or other medications."], "Patient Symptoms": ["She reported a 2-day history of skin lesions on her ears without trauma."], "Examination and Results": ["Vital signs included a blood pressure of 140/70 mm Hg, heart rate of 168/min, respiratory rate of 30/min, temperature of 40.9\u00b0C, and oxygen saturation of 90% on room air.", "Physical examination revealed decreased right basilar breath sounds with dullness to percussion, tachycardia without murmurs or rubs, lower extremity edema, and bilateral cutaneous necrosis of her pinnae (Figure 1).", "Laboratory findings showed a white blood cell count of 7700 cells/\u00b5L (neutrophils, 82.4%; lymphocytes, 10.6%; monocytes, 6%; eosinophils, 0.2%; basophils, 0.8%), hemoglobin level of 9.0 g/dL (mean corpuscular volume, 84 fL), platelet count of 151 \u00d7103/\u00b5L, partial thromboplastin time of 61 seconds (reference range, 22-32), and an international normalized ratio (INR) of 1.4.", "An ultrasound showed a right above-the-knee deep venous thrombosis (DVT), and a chest computed tomography angiogram showed a large right pleural effusion without evidence of pulmonary embolism.", "Pleural fluid was exudative; Gram stain and culture were negative."]}
{"Patient Personal Background": ["The patient reported no alcohol or drug use and no personal or family history of liver disease.", "Medications included diltiazem and furosemide."], "Patient Symptoms": ["She was anicteric with mild bilateral temporal wasting and jugular venous distension."], "Examination and Results": ["On physical examination, her blood pressure was 108/54 mm Hg and pulse was 64/min.", "Further pertinent findings included regular heart rate and rhythm with an accentuated P2, grade 1/6 holosystolic murmur in the left lower sternal border, full bulging abdomen with flank dullness, and scattered spider angiomata on her chest.", "Doppler ultrasound revealed an irregular liver echo pattern without lesions, normal common bile duct, patent portal and hepatic vasculature, splenomegaly, and ascites."], "Others": ["Laboratory results including diagnostic paracentesis are shown in Table 1.Her ascites is primarily due to chronically elevated pressures on the right side of the heart.Her ascites is primarily due to abdominal malignancy.Her ascites is primarily due to spontaneous bacterial peritonitis."]}
{"Patient Personal Background": ["There were no other associated symptoms, including dyspnea, cough, urinary tract symptoms, or gastrointestinal symptoms.His medical history was significant for hypertension, poorly controlled type 2 diabetes, hypercholesterolemia, and biopsy-proven autoimmune hepatitis.", "His other regular medications include aspirin, metformin, verapamil, and pravastatin.Examination was remarkable for a temperature of 38\u00b0C, an exquisitely tender erythematous papulonodular rash on the extensor surface of his lower and upper limbs, and bilaterally tender knees with a patellar tap (Figure 1)."], "Patient Symptoms": ["His other regular medications include aspirin, metformin, verapamil, and pravastatin.Examination was remarkable for a temperature of 38\u00b0C, an exquisitely tender erythematous papulonodular rash on the extensor surface of his lower and upper limbs, and bilaterally tender knees with a patellar tap (Figure 1)."], "Examination and Results": ["Laboratory findings included a white blood cell count of 10\u202f500/\u03bcL (with neutrophil level elevated at 9900/\u03bcL [94%]) and elevated inflammatory markers (C-reactive protein level, 76 mg/L [724 nmol/L]; erythrocyte sedimentation rate, 69 mm/h).", "Rheumatoid factor was slightly elevated at 16 IU/mL, but testing for anti\u2013citrullinated protein antibody was negative.", "Tests for double-stranded DNA, extractable nuclear antibodies, and anti-antistreptolysin O were negative.", "Renal function was normal, and there were no leukocytes, nitrates, red cells, or casts noted in the urine.", "Chest radiograph was also normal.", "Synovial fluid analysis showed a noninflammatory picture with a leukocyte count of 700 cells/L; no bacteria or crystals were seen.Tender erythematous papulonodular lesions on extensor surfaces of lower (left) and upper (right) extremities."], "Treatment": ["He was started on azathioprine for autoimmune hepatitis at a dose of 75 mg 10 days prior to his presentation after thiopurine methyltransferase activity was found to be normal."]}
{"Examination and Results": ["Endometrial carcinoma was found on dilation and curettage.", "Family history was significant for prostate cancer in her father and paternal grandfather.Her tumor was screened for Lynch syndrome by immunohistochemistry staining for DNA mismatch repair proteins (mutL homolog 1 [MLH1]; MutS homologs 1 and 6 [MSH1, MSH6]; PMS 1 homolog 2 [PMS2]) and microsatellite instability testing (MSI)1 (Table 1)."], "Treatment": ["Hysterectomy and surgical staging confirmed stage IA endometrial cancer."], "Diagnosis": ["Hysterectomy and surgical staging confirmed stage IA endometrial cancer."]}
{"Patient Personal Background": ["The eruption presented abruptly over a 2-week course, and the patient attributed it to contact with plants while working in his yard.", "He denied having similar lesions in the past.", "He denied recent sexual intercourse, penile discharge, fevers, chills, nausea, or vomiting."], "Patient Symptoms": ["He had used over-the-counter topical antibiotic and antihistamine creams, which alleviated the pruritus."], "Examination and Results": ["Physical examination of the bilateral cheeks, glabella, dorsal nose, and chin revealed multiple skin-colored papules, nodules, and vegetative plaques ranging in size from 4 to 6 mm in diameter, with central umbilication, erosions, and overlying yellow crust (Figure, A).", "There were similar lesions on the scrotum and inner thighs, with sparing of the penis (Figure, B).", "There was also a 1-cm ulceration on the left lower lip.", "The palms and soles were spared.", "There was no lymphadenopathy noted.", "One 4-mm punch biopsy specimen was obtained from a nodule on the left medial cheek, bisectioned, and sent for both hematoxylin\u2013eosin staining and tissue cultures for bacteria, fungi, and atypical mycobacteria (Figure, C and D).A, Multiple crusted and ulcerative papules and nodules on the face."], "Treatment": ["He had used over-the-counter topical antibiotic and antihistamine creams, which alleviated the pruritus."], "Others": ["B, Multiple ulcerated healing papules on the scrotum and umbilicated papules on the left inner thigh.", "C, Low-power image (hematoxylin-eosin, original magnification \u00d740).", "D, A Warthin-Starry silver impregnation stain (original magnification \u00d740)."]}
{"Patient Personal Background": ["She was taking no medications and had not had active gastrointestinal symptoms of CD in several years."], "Patient Symptoms": ["The growths had been present for 1 year."], "Examination and Results": ["Physical examination revealed a tender perianal plaque with a papular, cobblestone-like surface (Figure, A).", "A biopsy specimen from the perianal plaque was obtained (Figure, B and C).A, Multiple flesh-colored perianal papules and a pebbly plaque in a middle-aged woman with Crohn disease.", "B, A biopsy specimen of the perianal plaque was obtained, and histopathology revealed a dermal perivascular and nodular infiltrate composed of aggregates of histiocytes and (C) numerous multinucleate giant cells surrounded by mature lymphocytes.", "Acid-fast and silver stains were negative (not shown)."]}
{"Patient Personal Background": ["The patient lived in a farm community that used well water for drinking.", "He denied wading in local water sources and had not traveled abroad recently.", "The patient denied systemic symptoms, and further physical examination results were unremarkable."], "Patient Symptoms": ["The lesion appeared 2 months prior and had been mildly itchy."], "Examination and Results": ["Recent laboratory blood work was notable for peripheral eosinophilia.", "A punch biopsy was performed (Figure, B).A, Photograph shows a serpiginous erythematous plaque on the abdomen.", "B, Histopathological analysis of a punch biopsy specimen demonstrates eosinophilic cuticle (external tegument) and calcareous bodies (basophilic internal structures)."], "Others": ["C, Histopathological analysis of a punch biopsy specimen.", "D, Detail of a longitudinal section."]}
{"Patient Personal Background": ["She had no alcohol abuse or smoking history.", "Dyslipidemia and a transient ischemic attack 3 years before were her only medical history.", "She had never had a colonoscopy or a gastroscopy.", "Her medication included atorvastatin and acetylsalicylic acid.", "The only past operation she reported was for treating carpal tunnel syndrome.", "She was a sheep breeder and was in close contact with animals for 8 to 12 hours every day.During physical examination, the heart and the lungs were normal."], "Patient Symptoms": ["The pain was localized to the epigastrium and had acute onset  that prevented her from working for the rest of the day.", "There was no association between the pain and eating."], "Examination and Results": ["Her abdomen was soft with tenderness in the epigastrium.", "The laboratory evaluation results revealed normocytic anemia (hematocrit level of 28.1% [to convert to proportion of 1.0, multiply by 0.01] and hemoglobin level of  9.3 g/dL [to convert to grams per liter, multiply by 10]) including a normal white blood cell count of 7600/\u00b5L (to convert to \u00d7109 per liter, multiply by 0.001).", "Results from a complete metabolic panel were normal.", "An abdominal radiography was performed (Figure 1).Anteroposterior abdominal x-ray film in erect position.", "In the right side of the mid to lower quadrant, at the level of L5 vertebral body, there is a rounded radio-opaque lesion (arrowhead) that seems to contain a second smaller sclerotic lesion within its central part (a lesion-in-lesion appearance)."]}
{"Patient Personal Background": ["He had no history of abdominal trauma, infection, or surgery."], "Patient Symptoms": ["A physical examination revealed mild tenderness over the posterior left upper quadrant."], "Examination and Results": ["A precontrast computed tomographic scan revealed a large, well-defined, cystic mass (7 by 6 cm) with mural calcification in the spleen (Figure 1A), and the cyst was not enhanced in the arterial phase.", "The laboratory test results, including carcinoembryonic antigen and carbohydrate antigen 19-9 levels, were all within normal ranges, except for a mild increase in the carbohydrate antigen 72-4 level, which was 11.89 U/mL (normal range, 0-6.9 U/mL).A, Computed tomography (CT) revealed a large, well-defined, cystic mass with mural calcification in the spleen.", "B, The surface of the cyst was extremely dense and appeared to have an eggshell-like calcification; the cyst was filled with about 300 mL of yellowish opalescent fluid containing numerous cholesterol-like crystals (arrowhead).During a laparotomy, a huge hard mass, which was partially covered by fibrous and necrotic tissue, was found emerging from the lower pole of the spleen."], "Treatment": ["A total splenectomy was performed, and a gross pathologic examination revealed that the lower end of the spleen was occupied by a cyst, the surface of which was extremely dense and appeared to have an eggshell-like calcification (Figure 1B)."], "Others": ["The cyst was filled with about 300 mL of yellowish opalescent fluid containing numerous cholesterol-like crystals (Figure 1B)."]}
{"Patient Personal Background": ["Two weeks prior to her visual symptoms, she had noticed intermittent painless, postmenopausal vaginal bleeding.Her medical and ocular history were unremarkable."], "Patient Symptoms": ["Two weeks prior to her visual symptoms, she had noticed intermittent painless, postmenopausal vaginal bleeding.Her medical and ocular history were unremarkable.", "Ophthalmologic examination revealed a visual acuity of no light perception OU."], "Examination and Results": ["Her examination reults 2 years prior were normal, with a visual acuity of 20/20 OU.In the emergency department, the patient had a computed tomographic scan of the brain and orbits that was normal, and she was referred to Ophthalmology.", "Ophthalmologic examination revealed a visual acuity of no light perception OU.", "Pupils were unreactive to light but constricted to a near target.", "Extraocular movements were full.", "Slitlamp examination of the anterior chamber revealed mild nuclear sclerosis in each eye and quiet anterior chambers.", "A dilated fundus examination is shown  in the Figure."]}
{"Patient Symptoms": ["The right eye was temporally hyperemic and mildly tender to touch."], "Examination and Results": ["Her visual acuity was 20/200 OD and 20/20 OS.", "Fundus examination revealed an elevated whitish lesion in the superotemporal quadrant of the right eye, associated with subretinal fluid at the fovea (Figure 1).", "A- and B-scan ultrasonography demonstrated a choroidal mass with moderate internal reflectivity.An elevated whitish lesion is noted in the superotemporal quadrant of the right eye, associated with subretinal fluid at the fovea."]}
{"Patient Personal Background": ["Her history consisted of non\u2013small cell lung cancer treated with wedge resection 2 years prior, and she had been receiving chemotherapy until 1 year previously.", "She was declared free of cancer 6 months earlier based on systemic surveillance."], "Examination and Results": ["Visual acuity was 20/80 OD and 20/20 OS.", "Intraocular pressures were 19 mm Hg OU.", "Biomicroscopy showed trace anterior chamber cells in the right eye with mild vitritis.", "Fundus examination demonstrated parafoveal whitening with hemorrhage and focal aggregations (Figure, A).", "The lesion stained on fluorescein angiography (Figure, B).", "There was no evidence of disc edema or vasculitis.", "Optical coherence tomography showed disorganization of the retina.A, The fundus montage shows a white retinal hemorrhagic lesion on initial presentation, which subsequently gradually enlarged.", "B, Wide-field fluorescein angiography demonstrates late staining of the lesion.", "Aqueous polymerase chain reaction testing was negative for cytomegalovirus, herpes simplex virus, varicella zoster virus, and toxoplasmosis.", "Systemic testing was negative for cytomegalovirus, herpes simplex virus, varicella zoster virus, Lyme disease, syphilis, Toxocara, toxoplasmosis, tuberculosis, and Bartonella."], "Treatment": ["The patient was treated with a vitreous tap and intravitreous injection of foscarnet sodium and ganciclovir sodium, and she began valgancyclovir hydrochloride therapy.", "Sulfamethoxazole\u2013trimethoprim sulfate was started to cover possible toxoplasmosis.", "Doxycycline hyclate was initiated, but subsequent titers were negative."], "Diagnosis": ["C, The lesion is regressing after external beam radiation therapy with a radiosensitizing adjuvant.There was no vasculitis, but an atypical presentation of viral retinitis was suspected given her history of immunosuppression, vitritis, and retinal whitening.", "The diagnosis was indeterminate, but treatment was recommended due to macular involvement.", "Rickettsia retinitis was also suspected clinically."]}
{"Patient Symptoms": ["She denied pain but described a pressure sensation behind her left eye.", "There was moderate restriction to elevation of the left eye."], "Examination and Results": ["Uncorrected visual acuity measured 20/80 OD and 20/60 OS, improving to 20/40 OD and 20/30 OS with pinhole testing.", "Pupils were round and reactive without an afferent pupillary defect.", "Intraocular pressure was 18 mm Hg OU by applanation tonometry.", "Hertel exophthalmometer measurements demonstrated 7 mm of proptosis OS.", "Anterior segment and ophthalmoscopic examination results were unremarkable.Computed tomography of the orbits with and without contrast was performed (Figure).", "A homogeneously enhancing, well-demarcated, ovoid mass was visualized within the medial intraconal space, measuring 2.0\u2009\u00d7\u20092.2\u2009\u00d7\u20092.6 cm.", "The lesion displaced the globe inferiorly and anteriorly.", "Smooth bony remodeling was present without erosive changes.", "Magnetic resonance imaging of the orbits corroborated these findings.", "Conventional angiography demonstrated a tortuous branch of the left ophthalmic artery supplying the medial aspect of the orbital mass.Computed tomography and conventional angiography of the orbital mass."], "Others": ["A, Computed tomography of the orbits demonstrates a homogeneously enhancing mass within the intraconal space (blue arrowhead).", "Smooth bony remodeling was present without erosive changes.", "B, Cerebral angiography demonstrated a branch of the left ophthalmic artery supplying the orbital mass (black arrowhead)."]}
{"Patient Symptoms": ["This condition had been present for 4 weeks and included areas of the scalp, face, chest, abdomen, back, axillae, arms, legs, perineum, and buttocks.", "There were no aggravating factors, and no family member in contact with the patient had a rash with similar characteristics."], "Examination and Results": ["The physical examination findings were notable for a well-appearing infant with pink to brown nummular patches and plaques with thick white scale on the scalp, cheeks, trunk, back, axillae, inguinal crease, scrotum, and umbilicus and posterior to the ears (Figure 1).", "The patient had no lymphadenopathy or hepatosplenomegaly.", "B, Pink and brown scaly patches on the abdomen within the inguinal crease."], "Treatment": ["The parents tried moisturizers and topical antiyeast medications with no change in the rash."], "Others": ["He was up to date on all immunizations and was full term.A, Infant at presentation, with pink to brown round scaly patches and plaques widespread on the trunk including umbilicus and axillae."]}
{"Patient Personal Background": ["She had undergone aortic valve replacement for aortic stenosis, 2-vessel coronary artery bypass, and permanent pacemaker placement 1 year before presentation.", "She had a history of mantle chest radiotherapy for Hodgkin lymphoma at age 17 years, which was curative."], "Examination and Results": ["After successful intravenous diuresis, neck examination at approximately 60\u00b0 (Figure 1A and Video) revealed a regular carotid pulsation and discernible internal jugular venous pulse.", "Hemodynamic data at left and right heart catheterization are shown in Figure 1B.A, Neck examination at 60\u00b0 shows the location of the carotid and internal jugular pulsations.", "B, High-fidelity micromanometer simultaneous recording of the left ventricular (LV) and right atrial (RA) pressures."], "Others": ["After examination of the neck at rest, the patient took a small breath and held it for a few seconds."]}
{"Patient Personal Background": ["He had no history of dysphagia and/or odynophagia, hoarseness, vision changes, dry mouth, decreased ipsilateral sweating, weight loss, fevers, chills, or a history of tobacco or alcohol use."], "Patient Symptoms": ["He did not have facial pain, weakness, numbness, trismus, or difficulty chewing."], "Examination and Results": ["Physical examination revealed a palpable nontender mass in the left parapharyngeal space.", "Cervical lymphadenopathy was not palpable.", "Nasopharyngoscopy revealed slight bulging of the lateral pharyngeal wall into the oropharynx with no discrete masses seen.", "Computed tomography\u2013guided fine-needle aspiration biopsies were nondiagnostic.", "Axial T2-weighted MRI showed a lesion arising from the left parapharyngeal space, arising from the deep lobe of the parotid gland.", "The lesion caused loss of the fat plane between the parapharyngeal space and masticator space with subsequent inflammation of the pterygoid space.", "The pharyngeal mucosa of the left lateral pharyngeal wall was effaced owing to mass effect (Figure, A).", "Hematoxylin-eosin staining showed sections of confluent amorphous eosinophilic masses with surrounding foreign-body giant cell reaction and lymphoplasmacytic infiltrates (Figure, B).", "Sheets of plasma cells were positive for \u03ba and CD138 and negative for \u03bb, consistent with clonal \u03ba light-chain restricted plasma cell infiltrates around amorphous tissue (Figure, C).", "Congo red stain showed apple-green birefringence demonstrated on polarized microscopy (Figure, D).A, Magnetic resonance imaging (MRI) of a lesion in the left parapharyngeal space."], "Treatment": ["The mass was surgically resected in its entirety."], "Others": ["B-D, Histopathological images."]}
{"Patient Personal Background": ["Twenty-nine months prior to presentation, the patient had been diagnosed as having myelodysplastic syndrome, which 7 months later progressed to AML."], "Patient Symptoms": ["His physical examination was notable for a \u201cbreathy\u201d voice with no respiratory distress or cervical lymphadenopathy."], "Examination and Results": ["Flexible nasal endoscopy revealed an immobile right vocal fold with broad submucosal fullness on the right false vocal cord and arytenoid.", "Computed tomography (CT) demonstrated a right-sided laryngeal mass extending from the level of the free margin of the epiglottis to the level of the glottis (Figure, A).", "In the operating room, during direct laryngoscopy a polypoid mass was seen based on the right arytenoid, also involving the right false vocal cord (Figure, B).", "Frozen section confirmed polypoid ulcerated tissue with granulation consistent with an inflammatory process, and histopathologic analysis demonstrated a mixed infiltrate containing numerous mononuclear myeloid cells positive for myeloperoxidase, CD34, CD68, and CD33 but negative for CD117 (Figure, C and D).", "There are small numbers of scattered CD3+ T-cells and CD20+ B-cells.A, Right-sided laryngeal mass.", "B, Polypoid mass on the right arytenoid.", "C, Neoplastic cells admixed with lymphoplasmacytic inflammatory cells."], "Treatment": ["During treatment for AML with low-dose cytarabine, his course was complicated by neutropenic sepsis requiring intubation, resulting in his head and neck symptoms."], "Others": ["C and D, Histopathologic images."]}
{"Patient Personal Background": ["She denied pain and was an otherwise healthy nonsmoker."], "Patient Symptoms": ["The size now caused intermittent gagging and a foreign-body sensation in her throat."], "Examination and Results": ["Examination of the oral cavity revealed an approximately 1-cm, pedunculated mass of the posterior dorsal tongue just lateral to the circumvallate papillae.", "The lesion was mobile and well-circumscribed without ulceration or surrounding mucosal abnormalities.", "It was nontender to palpation without drainage or discharge.", "Flexible fiber-optic laryngoscopy showed no other lesions.", "Neck ultrasonography showed a normal thyroid gland.", "Histopathologic examination revealed a discrete proliferation of mature bone with overlying mildly hyperplastic stratified squamous epithelium without surrounding inflammation (Figure, A).", "The core was composed of dense lamellar osseous matrix with numerous Haversian canals and associated regularly dispersed osteocytes in lacunae (Figure, B)."], "Treatment": ["Excisional biopsy was performed with the patient under local anesthesia, and the entire lesion was sent for pathologic examination."], "Others": ["Grossly, the firm, polypoid mass measured 0.5\u2009\u00d7\u20090.5\u2009\u00d7\u20090.8 cm."]}
{"Examination and Results": ["Physical examination demonstrated no lymphadenopathy.", "The oropharynx and oral cavity were clear.", "Anterior rhinoscopy demonstrated thick, clear to yellow mucus bilaterally in the nasal cavities and bilateral inferior turbinate hypertrophy.", "There was right to left nasal septal deviation.", "Rigid nasal endoscopy demonstrated moderate mucosal edema responsive to topicalization.", "Thick, clear to yellow mucus was evacuated with suction from the middle meatus and sphenoethmoidal recess, revealing a large, lobulated, flesh-colored mass filling the entire nasopharynx with an irregular surface and firm consistency.", "The fossae of Rosenmuller were effaced bilaterally.", "There was no overt surface ulceration or bleeding.", "Computed tomography (CT) revealed a well-defined, round, 2-cm midline posterior nasopharyngeal mass, situated between the longus colli muscles (Figure, A).", "The lesion appeared hypodense on CT, without calcification, enhancement, or bony erosion.", "Magnetic resonance imaging (MRI) (Figure, B-D) demonstrated the lesion to be hypointense on T1 sequence and hyperintense on T2 sequence with mild heterogeneous enhancement.", "No clival sinus tract was seen."], "Treatment": ["Endoscopic biopsy of this mass was performed."]}
{"Patient Personal Background": ["The patient had a history of hypertension and laminectomy, and he never smoked."], "Examination and Results": ["Family history was notable for prostate cancer in his father, but the patient\u2019s prostate-specific antigen and digital rectal examination results were normal.Perform a computed tomographic scan to evaluate for source of hematuria.Perform microscopic urinalysis to confirm the presence of blood in the urine.Refer to urology for cystoscopy to evaluate the source of hematuria."], "Treatment": ["Family history was notable for prostate cancer in his father, but the patient\u2019s prostate-specific antigen and digital rectal examination results were normal.Perform a computed tomographic scan to evaluate for source of hematuria.Perform microscopic urinalysis to confirm the presence of blood in the urine.Refer to urology for cystoscopy to evaluate the source of hematuria."], "Others": ["Results are shown in the Table."]}
{"Patient Symptoms": ["Her mother described an intermittent inflammatory reaction localized only to the patient\u2019s abnormal skin lesions that was reproducible in febrile states and was concerned about asymptomatic, stable, dark brown lesions that had developed in areas of prior blistering and scarring on the patient\u2019s right arm, left knee, and right upper back."], "Examination and Results": ["There was no history of developmental delay, eye abnormalities, or seizures.Examination revealed irregular, dark brown, well-demarcated macules with regular pigment networks on dermoscopy within prominent soft, yellow, papular protrusions in a Blaschkolinear arrangement on her upper arms, particularly her right arm.", "The right flank demonstrated linear, atrophic pink plaques with focal erosions and crusting, evidencing recent inflammation described by the patient\u2019s mother (Figure, A).", "Additional irregular, well-demarcated, evenly pigmented dark brown macules were present within pink, atrophic scars located on the right side of the trunk, the right upper back, and the left knee.", "She had well-healed surgical scars on the hands, syndactyly of the toes, and ventral pterygium and dystrophy of the fingernails and toenails (Figure, B).A, Irregular, dark brown, well-demarcated macules within prominent soft, yellow, papular protrusions in a Blaschkolinear arrangement on the upper arms; linear, atrophic pink plaques with focal erosions and crusting are seen on the right flank.", "B, Extracutaneous features show syndactyly of the toes and ventral pterygium and dystrophy of the toe nails.", "C, Hematoxylin-eosin staining of skin biopsy demonstrates close proximity of subcutaneous fat to the epidermis with attenuated collagen (original magnification\u2009\u00d7\u200920).Previous treatment had included surgical excision of a frequently symptomatic focus of affected skin with subsequent adjacent tissue transfer."], "Treatment": ["Additionally, she had received dental implantation of frontal upper incisors."], "Others": ["Histopathologic slides from the prior excision of affected skin were reviewed (Figure, C)."]}
{"Patient Symptoms": ["According to her mother, lesions had started 2 days prior.", "The lesions appeared on the 13th day of life."], "Examination and Results": ["Physical examination revealed vesicles filled with clear fluid disposed in a linear arrangement forming whorls and swirls (Figure, A).A, Linear vesicles on the calf of the newborn patient.", "C and D, A biopsy specimen of a vesicle was obtained.Herpes simplex and varicella zoster virus polymerase chain reactions were negative.", "Syphilis, cytomegalovirus, and toxoplasma serologies were negative.", "Bacterial and fungal cultures of the vesicles were negative."], "Others": ["B, After 15 months, the lesions had evolved into small hyperpigmented macules in a linear arrangement.", "A biopsy sample of a vesicle was obtained.Over time, lesions healed leaving residual grayish hyperpigmentation (Figure, B)."]}
{"Patient Personal Background": ["The patient\u2019s medical history included hypertension, and review of his family medical history was noncontributory."], "Patient Symptoms": ["He endorsed polyuria and polydipsia but was otherwise asymptomatic."], "Examination and Results": ["Recent extensive laboratory data revealed mildly elevated triglycerides (209 mg/dL [to convert to mmol/L, multiply by 0.0113]) but otherwise were all within normal limits.", "On physical examination, numerous coalescing reddish-yellow pedunculated papules were present in both axillae (Figure, A and B).", "No other cutaneous lesions were present.", "Shave biopsy of one of the left axillary papules was performed (Figure, C and D) with additional immunohistochemistry positive for CD68 antibody staining.A and B, Numerous coalescing reddish-yellow pedunculated papules in the right and left axillae.", "C, Histopathological analysis of a biopsy specimen taken from the left axilla shows histiocytes with foam cells, scattered lymphocytes, and few plasma cells; D, a classic wreath like Touton cell and foam cells with histiocytes."]}
{"Patient Personal Background": ["The patient reported being an infrequent smoker, with about 2 cigarettes a month.The patient during the first pain episode, with a red left eye, lacrimation, and periorbital swelling.She had no history of impaired vision, diplopia, facial trauma, prior head or neck surgery, or allergies."], "Patient Symptoms": ["She reported a strong unilateral headache located in her left cheek, eye, and forehead that evolved during the evening hours, peaked at night, and decreased again until the morning, without any remarkable trigger.", "This first episode went along with ipsilateral lacrimation, a red eye, and periorbital swelling but without ptosis, which she documented with her smartphone (Figure 1).", "During a painful night, she could not sleep.", "Pain remitted, but the swelling increased until the next morning and slowly decreased over approximately 36 hours.", "Recurrent but less intense episodes of several hours\u2019 duration occurred during the 2 subsequent nights with no symptoms during the following 14 days.", "The patient reported no nasal congestion, nausea, vomiting, or phonophobia or photophobia."], "Examination and Results": ["Examination of her head and neck showed no particularities, periorbital edema or proptosis, or enlarged lymph nodes.", "The neurological examination was unremarkable, with normal visual acuity, symmetrically reactive pupils, and unimpaired ocular movements, as was a differential hemogram, which showed normal white blood cell count of 5500/\u03bcL (to convert to \u00d7109/L, multiply by 0.001)."]}
{"Patient Personal Background": ["The patient\u2019s history revealed chronic constipation, relieved by the use of laxatives."], "Patient Symptoms": ["The pain radiated throughout the right leg and was related to nausea without vomiting."], "Examination and Results": ["Furthermore, results of an abdominal physical examination were also normal, and no neurological or vascular deficits were found.The abdominal computed tomographic scans performed in the emergency department are shown in the Figure."], "Others": ["The patient never noticed any inguinal protrusion or mass."]}
{"Examination and Results": ["Physical examination showed no notable abnormalities.", "Blood test results revealed anemia (hemoglobin 9.8 g/dL [to convert to grams per liter, multiply by 10]) but were otherwise unremarkable.", "Upper gastrointestinal series showed subtotal occlusion in the second part of the duodenum (Figure 1 A).", "Computed tomography of the abdomen confirmed intraluminal narrowing of the duodenum without signs of a mass (Figure 1 B, arrowhead).", "Gastroduodenoscopy revealed a duodenal ulcer with pinpoint stenosis that could not be passed or dilated.", "Multiple biopsies were negative for cancer."], "Treatment": ["Total parenteral nutrition was started and the patient was scheduled for surgery.A, Coronal upper gastrointestinal series demonstrate subtotal occlusion in the second part of the duodenum."], "Others": ["B, Axial computed tomography image shows intraluminal narrowing of the duodenum without signs of a mass (arrowhead)."]}
{"Patient Personal Background": ["He had no relevant medical history and his family history was negative for malignancy.Clinical examination revealed an area of ulceration centrally along the left upper eyelid margin, measuring approximately 8 mm\u2009\u00d7\u20092 mm (Figure 1A)."], "Patient Symptoms": ["This was accompanied by foreign-body sensation and discomfort of the left eye and was preceded by a week of general malaise without fevers or chills.", "He denied vision changes, light sensitivity, or drainage from the eye.", "He denied previous similar episodes of eyelid swelling or recurrent chalazia.", "There was mild madarosis in the area of ulceration.", "There was also a tender and enlarged preauricular lymph node on the ipsilateral side."], "Examination and Results": ["He had no relevant medical history and his family history was negative for malignancy.Clinical examination revealed an area of ulceration centrally along the left upper eyelid margin, measuring approximately 8 mm\u2009\u00d7\u20092 mm (Figure 1A).", "The eyelid demonstrated mild boggy edema; however, there were no associated nodules, vesicles, or plaques on the surrounding skin or face.", "There was mild madarosis in the area of ulceration.", "There was also a tender and enlarged preauricular lymph node on the ipsilateral side.", "The remainder of the clinical examination was unremarkable, including visual acuity, intraocular pressure, slitlamp biomicroscopy, and dilated fundus examination."], "Others": ["A photomicrograph of a hematoxylin-eosin\u2013stained section from an incisional biopsy specimen is shown in Figure 1B.A, External photograph of the left eye demonstrating central upper eyelid margin ulceration with sparse lashes and surrounding edema."]}
{"Patient Personal Background": ["Medical history was significant for a heart murmur with no known history of chickenpox."], "Patient Symptoms": ["He presented with a 2-day history of painful, left-sided vesicular rash around his eyelid and forehead."], "Examination and Results": ["Best-corrected visual acuity was 20/20 OD and 20/25-2 OS.", "On examination, clear vesicles on erythematous bases were noted in the V1 distribution with left upper eyelid edema and erythema.", "Pupils were equally reactive with no relative afferent pupillary defect.", "Visual fields were full in both eyes.", "Anterior examination was significant for left-sided conjunctivitis, dendritic keratitis (Figure), and anterior uveitis.", "The findings of the remainder of the examination, including the anterior segment of the right eye and the dilated fundus examination of both eyes, were unremarkable.Slitlamp photograph showing branching corneal pseudodendrites with minimal fluorescein uptake."], "Treatment": ["His pediatrician prescribed oral acyclovir and ibuprofen as needed for pain."]}
{"Patient Personal Background": ["He had a history of human immunodeficiency virus (HIV) infection with a CD4 count of 25 and retinal detachment of the left eye secondary to cytomegalovirus (CMV) retinitis.", "He was taking trimethoprim-sulfamethoxazole for prophylaxis of Pneumocystis jiroveci pneumonia (formerly Pneumocystis carinii)."], "Examination and Results": ["On examination, visual acuity was 20/30 OD and no light perception OS, which was phthisical with no view of the fundus.", "In the right eye, the anterior segment was quiet, and there was 1+ nuclear sclerosis.", "Dilated fundus examination showed no vitritis, multiple discrete hyperpigmented scars (Figure, A, black arrowhead), and an area of inferotemporal retinal whitening (Figure, A, white arrowhead) with associated hemorrhage.", "On his return, his visual acuity had declined to 20/50 OD, there was mild vitritis, and there were new areas of retinitis along the inferior arcade (Figure, B, white arrowheads) and vascular sheathing (Figure, B, black arrowhead).Fundus photographs of the right eye."], "Treatment": ["He was treated with oral valgancyclovir, but 3 weeks later, the lesions had progressed, prompting admission for intravenous ganciclovir before being lost to follow-up for 1 month."], "Diagnosis": ["The patient was presumptively diagnosed as having CMV retinitis based on the history of CMV retinitis in the contralateral eye, and the findings of hemorrhagic retinitis adjacent to chorioretinal scars suggestive of prior, healed CMV retinitis."], "Others": ["A, Inferotemporal area of retinal whitening (white arrowhead) with intraretinal hemorrhage adjacent to chorioretinal scars (black arrowhead).", "There is retinal vascular sheathing within the area of retinitis."]}
{"Patient Symptoms": ["Findings from the examination were remarkable for reduced visual acuity in the left eye (20/80), proptosis with hypoglobus in the left eye, S-shaped left blepharoptosis, and left retinochoroidal folds (Figure 1A).", "B, Results of coronal, T1-weighted, postcontrast, fat-suppressed magnetic resonance imaging (MRI) of the orbits showing a 2\u2009\u00d7\u20093\u2009x\u20092.8-cm well-defined lesion of the lacrimal gland with inferior displacement of the globe and lateral rectus muscle.When the patient was reevaluated 2 weeks later, the pain at rest had resolved, but pain on palpation of the superotemporal left orbit persisted."], "Examination and Results": ["Findings from the examination were remarkable for reduced visual acuity in the left eye (20/80), proptosis with hypoglobus in the left eye, S-shaped left blepharoptosis, and left retinochoroidal folds (Figure 1A).", "Magnetic resonance imaging (MRI) of the orbits with contrast demonstrated a well-defined superotemporal mass with homogeneous enhancement (Figure 1B).", "Results of a complete blood cell count, comprehensive metabolic panel, antineutrophil cytoplasmic antibody, antinuclear antibody, Lyme titer and serum angiotensin-converting enzyme levels, chest radiograph, erythrocyte sedimentation rate, C-reactive protein levels, urinalysis, and IgG4 index were normal.", "The patient\u2019s pain nearly resolved after 3 days of intravenous methylprednisolone treatment, and he was discharged with a regimen of 80 mg/d of oral prednisone.A, Left eye at initial presentation showed proptosis with hypoglobus, S-shaped blepharoptosis, and retinochoroidal folds.", "B, Results of coronal, T1-weighted, postcontrast, fat-suppressed magnetic resonance imaging (MRI) of the orbits showing a 2\u2009\u00d7\u20093\u2009x\u20092.8-cm well-defined lesion of the lacrimal gland with inferior displacement of the globe and lateral rectus muscle.When the patient was reevaluated 2 weeks later, the pain at rest had resolved, but pain on palpation of the superotemporal left orbit persisted.", "Results of the examination were otherwise unchanged."], "Treatment": ["The patient was admitted for a trial of intravenous methylprednisolone, 1000 mg, for presumed inflammatory dacryoadenitis.", "The patient\u2019s pain nearly resolved after 3 days of intravenous methylprednisolone treatment, and he was discharged with a regimen of 80 mg/d of oral prednisone.A, Left eye at initial presentation showed proptosis with hypoglobus, S-shaped blepharoptosis, and retinochoroidal folds."], "Diagnosis": ["The patient was admitted for a trial of intravenous methylprednisolone, 1000 mg, for presumed inflammatory dacryoadenitis."]}
{"Patient Personal Background": ["She had a history of mild atopic dermatitis and was not taking any medications.", "She had no known history of drug allergy or contact allergy.", "The patient lived with her 2 siblings and both parents, who were all asymptomatic.", "She had no pets and no recent travel, and her vaccinations were up to date.On physical examination, the patient was actively scratching the involved skin."], "Patient Symptoms": ["The rash started as small pink bumps on her arms that spread to involve the axillae, neck, and upper chest.", "Four days prior to arrival, she developed significant redness and pruritus of her face.", "On arrival, her parents noted black streaks on her right arm, prompting an urgent emergency department evaluation.", "The bilateral arms, axillae, anterior neck, and face had poorly defined, blanching pink-red patches and edematous plaques without epidermal change (Figure, A).", "Jet black, well-defined, and slightly shiny linear streaks with peripheral erythema were noted on her right forearm, with smaller circular, black macules on the ipsilateral biceps and axilla (Figure, B).Widespread pruritic eruption."], "Examination and Results": ["The bilateral arms, axillae, anterior neck, and face had poorly defined, blanching pink-red patches and edematous plaques without epidermal change (Figure, A).", "Jet black, well-defined, and slightly shiny linear streaks with peripheral erythema were noted on her right forearm, with smaller circular, black macules on the ipsilateral biceps and axilla (Figure, B).Widespread pruritic eruption.", "A, Poorly defined, blanching pink-red patches and edematous plaques on the upper chest, neck, proximal arms, and face.", "B, Jet black, well-defined, and slightly shiny linear streaks with peripheral erythema on the right forearm."], "Treatment": ["Treatment prior to presentation included diphenhydramine, cetirizine, and a 20-mg dose of prednisone without improvement."], "Others": ["The patient was otherwise healthy with normal development and growth."]}
{"Examination and Results": ["Angiography demonstrated widely patent grafts to the left anterior descending and right coronary arteries and a totally occluded graft to the obtuse marginal branch, which was known from a prior cardiac catheterization.", "Disease in the obtuse marginal branch appeared stable, but there was worsening of disease in the ramus branch, where 2 serial lesions were identified.", "Intravenous adenosine was administered at 140 \u00b5g/kg/min to induce maximal hyperemia, and fractional flow reserve (FFR) was measured in the ramus, revealing a nadir value of 0.43 across both lesions (Figure 1).", "A slow, pull-back maneuver across the distal lesion demonstrated that the proximal lesion had an FFR value of 0.82.A, Angiography shows 2 serial lesions of intermediate severity in the ramus intermedius (red arrowheads).", "B, Fractional flow reserve (FFR) measurement was performed after induction of maximal hyperemia, demonstrating a nadir value of 0.43."], "Treatment": ["Intravenous adenosine was administered at 140 \u00b5g/kg/min to induce maximal hyperemia, and fractional flow reserve (FFR) was measured in the ramus, revealing a nadir value of 0.43 across both lesions (Figure 1)."], "Others": ["HR indicates heart rate; iPa, instantaneous proximal (aortic) pressure; iPd, instantaneous distal (coronary) pressure; Pa, proximal (aortic) pressure; and Pd, distal (intracoronary) pressure.The proximal lesion is ischemic while the distal lesion is nonischemic.", "Only the proximal lesion should have a stent placed.The distal lesion is ischemic while the proximal lesion is nonischemic.", "Only the distal lesion should have a stent placed.Both lesions are ischemic and should have a stent placed.FFR with adenosine should be remeasured after placing a stent in the distal lesion to better assess the proximal lesion."]}
{"Patient Personal Background": ["His medical history was notable for bilateral retinoblastoma when he was an infant, which was treated with right-eye enucleation and left-eye irradiation.", "As a teenager, he developed an advanced malignant small blue cell tumor, which was interpreted as an olfactory neuroblastoma and treated with radiation and chemotherapy."], "Patient Symptoms": ["When the patient returned 2 months later with increasing pain, endoscopy revealed a polypoid lesion occupying the biopsied site."], "Examination and Results": ["On examination, the patient had a hard, fixed, rounded 2-cm lesion in the right supraorbital region.", "Computed tomography (CT) showed an irregular mass in the right frontal, maxillary, and ethmoid sinuses with surrounding sclerotic and erosive bony changes.", "A fine-needle aspirate (FNA) revealed atypical, mitotically active cells.", "Bone shavings obtained operatively were interpreted as chronic sinusitis with sclerotic bone.", "The surgical specimen showed multinucleated giant cells and bizarre stromal cells suggestive of treatment effect (Figure, A) and normal-appearing bone.", "On repeated operative biopsy, histologic examination showed similar giant cells and atypical stromal cells (Figure, B).", "However, other areas demonstrated osteoid formation with fine calcifications and severely atypical spindle cells with mitotic figures (Figure, C), as well as osteoid-entrapped, malignant-appearing cells (Figure, D)."], "Treatment": ["As a teenager, he developed an advanced malignant small blue cell tumor, which was interpreted as an olfactory neuroblastoma and treated with radiation and chemotherapy."], "Others": ["A second opinion was reported as chronic sinusitis and atypical stromal cells."]}
{"Patient Personal Background": ["His extensive medical history was notable for congestive heart failure, M\u00e9ni\u00e8re\u2019s disease after multiple endolymphatic shunts, a benign parotid tumor (which had been excised), and chronic abdominal pain secondary to pancreatic steatorrhea."], "Patient Symptoms": ["His only symptom was frontal and ethmoid sinus pressure.", "He denied difficulty breathing, postnasal drip, rhinorrhea, epistaxis, or anosmia and had no history of sinus or upper respiratory infections."], "Examination and Results": ["Flexible nasal endoscopy confirmed a central posterior bulge in the posterior nasal cavity with normal overlying mucosa and clear nasopharynx.", "The noncontrast CT bone window showed an expansile anterior nasal septum mass measuring 1.9\u2009\u00d7\u20092.4 cm with internal matrix mineralization (Figure, A-C)."], "Treatment": ["A complete septectomy was performed, which involved near-complete resection of the quadrangular cartilage and resection of the adjacent anterior portion of the periosteum of the vomer bone."], "Others": ["Biopsy and magnetic resonance imaging (MRI) were recommended as baseline studies for follow-up, but were not completed.", "A histological specimen is shown in the Figure, D.A-C, Computed tomographic images without contrast of the head using a bone algorithm.", "D, Histopathological image from the nasal cavity mass."]}
{"Patient Symptoms": ["She reported return of her symptoms after 11 months to include mouth breathing, snoring, and nasal obstruction with hyponasality and eustachian tube dysfunction.", "She also began to experience transient upper extremity paraplegias."], "Examination and Results": ["On examination, she was noted to have abnormal asymmetry of the posterior nasopharyngeal wall by flexible fiber-optic laryngoscopy without any overlying mucosal changes.", "Magnetic resonance imaging revealed a complete recurrence and enlargement of the retropharyngeal mass with dimensions of 4.2 (anterior to posterior)\u2009\u00d7\u20096.3 (transverse)\u2009\u00d7\u20095.1 (craniocaudal) cm.", "The mass was heterogeneously hyperenhancing on T1-weighting and centered at the atlantoaxial joint causing erosion of the upper dens, anterior arch of C1, and the basion (Figure).A, T1-weighted magnetic resonance imaging (MRI)."], "Treatment": ["She required hospital admission with steroid and anti-inflammatory treatment for partial resolution of symptoms."], "Others": ["Arrowhead indicates the oropharynx.", "B, T2-weighted MRI.", "Arrowhead indicates soft tissues; asterisk, thecal sac.", "C, Fat-saturated T1-weighted postcontrast MRI.", "D, Computed tomographic image (CT), bone windows."]}
{"Examination and Results": ["Computed tomography (CT) of the temporal bone detected middle ear, mastoid, and infralabyrinthine involvement (Figure, A).", "Gadolinium-enhanced magnetic resonance imaging (MRI) of the brain demonstrated meningitis and a large cerebellar lesion with rim enhancement.", "Moreover, diffusion-weighted imaging (DWI) images and apparent diffusion coefficient (ADC) maps were consistent with cerebellar abscess (Figure, B-D).Imaging of the head."], "Treatment": ["She had undergone an emergency craniotomy for brain decompression the day before.", "She was receiving intravenous antibiotics and steroids and was sedated and mechanically ventilated."], "Diagnosis": ["Moreover, diffusion-weighted imaging (DWI) images and apparent diffusion coefficient (ADC) maps were consistent with cerebellar abscess (Figure, B-D).Imaging of the head."], "Others": ["ADC indicates apparent diffusion coefficient; CT, computed tomography; FLAIR, fluid attenuated inversion recovery; MRI, magnetic resonance imaging."]}
{"Patient Personal Background": ["She had no history of trauma, and there was no response to steroids."], "Patient Symptoms": ["She had not experienced headaches, disequilibrium, or tinnitus."], "Examination and Results": ["Findings from a physical examination were notable for left House-Brackmann grade III/VI facial palsy, hypoesthesia in left trigeminal nerve distribution, and no left audiologic responses to bone or air stimuli.", "A non\u2013contrast-enhanced computed tomographic (CT) scan showed a left petrous apex expansile lesion involving the internal auditory canal (Figure, A).", "Magnetic resonance imaging (MRI) showed a well-circumscribed lesion (Figure, B) extending into the fundus of the internal auditory canal (Figure, C).", "There was a fluid-fluid level in the lesion (Figure, B), consistent with presence of blood products.", "The displaced adjacent cranial nerve V (Figure, C) extended along the surface of the lesion.", "After the administration of an intravenous contrast agent, there was a nodular focus of enhancement at the anterior aspect of the lesion (Figure, D) and linear areas of enhancement at the periphery and of internal septations (Figure, D)."], "Treatment": ["The lesion was completely excised via a middle fossa craniotomy."], "Others": ["Postoperatively, the patient regained full function of all cranial nerve deficits, including the hearing loss."]}
{"Patient Symptoms": ["The symptoms started approximately 3 months prior and had progressively worsened with interval difficulty weight bearing and ambulating up and down stairs.", "The patient noted night sweats 2 weeks prior to presentation but denied any associated fevers, unintentional weight loss, fatigue, or change in appetite."], "Examination and Results": ["Physical examination revealed limited range of motion of the left leg related to pain.", "There was no cervical, axillary, or inguinal lymphadenopathy.", "Laboratory evaluation demonstrated a hemoglobin level of 10.3 g/dL and a lactic acid dehydrogenase level of 599 u/L.", "Serum protein electrophoresis testing did not detect a monoclonal protein.", "A plain radiograph of the left femur showed a 15-cm area of moderate destruction in the proximal femoral shaft extending distally from the level of the lesser trochanter with concern for impending fracture (Figure 1A and B).", "A computed tomography (CT) scan of the chest, abdomen, and pelvis did not visualize any metastatic disease, and results were negative for lymph node enlargement.", "A nuclear medicine bone scan demonstrated increased uptake in the left femur with no other focal abnormalities."], "Treatment": ["The patient underwent a CT-guided needle biopsy of the left femur (Figure 1C).A and B, Radiographs of the left femur; C, biopsy specimen; original magnification \u00d7 400."]}
{"Patient Personal Background": ["He underwent colostomy after unsuccessful surgical correction for an enterocutaneous fistula and had required total parenteral nutrition (TPN) for the past year.", "He had not noticed any significant changes in ostomy output during this time."], "Patient Symptoms": ["The rash was accompanied by diffuse alopecia of the face, scalp, axillae, and groin (Figure)."], "Examination and Results": ["Generalized alopecia and erythematous, scaly rash involving face and scalp.Dermatologic examination revealed widespread erythematous plaques on the face, scalp, and medial aspect of the thighs bilaterally and scattered papules with scaling on the face, scalp, chest, and back.", "Diffuse, nonscarring alopecia was present on the face, scalp, axillae, and groin."], "Treatment": ["There was no improvement in the rash despite multiple rounds of oral fluconazole, topical antibiotic ointment, and intravenous antibiotics."], "Others": ["Prior to development of the rash, he completed neoadjuvant chemotherapy followed by surgical resection."]}
{"Patient Symptoms": ["She reported night sweats and some excessive fatigue over the last few months."], "Examination and Results": ["Her physical examination revealed normal heart sounds and no splenomegaly (Table).The patient has a low-normal serum erythropoietin level."], "Diagnosis": ["She should be tested for JAK2V16F mutation status.The patient likely has familial polycythemia given her low-normal erythropoietin level."], "Others": ["She was unaware of any family history of blood disorders.", "She should be referred for genetic counseling.The patient likely has secondary causes of her elevated hematocrit level.", "No further workup is needed.These findings are likely due to dehydration.", "Further testing would likely indicate a normal red blood cell mass with a low plasma volume suggesting dehydration."]}
{"Examination and Results": ["He was cold to the touch; blood pressure was 85/55 mm Hg, heart rate was 36/min, respiratory rate was 14/min, and pulse oximetry was 100% on ambient air.", "Multiple temperature measurements, including a core temperature assessment via the rectal method, did not yield a detectable temperature.", "His chest examination was clear to bilateral auscultation.", "Chest radiographs and computed tomography of the head were negative for any acute pathology.", "His electrocardiogram (ECG) on presentation is shown in Figure 1."], "Treatment": ["Routine laboratory tests were ordered, and he was started on an intravenous fluid."]}
{"Patient Symptoms": ["The lesions had repeatedly recurred despite topical steroid therapy."], "Examination and Results": ["Physical examination revealed papules and plaques ranging up to 1 cm in diameter on the lateral cheeks and behind the ears and neck along with a red-brown hue (Figure, A).", "Complete blood cell count and comprehensive metabolic panel results were unremarkable.", "However, serum protein electrophoresis revealed polyclonal hypergammaglobulinemia.", "Antinuclear antibody and anti-Ro/SS-A and anti-La/SS-B antibodies were undetectable by indirect immunofluorescence or double immunodiffusion methods.", "Computed tomography (CT) revealed bilateral parotid gland swelling together with mild lymphadenopathy in the mediastinum and hilus.", "B and C, Hematoxylin-eosin\u2013stained skin biopsy specimens taken from papules show nodular inflammatory cell infiltration consisting of dense lymphocytes admixed with plasma cells and eosinophils.", "D, Papule specimen under IgG4 immunohistochemical stain."], "Others": ["The patient was otherwise healthy.", "A skin biopsy specimen was obtained from a papule on the neck for further analysis (Figure, B-D).A, Indurated papules and plaques are present on the lateral cheeks and behind the ears and neck along with a red-brown hue."]}
{"Patient Symptoms": ["Dermatology was consulted for evaluation of 5-day history of new tender lesions on the scalp.", "The patient did not have a history of recent travel or trauma."], "Examination and Results": ["Flow cytometry showed myeloid blasts, most of which (\u226590%) expressed CD13, CD33, CD117, and partial CD11b (\u226550%).", "Blasts were also \u201chighly positive\u201d for myeloperoxidase.", "Stains were weak for CD4 and were negative for CD34 and HLA-DR. Cytogenetic studies revealed a normal karyotype with NPM1 and FLT3-ITD mutations.", "Physical examination revealed several tender purpuric papules and plaques with central necrosis and hemorrhagic crusting on the scalp (Figure, A).", "Similar lesions were present on the right dorsal hand and left lower leg.", "On the right forearm, there was a tender erythematous plaque with overlying vesicles and mild hemorrhagic crusting.", "On the left medial thigh, there was a large indurated, tender red-brown plaque.", "Wound cultures and polymerase chain reaction studies from the right forearm were negative for herpes simplex virus and varicella zoster virus infections.", "Punch biopsy specimens from lesions on the scalp, right forearm, and left thigh were sent for histopathological and immunohistochemical assessment and tissue culture (Figure, B-D).A, Clinical image of tender purpuric papules and plaques with central necrosis on the scalp.", "B-D, Histologic images of a punch biopsy specimen from a scalp lesion."]}
{"Patient Personal Background": ["He had a past medical history significant for metastatic renal cell carcinoma, a lung transplant secondary to chronic obstructive pulmonary disease, end-stage kidney disease being treated with hemodialysis, and multiple nonmelanoma skin cancers."], "Patient Symptoms": ["A dermatologist was consulted during his admission to evaluate a friable, growing lesion on his right elbow that had appeared 2 months prior."], "Examination and Results": ["Physical exam revealed 2 closely adjacent dome-shaped erythematous nodules with edematous borders (Figure, A).", "A 4-mm punch biopsy was performed.A, Two closely adjacent friable, erythematous nodules with rolled borders on the left elbow.", "B, Pseudoepitheliomatous hyperplasia of the epidermis with focal ulceration and multiple collections of neutrophils.", "C, Mixed inflammatory infiltrate containing neutrophils, plasma cells, histiocytic, and multinucleate giant cells containing refractile spore-like structures.", "D, Numerous spores and pseudohyphae staining positively for pigment."]}
{"Patient Symptoms": ["This was her first episode, and she denied any pain.", "C, Fluorescein angiography demonstrates hyperfluorescence of an arterial midsegment with distal nonperfusion.The next day, the patient developed severe headaches and presented to the local emergency department."], "Examination and Results": ["Visual acuity was 20/25\u2009+\u20092 OD and 20/20 OS.", "Confrontation visual fields detected a superior field defect in the left eye.", "Pupils, intraocular pressures, and anterior segment examination results were within normal limits.", "Dilated fundus examination revealed whitening and attenuation of a small arteriole in the inferior arcade of the right eye (Figure, A).", "Examination of the left eye revealed an inferior branch retinal artery occlusion and a patch of retinal whitening superior to the optic disc approximately one-third disc diameter in size (Figure, B).", "No Hollenhorst plaques were identified.", "Fluorescein angiography demonstrated segments of arteriole hyperfluorescence with distal nonperfusion in both eyes (Figure, C).", "This hyperfluorescence and nonperfusion occurred within straight arteriole segments, not at arteriole bifurcations."], "Treatment": ["An outpatient workup composed of fluorescent treponemal antibody absorption, QuantiFERON\u2013TB Gold (Quest Diagnostics), erythrocyte sedimentation rate, antinuclear antibody, complete blood cell count, prothrombin time, and partial thromboplastin time was ordered.A, Fundus photograph of the right eye shows subtle whitening and attenuation of an arteriole."], "Diagnosis": ["The differential diagnosis included systemic lupus erythematosis, polyarteritis nodosa, Beh\u00e7et disease, granulomatosis with polyangiitis (Wegener disease), acute retinal necrosis, syphilis, and hypercoagulability."], "Others": ["B, Left eye illustrates an inferior branch retinal artery occlusion and retinal whitening superior to the optic disc."]}
{"Examination and Results": ["She had been seen 7 months prior to presentation for a comprehensive eye evaluation.", "She was found to have a bilateral posterior vitreous detachment, and the results of her retinal examination at that time were normal.Her best-corrected vision was 20/20 OU, and the intraocular pressure in each eye was normal.", "An anterior segment examination of the left eye revealed trace keratic precipitates on the inferior cornea and 1+ cell.", "A posterior segment examination revealed 1+ vitreous cell."], "Others": ["A photograph from a fundus examination is shown in Figure 1."]}
{"Patient Personal Background": ["He had no other medical history or medication use.Ocular and skin findings."], "Patient Symptoms": ["He also noted red spots on his arms and legs.", "He denied blurry vision, discharge, photophobia, fevers, allergies, or recent illnesses.", "The patient had conjunctival hyperemia in his left eye."], "Examination and Results": ["A, Left eye with nasal hyperemia and conjunctival foreign body.", "B, Elevated erythematous lesions on extremity.Physical examination demonstrated discrete papules 5 mm in diameter with dark centers, localized to his extremities and trunk (Figure, B).", "The patient had conjunctival hyperemia in his left eye."], "Others": ["Inset: magnified image.", "His wife had picked him up after his hike and developed a similar lesion on her left arm."]}
{"Patient Personal Background": ["She claimed to be in good health and denied any concurrent medical conditions.", "She had undergone a weight loss procedure known as a duodenal switch the year prior.On ophthalmologic examination with a Snellen eye chart, her visual acuity was best corrected to 20/40 OD and 20/30 OS."], "Patient Symptoms": ["She had little to no improvement over the last few months with an artificial tear solution.", "She had a marked uptake of lesions, which were revealed with lissamine green stain on the conjunctivae, and an overall appearance of diffuse punctate keratopathy.", "She had bilateral conjunctival lesions with a foamy appearance both temporally and nasally (Figure)."], "Examination and Results": ["Her pupils were normal without afferent pupillary defect.", "The lenses were clear, and ophthalmoscopy revealed no abnormal findings.", "Macular optical coherence tomography revealed normal contour with a bilateral cube volume of 9.4 mm3 and a central subfield thickness of 220 and 222 \u03bcm for the right and left eyes, respectively.", "Visual field testing revealed general constriction bilaterally.Conjunctival lesion stained with lissamine green."]}
{"Patient Personal Background": ["She underwent gastric surgery more than 25 years ago, of which no details were available.On general physical examination, her vital signs were stable."], "Patient Symptoms": ["There was epigastric tenderness."], "Examination and Results": ["The abdomen was soft and nondistended.", "The results from initial blood tests, including hemogram, liver and kidney function tests, and serum amylase, were unremarkable.", "Contrast-enhanced abdominal computed tomography was performed (Figure 1)."]}
{"Patient Symptoms": ["On review of systems, she endorsed anorexia and malaise for the past several days.", "She was in no acute distress but appeared languid."], "Examination and Results": ["She was found to have severely elevated blood pressure at an urgent care center, prompting her transfer to the hospital.", "Her blood pressure was 210/110 mm Hg.", "Physical examination demonstrated periorbital and 1+ bipedal pitting edema.", "She had mild tenderness to percussion of both flanks.Serum studies revealed a creatinine level of 13 mg/dL (to convert to micromoles per liter, multiply by 88.4), potassium level of 6.6 mEq/L (to convert to millimoles per liter, multiply by 1.0), and bicarbonate level of 16 mEq/L (to convert to millimoles per liter, multiply by 1.0).", "Her serum calcium level was 8.5 mg/dL (to convert to millimoles per liter, multiply by 0.25) and her serum phosphate level was elevated at 5 mg/dL (to convert to millimoles per liter, multiply by 0.323).", "Computed tomography of the abdomen and pelvis revealed severe bilateral hydronephrosis with renal cortical thinning and obstructing calculi at both ureteropelvic junctions (Figure 1).", "Interestingly, her serum calcium level elevated to 12 mg/dL and her serum phosphate level became low at 2.4 mg/dL.Computed tomographic scans of the abdomen and pelvis without contrast, showing obstructing calculi bilaterally at the ureteropelvic junctions (arrowheads) with resultant severe hydronephrosis and renal cortical thinning (A) and significant renal stone burden in the lower pole of the left kidney (B)."], "Treatment": ["The patient underwent emergent dialysis followed by placement of bilateral percutaneous nephrostomy tubes.", "Subsequently, her blood pressure normalized, edema improved, hyperkalemia and metabolic acidosis resolved, and serum creatinine level decreased to 1.6 mg/dL."]}
{"Patient Personal Background": ["His parents said that he is a \u201cpicky eater,\u201d with a diet consisting exclusively of orange soda, meat, and chili."], "Patient Symptoms": ["His mother reported that he was having difficulty grasping objects and recently started biting his fingers.", "A physical examination revealed a very irritable, inconsolable child with diffuse muscle tenderness."], "Examination and Results": ["The results of an extremity examination were consistent with carpal spasm, with a fully extended first finger with hyperextended distal interphalangeal joint, thumb constantly adducted to the hand, and last 3 digits mildly flexed and adducted together.", "The extremity examination also revealed twitching of facial muscles in response to tapping over area of facial nerve (ie, a positive Chvestok sign1).", "Laboratory studies confirm hypocalcemia (with a calcium level of 5.5 mg/dL [to convert to millimoles per liter, multiply by 0.25]), and a diagnosis of tetany is made.", "Additional physical examination findings include wrists that are unusually wide with prominent styloid processes of the radius and ulna; radiographs were abnormal (Figure, A and B).A, The patient\u2019s wrist is unusually wide and notable for prominent styloid processes of the radius and ulna.", "B, Wrist radiograph shows widening of the physes of the distal radius.", "There is associated transverse splaying, fraying, and cupping of the adjacent metaphyses, with loss of the zone of peripheral calcification.Further investigation revealed a parathyroid hormone (PTH) level of 798 pg/mL (normal range, 15-87 pg/mL [to convert to nanograms per liter, multiply by 1.0]), a vitamin D level of 7 pg/mL (normal level, >25 pg/mL [to convert to picomoles per liter, multiply by 2.6]), and a normal phosphorous level of 4.5 mg/dL (to convert to millimoles per liter, multiply by 0.323)."], "Treatment": ["Oral and intravenous supplementations of calcium were started, but the patient\u2019s calcium levels remained refractory, even after correction of other electrolytes, including potassium and magnesium.", "He was placed on a continuous intravenous calcium infusion for 3 days with eventual normalization of his calcium level."], "Diagnosis": ["Laboratory studies confirm hypocalcemia (with a calcium level of 5.5 mg/dL [to convert to millimoles per liter, multiply by 0.25]), and a diagnosis of tetany is made."]}
{"Patient Personal Background": ["His medical history was significant with hypertension, intracranial hemorrhage, and chronic kidney disease (CKD)."], "Patient Symptoms": ["After admission, his chest discomfort resolved in 2 days, but he was still febrile, and pericardial effusion did not decrease."], "Examination and Results": ["On arrival, his blood pressure was 130/64 mm Hg, heart rate was 104 beats/min, respiratory rate was 32 breaths/min, body temperature was 37.1\u00b0C, and arterial oxygen saturation was 95% on room air.", "There was no murmur, rub, or gallop in chest auscultation.", "Electrocardiographic (ECG) findings were significant for diffuse ST-segment elevation (Figure 1, A).", "Laboratory examination revealed leukocytosis with normal cardiac enzyme levels and mild renal dysfunction (serum creatinine, 1.4 mg/dL [to convert to micromoles per liter, multiply 88.4]).", "The C-reactive protein level was also elevated.", "Computed tomography (CT) of the chest was performed (Figure 1, B and C)."], "Diagnosis": ["He was admitted to the hospital with the suspected diagnosis of acute pericarditis."]}
{"Patient Personal Background": ["His family history was positive for a similar presentation involving his mother."], "Patient Symptoms": ["Physical examination revealed left orbital swelling and erythema with proptosis."], "Examination and Results": ["Cranial nerve function and ocular range of motion were intact.", "Contrast-enhanced computed tomographic (Figure, A) and magnetic resonance imaging studies of the paranasal sinuses (Figure, B) disclosed extensive preseptal and postseptal orbital inflammation, bilateral frontal sinus opacification from a large left frontal osteoma occupying the inferior aspect of the left frontal sinus, and left epidural abscess.", "Genetic analysis was positive for mutation in the APC gene at 5q21, resulting in a stop codon.A, Contrast-enhanced computed tomographic (CT) in bone windows."], "Treatment": ["The patient underwent a bicoronal approach osteoplastic flap and endoscopic frontal sinusotomy for access and drainage of left frontal sinus disease and obstructive osteoma excision.", "The patient\u2019s postoperative period progressed without incident, and he was discharged home with oral antibiotics following resolution of symptoms."], "Others": ["In addition to frontal sinus osteoma, multiple 3- to 5-mm osteomas covering the calvarium were encountered (Figure, C).", "Histopathologic findings of operative specimens showed dense lamellar bone (Figure, D).", "B, T1-weighted magnetic resonance image (MRI).", "C, Reflected osteoplastic flap, frontal sinusotomy.", "D, Hematoxylin-eosin, original magnification \u00d7400."]}
{"Patient Personal Background": ["His medical history was significant for hypertension, dyslipidemia, and cigarette smoking."], "Examination and Results": ["Flexible fiber-optic laryngoscopy revealed a 15-mm submucosal swelling in the right aryepiglottic fold.", "The vocal folds were free of lesions and had intact motion.", "Findings from the rest of the head and neck examination were unremarkable.", "A computed tomographic (CT) scan of the neck revealed a submucosal hypodense supraglottic mass on the right side that was compressing the airway.", "A magnetic resonance imaging study (MRI) of the neck demonstrated a soft-tissue mass measuring 27\u2009\u00d7\u200917 mm and causing deviation of the right aryepiglottic fold medially and compressing the airway (Figure, A and B).", "The patient underwent direct laryngoscopy, and a submucosal mass was observed in the right aryepiglottic fold (Figure, C).", "Results from the S100 protein immunostain were positive."], "Treatment": ["The mass was dissected submucosally, excised completely, and sent for a histopathologic examination (Figure, D)."], "Others": ["The postoperative course was uneventful, and after 5 months, the patient had no detectable laryngeal lesions and the vocal fold movement was intact."]}
{"Patient Personal Background": ["Her medical history was notable for dyspepsia, hypertension, and diabetes.", "She had no history of smoking, type B symptoms, angiotensin-converting enzyme-inhibitor use, or known cardiac pathologic abnormalities."], "Patient Symptoms": ["Initial treatment with proton pump inhibitors and evaluation by the gastroenterology unit did not improve her symptoms, so further workup was undertaken."], "Examination and Results": ["Findings from a complete head and neck examination were within normal limits aside from laryngeal findings.", "Flexible laryngoscopy with videostroboscopy revealed right vocal fold polyp and left vocal fold desquamation, with bilateral linear bands along the vocal folds.", "Noncontrast computed tomography (CT) revealed numerous calcified subglottic and tracheal nodules extending from the cricoid to the left mainstem bronchus (Figure, A).", "Further examination revealed edema of the vocal folds with multiple submucosal masses in the subglottis and upper trachea (Figure, B-D).", "The lesions were varying sizes, and not all were calcified.", "They affected the anterior cartilaginous trachea and the posterior membranous portion.", "Biopsy specimens of representative lesions revealed amorphous, eosinophilic material with calcification, metaplastic ossification, and multinucleated foreign-body giant cells."], "Treatment": ["She underwent direct laryngoscopy and bronchoscopy with biopsies.", "The disease was treated with debulking of scattered lesions from the glottis through to both main stem bronchi and airway dilation, which provided symptomatic relief.A, Calcified subglottic, upper tracheal, and left mainstem bronchus lesions."], "Others": ["On induction, subglottic firm mass consistent with calcification prevented passage of an endotracheal tube, and the patient\u2019s airway was secured with a rigid bronchoscope.", "B, Waxy, friable deposits in the supraglottic airway.", "C, Nodular lesions scattered circumferentially in the trachea.", "D, Nodular lesions extending into bronchi and lower airways."]}
{"Patient Personal Background": ["She mentioned that she had a cold sore once several years ago."], "Patient Symptoms": ["Two months after the last dose of radiation she developed pruritic pustules and papules on the skin of the ipsilateral right breast."], "Examination and Results": ["Physical examination findings showed pustules surrounding the areola on the right breast with an increasing number in the submammary fold (Figure 1)."], "Treatment": ["Levoceterizine gave some relief of the itch."]}
{"Patient Personal Background": ["Three years prior he had developed neutropenia and mild thrombocytopenia."], "Patient Symptoms": ["He noted fatigue, but otherwise felt well."], "Examination and Results": ["A bone marrow biopsy sample demonstrated refractory cytopenia with multilineage dysplasia.", "Cytogenetic testing results were normal, and there were 5% bone marrow blasts.", "After approximately 2 years, he developed more pronounced cytopenias and presented with a white blood cell count of 2100/\u03bcL(480 neutrophils), hemoglobin level of 8.4 g/dL, and platelet count of 92\u202f000/\u03bcL.", "It had been recently biopsied without definitive diagnosis, but since the biopsy, the mass had increased in size.An isolated polypoid mass affecting the right upper labial mucosa."], "Treatment": ["The patient was treated initially with cyanocobalamin 250 micrograms daily, then danazol 200 milligrams 3 times daily, then epoietin \u03b1 60,000 units weekly.", "Filgrastim 300 micrograms weekly was added to epoietin \u03b1 to attempt to augment response after 1 year of therapy."], "Others": ["Physical examination revealed an isolated, symptomatic polypoid mass involving his right upper labial mucosa (Figure)."]}
{"Patient Personal Background": ["The patient lived in North Carolina with no recent travel or known tick bite."], "Patient Symptoms": ["The lesion, initially attributed to a bug bite by her mother, enlarged and developed central clearing.", "She had no symptoms other than mild local itching."], "Examination and Results": ["Examination results were normal except for a 2.0-cm annular lesion with central clearing and peripheral flaking (Figure)."], "Treatment": ["After several weeks, the patient\u2019s mother applied over-the-counter topical antifungal cream and the lesion faded.", "The pediatrician ordered serologic testing for Lyme disease, prescribed 14 days of doxycycline based on the results (Table), and referred the patient to an infectious disease specialist for evaluation.Complete 14 days of antibiotic treatment for Lyme disease."], "Diagnosis": ["The pediatrician ordered serologic testing for Lyme disease, prescribed 14 days of doxycycline based on the results (Table), and referred the patient to an infectious disease specialist for evaluation.Complete 14 days of antibiotic treatment for Lyme disease."], "Others": ["After 10 days of antifungal therapy, the patient was evaluated by her pediatrician.", "No further testing is indicated.Complete 14 days of antibiotic treatment for Lyme disease.", "Repeat Lyme disease serology in 1 month to evaluate response."]}
{"Patient Personal Background": ["She was started on levothyroxine and takes no other medications.Currently, vital signs and physical examination are normal."], "Examination and Results": ["She was admitted recently for hypothyroidism, with a thyroid-stimulating hormone level of  209.1 \u00b5IU/mL (reference range, 0.4-4.0 \u00b5IU/mL) and free thyroxine level of 0.4 ng/dL (reference range, 0.7-1.5 ng/dL).", "Complete blood cell count then revealed a leukocyte count of 3800/\u00b5L; platelet count, 158 \u00d7103/L; hemoglobin level, 6.9 g/dL; and mean corpuscular volume, 107 \u03bcm3.", "Laboratory values include a leukocyte count of 2600/\u00b5L; platelet count, 86 \u00d7103\u00b5L; hemoglobin, 6.3 g/dL; reticulocyte count, 3.1%; and mean corpuscular volume, 106 \u03bcm3.", "Levels of thyroid-stimulating hormone and free thyroxine are 31.4 \u00b5IU/mL and 0.7 ng/dL, respectively.", "Lactate dehydrogenase (LDH) level is 3116 U/L (reference range, 0-271); haptoglobin, less than 8 mg/dL (reference range, 30-200); vitamin B12, 1313 pg/mL (reference range, 200-933), and serum folate, greater than 25 ng/mL (reference, >5.9).A, Peripheral blood smear showing microcytes and macrocytes, teardrop cells, absolute neutropenia, and thrombocytopenia (Wright-Giemsa, original magnification \u00d7100).", "The nucleated cell in the center is a polychromatophilic megaloblast containing a Howell-Jolly body."], "Treatment": ["She was started on levothyroxine and takes no other medications.Currently, vital signs and physical examination are normal."], "Others": ["A peripheral blood smear (Figure, panel A) and bone marrow biopsy (Figure, panel B) were obtained."]}
{"Patient Personal Background": ["Three weeks prior, he had undergone coronary angiography and coronary artery bypass graft surgery after myocardial infarction."], "Patient Symptoms": ["On physical examination, he had exquisitely tender blue macules, patches, and papules on the plantar aspect of several toes (Figure 1A) and red, tender macules on his hands (Figure 1B)."], "Examination and Results": ["Laboratory examination was notable for a white blood cell count of 9100/\u03bcL with 22% eosinophils, blood urea nitrogen level of 70 mg/dL (25 mmol/L), and creatinine level of 6.1 mg/dL (539.2 \u03bcmol/L).", "Urinalysis was remarkable for 1+ blood and 2+ protein.A, Blue toes and associated skin changes over the lower extremity."]}
{"Patient Personal Background": ["No other family members were similarly affected.", "As an infant, her mother had taken her to their physician owing to dark discoloration of her diapers, but this was not investigated further.Examination revealed slate blue macular pigmentation within the antihelix and conchal bowls of both ears (Figure, A)."], "Patient Symptoms": ["She had mild knee arthralgia that was treated with nonsteroidal anti-inflammatory drugs (NSAIDs)."], "Examination and Results": ["There were prominent dark brown deposits on the conjunctivae medial and lateral to the iris of both eyes (Figure, B).", "No other pigmentary changes were noted on the skin or mucosal surfaces.", "A punch biopsy specimen from the pigmented area on the left ear was obtained (Figure, C).A, Examination of the left ear revealing slate blue macular discoloration, most prominent over the antihelix.", "B, Examination of the left eye showing dark brown pigment deposition of the conjunctiva lateral to the iris.", "Similar deposits were seen medial to the iris, bilaterally in both eyes.", "C, Hematoxylin-eosin stain on punch biopsy specimen of pigmented area on left ear demonstrating large pigment deposit in the dermis and adjacent to the cartilage (original magnification \u00d7150)."], "Treatment": ["She had mild knee arthralgia that was treated with nonsteroidal anti-inflammatory drugs (NSAIDs)."], "Diagnosis": ["She was seeing an ophthalmologist annually regarding brown spots on both eyes diagnosed as conjunctival nevi."]}
{"Patient Personal Background": ["The neonate was the product of a dichorionic, diamniotic twin pregnancy.", "They were born to a previously healthy woman who had been hospitalized 12 days prior for tocolytic therapy.", "One day prior to delivery, the mother was noted to have yeast on urinalysis.", "The presence of epithelial cells in the sample suggested vaginal contamination."], "Examination and Results": ["Physical examination of the affected twin revealed an afebrile, 1200 g preterm infant.", "Skin examination showed 100 to 200 pink papules, 0.05 to 0.2 cm in size, distributed on the trunk, extensor upper arms, and upper legs (Figure, A and B).", "A subset of the lesions appeared vesiculopustular, but no fluid was evident after attempted unroofing.", "The second twin had normal cutaneous examination findings.", "Laboratory analysis revealed a white blood cell (WBC) count of 6000/\u03bcL, which was composed of 21% neutrophils, 38% lymphocytes, 24% monocytes, and 5% eosinophils.", "Gram stain of lesional scrapings did not reveal bacteria nor WBCs, though potassium hydroxide staining showed numerous yeast forms.", "Lesional polymerase chain reaction was negative for herpes simplex virus.", "Bacterial cultures from the skin and the blood were ultimately negative.", "The placentas from both neonates were sent for pathologic analysis (Figure, C and D).A, Pink papules and vesicopustules were noted on the trunk, arms, and extensor thighs, but spared the diaper area; B, morphology of lesions; C and D, histopathologic images of umbilical cord section."], "Treatment": ["Despite tocolytic therapy, labor ultimately progressed the following day and cesarean delivery was performed owing to breech presentation of the unaffected twin."], "Others": ["The other twin did not have any dermatalogic abnormalities.", "The diaper area, hands, feet, nails, and oral mucosa were unaffected."]}
{"Patient Personal Background": ["Social, family, and past medical history were noncontributory."], "Patient Symptoms": ["Physical examination revealed reddish-brown hyperkeratotic papules on the neck, trunk, and extremities and diffuse brown macules, many in a reticulated pattern, on the face, neck, trunk, and extremities."], "Examination and Results": ["There were no nail or mucosal changes.", "Laboratory data was noncontributory.", "A punch biopsy specimen was collected from both the arm and trunk and histologic examination was performed (Figure, C and D).Photographs of clinical findings of reticulate hyperpigmentation of the (A) neck and chest and (B) lower extremities.", "Hematoxylin-eosin of (C) hyperorthokeratosis, epidermal acanthosis and elongated epidermal rete ridges with bud-like filiform projections and suprapapillary plate thinning (original magnification \u00d74) and (D) focal acantholysis without dyskeratosis (original magnification \u00d710)."], "Treatment": ["She was treated with fluorouracil and tazarotene, 0.1%, cream with mild improvement, but she continued to develop new lesions."], "Diagnosis": ["She was previously diagnosed with Darier disease after biopsy revealed acantholytic dyskeratosis."]}
{"Patient Symptoms": ["Two weeks prior to presentation, she reported a gradual increase in blurred vision with intermittent floaters in the right eye but denied pain or inciting events."], "Examination and Results": ["Her BCVA was 20/50 OD.", "There were large keratic precipitates, 1+ anterior chamber cell and flare, and no hypopyon.", "Numerous white precipitates were noted on the anterior and posterior surface of a 3-piece posterior chamber intraocular lens (Figure, A).", "There were 2+ to 3+ anterior vitreous cells and a 2\u2013disc area chorioretinal scar along the superior retinal arcades with extramacular drusen, but no areas of chorioretinitis (Figure, B).", "B-scan ultrasonography showed a posterior vitreous detachment and moderate vitreous opacities.", "The contralateral phakic eye showed similar drusen but was otherwise unremarkable.Chronic pseudophakic endophthalmitis.", "A, Slitlamp photograph showing large keratic precipitates, anterior chamber cell and flare, and an intraocular lens with white precipitates on the anterior and posterior surface.", "B, Fundus photograph showing no areas of active chorioretinitis and an inactive 2\u2013disc area chorioretinal scar along the superior retinal arcades with extramacular drusen.The patient underwent a vitreous tap, which was negative for organisms, as well as injection of intravitreal vancomycin hydrochloride and ceftazidime in the right eye."], "Treatment": ["Topical prednisolone acetate and ofloxacin were started 4 times daily, and steroids were increased to every 2 hours while awake at follow-up.", "Her BCVA improved to 20/30 OD 4 days later.", "Topical antibiotics were stopped and topical steroids were gradually tapered."], "Diagnosis": ["The contralateral phakic eye showed similar drusen but was otherwise unremarkable.Chronic pseudophakic endophthalmitis."], "Others": ["The BCVA remained excellent and keratic precipitates dissipated by 1 month of follow-up, with stable findings in the posterior pole."]}
{"Patient Personal Background": ["Her ophthalmic history was significant for mixed-mechanism glaucoma due to uveitis and chronic angle closure with prior implantation of bilateral superotemporal Baerveldt drainage implants.", "In addition, she had Fuchs corneal dystrophy."], "Patient Symptoms": ["Her visual acuity worsened from counting fingers to hand motions."], "Examination and Results": ["At that time, visual acuity was counting fingers at 1 ft OD.", "On the first postoperative visit, IOP was 14 mm Hg OD by Goldmann applanation.", "On postoperative day 11, IOP remained stable at 7 mm Hg OD by Goldmann applanation and topical atropine was discontinued.", "At presentation 3 weeks postoperatively, IOP was 30 mm Hg OD by Goldmann applanation.", "Slitlamp examination of the right eye revealed a superotemporal Baerveldt drainage implant with fluid over the plate."], "Treatment": ["Her intraocular pressure (IOP) was controlled with topical brinzolamide.", "A month earlier, she had undergone Baerveldt implant repositioning from the anterior chamber to the sulcus in the right eye in preparation for future Descemet stripping endothelial keratoplasty owing to severe corneal decompensation.", "She was discharged with therapy including topical steroids, antibiotics, and atropine sulfate.", "On postoperative day 11, IOP remained stable at 7 mm Hg OD by Goldmann applanation and topical atropine was discontinued."], "Others": ["High-resolution ultrasonography was performed (Figure).High-resolution B-scan ultrasonographic image of the right eye."]}
{"Patient Personal Background": ["She denied any history of serious infections, including tuberculosis and syphilis, and denied having family members with visual difficulties.", "Her ocular history was remarkable only for bilateral cataract surgery by phacoemulsification many years prior."], "Patient Symptoms": ["The patient had no visual complaints but stated that it was difficult for her to see at night."], "Examination and Results": ["Visual acuity was 20/50 OU and pupillary responses, external examination, extraocular motility, and intraocular pressures were normal.", "Confrontation visual field testing showed peripheral constriction in each eye.", "Slitlamp examination showed the absence of anterior chamber inflammation and the presence of posterior chamber intraocular lenses and liquefied vitreous with a few vitreous strands bilaterally.", "Fundus examination (Figure, A) revealed poor foveal light reflexes, an annular pattern of outer retinal hypopigmentation approximating the border of the temporal arcades, and inferotemporal clumped pigment deposits in each eye.", "Spectral-domain optical coherence tomography (Figure, B) showed outer retinal foveoschisis as well as outer retinal thinning with interruptions in the ellipsoid in the peripheral macula in each eye.", "Fluorescein angiography showed no disc leakage or angiographic macular edema (Figure, C); there was faint staining of the annular area of hypopigmentation seen on fundus examination.", "Fundus autofluorescence showed a ring of abnormal hyperautofluorescence.A, Fundus photograph of the right eye shows poor foveal light reflex, an annular pattern of outer retinal hypopigmentation approximating the border of the temporal arcade, and inferotemporal clumped pigment deposits (seen in both eyes).", "B, Spectral-domain optical coherence tomographic (SD-OCT) image of the right eye shows outer retinal foveoschisis and outer retinal thinning with interruptions of the ellipsoid in the peripheral macula (seen in both eyes)."]}
{"Patient Symptoms": ["He reported fatigue, muscle stiffness, joint pain, and a 10-lb unintentional weight loss."], "Examination and Results": ["On ocular examination, his best-corrected visual acuity was 20/25 OD and 20/60 OS.", "Anterior segment examination findings were unremarkable.Fundus examination revealed bilateral microaneurysms and dot hemorrhages throughout the posterior pole, along with bilateral macular edema and serous neurosensory detachment in the left eye (Figure 1A).", "Optical coherence tomography of the right eye revealed severe cystoid macular edema, and fluorescein angiography showed normal filling with multiple microaneurysms.", "An optical coherence tomographic image of the left eye showed a large neurosensory detachment with overlying and surrounding cystoid macular edema.", "Fluorescein angiography of the left eye demonstrated hypofluorescence without pooling or leakage of fluorescein dye over the area of neurosensory detachment, which was persistent in later frames (Figure 1B).A, Fundus photograph of left eye showing neurosensory detachment."]}
{"Patient Personal Background": ["She denied any antecedent trauma or neck manipulation.", "She had no known history of renal dysfunction or poorly controlled hypertension and was a lifelong nonsmoker."], "Examination and Results": ["She was seen in the emergency department and underwent brain magnetic resonance imaging, which demonstrated patchy enhancement in the left basal ganglia and corona radiata concerning for demyelinating lesions.", "Pertinent laboratory results included C-reactive protein level of 0.01 mg/L (to convert to nanomoles per liter, multiply by 9.524), erythrocyte sedimentation rate of 6 mm/h (to convert to millimeters per hour, multiply by 1), and normal cholesterol panel.", "She underwent an extensive imaging workup consisting of bilateral carotid duplex, computed tomographic neck angiography (Figure 1A) and cerebral arteriogram (Figure 1B).A, Computed tomographic arteriogram of the neck demonstrating near occlusion of the proximal left internal carotid artery (arrowhead).", "B, Cerebral arteriogram demonstrating a string sign in the proximal left internal carotid artery (arrowhead)."], "Others": ["She was admitted and underwent further workup."]}
{"Patient Personal Background": ["The product of a full-term normal delivery, she had had occasional mouth ulcers and recurrent tonsillitis treated with oral antibiotics by her family physician."], "Patient Symptoms": ["Her vaccinations were all up to date including the measles, mumps, and rubella vaccine given 2 days before hospitalization, the day of fever onset.Admission examination revealed severe exudative pharyngitis and oral candidiasis.", "Admission blood and throat culture results were negative.Two days later, at approximately 8:00 am, her mother noticed 2 purple spots in the diaper area.", "By 4:00 pm, the lesions were described as firm, nontender purpuric nodules.", "By 9:00 pm, the lesions had progressed, with the emergence of multiple discrete ulcers involving the labial, perineal, and gluteal areas."], "Examination and Results": ["Her vaccinations were all up to date including the measles, mumps, and rubella vaccine given 2 days before hospitalization, the day of fever onset.Admission examination revealed severe exudative pharyngitis and oral candidiasis.", "Laboratory parameters included a hemoglobin level of 11.4 g/dL (to convert to grams per liter, multiply by 10), white blood cell count of 5600/\u03bcL (to convert to \u00d7\u2009109 perliter, multiply by 0.001), absolute lymphocyte count of 5600/\u03bcL (to convert to \u00d7\u2009109 perliter, multiply by 0.001), absolute neutrophil count of 300/\u03bcL (to convert to \u00d7\u2009109 perliter, multiply by 0.001), platelet count of 327\u2009\u00d7 103/\u03bc (to convert to \u00d7\u2009109 per liter, multiply by 1), and C-reactive protein level of 183 mg/L (normal range, <10mg/L; to convert to micromoles per liter, multiply by 9.524).", "She rapidly deteriorated with onset of septic shock, her white blood cell count fell to 0/\u03bcL, and her C-reactive protein level increased to 404 mg/L.Following stabilization and initiation of broad-spectrum antibiotics, she was transferred to a pediatric intensive care unit where Figure 1 was obtained.Multiple ulcers with an erythematous rim and notable absence of pus."], "Treatment": ["Intravenous benzylpenicillin was initiated and was followed by defervescence and improvement in her condition.", "She rapidly deteriorated with onset of septic shock, her white blood cell count fell to 0/\u03bcL, and her C-reactive protein level increased to 404 mg/L.Following stabilization and initiation of broad-spectrum antibiotics, she was transferred to a pediatric intensive care unit where Figure 1 was obtained.Multiple ulcers with an erythematous rim and notable absence of pus."], "Others": ["She remained afebrile and clinically stable."]}
{"Examination and Results": ["The resting 12-lead electrocardiogram showed sinus rhythm with no preexcitation or repolarization abnormalities.", "There were incessant multiple runs of nonsustained ventricular tachycardia with right bundle branch block morphologic features.", "QRS complexes were negative in the rest of the precordial leads (V2-V6) and in leads I and avL, but positive in III, avR, and avF, suggesting a left (lateral) ventricular apical origin (Figure 1).", "The echocardiogram showed no structural abnormalities.", "Invasive electrophysiological mapping of the left ventricle endocardium demonstrated that the ventricular tachycardia probably originated from the epicardial surface of left ventricular apex.Twelve-lead surface electrocardiogram during tachycardia."], "Treatment": ["The patient was prescribed sotalol but her symptoms did not improve."]}
{"Patient Personal Background": ["He reported labyrinthitis 2 years previously with possible reduced hearing afterward.", "He took no regular medications, had no allergies or clinically significant family history, and was an occasional smoker and alcohol drinker."], "Patient Symptoms": ["It was associated with a whistling tinnitus and occasional sharp otalgia lasting for a few minutes, approximately twice a week, without otorrhea."], "Examination and Results": ["Examination showed a smooth mass behind the left tympanic membrane.", "Findings from flexible nasoendoscopy were unremarkable.", "There was no palpable lymphadenopathy.", "Pure-tone audiometry demonstrated a mixed hearing loss on the left side.", "Results from tympanometry of the left ear were normal.", "A computed tomographic scan showed an expansile ground-glass density lesion arising within the lateral aspect of the otic capsule on the left (Figure, A and B).", "The lesion eroded into the lateral aspect of the basal and second turns of the cochlea as well as the tympanic portion of the facial nerve canal.", "Magnetic resonance imaging demonstrated a 7\u2009\u00d7\u20098-mm lesion arising from the otic capsule, with mild uniform enhancement following gadolinium.", "A technetium bone scan showed a lesion in the temporal bone, and a focus of increased uptake in the left lateral eighth rib (no fracture was demonstrated) (Figure, C).", "To obtain a diagnosis, a bony sample was obtained, which consisted of small fragments of woven bony tissue with mild osteocyte nuclei enlargement and hyperchromasia, with no sign of neoplasia.A and B, Computed tomographic (CT) images showing left otic capsule lesion."]}
{"Patient Personal Background": ["Her medical history was significant for gastroesophageal reflux disease, hypertension, stable angina, and obstructive sleep apnea for which she was using continuous positive airway pressure therapy at night."], "Examination and Results": ["A repeated computed tomographic (CT) scan, when compared with a study 3 years prior, indicated clinically significant growth.", "A positron emission tomographic/CT scan was significant for increased metabolic activity in the mass.", "Gross examination revealed an encapsulated, 11.0\u2009\u00d7\u20098.4\u2009\u00d7\u20098.2-cm, tan-orange, predominantly hemorrhagic, necrotic nodule without grossly identifiable thyroid parenchyma (Figure, B).", "Extensive sampling revealed pleomorphic epithelioid cells with enlarged, hyperchromatic nuclei, irregular nuclear membranes, and increased mitotic activity (Figure, C).", "There was evidence of angiogenesis and formation of nests around areas with organizing hemorrhage.", "Tumor cells showed strong membrane reactivity for CD31, confirming an endothelial origin of the lesion (Figure, D).", "Adjacent thyroid parenchyma showed multinodular goiter and chronic lymphocytic thyroiditis.", "The neck dissection revealed normal lymphatic contents.A, Intraoperative view of the mass."], "Treatment": ["Surgical intervention was recommended for alleviation of symptoms and definitive diagnosis.", "A left thyroidectomy with partial right thyroidectomy (Figure, A) and a left modified neck dissection (levels II-IV) were performed."], "Others": ["B, Central hemorrhage and necrosis.", "C, Enlarged, hyperchromatic nuclei and mitoses.", "D, Neoplastic cells showing immunoreactivity to CD31."]}
{"Patient Symptoms": ["She had not experienced shortness of breath, gastric reflux, smoking, cough, dysphagia, odynophagia, fevers, or chills.", "Findings from a physical examination were remarkable for a rough voice."], "Examination and Results": ["Flexible nasolaryngoscopy revealed normal abduction and adduction of the vocal folds with a white sessile lesion starting at the right midfold on the superior and medial surfaces that crossed the midline to involve the entire left vocal fold as shown in the Figure, A. Histopathologic images of the biopsied lesion are shown in the Figure, B-D.Laryngeal lesion."], "Others": ["A, Gross appearance of vocal folds by flexible nasolaryngoscopy.", "B, Hematoxylin-eosin, original magnification \u00d7400.", "C, Gram stain, original magnification \u00d7400.", "D, Gomori methenamine silver stain, original magnification \u2009\u00d7\u2009400."]}
{"Patient Personal Background": ["Her surgical history was significant for having undergone a cesarean section.", "She denied any radiation exposure."], "Patient Symptoms": ["The incidental finding of a mediastinal mass prompted a referral to her primary care physician, who elicited from the patient some complaints of mild but worsening orthopnea that was exacerbated when she would lie down.", "She denied any recent weight loss, muscle weakness, or diplopia."], "Examination and Results": ["A computed tomographic scan of the chest was obtained (Figure, A), and the patient was referred to surgery for evaluation.A, Computed tomographic scan of the chest revealing a mediastinal mass.", "B, Intraoperative dissection following median sternotomy.A physical examination identified a midline trachea, no significant thyromegaly in the neck, no significant lymphadenopathy, and no additional significant findings."], "Treatment": ["The patient was taken to the operating room for surgery to remove the mass (with gross findings as seen in Figure, B)."]}
{"Patient Personal Background": ["A clinically significant cardiac history precluded the option of surgery."], "Patient Symptoms": ["Approximately 5 months after treatment, he awakened with abrupt onset of severe right shoulder pain.", "The pain was sharp, constant, and localized to his right scapula and ultimately progressed to the point of radiating down the extensor surface of his arm ending at his elbow.", "He denied paresthesias, weakness, or any inciting events that could have led to its onset."], "Examination and Results": ["Chest radiography identified a right lung nodule, with complete workup revealing a T2aN0M0 right upper lobe non\u2013small-cell lung cancer (NSCLC) measuring 4.3\u2009\u00d7\u20092.9 cm.", "A surveillance computed tomographic (CT) scan obtained at 3 months demonstrated that the right upper lobe tumor had decreased by 1 cm in all dimensions, and at this time the patient denied any new symptoms, including pain.", "His primary care physician obtained a CT scan, followed 2 days later by a magnetic resonance image (MRI) of his right shoulder (Figure 1).Right shoulder diagnostic imaging 5 months after treatment."], "Treatment": ["He was treated with a definitive accelerated hypofractionated course of radiotherapy to a total of dose 60 Gy in 8 fractions."], "Diagnosis": ["Chest radiography identified a right lung nodule, with complete workup revealing a T2aN0M0 right upper lobe non\u2013small-cell lung cancer (NSCLC) measuring 4.3\u2009\u00d7\u20092.9 cm."], "Others": ["Acute toxic effects were not observed, with the exception of minor fatigue that resolved 1 month after treatment.", "CT indicates computed tomography; MRI, magnetic resonance imaging."]}
{"Examination and Results": ["Diagnostic mammography revealed 2 separate masses: a 1.4-cm mass at the 3 o\u2019clock position, 10 cm from the nipple; and a 1.3-cm mass in the lateral breast, 4 cm from the nipple.", "Ultrasound of the axilla revealed an enlarged lymph node found to be malignant on fine-needle aspiration cytology.", "Image-guided core biopsies of both masses revealed a poorly differentiated invasive ductal adenocarcinoma.", "Estrogen receptor (ER) was strongly positive in 95% of tumor cells, progesterone receptor (PR) was positive in less than 5% of tumor cells, and human epidermal growth factor receptor 2 (ERBB2 [HER2]) by immunohistochemistry (IHC) was scored as 1+ (Table).The result is equivocal and repeat testing is needed."], "Diagnosis": ["Ultrasound of the axilla revealed an enlarged lymph node found to be malignant on fine-needle aspiration cytology.", "Image-guided core biopsies of both masses revealed a poorly differentiated invasive ductal adenocarcinoma."]}
{"Patient Personal Background": ["He denied any prior history of Raynaud phenomenon; heart, kidney, or liver disease; diabetic retinopathy; nephropathy; or neuropathy.", "He had quit smoking 24 years ago and reported currently drinking 3 glasses of wine per week.", "His medications included rosiglitazone, glimepiride, and levothyroxine.On examination, he weighed 131.5 kg (body mass index, 40.57); his heart rate was 82/min and blood pressure was 161/89 mm Hg."], "Patient Symptoms": ["Acetaminophen and meloxicam provided only partial relief.", "He also noted progressive thickening of skin in the nape of his neck.", "He had facial swelling and brawny periorbital edema (Figure 1A).", "He also had a large area of diffuse, slightly erythematous, nonpitting woody induration extending from the nape of his neck (Figure 1B), to the upper back, shoulders, and upper arms.", "This resulted in limitation of range of motion of his neck."], "Examination and Results": ["His medications included rosiglitazone, glimepiride, and levothyroxine.On examination, he weighed 131.5 kg (body mass index, 40.57); his heart rate was 82/min and blood pressure was 161/89 mm Hg.", "Examination of his heart, lungs, abdomen, and lower extremities was unremarkable.A, Facial swelling and periorbital edema.", "B, Woody induration involving the nape of neck and upper back.Laboratory testing showed a fasting blood glucose level of 178 mg/dL (9.9 mmol/L).", "Complete blood cell count, levels of thyroid-stimulating hormone and albumin, and the remainder of his comprehensive metabolic panel were normal.", "Urinalysis showed trace protein without blood.", "Erythrocyte sedimentation rate was 34 mm/h, C-reactive protein level was 0.3 mg/dL (2.9 nmol/L), and hemoglobin A1C level was 7.5%.", "An antinuclear antibody panel was negative."]}
{"Patient Personal Background": ["His medical history included type 2 diabetes mellitus, hypertension and secondary chronic renal insufficiency, cardiovascular disease, and gout.", "His long-term medications included lisinopril, glipizide, terazosin, insulin glargine, labetalol, allopurinol, hydrochlorothiazide, and erythropoietin."], "Patient Symptoms": ["Examination of the head and neck revealed the incidental finding of bilateral auricular rigidity and immobility.", "The patient recalled that his barber had noted an increase in difficulty trimming hair in the areas around his auricles owing to their inflexibility.", "The only other notable finding was increased rigidity of his nasal cartilage."], "Examination and Results": ["Both ears appeared normal and were nontender and asymptomatic (Figure, A).", "Hematoxylin-eosin staining of the biopsy specimen showed regions of ossification and calcification (Figure, B).", "A computed tomographic (CT) scan of the head was performed within 2 weeks of his original biopsy and showed extensive calcification in the area of the auricles (Figure, C).", "The patient\u2019s laboratory workup showed an elevated creatinine level of 1.8 mg/dL (reference range, 0.6-1.2 mg/dL), which had been his baseline level for the past 2 years.", "He had a hemoglobin level of 11.1 g/dL (reference range, 14-18 g/dL), which was felt to be secondary to his chronic renal failure.", "His serum calcium level  had been normal with the exception of an elevated value noted of 10.4 mg/dL noted 1 year ago (reference range, 8.7-10.2 mg/dL)."], "Treatment": ["An incisional biopsy of his left auricle was performed."], "Others": ["The patient denied any decrease in auditory acuity, frostbite, or any previous trauma to his ears.", "His phosphorus, alkaline phosphorus, electrolyte, and AM cortisol levels; parathyroid function; and thyroid function were within normal limits.A, Photograph of ear.", "B, Photomicrograph of biopsy sample.", "C, Head computed tomographic image."]}
{"Patient Symptoms": ["It had started as swelling of the feet, followed by erythematous acral lesions.", "Numbness of the hands and feet had begun 1\u00bd years previously, spreading gradually to the forearm and legs.", "Black eschar and ulceration with purulent discharge was seen over the soles and elbows.", "There were triangular and bizarre purpuric and necrotic lesions over the legs, thighs, and dorsum of the hands (Figure, A) with necrosis of pinnae and nasolabial folds.", "The scrotum was also affected.", "There was diffuse infiltration of the face and madarosis of the lateral half of the eyebrows.", "He also had hypoesthesia over the palms, proximal forearms, feet, and legs."], "Examination and Results": ["Peripheral nerve examination revealed thickening of the right radial cutaneous and both ulnar nerves.", "Bilateral inguinal lymphadenopathy was present.", "Findings from the rest of the general physical and systemic examination were normal.", "Punch biopsy specimens were obtained (Figure, B-D).A, Multiple bizarrely shaped purpuric and necrotic plaques on the hands and lower limbs."], "Others": ["He had no history of fever, joint pains, or epistaxis.", "Erosion is seen on the scrotum.", "B-D, Histopathologic images."]}
{"Patient Symptoms": ["The patient admitted to occasional burning sensation of new lesions.", "On review of systems, the patient denied fevers, fatigue, myalgias, arthritis, shortness of breath, oral ulcers, and recent infections."], "Examination and Results": ["Clinical examination revealed several erythematous patches and plaques on the arms and lower legs, and nontender violaceous firm nodules on the elbows, wrist, ankle, interphalangeal, and metatarsophalangeal joints (Figure 1A and B).", "There was no lymphadenopathy present.", "A punch biopsy specimen from a plaque on the right forearm was obtained (Figure 1C and D)."]}
{"Patient Personal Background": ["He denied headaches, fevers, cough, risk factors for immunosuppression, or travel outside of the northwestern United States.His medical history was notable for hypertension and a 50-packs-per-year smoking history."], "Patient Symptoms": ["Despite this, his leg weakness worsened."], "Examination and Results": ["Two months prior he had undergone lumbar vertebra 3\u2013sacra vertebra 1 lumbar laminectomies performed for symptomatic spinal stenosis.", "Physical examination was notable for a thin, frail-appearing man with normal vital signs and intact mentation.", "Cranial nerve examination revealed visual acuity of 20/400 OS, with an afferent pupillary defect and left-sided facial weakness including eye closure.", "He demonstrated profoundly decreased bulk and hypotonia throughout all extremities, with fasciculations apparent across his chest and lower extremities.", "Lower extremity muscle strength was graded 2/5 throughout with absent reflexes and intact sensation.Initial laboratories revealed a normal complete blood cell count and chest radiography.", "Magnetic resonance imaging of the neuroaxis revealed leptomeningeal enhancement around the cerebral convexities, cerebellum, and spinal cord including the cauda equina (Figure 1).", "Cerebrospinal fluid (CSF) studies revealed a white blood cell count of 29/\u03bcL (to convert to \u00d7 109 per liter, multiply by .001) with a near-complete lymphocytic predominance, a red blood cell count of 363 \u00d7 106/\u03bcL (to convert to \u00d7 1012 per liter, multiply by 1), a protein level of 0.142 g/dL (to convert to grams per liter, multiply by 10), and glucose level of 19 mg/dL (to convert to millimoles per liter, multiply by 0.0555).", "Cerebrospinal fluid cytology analysis did not identify malignant cells, with negative assay results for tuberculosis and fungal infections.", "Repeated flow cytometry did not identify abnormal B-cell or T-cell population.", "Whole-body positron emission tomography\u2013computed tomography showed extensive leptomeningeal and nerve root hypermetabolism without evidence of a primary malignancy.Sagittal T1-weighted MRI of the lumbar spine without (A) and with (B) contrast showing leptomeningeal enhancement of the lumbar spinal cord, cauda equina, and multilevel postsurgical changes."]}
{"Patient Personal Background": ["B, Optical coherence tomography demonstrates neurosensory retinal detachment overlying irregular retinal pigment epithelium and thickened choroid.The patient denied recent corticosteroid use, joint pain, weight loss, myalgias, or cardiovascular, neurologic, or gastrointestinal symptoms.", "He had fevers and mild upper respiratory tract symptoms 2 weeks before his presentation, closely followed by a rash on his hands and thighs."], "Patient Symptoms": ["He had fevers and mild upper respiratory tract symptoms 2 weeks before his presentation, closely followed by a rash on his hands and thighs."], "Examination and Results": ["His visual acuity was 20/200 OD and 20/20 OS.", "There was no afferent pupillary defect, his color vision was intact bilaterally, and his intraocular pressures were normal.", "No anterior chamber or vitreal inflammation was present.", "Ophthalmoscopic examination of the right macula revealed a 2\u2013disc diameter area of heterogeneous yellow retinal pigment epithelial (RPE) discoloration with overlying neurosensory retinal detachment and several small retinal hemorrhages (Figure 1A).", "The optic disc and retinal vessels were unremarkable, and ophthalmoscopic examination of the left eye revealed no abnormalities.A, Fundus photography of the right eye shows retinal pigment epithelial discoloration and retinal hemorrhages.", "A young family member had similar symptoms.Spectral-domain optical coherence tomography (SD-OCT) revealed a fovea-involving neurosensory retinal detachment, outer photoreceptor thickening, and an intact external limiting membrane overlying a zone of mildly thickened, irregular RPE.", "The submacular choroid was relatively thick bilaterally on enhanced depth imaging OCT (Figure 1B).", "Combined fluorescein and indocyanine green angiography demonstrated mottled early hyperfluorescence with late staining and minimal pooling.", "There was no leakage from the retinal vessels or optic discs bilaterally, and uninvolved areas of RPE and choroidal vasculature were unremarkable."]}
{"Examination and Results": ["The patient\u2019s corrected visual acuity was 20/20 OU.", "His pupils, intraocular pressures, motilities, and confrontational visual fields were normal in each eye.", "Findings from the anterior slitlamp examination were normal in both eyes.", "A dilated fundus examination of the right eye was unremarkable, but examination of the fundus of the left eye revealed a lesion in the temporal periphery.", "Figure 1 shows a wide-field photograph and the results of ultrasonography of the lesion.Intraocular mass in the left eye of a man in his 40s.", "A, Wide-field photograph of the fundus of the left eye.", "B, Ultrasonographic image of the left eye demonstrating a large cyst in the temporal peripheral retina."]}
{"Patient Symptoms": ["A scar resulting from the stab wound was clearly visible just below his left brow.", "The pulsatile proptosis had a difference of 14 mm between his eyes.", "His left eye had a palpable thrill, audible bruit, chemosis, dilated conjunctival blood vessels, and a swollen upper eyelid.His intraocular pressures (IOPs) measured 40 mm\u2009Hg in the left eye and 24 mm\u2009Hg in the right eye by Goldmann tonometry."], "Examination and Results": ["His visual acuity was 6/6 Snellen in both eyes with restricted elevation of his left eye.", "Gonioscopy (Schaffer grading) revealed 360\u00b0 open angles, grade 2 in the left eye and grade 3 in the right eye, with blood visible in the Schlemm canal in the left eye only.", "His left disc was pathologically cupped with a cup-disc ratio of 0.8, and his right disc had a ratio of 0.5.", "A computed tomographic scan revealed an enlarged left superior orbital fissure (SOF) (Figure 1A) and engorged orbital veins (Figure 1B).A, Enlarged left superior orbital fissure (arrowhead) shown on 3-dimensional computed tomography (CT)."], "Treatment": ["His IOP did not reduce with maximum medical treatment, which included acetazolamide sodium, latanoprost, timolol maleate, brimonidine tartrate, and mannitol, 20%."]}
{"Patient Personal Background": ["His medical history was significant for trisomy 21, with mild cognitive delay and baseline dysarthria, but no aphasia.", "He had been self-sufficient with daily activities.", "He was taking acetaminophen and 10 mg of oxycodone every 4 hours."], "Patient Symptoms": ["He was somnolent immediately following the procedure, and had not spoken since the day after the procedure.", "Right-sided hand and face weakness developed 2 days after the procedure.", "In the emergency department, his examination was significant for a temperature of 38.1\u00b0C and significant scrotal swelling and pain."], "Examination and Results": ["The neurologic examination was remarkable for somnolence, right hemineglect, right facial droop with right hand weakness, right patellar hyperreflexia, and mutism, although he attempted to use sign language.", "His laboratory values showed a white blood cell count of 6.8\u2009\u00d7\u2009103/\u03bcL (to convert to \u2009\u00d7\u2009109/L, multiply by 0.001), platelet count of 248\u00d7103/\u00b5L (to convert to\u2009\u00d7\u2009109/L, multiply by 1), hematocrit level of 30.9% (to convert to proportion of 1.0, multiply by 0.01), hemoglobin level of 10.2 g/dL (to convert to grams per liter, multiply by 1) with a normal differential, activated partial thromboplastin time of 40 seconds, fibrinogen level of 678 mg/dL (to convert to grams per liter, divide by 100), and normal urinalysis results."], "Treatment": ["The right face and hand weakness persisted, and he was unable to walk independently."], "Others": ["Magnetic resonance imaging of the brain was performed (Figure 1)."]}
{"Examination and Results": ["Physical examination revealed a mobile, nontender, 4-cm mass in the left side of the floor of mouth.", "A contrast-enhanced computed tomographic scan of the neck showed a 3.8-cm cystic neck mass in the left floor of mouth (Figure, A).", "An ultrasonography (US)-guided fine-needle aspiration (FNA) biopsy showed bland-appearing cuboidal to columnar epithelial cells arranged in clusters; no malignant cells were identified.", "Repeated US-guided FNA biopsy showed a hypercellular specimen composed of numerous fragments of bland-appearing cuboidal and columnar epithelium and granular debris, which was eosinophilic in cell block sections and papillary structures with fibrovascular cores.", "The hypercellularity was atypical, and a low-grade neoplasm could not be ruled out.", "A core biopsy showed a well-differentiated papillary neoplasm with hyalinized fibrovascular cores and some degenerative changes (Figure, B-D).", "Immunophenotypically, the neoplastic cells were negative for the markers TTF-1, PAX-8, estrogen receptor, and thyroglobulin.", "Pathologic examination revealed a cystic, 2.5-cm encapsulated mass arising from a minor salivary gland.A, Computed tomographic image of the neck showing a mass in the left floor of mouth."], "Treatment": ["She underwent excision of the cystic floor of mouth mass and a level I neck dissection."], "Diagnosis": ["These results, with the morphologic characteristics, were most consistent with a low-grade salivary neoplasm."], "Others": ["At this point, the patient elected observation of the mass and a repeated biopsy.", "B-D, Histopathologic images."]}
{"Patient Symptoms": ["On evaluation, the patient had a bulging, hyperemic left tympanic membrane, along with fullness of the postauricular, upper cervical region."], "Examination and Results": ["She was eventually transferred to our hospital after a computerized tomographic (CT) scan was performed showing potential clinically significant ear abnormalities.", "A CT scan of the temporal bones with contrast was performed at our facility (Figure).A-C, Axial computed tomographic (CT) scans with contrast."], "Others": ["Facial nerve function was intact.", "No focal neurologic deficits or meningeal signs were observed."]}
{"Patient Personal Background": ["He was obese and had congestive heart failure and hypertension."], "Patient Symptoms": ["He did not have facial weakness."], "Examination and Results": ["Biopsy of the soft tissue at the external ear canal (EEC) showed granulation tissue.", "Findings from the otolaryngologic examination were otherwise unremarkable.", "Advanced-stage mixed conductive and sensorineural hearing loss in the left ear were noted.", "Computed tomography (CT) showed a soft-tissue mass in the mastoid and middle ear cavity extending to the EEC with no significant erosion of ossicles (Figure, A).", "Histopathological examination revealed a polypoid lesion showing typical papillary architecture with central fibrovascular cores and dilated glandular structures, lined by a bland-looking single layer of high columnar/cuboidal epithelial cells (Figure, B).", "The richly vascularized fibrotic stroma consisted of cholesterol clefts, foamy macrophages, lymphocytes, and eosinophils, reminiscent of inflammatory granulation tissue (Figure, C).", "The epithelial cells were positive for cytokeratin-7 (CK7) (Figure, D), CK19, epithelial membrane antigen, and glial fibrillary acidic protein.", "Ki-67 immunostain showed a proliferation index of less than 1%.A, Temporal bone at the level of external acoustic canal."], "Treatment": ["During modified radical mastoidectomy, the mastoid cavity was found to be full of edematous, fragile soft tissue with mucoid secretions."], "Others": ["The incus was intact but dislocated.", "No mitotic activity or necrosis was detected.", "M indicates mastoid cavity; J, jugular bulb; C, carotid canal; E, external ear canal.", "B-D, Histopathologic images.", "B, Papillary structures; original magnification \u00d720.", "C, Papillary and dilated glandular structures; original magnification \u00d710.", "D, Strong CK7 positivity; original magnification \u00d720."]}
{"Patient Personal Background": ["Her parents stated that at the age of 3 years she sustained minor trauma to her nose while at a playground but that she had not experienced any major head trauma.", "The patient had a history of frequent cough and congestion, seasonal allergies, monthly migraine headaches, and considerable nose congestion at night.", "Her family history was otherwise normal and did not include any pattern of familial anosmia or delayed puberty."], "Patient Symptoms": ["The patient had a history of frequent cough and congestion, seasonal allergies, monthly migraine headaches, and considerable nose congestion at night.", "She reported the ability to detect very strong odors but not subtle ones.", "She was even unable to smell smoke at times."], "Examination and Results": ["Physical examination revealed a clinically significant hump on the dorsum of the nose consistent with minimal prior trauma, but no other abnormal findings.", "The patient failed the Penn smell tests, correctly identifying only 3 of the 11 smells.", "Flexible fiber-optic examination of the nose revealed no masses, polyps, or cysts.", "A magnetic resonance image of the anterior skull base demonstrated absent olfactory sulci (OS) and bilateral olfactory grooves containing minimal tissue (Figure, A, yellow arrowheads)."], "Others": ["She did not recall a history of recurrent sinusitis, snoring, or mouth breathing.", "The Figure, B, depicts normal OS (pink arrowheads) and bulbs (yellow arrowheads) from a different patient for comparison.A, The anterior skull base of the study patient.", "B, A normal patient."]}
{"Patient Symptoms": ["Despite several previous attempts at surgical resection, the drainage had persisted for 6 years."], "Examination and Results": ["Initial computed tomography (CT) identified infiltration of the subcutaneous tissues in the left side of the neck anterior to the strap muscle at the level of the larynx, without discrete abscess.", "Computed tomography also showed a small tract that extended from the skin of the lateral side of the neck to the left strap muscles.", "When the patient stated that he tasted contrast material, the infusion was terminated, and the patient was transferred to the CT service, where axial images of the neck were obtained and reformatted in multiple planes (Figure, B and C).A, Conventional fluoroscopic fistulogram of the neck.", "B and C, Maximum-intensity projection reformatted computed tomographic (CT) images of the neck."], "Treatment": ["The patient was referred to radiology, where a 22-gauge intravenous access catheter was inserted into the draining puncta.", "Isovue-300 was infused under conventional fluoroscopic guidance (Figure, A)."]}
{"Patient Personal Background": ["The patient denied history of prior abdominal or lower extremity surgery, trauma, or cardiovascular problems.", "Review of systems and family history revealed nothing remarkable."], "Patient Symptoms": ["The pain was aching, relieved with rest, and primarily in her buttocks and thighs bilaterally."], "Examination and Results": ["Physical examination revealed normal sinus rhythm and normal blood pressure.", "She had no abdominal tenderness and no palpable masses.", "Femoral pulses were weakly palpable and symmetric, and pedal pulses were not palpable.", "Laboratory findings were unremarkable except for an elevated erythrocyte sedimentation rate (ESR) (34 mm/h).", "Blood and urine cultures were negative.", "Noninvasive arterial flow studies demonstrated an ankle brachial index of 0.60 on the right and 0.62 on the left with biphasic waveforms in the femoral, popliteal, and tibial vessels.", "Subsequent magnetic resonance angiography (MRA) of the chest, abdomen, and pelvis showed mild stenosis of bilateral subclavian arteries and an abnormal-appearing infrarenal aorta (Figure 1).Magnetic resonance angiography of the abdomen and pelvis."]}
{"Examination and Results": ["He was hypotensive (blood pressure, 87/55 mm Hg) on arrival to the emergency department.", "The patient\u2019s condition was rapidly stabilized and computed tomography with contrast demonstrated a large (12.4\u2009\u00d7\u200910.2-cm) right hepatic mass with heterogeneous enhancement on arterial phase and intrahepatic and intraperitoneal hemorrhage (Figure 1A).", "Emergency angiography was performed by interventional radiology, demonstrating active contrast extravasation originating from the right hepatic artery."], "Treatment": ["Embolization was performed with Gelfoam and microparticles, resulting in hemodynamic stability and a quick recovery.", "Delayed liver resection was subsequently performed (Figure 1B).A, Large hepatic mass seen on computed tomography, with evidence of intrahepatic and intraperitoneal hemorrhage."], "Others": ["B, Pathologic specimen after delayed surgical treatment of the underlying mass."]}
{"Patient Symptoms": ["He presented with progressive inguinal lymphadenopathy and a leukocytosis of 144\u202f000/\u00b5L with 97% lymphocytes (intermediate modified Rai stage)."], "Examination and Results": ["He presented with progressive inguinal lymphadenopathy and a leukocytosis of 144\u202f000/\u00b5L with 97% lymphocytes (intermediate modified Rai stage).", "Bone marrow cytogenetics and fluorescence in situ hybridization demonstrated 11q and 13q deletions.", "A next-generation sequencing (NGS) panel was ordered on peripheral blood to evaluate for potentially targetable genomic alterations (Table).CARD11 mutation is associated with ibrutinib resistance, therefore ibrutinib should not be used.CARD11 mutation is found only in a subclonal population and thus ibrutinib should be avoided.The significance of the amino acid exchange in CARD11 is a variant of unknown significance, so treatment with ibrutinib may be considered.The significance of the amino acid exchange in CARD11 is a variant of unknown significance, so treatment with ibrutinib should not be considered."], "Treatment": ["He received fludarabine, cyclophosphamide, and rituximab, achieving a complete remission.", "He received bendamustine plus rituximab, with resolution of lymphadenopathy and lymphocytosis."], "Others": ["Six months later, he experienced disease recurrence.", "Prolonged cytopenias precluded continuation of therapy, and lymphadenopathy and lymphocytosis again recurred."]}
{"Patient Personal Background": ["He had been diagnosed with the metabolic syndrome many years previously but has not seen his physician in years.", "He reported no current use of medications."], "Examination and Results": ["On examination, he had a body mass index of 30.6 and a blood pressure of 160/102 mm Hg."]}
{"Patient Personal Background": ["She has had fewer than 6 menstrual cycles per year since menarche at 13 years of age."], "Patient Symptoms": ["The gynecologist referred the patient to an endocrinologist.The patient reported having oily skin, acne, and excessive facial hair growth since menarche.", "Her friends noted thinning of her hair.", "She had recently gained 20 lb (9 kg) and has had a difficult time losing weight despite increasing her physical activity.On examination, the patient\u2019s body mass index was 28 (calculated as weight in kilograms divided by height in meters squared), and she had excessive coarse dark hair on the chin and abdomen (upper and lower; Ferriman-Gallwey score of 9) and acne on the face and back."], "Examination and Results": ["Her gynecologist considered the possibility of polycystic ovary syndrome (PCOS) and obtained laboratory measurements for thyrotropin, prolactin, follicle-stimulating hormone, and luteinizing hormone but questioned the diagnosis of PCOS because of a normal luteinizing hormone-to-follicle-stimulating hormone ratio (Table 1).", "Laboratory results from her gynecological visit were reviewed and additional tests were obtained.The elevated testosterone level is consistent with polycystic ovary syndrome (PCOS).The normal fasting glucose level excludes abnormal glucose tolerance.The normal leuteinizing hormone-to-follicle-stimulating hormone ratio excludes PCOS.The diagnosis of PCOS requires documentation of polycystic ovaries by ultrasonography."], "Diagnosis": ["Laboratory results from her gynecological visit were reviewed and additional tests were obtained.The elevated testosterone level is consistent with polycystic ovary syndrome (PCOS).The normal fasting glucose level excludes abnormal glucose tolerance.The normal leuteinizing hormone-to-follicle-stimulating hormone ratio excludes PCOS.The diagnosis of PCOS requires documentation of polycystic ovaries by ultrasonography."], "Others": ["Her last menstrual cycle was 9 months ago, and at that time, she sought gynecologic evaluation."]}
{"Patient Personal Background": ["Six months ago he had a myocardial infarction complicated by heart failure with an ejection fraction of 35%.", "His medications were lisinopril, metoprolol succinate, insulin, and furosemide."], "Patient Symptoms": ["Two days ago he noticed generalized weakness, which had worsened over the last 24 hours."], "Examination and Results": ["Physical examination showed resolving cellulitis on the right leg.", "Other than symmetrical 3/5 strength in the upper and lower extremities, his neurologic examination results were normal.", "An electrocardiogram was unchanged from 2 months ago.", "Laboratory results are shown in the Table."], "Treatment": ["One week ago, he was diagnosed with cellulitis of the right leg and prescribed a 7-day course of trimethoprim-sulfamethoxazole."], "Diagnosis": ["One week ago, he was diagnosed with cellulitis of the right leg and prescribed a 7-day course of trimethoprim-sulfamethoxazole."]}
{"Patient Personal Background": ["She was taking folic acid and intramuscular cyanocobalamin supplements owing to deficiencies attributed to a dietary cause."], "Patient Symptoms": ["This was associated with enlargement of the tongue over the past 3 months, leading to difficulty with mastication.", "She also reported numbness with no associated weakness of her distal lower limbs for 3 months.", "This restricted her mobility to the extent that she required diapers.", "This was accompanied by macroglossia, glossitis, and a hemorrhagic erosion on the hard palate (Figure, B)."], "Examination and Results": ["On examination, there were circinate purpuric patches with erosions on the natal cleft, buttocks, inguinal creases, and vulva (Figure, A).", "Hemorrhagic flaccid bullae were observed on the posterior perineum.", "There were purpuric macules periorbitally and on the lips, inframammary folds, forearms, and thighs.", "Laboratory findings revealed a platelet count of 171\u2009\u00d7\u2009103/\u03bcL (reference range, 140-440\u2009\u00d7\u2009103/\u03bcL), prothrombin time of 11.7 seconds (reference range, 9.9-11.4 seconds), activated partial thromboplastin time of 36.0 seconds (reference range, 25.7- 32.9 seconds), and serum zinc levels of 34.4 \u03bcg/dL (reference range, 72.4-124.4 \u03bcg/dL).", "Results from initial punch biopsies from a purpuric macule on the right inframammary fold and a blister at the perineum were inconclusive.", "B, Clinical findings of macroglossia and glossitis with purpura of the lips.", "C, Punch biopsy specimen of a flaccid bulla showing the floor of a subepidermal blister lined by fibrin and a chronic inflammatory infiltrate.", "D, Scattered short eosinophilic amorphous bands in the dermis."], "Treatment": ["She had IgG \u03bb-type multiple myeloma complicated by anemia and lytic lesions in the calvarium, which was managed conservatively with transfusions."], "Diagnosis": ["She had IgG \u03bb-type multiple myeloma complicated by anemia and lytic lesions in the calvarium, which was managed conservatively with transfusions."], "Others": ["However, she declined any further investigations for her peripheral neuropathy.", "(To convert zinc to micromoles per liter, multiply by 0.153.)", "A repeated biopsy from a hemorrhagic blister at the left groin was performed (Figure, C and D).A, Purpura and erosions at the buttocks."]}
{"Patient Personal Background": ["He disclosed full compliance with his HIV highly active antiretroviral therapy (HAART), which included ritonavir, darunavir, etravirine, and raltegravir.", "He also reported taking sumatriptan as needed for headaches."], "Patient Symptoms": ["The patient reported a 1-month history of \u201cpuffy and bumpy\u201d lips.", "He also described his lower lip as sometimes becoming \u201cdry and scaly\u201d during this time but denied any bleeding from the area.", "Findings of a complete review of systems were unremarkable, other than occasional headaches."], "Examination and Results": ["On physical examination, there were several erythematous papules at the vermillion border of the lower lip within a background of edema (Figure, A and B).", "In addition, the patient had slight fissuring of the tongue, but the remainder of the oral mucosa was normal and intact.", "Numerous laboratory tests were performed, including a complete blood cell count, complete metabolic panel, CD4 count, HIV viral load, and assays for C-reactive protein, erythrocyte sedimentation rate, angiotensin-converting enzyme, and rapid plasma reagin; all results were normal except for a slightly elevated angiotensin converting enzyme level (84 \u00b5g/L; normal, 9-67 \u00b5g/L).", "His CD4 count was within normal limits (520 cells/\u00b5L) and HIV viral load was undetectable.", "A biopsy was performed on the right lower lip (Figure, C and D).Clinical images (A and B) show persistent, nontender swelling of the lips in a patient with human immunodeficiency virus, showing erythematous papules at the vermillion border and edema of the lower lip."]}
{"Patient Personal Background": ["C, Sebaceous tumor with a modestly increased ratio of basaloid cells to sebocytes.The patient\u2019s medical history included diabetes mellitus type 2, hypercholesterolemia, hypertension, and depression.", "Review of her family medical history revealed that her paternal grandfather died from melanoma and that her father died from colon cancer.", "She stated that most of the men in her family had died from some form of cancer by the fourth decade of life.On physical examination, a tender, centrally depressed, firm, pink 1.1-cm nodule was present on her upper cutaneous lip (Figure, A)."], "Patient Symptoms": ["She stated that most of the men in her family had died from some form of cancer by the fourth decade of life.On physical examination, a tender, centrally depressed, firm, pink 1.1-cm nodule was present on her upper cutaneous lip (Figure, A)."], "Examination and Results": ["She was otherwise asymptomatic.A, Centrally depressed, firm, pink 1.1-cm nodule on the upper cutaneous lip and skin-colored papule on the left medial cheek (above marker dots).", "She stated that most of the men in her family had died from some form of cancer by the fourth decade of life.On physical examination, a tender, centrally depressed, firm, pink 1.1-cm nodule was present on her upper cutaneous lip (Figure, A).", "Three other skin-colored to pink papules were present on her face and neck.", "Shave biopsies of all 4 skin lesions were performed (Figure, B and C)."], "Others": ["B, Cup-shaped tumor demonstrated keratinocyte atypia with a central core of keratinaceous debris."]}
{"Patient Symptoms": ["He was recently hospitalized for confusion, short-term memory loss, vomiting, and diarrhea.", "He also experienced hair loss (Figure 1), a facial rash, hoarseness, and painful peripheral neuropathy in his feet.", "He reported difficulty opening his eyelids during hospitalization but denied any history of diplopia."], "Examination and Results": ["His blood pressure on admission was 150/102 mm Hg, his pulse was 118 beats/min, and ophthalmic examination findings demonstrated decreased visual acuity and dyschromatopsia.", "Results of a complete blood cell count, comprehensive metabolic panel, and erythrocyte sedimentation rate were within reference limits, and computed tomography of the head without contrast showed no abnormalities.", "A lumbar puncture showed normal opening pressure with a mildly elevated protein level in the cerebrospinal fluid.Alopecia was noted in our patient in addition to temporal thinning of the lateral half of the eyebrows.On our examination, best-corrected visual acuity was 20/70 OU.", "Extraocular motility was full in both eyes, and confrontational visual field test findings were full in all quadrants.", "The patient missed 4 color plates on Ishihara pseudoisochromatic testing.", "The slitlamp examination revealed an unremarkable anterior segment, and results of dilated ophthalmoscopy showed temporal optic nerve pallor in both eyes.", "The macula, vessels, and retinal periphery were unremarkable on examination."]}
{"Patient Personal Background": ["He denied any history of diabetes or past ocular problems and reported having mild hypertension for which he was taking lisinopril."], "Patient Symptoms": ["He had been experiencing nonprogressive diminished vision in his left eye for 6 weeks.", "Review of systems was positive for fatigue of his tongue while eating but he denied any jaw claudication, fevers, malaise, joint pain, or weight loss."], "Examination and Results": ["His best-corrected visual acuity was 20/25 OD and 20/30 OS.", "Pupillary and anterior segment examination in both eyes were unremarkable with the exception of bilateral nuclear sclerotic cataracts.", "Dilated fundus examination of the right eye showed a nerve fiber layer infarct (NFLI) inferior to the optic nerve (Figure 1A).", "In the left eye, there were several scattered NFLIs in the peripapillary region (Figure 1B).", "Fluorescein angiography (FA) showed relatively normal flow without evidence of occlusion or vasculitis.", "An extensive inflammatory and infectious laboratory workup revealed a hemoglobin level of 12.6 g/dL and elevated erythrocyte sedimentation rate and C-reactive protein level of 54 mm/h and 6.16 mg/L, respectively (to convert hemoglobin to grams per liter, multiply by 10, and C-reactive protein to nanomoles per liter, multiply by 9.524).", "Antinuclear antibody testing was positive (1:80 with homogenous pattern).", "Further workup including human immunodeficiency virus testing was nonrevealing.Fundus photographs of the right and left eye demonstrating nerve fiber layer infarcts in the peripapillary region."]}
{"Patient Personal Background": ["She had a history of alcohol, tobacco, cocaine, and marijuana use but denied current illicit drug use.", "She had not taken any medications prior to the appearance of the lesions."], "Patient Symptoms": ["Three weeks previously, she noticed painful erosions throughout her mouth.", "A week later, painful blisters appeared on her upper extremities, trunk, and thighs.", "She also reported 2 pruritic and painful lesions on her scalp that had appeared 6 months prior, shortly after a chemical hair treatment.", "The patient reported a 2.25-kg weight loss, subjective fevers, and chills but no urinary symptoms.On admission, the patient was tachycardic (113/min), but she was afebrile and other vital signs were normal."], "Examination and Results": ["Physical examination revealed crusted plaques on her scalp bilaterally (Figure).", "Erosive stomatitis involving the lower lip, buccal mucosa, hard palate, soft palate, and tongue was noted (Figure).", "Multiple well-circumscribed, round-to-oval bullae, erosions, and hyperpigmented patches were noted on her upper extremities, trunk, and thighs (Figure).", "Laboratory evaluation revealed a serum creatinine level of 7.1 mg/dL (627.6 \u03bcmol/L), up from a baseline (10 days prior) level of 0.9 mg/dL (79.6 \u03bcmol/L).", "Urinalysis revealed a specific gravity of 1.015 and was positive for hyaline casts and protein but negative for white blood cells, red blood cells, and bacteria.", "A complete blood cell count was unremarkable.", "Results of human immunodeficiency virus screen and urine drug screen were normal.Left, Crusted plaques on scalp of patient."]}
{"Patient Symptoms": ["On day 8 after birth, a 0.5-cm, circular, crusted papule with a surrounding rim of erythema on the left hip was noted (Figure, A)."], "Examination and Results": ["The patient\u2019s premature birth was complicated by acute respiratory distress that necessitated intubation and necrotizing enterocolitis that required parenteral nutrition.", "At birth, the patient was found to be mildly anemic (hemoglobin level, 11.0 g/dL [to convert to grams per liter, multiply by 10]) and thrombocytopenic (platelet count, 120 \u00d7 103/\u00b5L [to convert to 109/L, multiply by 1]) with concomitant intraventricular hemorrhage.", "A cerebrospinal fluid culture result was positive for Staphylococcus epidermidis, but the results of additional blood cultures were negative for organisms.", "A punch biopsy of the lesion was performed (Figure, B and C).A, Crusted circular papule with a surrounding rim of erythema and induration on the left hip.", "B, Biopsy specimen revealing epidermal necrosis with fungal elements within the superficial dermis (hematoxylin-eosin, original magnification \u00d720).", "C, Biopsy specimen highlighting branching and septate hyphae within the superficial dermis (specimen was stained with Gomori methenamine silver, original magnification \u00d740)."], "Treatment": ["Although afebrile, he was treated empirically for sepsis with vancomycin hydrochloride and cefepime hydrochloride."]}
{"Patient Personal Background": ["He reported a history of moderate alcohol consumption, drinking 1 beer per day during the week and approximately 5 to 8 beers over the weekend, but denied any use of nutritional supplements or illicit drugs.", "There was no recent travel outside the state.", "Human immunodeficiency virus test results on admission were negative."], "Patient Symptoms": ["The patient noted swelling on the right side of the neck and a 5-kg weight loss over the past 2 months."], "Examination and Results": ["Physical examination revealed scleral icterus, jaundice, and a fixed right supraclavicular lymph node conglomerate measuring 6\u2009\u00d7\u20093 cm.", "There was no cervical, left supraclavicular, axillary, or inguinal lymphadenopathy.", "Computed tomography of the neck, chest, abdomen, and pelvis demonstrated a large right supraclavicular lymph node, extensive mediastinal lymphadenopathy, a large extracardiac mass abutting the left atrium, hepatomegaly, and multiple splenic lesions.", "Laboratory evaluation demonstrated a total serum bilirubin level of 10.5 mg/dL with a direct component of 8.4 mg/dL (to convert to micromoles per liter, multiply by 17.104).", "Renal function was normal.", "Mild leukopenia and slight thrombocytopenia in the absence of associated anemia was noted on initial complete blood cell count."]}
{"Patient Personal Background": ["Her medical history was significant for chronic gastritis, which was being treated with esomeprazole 20 mg; a laparoscopic cholecystectomy 18 years prior; and excision of a 26-mm Merkel cell carcinoma of the left knee with negative results of the sentinel lymph node biopsy (stage II) 19 months prior."], "Examination and Results": ["Results of the patient\u2019s follow-up examinations were negative until a high-resolution computed tomographic scan showed a 45\u2009\u00d7\u200940-mm intraluminal protruding mass with slightly enlarged lymph nodes along the lesser curvature of the gastric fundus (Figure, A).", "Results of fluorine 18\u2013labeled fluorodeoxyglucose and gallium citrate Ga 68\u2013labeled 1,4,7,10-tetraazacyclododecane-N,N',N'',N'''-tetraacetic (DOTA)-D-Phe1-Try3-octreotide (DOTATOC) positron emission tomography confirmed the presence of a metabolically active mass in the gastric fundus (maximum standardized uptake value, 6) with intense 68Ga\u2013DOTATOC uptake (maximum standardized uptake value, 24) as well as mild 68Ga\u2013DOTATOC uptake in 2 lymph nodes of the lesser curvature.A, Multislice computed tomographic scan showing the 45\u2009\u00d7\u200940-mm mass in the gastric fundus.", "B, Endoscopic image showing the endophytic lesion in the posterior wall of the gastric fundus at the esophagogastric junction.Preoperative workup was completed via esophagogastroduodenoscopy, which showed the presence of the polypoid lesion in the posterior wall of the gastric fundus at the level of the esophagogastric junction (Figure, B)."], "Others": ["Multiple biopsies were performed at the time of the endoscopy."]}
{"Patient Personal Background": ["His medical history was uneventful, and there was no weight loss.", "However, the patient\u2019s father had died of a pancreatic carcinoma the previous year at the age of 65 years."], "Patient Symptoms": ["A similar episode had occurred 1 month before admission that improved spontaneously.A physical examination did not reveal any clinical abnormities, but the patient reported dysuria and abnormally frequent urination."], "Examination and Results": ["A computed tomographic scan of the abdomen revealed nephrolithiasis with a 4-mm kidney stone on the right side and a slightly congested right kidney.", "During computed tomography, we incidentally found a 10\u2009\u00d7\u200910\u2009\u00d7\u20098-cm mass in the tail of the pancreas (Figure 1), as well as thrombosis of the splenic vein.", "The patient\u2019s laboratory values, including cancer antigen 19-9 and carcinoembryonic antigen levels, were normal.Computed tomographic (CT) scans of the abdomen reveal the mass in the pancreas (arrowheads)."]}
{"Patient Personal Background": ["The patient had a history of an ovarian cyst treated conservatively, and cosmetic breast augmentation.", "She had a 10 pack-year smoking history and denied alcohol or illicit drug use."], "Examination and Results": ["Examination revealed distant heart sounds but otherwise had unremarkable results.", "An echocardiogram demonstrated a mass in the left ventricular myocardium.", "Cardiac magnetic resonance imaging was obtained to further assess the mass lesion.", "This revealed multiple intramyocardial masses involving the left ventricle, the largest of which measured 2.7 \u00d7 2.2 cm; aortopulmonary window lymphadenopathy; and moderate pericardial effusion (Figure).", "Computed tomographic imaging of the chest, abdomen, and pelvis with contrast failed to reveal discrete masses or lymphadenopathy elsewhere.", "A transcutaneous biopsy of the left ventricular mass was nondiagnostic."]}
{"Patient Personal Background": ["In September 2013, she began receiving trastuzumab treatment and received adjuvant radiotherapy (5000 Gy in 25 fractions) 1 month later."], "Patient Symptoms": ["In June 2014, she developed a generalized nonpruritic, nontender rash, without fevers or other constitutional symptoms."], "Examination and Results": ["Physical examination showed multiple red-brown plaques and papules of various sizes on the chest, abdomen, back, and limbs (Figure 1).", "Laboratory evaluation revealed pancytopenia (white blood cells, 1460/\u03bcL; hemoglobin, 8.3 g/dL; and platelets, 99\u202f000/\u03bcL [leukocyte differential: 0% blasts, 0% promyeloctes, 0% myelocytes, 0% metamyelocytes, 0% banded neutrophils, 30.1% segmented neutrophils, 4.1% eosinophils, 0.7% basophils, 0.7% monocytes, 64.4% lymphocytes])."]}
{"Patient Personal Background": ["She had no fever or any other systemic symptoms.", "She was otherwise in excellent health, with no history of allergies, no recent travel, and no animal exposure or trauma to her arm.Swelling and keloid formation within red ink area of tattoo.On examination, the patient was afebrile and appeared healthy."], "Patient Symptoms": ["Topical hydrocortisone cream (1%) applied for 1 week had provided no benefit.", "Marked swelling and keloid formation within the red ink area of the tattoo were noted."], "Examination and Results": ["She was otherwise in excellent health, with no history of allergies, no recent travel, and no animal exposure or trauma to her arm.Swelling and keloid formation within red ink area of tattoo.On examination, the patient was afebrile and appeared healthy.", "There was no drainage, local warmth or tenderness, or pustule formation.", "Notably, there was no swelling or discoloration over the black ink area of the tattoo."], "Treatment": ["Topical hydrocortisone cream (1%) applied for 1 week had provided no benefit."]}
{"Patient Personal Background": ["He previously made an informed decision to undergo prostate-specific antigen (PSA) screening for prostate cancer."], "Examination and Results": ["His digital rectal examination (DRE) revealed an enlarged prostate without nodules.", "His PSA history is displayed in the Table.The patient\u2019s slow rise in prostate-specific antigen (PSA) level and enlarged prostate are consistent with benign prostatic hyperplasia, and his probability of prostate cancer is less than 10%.The patient\u2019s rise in PSA level means his probability of prostate cancer is more than 50%.The patient\u2019s probability of prostate cancer is approximately 6% for a high-grade cancer and 18% for a low-grade cancer.Variability in the patient\u2019s PSA level makes it likely the tests were done in different laboratories."], "Diagnosis": []}
{"Patient Personal Background": ["He had no other symptoms.The patient's medical history included hypertension (controlled with lisinopril and hydrochlorothiazide), a low-density lipoprotein level of 155 mg/dL, and a high-density lipoprotein level of 44 mg/dL.", "He did not smoke or have family history of premature coronary artery disease (CAD)."], "Patient Symptoms": ["He reported substernal chest pain, lasting less than 5 minutes, which sometimes occurred if he ran more than 2 miles."], "Examination and Results": ["The patient\u2019s physical examination results were unremarkable, blood pressure was 134/80 mm Hg, body mass index was 26 (calculated as weight in kilograms divided by height in meters squared), and resting electrocardiogram (ECG) results were normal.The patient had no chest pain during ETT."], "Others": ["Results are reported in the Table.Further testing is unnecessary because the patient is asymptomatic and has high exercise capacity.Further testing is needed because of the ST depressions during recovery.Further testing is unnecessary because ST depressions are not significant unless 2 mm or greater.Further testing is needed because inferolateral ST depressions indicate obstructive coronary artery disease in the right coronary artery, the left circumflex artery, or both arteries."]}
{"Patient Personal Background": ["She stated that it began before her diagnosis of acute myelogenous leukemia and the initiation of treatment with hydroxyurea 4 years later.", "Her additional daily medication regimen included donepezil hydrochloride, melatonin, and aspirin, 81 mg.Findings from the patient\u2019s physical examination revealed background erythema with numerous rough horny spicules at the follicular ostia on her face, ears, and neck; the upper part of her chest; and her bilateral forearms."], "Patient Symptoms": ["She denied having pruritus or pain, but her skin had a rough sandpapery sensation.", "She reported that the involvement extended to her neck, the upper part of her chest, and her bilateral forearms."], "Examination and Results": ["Findings from the rest of her examination revealed a pigmented macule on her right cheek.", "Two punch biopsy specimens were obtained from her right cheek and right postauricular area and submitted for histopathologic examination (Figure).Histopathologic images (hematoxylin-eosin) of the punch biopsy specimen from the right side of the lateral neck."], "Treatment": ["She had previously received treatment with long courses of triamcinolone acetonide cream, 0.1%, bacitracin ointment, and a combination antibiotic ointment of neomycin sulfate, polymyxin B, and bacitracin, with no improvement of her skin\u2019s condition."], "Diagnosis": ["She associated the onset of the textural changes with her diagnosis of polycythemia vera."]}
{"Patient Personal Background": ["The patient had no history of medical problems.", "He was born in Spain and had received his childhood immunizations."], "Patient Symptoms": ["He remembered insect bites on his feet, but the lesions later became ulcerated and painful.", "The patient denied experiencing fever, arthralgia, or a sore throat.Findings from the physical examination revealed 6 painful ulcerated, exudative nodules with a grayish membrane over the ulcers on the dorsal aspect of his feet (Figure 1)."], "Examination and Results": ["The patient denied experiencing fever, arthralgia, or a sore throat.Findings from the physical examination revealed 6 painful ulcerated, exudative nodules with a grayish membrane over the ulcers on the dorsal aspect of his feet (Figure 1).", "No signs of lymphangitis or lymphadenopathy were detected.", "A 4-mm punch biopsy specimen from one lesion was obtained and stained with hematoxylin-eosin and Gram stain for histopathologic analysis.", "Another skin specimen was cultured for microbiologic analysis."]}
{"Patient Symptoms": ["According to her mother, new lesions had appeared during the past weeks on the shoulders."], "Examination and Results": ["Physical examination revealed coarse facial features, hepatomegaly (7 cm below the costal arch), distinctive lumbar kyphosis, and muscular hypotonia compared with her twin brother.", "Dermoscopy showed faint clouds of nonhomogeneously distributed light brown pigment.A, Polycyclic, brown, partly livid shimmering macules covered large areas of the back, neck, buttocks, and lower extremities.", "B, Fusiform and dendritic cells were found scattered in the dermis (hematoxylin-eosin, original magnification \u00d7100).", "C, Immunohistological staining of the same specimen (original magnification \u00d7200).", "S-100 protein positivity identified these cells as melanocytes.", "D, A triangle-shaped first lumbar vertebral body is shown."]}
{"Patient Personal Background": ["The woman\u2019s medical history was significant for type 2 diabetes mellitus (DM), hypertension, recurrent urinary tract infections, onychomycosis, end-stage renal failure, and a history of living, unrelated donor renal transplant 12 years earlier, kidney transplant rejection, and prior episodes of syncope.", "Medications included tacrolimus, mycophenolate mofetil hydrochloride, prednisone (1 mg/d), losartan potassium, and insulin.", "Family history was notable for her father having died of lung cancer and her mother had heart disease and DM.", "Social history did not reveal any unusual exposures."], "Patient Symptoms": ["Neurologic findings revealed reasonably preserved mental status, with bedside examination revealing normal attention, language, and orientation but mild memory deficits for short-term recall (2 of 3 words recalled at a 5-minute delay) and long-term fund of knowledge.", "Cranial nerve, motor, sensory, and reflex examination results were significant only for gait ataxia, with an inability to perform tandem gait."], "Examination and Results": ["Urinalysis revealed a urinary tract infection, but computed tomography (CT) of the head showed extensive mass lesions with bilateral edema.", "Magnetic resonance imaging (MRI) of the brain delineated expansile mass lesions of the splenium of the corpus callosum, with T2\u2013fluid-attenuated inversion recovery hyperintensity in the bilateral parietal lobes, left thalamus, and midbrain (Figure, A); administration of contrast revealed multiple ring-enhancing lesions (Figure, B).", "Physical examination results showed a transplant surgical scar and onychomycosis.", "Blood test results were consistent with DM.", "Findings from cerebrospinal fluid (CSF) examination included a white blood cell count of 9/\u00b5L, with differential examination showing 84% lymphocytes, 13% monocytes, and 3% neutrophils; red blood cell count of 1080/\u00b5L; protein level, 180 mg/dL; and glucose level, 87 mg/dL.", "Flow cytometry revealed B and T lymphocytes but no monoclonal populations of cells.", "Polymerase chain reaction amplification tests on CSF revealed no evidence of cytomegalovirus or herpes simplex virus 1 or 2 genetic material.", "Serum and CSF serologic test results were negative for antibodies to toxoplasma; testing using polymerase chain reaction on blood for Epstein-Barr virus (EBV) revealed minimal (very low positive) viral DNA at 52 IU/mL.", "A CT scan of the chest, abdomen, and pelvis showed a small, subpleural nodule; fatty liver; diverticulosis; failed native kidneys; and normal transplanted kidney.", "Dexamethasone sodium phosphate and levetiracetam were administered.", "The patient underwent a diagnostic procedure.Brain magnetic resonance imaging showing unsuspected mass lesions.", "A, A T2 fluid-attenuated inversion recovery (FLAIR) sequence illustrating prominent T2 hyperintensity in the right more than the left parietal white matter suggestive of edema, an expansive mass lesion on the right more than the left splenium of the corpus callosum, and an infiltrative mass lesion in the left thalamus extending into the mesencephalon."], "Treatment": ["Whole-body positron emission tomography revealed hypermetabolic regions in the brain."]}
{"Patient Personal Background": ["He was born at full term weighing 3.63 kg after a normal pregnancy, labor, and delivery."], "Patient Symptoms": ["He grew appropriately until 3 months of age, after which his weight dropped from the 50th percentile to the fifth percentile in 2 months despite maintenance of a fairly adequate caloric intake.", "The patient had multiple episodes of emesis.", "His head was of normal size, although it appeared large relative to his small body size."], "Examination and Results": ["Results of his gastrointestinal evaluation were normal.", "At 6 months of age, he developed a constant rapid nystagmus of the right eye.On presentation, he was a happy, engaged, alert child with an emaciated appearance (Figure, A).", "During the examination, the patient was socially interactive and visually attentive.", "He had normal, optokinetic responses and brisk pupillary responses with no relative afferent pupillary defect.", "He had a rapid pendular horizontal nystagmus, with no associated strabismus, head nodding, or torticollis (Video).", "The patient looked readily toward objects held in the peripheral visual field of either eye.", "The retinal examination showed normal-sized optic discs without swelling or pallor.", "The patient had no history or findings suggestive of neurofibromatosis type 1.A, On presentation, the patient appeared emaciated but alert."]}
{"Patient Symptoms": ["However, the therapy was complicated by avascular hip necrosis that required total hip arthroplasty, and his visual symptoms recurred with corticosteroid tapering.At presentation, his visual acuity was 20/150 OD and 20/15 OS."], "Examination and Results": ["The anterior segment was normal in both eyes.", "Dilated ophthalmoscopic examination of the right eye revealed a diffuse subretinal yellow mass and an exudative retinal detachment temporal to the fovea (Figure 1).", "Ophthalmoscopic examination of the left eye was normal.", "B-scan of the right eye showed a dome-shaped choroidal lesion with an apical height of 3.4 mm and medium to high internal reflectivity.", "Fluorescein angiography demonstrated heterogeneous leakage, and optical coherence tomography of the macula showed subretinal fluid with irregular retinal and choroidal thickening.", "Results from extensive workup for infectious and autoimmune etiologies (including serum angiotensin-converting enzyme, lysozyme, lumbar puncture, magnetic resonance imaging of the brain and orbits, and computed tomography of the chest) were negative, except for positive purified protein derivative skin testing and positive interferon-\u03b3 release assay (QuantiFERON-TB Gold; Cellestis, Inc).Large choroidal tuberculoma at presentation.", "In a fundus view of the right eye, a moderate amount of subretinal fluid is seen adjacent to the lesion, involving the fovea center.", "B-scan (not shown) measured an apical height of 3.4 mm."], "Treatment": ["Oral prednisone provided visual improvement.", "However, the therapy was complicated by avascular hip necrosis that required total hip arthroplasty, and his visual symptoms recurred with corticosteroid tapering.At presentation, his visual acuity was 20/150 OD and 20/15 OS."]}
{"Patient Personal Background": ["She reported recently injuring her hand on a metal fence at home and biting her nails frequently.", "She lives on a farm in Ohio and has extensive direct contact with sheep and cows; family pets include a cat, a dog, and a hamster."], "Patient Symptoms": ["She reported recently injuring her hand on a metal fence at home and biting her nails frequently.", "She reported mild tender lymphadenopathy of the right axilla but denied fever.Examination revealed an erythematous, 1 \u00d7 1.5-cm, well-defined eroded pustule with central crusting and an erythematous border (Figure)."], "Examination and Results": ["She reported mild tender lymphadenopathy of the right axilla but denied fever.Examination revealed an erythematous, 1 \u00d7 1.5-cm, well-defined eroded pustule with central crusting and an erythematous border (Figure).", "There were several slightly enlarged, mildly tender lymph nodes noted in the right axilla.Eroded and crusted pustule with surrounding inflammation on the thumb.Complete blood cell count, erythrocyte sedimentation rate, and basic metabolic panel results were unremarkable.", "Findings on radiography revealed focal soft-tissue swelling with no evidence of foreign body, subcutaneous gas, or osseous involvement."], "Others": ["There was no known recent travel or contact with anyone with a similar lesion."]}
{"Patient Personal Background": ["He denied any heartburn, hemoptysis, pain, neck masses, or smoking history.", "Prior treatment with 2 rounds of oral antibiotics and 1 round of oral steroids from his primary care physician did not improve his symptoms."], "Patient Symptoms": ["He described a progressively worsening voice with use to the point where he was nearly aphonic by the end of his workday.", "Objectively, the patient\u2019s voice was rough, diplophonic, and very strained."], "Examination and Results": ["Videostroboscopic examination in the clinic revealed a broad-based submucosal mass in the anterior two-thirds of the right true vocal fold (Figure, A) that disrupted vibration of both vocal folds owing to its size and anterior location (Figure, B and Video).", "Findings from the remainder of his head and neck examination were unremarkable."], "Treatment": ["The patient was taken to the operating room for microdirect laryngoscopy under general anesthesia (Figure, C).", "A microflap incision along the lateral aspect of the right true vocal fold mass was performed, and a firm, submucosal, tan-colored, seemingly encapsulated, multilobulated mass was removed en bloc with narrow margins and sent for permanent section analysis (Figure, D)."], "Others": ["The mass was deep to the epithelium of the true vocal fold and superficial to the vocal ligament.A and B, Clinical views of endoscopic appearance of the anterior right true vocal fold mass.", "A, View showing vocal folds abducted.", "B, View showing vocal folds adducted.", "C and D, Intraoperative endoscopic views.", "C, Submucosal mass.", "D, A microflap incision was performed along the lateral aspect of the lesion and a multilobulated, firm submucosal mass deep to the epithelium but superficial to the vocal ligament was resected."]}
{"Patient Symptoms": ["She denied other sinonasal symptoms, history of epistaxis, nasal trauma, or surgery."], "Examination and Results": ["Clinical evaluation revealed a soft-tissue mass filling the left nasal cavity and based on the mucosal surface of the anterolateral nasal vestibule.", "Noncontrast paranasal sinus computed tomography showed a 1.2\u2009\u00d7\u20090.8-cm ovoid soft-tissue mass opacifying the posterior aspect of the left nasal vestibule (Figure, A, arrowhead).", "B-D, Histopathologic images from the nasal cavity mass, original magnifications \u00d7100."], "Treatment": ["Endoscopic excision under local anesthesia was performed to remove a broad-based soft-tissue mass from the left nasal vestibule mucosa with a cuff of grossly healthy submucosa."], "Others": ["A tissue specimen was biopsied (Figure, B-D).", "The patient had an uneventful postoperative course, and her epistaxis symptoms were resolved at the 5-month follow-up.A, Noncontrast paranasal sinus computed tomographic image."]}
{"Patient Symptoms": ["Rapid correction to 136 mEq/L occurred, resulting in lethargy, aphasia, and ataxia.", "Over the subsequent 2 weeks, the hyponatremia resolved and the patient was left with slight dysarthria and difficulties with fine-motor movements."], "Examination and Results": ["Laboratory evaluation revealed a sodium level of 109 mEq/L.", "Magnetic resonance imaging (MRI) demonstrated an abnormal signal within the basal ganglia and insular cortex.", "A 2.5\u2009\u00d7\u20091.5\u2009\u00d7\u20091.8-cm mass was found in the superior right maxillary sinus with extension into the infundibulum (Figure, A).", "Computed tomographic (CT) scans of the sinuses without intravenous contrast demonstrated that the mass had calcifications.", "The submucosa contained a small, round, blue-cell tumor growing in circumscribed lobules and nests separated by vascularized fibrous stroma.", "The neoplastic cells had uniform, small, round nuclei with scant cytoplasm.", "Cells were arranged in a pseudorosette pattern (Figure, B).", "The nuclei demonstrated dispersed, salt and pepper nuclear chromatin and inconspicuous nucleoli.", "The cells were surrounded by a neurofibrillary matrix.", "There were prominent microcalcifications.", "No mitotic figures were seen.", "The tumor cells were diffusely positive for immunohistochemical marker synaptophysin (Figure, C).", "Results from cytokeratin staining were negative (Figure, D).A, T1-weighted postgadolinium magnetic resonance image, coronal view."], "Treatment": ["Owing to persistent hyponatremia (sodium level, 125-130 mEq/L) and an identifiable lesion, the patient was taken to the operating room for biopsy.", "He underwent a maxillary antrostomy with near-complete removal of the mass."], "Diagnosis": ["He was diagnosed as having idiopathic syndrome of inappropriate antidiuretic hormone secretion (SIADH)."], "Others": ["B-D, Histopathological images.", "B, Hematoxylin-eosin, original magnification \u00d7100.", "C, Tissue positivity for synaptophysin, original magnification \u00d7200.", "D, Tissue negativity for cytokeratin, original magnification \u00d7200."]}
{"Patient Personal Background": ["She reported a distant history of breast cancer and a recent history of an oral cavity lesion, which was not biopsied or followed up.", "She did not have any known tuberculosis exposure, recent foreign travel, exposure to unpasteurized food, history of immunodeficiency, or alcohol or tobacco use."], "Patient Symptoms": ["She did not have fever, chills, cough, dysphagia, or odynophagia."], "Examination and Results": ["Physical examination revealed a healthy-appearing woman with normal vital signs.", "She was found to have bilateral cervical lymphadenopathy, which included fixed and bulky nodes in level IB and IIA and nontender level IV and V nodes.", "An oral cavity examination revealed no evidence of masses or lesions, floor of mouth and base of tongue were soft, and the palatine tonsils had no lesions or ulcers.", "Flexible laryngoscopy revealed no evidence of pharyngeal or laryngeal lesions.", "Contrast-enhanced computed tomographic (CT) scans of the neck (Figure) revealed bilateral lymphadenopathy with central necrosis.Computed tomographic scan with contrast."], "Others": ["A, At the level of mandible.", "B, At the level of thyroid cartilage.", "C, Through the sphenoid.", "D, Through the temporomandibular joint."]}
{"Patient Personal Background": ["Her medical history included hypertension, diabetes mellitus, and right-sided chronic otitis media of 4 years\u2019 duration successfully treated surgically 1 year earlier (tympanoplasty type 1)."], "Patient Symptoms": ["She had no dyspnea or hoarseness."], "Examination and Results": ["On oral endoscopic examination, mild bilateral hyperemia of the tonsillar area and posterior pharyngeal wall were noted.", "A submucosal pulsatile mass was clearly visible in the right retropharyngeal area (Figure, A and B; Video).", "The base of tongue was normal.", "No other clinically significant abnormalities were noted.", "She was reevaluated after 15 days.A and B, Endoscopic examination of the oropharynx revealing a submucosal pulsatile mass in the right retropharyngeal area.", "C, Three-dimensional reconstruction.", "Abnormal medial course of the right internal carotid artery (arrow).", "D, T1-weighted gradient echo.", "Aberrant internal carotid artery in the retropharyngeal space."], "Treatment": ["Part of the clinical findings were suggestive of laryngopharyngeal reflux disease, and oral esomeprazole, 40 mg/d, was prescribed."], "Others": ["Head and neck magnetic resonance angiography was recommended (Figure, C and D)."]}
{"Patient Symptoms": ["When presenting for his fourth and final dose of ipilimumab, he reported central headaches, severe fatigue, poor appetite, intermittent nausea, and a mild rash."], "Examination and Results": ["On examination, vital signs were within normal limits.", "Physical examination had largely unremarkable results except for a slightly red, raised rash over his chest and proximal extremities.Laboratory testing showed the following: thyrotropin, 0.02 mIU/L (reference range, 0.3-5.0 mIU/L), and free thyroxine,\u2009less than\u20090.25 ng/dL (reference range, 0.5-1.2 ng/dL; to convert to picomoles per liter, multiply by 12.871).", "Cosyntropin stimulation test showed a cortisol peak level of 0.9 \u00b5g/dL (reference range, >20 \u00b5g/dL; to convert to nanomoles per liter, multiply by 27.588).", "He had low corticotropin (<5 pg/mL; reference range, 7-51 pg/mL; to convert to picomoles per liter, multiply by 0.22) and testosterone levels (<0.1 ng/mL; reference range, 2-11 ng/mL; to convert to nanomoles per liter, multiply by 0.0347).", "Magnetic resonance imaging (MRI) of the brain is shown in the Figure.Magnetic resonance imaging of the brain with contrast."], "Treatment": ["He then underwent inguinal lymph node dissection and was found to have 9 lymph nodes involved with melanoma (stage IIIC melanoma).He was then treated with ipilimumab (3 mg/kg), a monoclonal antibody to cytotoxic T lymphocyte antigen-4 (CTLA-4), every 3 weeks, as part of an investigational adjuvant therapy clinical trial."], "Diagnosis": ["Biopsy of a lymph node showed melanoma."], "Others": ["Several months earlier, he presented to the emergency department with shortness of breath.", "Imaging revealed pulmonary emboli and incidental groin lymphadenopathy."]}
{"Patient Personal Background": ["The patient noted no other symptoms.His medical history included atopic dermatitis and pulmonary tuberculosis.", "There was no family history of gastrointestinal pathology.", "He had not undergone any previous abdominal surgery, except inguinal hernia repair.", "He claimed to be a heavy smoker.", "No history of sexually transmitted diseases was found."], "Patient Symptoms": ["The anal lesion appeared 1 year earlier and grew slowly to the current size.", "The patient reported bleeding from the rectum after defecation and denied weight loss or fever.", "It was ulcerated, covered by purulent exudate, and very painful."], "Examination and Results": ["Physical examination revealed a 12\u2009\u00d7\u200910-cm hard mass on the left side of the anus (Figure 1A).", "The scrotum was mildly tender to palpation.", "Digital rectal examination and rectoscopy were not performed because of the pain and fecal incontinence.", "The abdomen was soft and nontender.", "Routine blood, liver, and renal function test results were normal, as were results for carcinoembryonic antigen and cancer antigen 19-9.", "Chest radiography showed no abnormalities.", "Computed tomographic scan of the pelvis showed a hypodense 12\u2009\u00d7\u20097\u2009\u00d7\u20093-cm mass extending to the anus, anal canal, and lower perirectal space (Figure 1B).", "Abdominal computed tomography showed no pathology.Clinical photograph of the giant perianal mass in the left perianal region (A) and abdominal computed tomographic scan showing the mass in the anus (B)."]}
{"Patient Personal Background": ["She had not received any medication, including contraceptive pills or hormones, for more than 10 years.Nine years before this examination, the patient underwent elective splenectomy and hepatic biopsy at another institution.", "However, she did not know the reason for removal of the spleen, and results of the histopathologic examination were not available.", "She had undergone a cesarean section at age 25 years.", "The patient had no history of trauma or other previous medical events.An abdominal computed tomographic scan revealed a well-defined, solid, heterogeneous mass, completely intrahepatic, with no enhancement and no liquid component, causing slight displacement of the right hepatic vein (Figure 1).Cross-sectional computed tomographic image of the abdomen shows a large, intrahepatic, 20-cm solid mass."], "Patient Symptoms": ["The patient was asymptomatic, and there were no significant findings on abdominal physical examination\u2014 the liver was not palpable."], "Examination and Results": ["The ultrasonographic scan showed a hepatic mass in the right lobe composing approximately 50% of the liver parenchyma.", "The patient was asymptomatic, and there were no significant findings on abdominal physical examination\u2014 the liver was not palpable.", "Results of whole blood analyses, including \u03b1-fetoprotein, were within the reference ranges."]}
{"Patient Personal Background": ["Her medical history included hypertension, diabetes, pulmonary sarcoidosis, and acid reflux, for which she takes amlodipine, carvedilol, repaglinide, hydroxychloroquine, and pantoprazole.", "Her history also included chronic renal insufficiency and chronic hepatitis C, for which she takes no medications."], "Patient Symptoms": ["She reported no fevers, new skin exposures, oral ulcers, arthritis, alopecia, or photosensitivity and no worsening pulmonary symptoms of cough or shortness of breath.", "The rash did not improve after 2 weeks of applying topical triamcinolone ointment (0.1%).Physical examination revealed annular coalescing scaly patches with erythematous borders on her forehead, neck, back, and upper and lower extremities (Figure, panels A and B)."], "Examination and Results": ["Laboratory workup revealed an antinuclear antibodies titer of 1:80 with a speckled pattern, elevated Sj\u00f6gren syndrome\u2013related antigen A (SS-A) level (>8 AI), and no elevation of Sj\u00f6gren syndrome\u2013related antigen B (SS-B), ribonucleoprotein, double-stranded DNA, Smith, or anti-histone antibodies.", "Complete blood cell count, erythrocyte sedimentation rate, and C-reactive protein level were within normal limits.", "Creatinine level was elevated but stable at 1.8 mg/dL (159.1 \u03bcmol/L).", "Skin biopsy revealed an inflammatory pattern of vacuolar interface dermatitis (Figure, panel C).A, Widespread annular and polycyclic scaly patches on the trunk and extremities."], "Treatment": ["The rash did not improve after 2 weeks of applying topical triamcinolone ointment (0.1%).Physical examination revealed annular coalescing scaly patches with erythematous borders on her forehead, neck, back, and upper and lower extremities (Figure, panels A and B)."]}
{"Patient Personal Background": ["He was taking sertraline for treatment of anxiety disorder, and had a 15-year-old son."], "Patient Symptoms": ["He reported no headache, erectile dysfunction, breast tenderness or mass, arthralgias, edema, or increase in glove, ring, or shoe size."], "Examination and Results": ["His examination was significant for the presence of bitemporal visual field defects on confrontation testing.", "Testicular size was 20 mL for each.", "Laboratory tests were performed (Table), which revealed low serum testosterone and thyrotropin and elevated serum prolactin levels.", "A neuro-ophthalmic examination revealed the presence of symmetric superior temporal visual field defects on perimetry."], "Others": ["He had no acromegalic features, gynecomastia, galactorrhea, or abnormal virilization.", "Magnetic resonance imaging (MRI) was obtained to examine his brain.The patient has hyperprolactinemia due to a nonfunctioning pituitary adenoma.The patient has hyperprolactinemia due to thyroid disease.The patient has hyperprolactinemia due to a prolactinoma."]}
{"Patient Personal Background": ["Her medications included metformin, lansoprazole, venlafaxine, diltiazem, atorvastatin, oxycodone/acetaminophen, ramopril, reglan, zolpidem, and clopidogrel."], "Patient Symptoms": ["She denied any history of trauma and had not applied anything topically in this area of skin.", "She denied fevers, systemic symptoms, joint pain, and skin thickening.", "She was treated with clobetasol cream (0.05%), and the plaque resolved in 4 weeks with postinflammatory hypopigmentation.Ten months later, the patient developed a tender, pink, indurated 7-cm plaque with telangiectasias and central ulceration in the same location, with no other cutaneous findings (Figure, B)."], "Examination and Results": ["Physical examination revealed an 8-cm solitary, erythematous plaque with vesiculation and central erosion on the right lateral area of her abdomen (Figure, A).", "The remainder of the physical examination was unremarkable.", "A punch biopsy showed a vacuolar interface dermatitis pattern, but a definitive clinical diagnosis was not established."], "Treatment": ["No precipitating factors could be identified."], "Others": []}
{"Patient Personal Background": ["She had previously undergone coronary artery bypass grafting with simultaneous aortic valve replacement and ileal conduit urinary diversion as a result of to recurrent upper urinary tract infections."], "Patient Symptoms": ["On day 7 of her hospital stay, she developed severe, unremitting left ankle pain with purpuric lesions on the skin."], "Examination and Results": ["Laboratory findings were significant for neutrophil-predominant leukocytosis (leukocyte count, 19\u202f400/\u03bcL [to convert to \u00d7109/L, multiply by 0.001]).Physical examination revealed multiple stellate, purpuric plaques with central flaccid bullae on the medial and lateral aspects of the left ankle (Figure, A).", "The remainder of her skin examination findings were unremarkable.", "Punch biopsy specimens were obtained along the border of normal and lesional skin (Figure, B and C), and she underwent transesophageal echocardiography.A, Stellate purpura with overlying flaccid bulla on the medial aspect of the ankle.", "B, Partially necrotic epidermis with intraepidermal bulla formation with marked perivascular infiltrates in the deep dermis and subcutaneous tissue (hematoxylin-eosin, original magnification \u00d725).", "C, A small blood vessel occluded with fibrinoid material with a perivascular lymphoneutrophilic infiltrate (hematoxylin-eosin, original magnification \u00d7400)."]}
{"Patient Personal Background": ["His medical history was significant for type 2 diabetes mellitus and hypertension, which were managed with metformin, glimepiride, and atenolol.Physical examination revealed hyperpigmented annular plaques with violaceous borders on his scalp and the superior part of his forehead (Figure, A)."], "Patient Symptoms": ["The eruption began during the summer 3 months before presentation."], "Examination and Results": ["There were violaceous papules on the dorsal aspect of the hands (Figure, B), extensor surface of the arms, and the nape of the neck.Physical examination findings.", "A, Hyperpigmented annular plaques with violaceous borders on the scalp.", "B, Violaceous papules on the dorsal aspect of the hands.", "C, Histopathologic analysis of violaceous eruption on the hand.", "Lymphocytic infiltrate at the dermoepidermal junction (hematoxylin-eosin, original magnification \u00d710).A punch biopsy specimen was obtained and sent for histopathologic evaluation (Figure, C)."]}
{"Patient Symptoms": ["The lesions subsequently involved her chest, abdomen, and back and flared with sun exposure."], "Examination and Results": ["Biopsy samples were obtained for histopathologic evaluation.A, This case shows well-demarcated plaques with an overlying scale crust occurring in a photodistributed pattern on the central face.", "C, Hematoxylin-eosin, original magnification \u00d710.Laboratory findings were significant for positive antinuclear antibody titers at 1:640, lymphopenia, and normocytic anemia.", "Test results were negative or within normal limits for levels of antiribonucleoprotein, antihistone, antiphospholipid, anti-Smith, anti-Ro/Sj\u00f6gren syndrome antigen A, and anti-La/Sj\u00f6gren syndrome antigen B antibodies, C3, C4, CH50, rapid plasma reagin, and creatinine; erythrocyte sedimentation rate; and a comprehensive metabolic profile.", "Urinalysis results were within normal limits."], "Treatment": ["A diagnosis of lupus erythematosus (LE) was favored, but the lesions failed to improve on a regimen that included hydroxychloroquine sulfate, fluocinonide ointment, 0.05%, and tacrolimus ointment, 0.1%."], "Diagnosis": ["A diagnosis of lupus erythematosus (LE) was favored, but the lesions failed to improve on a regimen that included hydroxychloroquine sulfate, fluocinonide ointment, 0.05%, and tacrolimus ointment, 0.1%."], "Others": ["B, Hematoxylin-eosin, original magnification \u00d74.", "A biopsy specimen was obtained (Figure, B and C)."]}
{"Patient Personal Background": ["The patient had received a diagnosis of human immunodeficiency virus (HIV) infection 4 months before, with a nadir in his CD4 count of 11/\u03bcL.", "He started highly active antiretroviral therapy, with improvement in his CD4 count to 101/\u03bcL most recently.", "In addition to highly active antiretroviral therapy, he received combined sulfamethoxazole and trimethoprim and azithromycin prophylaxis."], "Patient Symptoms": ["During the past few months, he had reported increasing fatigue and intermittent fevers thought to be owing to immune reactivation syndrome.", "Visual acuity is 20/100."], "Examination and Results": ["His visual acuity was 20/150 OD and 20/100 OS, and intraocular pressures were 6 and 10 mm Hg, respectively.", "On slitlamp examination, both eyes were injected with diffuse mutton-fat keratic precipitates and had more than 50 cells per 1\u00d71-mm slitlamp high-power beam in the anterior chamber.", "Results of a dilated ophthalmoscopic examination revealed bilateral vitritis, hyperemic optic nerves, and extensive whitening likely involving all layers of the retina (Figure 1).", "After 48 hours of treatment, his condition did not improve.Marked vitritis, hyperemia of the optic nerve, and coalescent areas of retinal whitening involving the posterior pole are seen in the left eye."], "Treatment": ["He was hospitalized and started therapy consisting of intravenous (IV) acyclovir sodium, 10 mg/kg every 8 hours, and prednisone, 30 mg/d.", "Samples for a laboratory workup for infectious causes were obtained."]}
{"Patient Personal Background": ["He had no ocular history, was not taking any medications, and had no known drug allergies.", "He smoked 2 to 4 packs of cigarettes per day, consumed 1 to 3 alcoholic drinks per day, and denied illicit drug use."], "Patient Symptoms": ["He had experienced eye redness for 1 week, which resolved with use of artificial tears; a mild posterior headache; and paresthesias of the left thumb and index and middle fingers.His medical history was significant for epilepsy as a child, although he had been seizure free for more than 10 years without medication.", "He denied recent travel, vaccinations, systemic illnesses, or influenza-like symptoms.His best-corrected visual acuity was 20/20 OD and 20/100 OS."], "Examination and Results": ["Amsler grid testing revealed a central scotoma in the left eye.", "No afferent papillary defect was apparent.", "Intraocular pressures were 16 mm Hg OU.", "Results of the external and anterior segment examinations were unremarkable, and no vitreous inflammation was noted.", "Results of the neurologic examination revealed decreased sensation to light touch, vibration, and temperature in his left upper and lower extremities.A, Subretinal and retinal pigment epithelial lesions (arrowheads) are visible in the left eye.", "B, Late staining of the macular lesion.", "The right eye showed similar findings."], "Others": ["Figure 1 shows findings of the posterior segment examination.", "The arrowheads outline the border of the area that was hypofluorescent in the early frames (not shown)."]}
{"Patient Personal Background": ["The patient lives in the southeastern United States and had no reported history of unusual exposures or insect or tick bites.A, A blanching, erythematous, macular rash present on the patient\u2019s cheeks."], "Patient Symptoms": ["Physical examination findings were significant for ill appearance, bilateral nonexudative conjunctivitis, shotty bilateral anterior cervical lymphadenopathy, diffuse abdominal tenderness (greatest in the right upper quadrant), and associated rebound and guarding.", "There was also a blanching, erythematous, macular rash on his cheeks (Figure, A) and an intermittent, erythematous, reticular rash on his chest, abdomen, arms, and legs (Figure, B) that spared his palms and soles and flared with fever."], "Examination and Results": ["Physical examination findings were significant for ill appearance, bilateral nonexudative conjunctivitis, shotty bilateral anterior cervical lymphadenopathy, diffuse abdominal tenderness (greatest in the right upper quadrant), and associated rebound and guarding.", "Laboratory studies were significant for an elevated aspartate transaminase level of 264 U/L (reference range, 12-47 U/L; to convert to microkatals per liter, multiply by 0.0167) and an alanine transaminase level of 251 U/L (reference range, 17-63 U/L; to convert to microkatals per liter, multiply by 0.0167).", "A complete blood cell count revealed leukopenia with a white blood cell count of 28\u00a0300/\u00b5L (to convert to \u00d7109/L, multiply by 0.001) (neutrophils, 64%; lymphocytes, 18%; monocytes, 4%; eosinophils, 2%; basophils, 1%; and bands, 11%), a low-normal hemoglobin level of 11.4 g/dL (to convert to grams per liter, multiply by 10), and thrombocytopenia with a platelet count of 610 \u00d7 103/\u00b5L (to convert to \u00d7109/L, multiply by 1).", "Computed tomography of the abdomen revealed a dilated appendix (7 mm) with mucosal hyperemia and an internal appendicolith; acute appendicitis could not be excluded radiographically, so the patient was admitted for further workup because of a concern for acute abdomen."], "Others": ["The remainder of his examination findings were unremarkable.", "B, An example of an intermittent, erythematous, reticular rash present on the patient\u2019s left arm."]}
{"Patient Personal Background": ["She had no significant medical history, had quit smoking cigarettes 4 year prior to presentation, but had a 20 pack-year smoking history."], "Patient Symptoms": ["She had no pain or neurosensory disturbances related to the lesion; however, she did have difficulty tolerating a regular diet owing to the bulk of the mass."], "Examination and Results": ["Findings from the physical examination were notable for a 4.9-cm exophytic, nodular, slightly mobile mass of the left lower posterior alveolar ridge, involving the buccal and lingual gingiva.", "Teeth 20 to 24 were mobile.", "She had no cervical lymphadenopathy.", "Previous biopsy demonstrated squamous mucosa with ulceration and chronic inflammation.", "Contrasted computed tomography revealed an exophytic complex mass with areas of calcification and ossification inferiorly and a necrotic, cystic irregularly enhancing portion superiorly (Figure, A-C)."], "Treatment": ["The mass was excised, and teeth 20 to 26 were removed.", "The alveolar ridge was recontoured, and the incision was closed primarily.A-C, Computed tomographic (CT) scans."], "Others": ["An additional biopsy was performed (Figure, D).", "A, Bone window, coronal view.", "B, Bone window, sagittal view.", "C, Soft-tissue window.", "D, Histopathologic image of biopsy specimen."]}
{"Patient Personal Background": ["She had no significant use of tobacco or alcohol in the past."], "Patient Symptoms": ["She had not experienced any dysphagia, dysphonia, dyspnea, fevers, or weight loss."], "Examination and Results": ["Findings from an otoscopic examination was unremarkable.", "Nasopharyngoscopy was performed and failed to reveal any masses, ulcerations, or mucosal lesions.", "A magnetic resonance image (MRI) revealed an enhancing 1\u2009\u00d7\u20096-mm lesion in the left side of the posterolateral tongue base (Figure, A).", "A biopsy of the mass revealed an intermediate-grade infiltrating neoplasm forming solid sheets and glandular structures (Figure, B).", "The tumor cells stained positive for CK7 and p63, and negative for CK20, p16, and S-100 by immunohistochemical analysis.", "Stain for mucicarmine was positive in glandular areas (Figure, C)."], "Treatment": ["After establishing the diagnosis, the patient was taken to the operating room for a left base of tongue resection via suprahyoid approach along with a left-sided neck dissection of levels I to IV.", "The tumor was removed with negative margins, and no positive cervical lymph nodes were found on final pathologic analysis.A, Magnetic resonance (MRI) image of a lesion in the left side of the posterolateral tongue base."], "Others": ["B and C, Histopathologic images.", "B, Intermediate-grade infiltrating neoplasm forming solid sheets and glandular structures.", "Hematoxylin-eosin, original magnification \u00d720.", "C, Mucicarmine stain in the glandular area, original magnification \u00d740."]}
{"Patient Symptoms": ["During the course of the second chemotherapy treatment, she developed left-sided mandibular pain.", "At initial evaluation by the otolaryngology service on hospital day 32, she had decreased sensation at the left mandibular branch of the trigeminal nerve and ecchymoses along the mandibular buccal-gingival borders bilaterally with induration of the left floor of mouth and buccal mucosa (Figure, A)."], "Examination and Results": ["A computed tomographic scan revealed cellulitic changes along the buccal cortex of the mandible and a small 2\u2009\u00d7\u200912-mm abscess formation.", "At initial evaluation by the otolaryngology service on hospital day 32, she had decreased sensation at the left mandibular branch of the trigeminal nerve and ecchymoses along the mandibular buccal-gingival borders bilaterally with induration of the left floor of mouth and buccal mucosa (Figure, A).", "Magnetic resonance imaging revealed a 7\u2009\u00d7\u200910\u2009\u00d7\u200935-mm abscess involving both gingival and lingual aspects of the left anterior mandible (arrowheads) (Figure, B).", "Biopsy specimens of the right mandibular gingiva are shown in the Figure, C and D.A, Patient photograph.", "B, Magnetic resonance image of abscess.", "C and D, Histopathologic images from biopsy specimens.", "C, Original magnification \u00d7250.", "D, Original magnification \u00d7500."], "Treatment": ["She was febrile at admission and treated empirically with antifungal, antibiotic, and antiviral medications in the setting of cultures that were negative for organisms.", "The initial chemotherapy regimen failed, requiring a more aggressive regimen, which left her pancytopenic.", "She continued to receive broad spectrum antimicrobial and antifungal coverage."], "Others": ["By hospital day 38, the patient had developed evidence of ischemia and necrosis along the gingival and lingual aspects of the left mandibular alveolar ridge, extending past midline to involve mucosa on the right side."]}
{"Patient Symptoms": ["There was no history of dysphagia, hoarseness of voice, dyspnea, or constitutional symptoms, such as fever, weight loss, or night sweats."], "Examination and Results": ["Clinical examination revealed a 7\u2009\u00d7\u20096-cm, well-defined, firm, nontender swelling extending from the angle of the mandible to the clavicle.", "Oropharyngeal examination revealed a mucosal bulge on the lateral pharyngeal wall with normal overlying mucosa.", "A computed tomographic (CT) scan of the neck was performed, which revealed a solid 7\u2009\u00d7\u20098\u2009\u00d7\u200910-cm right carotid space mass, with a few cystic areas and coarse specks of calcification within (Figure, A, yellow arrowhead).", "It showed heterogeneous postcontrast enhancement, predominantly around the calcific foci.", "It extended from the C2 to D1 vertebral level and displaced the right common carotid artery and internal jugular vein anterolaterally (Figure, A, red arrowhead).", "Fat planes around the mass were well maintained (Figure, B, arrowheads), and there was no bone destruction.", "No cervical lymphadenopathy was noted."], "Treatment": ["A biopsy was performed from the mass (Figure, C and D).A, Axial postcontrast computed tomographic (CT) image of the neck."], "Others": ["B, Coronal postcontrast CT image of the neck.", "C and D, Histopathologic images.", "C, Hematoxylin-eosin, original magnification \u00d7200.", "D, Hematoxylin-eosin, original magnification \u00d7400."]}
{"Patient Personal Background": ["The patient had a history of myelodysplastic syndrome (refractory anemia with excess blasts\u20132), prostate cancer treated with prostatectomy and radiation therapy 5 years prior, and colonic adenocarcinoma treated with right hemicolectomy 6 years prior.", "Four months before presentation, his myelodysplastic syndrome transformed into acute myeloid leukemia (AML)."], "Patient Symptoms": ["However, remission was successfully induced with mitoxantrone hydrochloride and etoposide therapy, as confirmed by bone marrow biopsy, and he was prescribed continuing melphalan therapy on an outpatient basis.Three days prior to presentation, the patient on awakening noticed an acute onset of blurred vision in his left eye without any pain, photophobia, diplopia, vision loss, or floaters."], "Examination and Results": ["Visual acuity was 20/20 in the right eye and 20/30 in the left.", "External examination had unremarkable results.", "Pupillary and motility assessments had normal results.", "Intraocular pressure was elevated bilaterally, measuring 29 mm Hg in the right eye and 41 mm Hg in the left.Slitlamp examination of the right eye revealed a 0.5-mm hypopyon with small hemorrhages on the iris surface (Figure 1A).", "In the left eye, examination demonstrated a 1.5-mm hypopyon mixed with hemorrhage, 1+ cells in the anterior chamber, and small hemorrhages on the iris surface (Figure 1B).", "Bilaterally, gonioscopy revealed open angles with few hemorrhages in the angle but no neovascularization.", "Dilated fundoscopic examination had unremarkable results bilaterally, with no retinal hemorrhages or optic disc swelling.Color slitlamp photographs illustrating bilateral hypopyon (black arrowheads) with iris surface hemorrhages (white arrowheads)."], "Treatment": ["He was randomized to experimental drug CPX-351 for induction, but treatment was discontinued as a result of renal failure.", "He had no history of ocular surgery or trauma."]}
{"Examination and Results": ["Routine laboratory test results showed total bilirubin of 4.74 mg/dL (to convert to millimoles per liter, multiply by 17.104) and amylase of 1.041 U/L (to convert to microkatals per liter, multiply by 0.0167).", "An abdominal ultrasonography scan demonstrated gallstones and a mildly dilated common bile duct (CBD).", "Magnetic resonance imaging of the abdomen confirmed these results and revealed cholelithiasis.", "Multiple gallstones were found within a dilated region of cystic duct."], "Treatment": ["The patient consequently underwent urgent laparoscopic cholecystectomy with intraoperative cholangiography (Figure, A).", "Intraoperative cholangiography revealed an unusual anatomical variant and subsequent transcystic choledochoscopy was performed, which demonstrated a double lumen at the distal CBD (Figure, B)."]}
{"Patient Personal Background": ["He did not report any previous abdominal surgery.", "The patient stated that he had not had any procedures with intravascular instrumentation in the past year, dental cleanings, intravenous drug use, cutaneous abscesses, or recent trauma."], "Patient Symptoms": ["The pain was sharp and constant with intermittent radiation to the back and associated anorexia with a 10-kg weight loss."], "Examination and Results": ["Physical examination revealed he was afebrile and in normal sinus rhythm; there was minimal epigastric abdominal tenderness without signs of peritonitis and no palpable masses.", "Femoral pulses were palpable and symmetric.", "Laboratory examination revealed mild anemia (hematocrit, 35% [to convert to a proportion of 1.0, multiply by 0.01]), no leukocytosis, and an elevated erythrocyte sedimentation rate (71 mm/h).", "Blood and urine cultures were negative for organisms.", "A computed tomographic (CT) angiogram showed asymmetric attenuation surrounding the infrarenal aorta (Figure 1).", "On comparison, a CT scan that was performed 6 months before presentation had identified no aneurysmal disease.Computed tomographic scan with arterial phase intravenous contrast with asymmetric attenuation surrounding the infrarenal aorta."]}
{"Patient Personal Background": ["She reported having a rectangular area of discolored skin for the past 10 years that developed as a result of a complication during an interventional radiology procedure for treatment of a splenic aneurysm.", "She denied international travel, drug use, incarceration, and high-risk sexual behavior.The patient had a history of uterine cancer at age 25, for which she underwent hysterectomy and chemotherapy.", "She also had a history of breast cancer in her 40s, for which she underwent lumpectomy and tamoxifen therapy.", "She had undergone surgical excision of a gastric polyp in her early 50s.", "She had no history of radiation therapy.On physical examination she was well-appearing and afebrile, with normal vital signs."], "Patient Symptoms": ["Two months prior to presentation this lesion became painful and enlarged, without improvement with triamcinolone cream or oral antibiotics.", "She also reported recent fevers, night sweats, nausea, and fatigue."], "Examination and Results": ["There was a 12\u2009\u00d7\u20097\u2013cm indurated pink and deep purple plaque on the right side of the abdomen, with 2 focal areas of ulceration (Figure).", "Extending outward from this plaque were finger-like projections of purple subcutaneous papules.", "Inferior to the plaque there was an approximately 3-cm, tender, orange-to-yellow patch."]}
{"Patient Symptoms": ["The headaches were severe enough to interfere with daily activities, occurred several times weekly, and were associated with nausea, vomiting, photophobia, and sensitivity to noise."], "Examination and Results": ["Funduscopic and neurologic examination results were normal."], "Treatment": ["A diagnosis of migraine headaches was made, but therapeutic trials with nonsteroidal anti-inflammatory drugs and sumatriptan were unsuccessful."], "Diagnosis": ["A diagnosis of migraine headaches was made, but therapeutic trials with nonsteroidal anti-inflammatory drugs and sumatriptan were unsuccessful."], "Others": ["She had no focal neurological symptoms."]}
{"Patient Personal Background": ["The patient explained that he usually plays soccer and sweats abundantly."], "Patient Symptoms": ["The lesions did not produce itching."], "Examination and Results": ["Physical examination revealed creamy yellow concretions along several hair shafts, in both armpits, with strong axillary odor (Figure, A).", "These concretions did not disappear when cleansed with alcohol.", "Hair samples of the affected areas were sent for microscopy examination (Figure, B-D) and microbiologic culture.", "Confirmation of the suspected diagnosis was made with the results of complementary tests.A, Clinical photograph of axillary hairs shows creamy yellow concretions along several axillary hairs.", "B, Direct microscopic examination of the hair shaft (original magnification \u00d740).", "C, Periodic acid\u2013Schiff stain (original magnification \u00d7400).", "D, Grocott silver stain (original magnification \u00d7400)."], "Treatment": ["Treatment with antiseptic soap and a miconazole nitrate cream was initiated."], "Others": ["He did not apply deodorant or any other products in the underarm, and he ensured proper hygiene of the area.", "After 2 weeks of treatment, the lesions had resolved and the patient had normal axillary hairs."]}
{"Patient Symptoms": ["He had initially developed lesions on his legs, which then spread to his neck, chest, and buttocks.", "This eruption was asymptomatic, and the patient reported no history of vesiculation.", "His mother noted minimal evolution of the lesions, except for recent flattening of those on the legs."], "Examination and Results": ["Physical examination showed numerous discrete (1 to 3 mm) smooth brown papules concentrated on the neck, chest, anterior and lateral thighs, and buttocks (Figure 1).", "Several lesions had a positive Darier sign (Figure 1A).A, Multiple small brown papules of the chest.", "Localized erythema developed around several lesions after firm stroking.", "B, Scattered small brown papules of the lateral thigh.There was no family history of similar lesions."], "Treatment": ["A punch biopsy of a papule on the left thigh was performed, and the specimen was submitted for pathological review."]}
{"Patient Personal Background": ["Her history was remarkable for rheumatoid arthritis treated with oral gold salts 15 years ago, but the total dosage of gold salts could not be determined."], "Examination and Results": ["These pigmented lesions corresponded exactly to areas that had previously received laser treatment.", "A skin biopsy specimen of the lesion on the right side of the woman\u2019s face was obtained, and histopathologic evaluation was conducted.A, Diffuse blue to slate-gray patches developed on the face, corresponding exactly to areas that had previously received laser treatment."], "Treatment": ["Rechallenge with the original Q-switched Nd:YAG laser was administered on the right forearm, and a similar slate-gray macule developed immediately (Figure 1B).", "B, A rechallenge test administered on the right forearm with the original Q-switched Nd:YAG laser yielded a similar slate-gray macule (arrowhead)."]}
{"Patient Symptoms": ["One year later, the patient complained of a 1-month history of gradually worsening vision in the right eye."], "Examination and Results": ["On examination, her best-corrected visual acuity was 20/20 OD and 20/20 OS.", "An external examination revealed ptosis of the right upper eyelid covering 40% of the surface of the eye.", "In each eye, the pupil, intraocular pressure, motility, and confrontational visual field were normal.", "An anterior segment examination revealed mild nuclear sclerotic cataracts in both eyes.", "A dilated fundus examination of the right eye was notable for revealing infarcts in several nerve fiber layers along the arcades and nasal to the optic disc and a few microaneurysms nasal to the optic disc.", "Fluorescein angiography of the right eye (Figure, A) revealed multiple areas of staining nasal to the nerve and inferotemporal to the nerve and to the areas of pinpoint leakage within the macula.", "No abnormalities were noted during the fundus examination of her left eye.", "Her visual acuity was 20/400 OD and 20/20 OS.", "A fundus examination of the right eye revealed thickening in the macular region.", "Optical coherence tomography of the right eye (Figure, B) revealed a central macular thickness of 454 \u03bcm and the presence of subretinal fluid in the subfoveal region.A, Fluorescein angiography of the right eye illustrating areas of staining nasal to the nerve and inferotemporal to the nerve and to the areas of pinpoint leakage within the macula."], "Treatment": ["She was observed and followed up every 4 months."]}
{"Patient Personal Background": ["He had seasonal allergies but was otherwise healthy.", "He had not been wearing his contact lenses since the episodes started."], "Patient Symptoms": ["A, The photograph shows eyelid edema and erythema, conjunctival injection, and a raised inflamed papule on the upper cheek."], "Examination and Results": ["Conjunctival cultures for bacteria or viruses (including adenovirus and herpes simplex virus) were negative.The patient\u2019s visual acuity with eyeglasses was 20/20 OU.", "Findings from examination of the right eye were significant for lower eyelid follicles and mild conjunctival injection.", "A nontender preauricular lymph node was noted as well as a raised erythematous papule on the patient\u2019s upper cheek (Figure 1A).", "Findings from examination of the skin revealed multiple raised papules on the right elbow and knee that were diagnosed as warts by the patient\u2019s dermatologist (Figure 1B)."], "Treatment": ["The patient\u2019s symptoms persisted despite previous treatment regimens with topical corticosteroids for atopic conjunctivitis and topical antibiotics for staphylococcal blepharitis.", "These papules had been present for about 6 months and, despite the use of topical salicylic acid and cryotherapy, they continued to spread.External photograph of the patient's right eye at presentation."]}
{"Patient Personal Background": ["He denied any history of alcohol abuse.", "Medications included metoprolol and aspirin.", "On examination, he was alert and oriented and vital signs were normal; body mass index was 24."], "Patient Symptoms": ["He reported unintentional weight loss without fevers or decreased appetite."], "Examination and Results": ["Neurologic examination revealed right eye heterotropia and nasal upshoot indicative of a fourth cranial nerve palsy (Figure 1A), left ptosis, flattening of the right nasolabial fold (Figure 1B), and bilateral restricted upgaze and ataxia (Video).", "Strength and reflexes were preserved.", "Results of a basic metabolic panel and complete blood cell count were normal.", "Screening for human immunodeficiency virus, Lyme disease, and drug use was negative.", "Contrast-enhanced magnetic resonance imaging (MRI) of the brain was unremarkable.", "Cerebrospinal fluid (CSF) sampling revealed elevated protein (75 mg/dL [reference range, 10-42]), lymphocyte predominant pleocytosis (21-66 cells/uL [reference range, 0-11]), and oligoclonal bands (OCBs).", "Pleural thickening was seen on routine chest radiography; chest computed tomography (CT) revealed mediastinal lymphadenopathy, subcentimeter pulmonary nodules, and calcified pleural plaques.A, Right fourth cranial nerve palsy."], "Others": ["On adduction, the right eye turns upward.", "This finding (nasal upshoot) suggests the presence of a fourth nerve palsy."]}
{"Patient Symptoms": ["When the patient was aged 4 weeks, the lesion became ulcerated and she was admitted to our hospital."], "Examination and Results": ["The patient had no systemic symptoms and was discharged and scheduled for an outpatient dermatology appointment.Physical examination showed a well-nourished, well-developed infant whose gluteal region had well-demarcated ulcers with scalloped borders on either side of the midline, superior to the anal verge.", "There was no exudate or drainage.", "The base of the ulcers was covered with fibrinous material and the residue of topical medications.", "Bright red matted telangiectasias extended from the anus to the ulcers (Figure).Two well-demarcated ulcers covered with white fibrinous material."], "Treatment": ["She was initially treated at an outside hospital with intravenous clindamycin hydrochloride for presumed perianal cellulitis and was discharged with a regimen of oral clindamycin hydrochloride.", "She was given intravenous antibiotics and mupirocin, 2%, ointment, triamcinolone, 0.1%, ointment, clotrimazole, 1%, cream, nystatin cream, and zinc oxide paste."], "Others": ["Results of cultures for bacteria and herpes simplex virus were negative."]}
{"Patient Personal Background": ["Her medical history was significant for localized invasive ductal carcinoma of the right breast treated with wide local excision 13 years previously.", "At presentation she was considered disease-free."], "Patient Symptoms": ["Six months later the patient developed discomfort around her right ear, prompting a referral to the local otolaryngology service."], "Examination and Results": ["Findings from the clinical examination, including otoscopy, were unremarkable.", "A magnetic resonance imaging (MRI) scan revealed an 8-mm lesion within the right parotid gland with a spiculated border and ill-defined surrounding enhancement extending close to the stylomastoid foramen (Figure, A).", "This was of low T2 signal with no perineural spread evident.", "A fine-needle aspirate and core biopsy were obtained under ultrasonographic guidance.", "The cytologic findings showed loosely cohesive groups of atypical epithelial cells.", "Histologic examination of the core biopsy revealed an infiltrative lesion composed of cords and nests of medium-sized cells surrounded by a densely hyalinized stroma (Figure, B).", "The cells contained hyperchromatic vesicular nuclei with moderate amounts of eosinophilic cytoplasm (Figure, C).", "Immunohistochemical analysis showed the cells were diffusely positive for cytokeratin 7 (CK7), estrogen receptor (ER), progesterone receptor (PR), and androgen receptor (Figure, D).A, Axial fast spoiled gradient echo gadolinium-enhanced magnetic resonance imaging (MRI) scan with fat suppression demonstrating lesion of the right parotid gland (arrowhead).", "B, Right parotid core biopsy specimen."], "Treatment": ["This resolved with oral steroids and antiviral drugs consistent with a presumed diagnosis of idiopathic facial nerve (Bell) palsy."]}
{"Patient Symptoms": ["Initially the lesion appeared to be acutely inflamed with erythema, overlying crusting, and tenderness to palpation.", "The child was otherwise healthy, and the parents stated that he had no systemic symptoms such as fever or weight loss."], "Examination and Results": ["On physical examination, a 1.5-cm superficial, ovoid firm lesion was noted in the left postauricular area (Figure, A).", "While the lesion was attached to the skin, it was mobile over the mastoid bone.", "There were no middle ear abnormalities on physical examination.", "Ultrasonography of the lesion revealed a nonvascular, well-circumscribed 1.7\u2009\u00d7\u20091.4\u2009\u00d7\u20090.6-cm lesion in the soft tissue posterior to the left ear.", "It demonstrated a heterogenous echotexture but was predominantly hypoechoic without internal vascularity or distinct calcifications.", "Pathologic examination revealed a neoplasm extending from the reticular dermis into the subcutaneous adipose tissue (Figure, B).", "There were lobules of lipidized histiocytic cells with eosinophils in a background of collagen (Figure, C).", "The lesion stained negatively for S-100 and CD1a (Figure, D).A, Gross photograph of left postauricular mass.", "B, High-powered (original magnification \u00d7100) view depicting some pale areas representing lipidized cells.", "C, High-powered (original magnification \u00d7400) view demonstrating pale, foamy cells (xanthoma cells)."], "Treatment": ["The child was treated with a course of antibiotics.", "The lesion had distinct borders and separated easily from the surrounding soft-tissue attachments.", "It was completely excised, including the overlying skin."], "Others": ["Four weeks after the initial evaluation, the acute inflammation had resolved, but the lesion had increased in size.", "Excisional biopsy under general anesthesia was performed owing to rapid enlargement and unclear etiology of the lesion.", "B-D, Histopathologic images (hematoxylin-eosin)."]}
{"Patient Personal Background": ["His medical history was significant for hypertension and coronary artery bypass surgery."], "Patient Symptoms": ["The patient was completely edentulous.", "He reported numbness of the lower lip and difficulty on swallowing."], "Examination and Results": ["On intraoral examination, the mass was hard in consistency with relatively normal overlying mucosa.", "Computed tomographic (CT) images with bone window showed a grossly expansile, multilocular, low-attenuation lesion of the anterior segment of the mandible (Figure, A and B).", "The images demonstrated severe erosion of the facial and lingual cortices with a remarkable scalloping pattern, and multiple wispy, ill-defined intralesional septa.", "Soft-tissue CT images indicated a cystic and solid nature of the mass (Figure, C and D)."], "Others": ["There was no remarkable weight loss."]}
{"Patient Personal Background": ["She stated that she had no other symptoms, and her family medical history was not remarkable."], "Examination and Results": ["On examination, the rigid indirect laryngoscopy revealed yellowish floppy granular proliferation affecting the bilateral arytenoids and posterior aspects of the aryepiglottic folds, with symmetrical vocal cord motion (Figure, A).", "The main lesions were clearly demarcated from the surrounding normal mucosa.", "The specimens mounted on the hematoxylin-eosin slides showed eosinophilic amorphous material underlying the epithelium (Figure, B).", "Staining for thioflavin T revealed yellow-green fluorescence (Figure, C).", "The fibrillar component emitted a characteristic apple-green birefringence under polarized light after binding to Congo red dye.", "No clinical evidence of systemic involvement and/or plasma cell dyscrasia was found.A, Endoscopic examination demonstrated symmetric yellowish lesions affecting the arytenoids and posterior aspects of the aryepiglottic folds, with a patent airway and mobile vocal folds.", "B, Eosinophilic amorphous material underlying the epithelium (hematoxylin-eosin, original magnification \u00d7200).", "C, Thioflavin T exhibited a typical yellow-green fluorescence after binding to amyloid fibrils (original magnification \u00d7200)."], "Treatment": ["The patient then underwent microlaryngeal surgery with biopsy under general anesthesia."], "Others": ["The nidus was fragile and bled copiously when traumatized."]}
{"Patient Symptoms": ["She had no associated symptoms."], "Examination and Results": ["On examination, she had a 6-cm nontender mass in the submentum.", "Her floor of mouth (FOM) was soft, and there was no cervical lymphadenopathy.", "Ultrasonography (US) (Figure, A) revealed a well-circumscribed, avascular, homogeneous, isoechoic lesion, measuring 6.2\u2009\u00d7\u20096.0\u2009\u00d7\u20096.0 cm along the FOM and left submandibular regions.", "Magnetic resonance imaging (MRI) of the neck revealed the lesion within the FOM, above the mylohyoid muscle.", "The lesion involved the root of the tongue in the midline and extended to the left, causing significant thinning of the left mylohyoid muscle without extension through it.", "The lesion demonstrated a fluid signal with T2 hyperintensity (Figure B), T1 hypointensity (Figure, C), and peripheral rim enhancement.", "Mild restricted diffusion was also noted.", "The mass was encapsulated and positioned above the mylohyoid muscle and extended into the FOM between bilateral genioglossus muscles.", "The mass was removed entirely via transcervical excision.A, Sagittal midline ultrasonography shows a floor of mouth lesion with uniform low-level echoes.", "B, Axial T2-weighted magnetic resonance image (MRI) revealing a hyperintense lesion involving the floor of mouth.", "C, Coronal postcontrast MRI revealing a T1 hypointense unilocular lesion involving the floor of the mouth and root of the tongue."], "Treatment": ["Attempted open biopsy at the time of thyroidectomy revealed only adipose tissue.", "The patient underwent transcervical excision of the mass (Figure, D)."], "Others": ["D, Intraoperative photograph during mass excision."]}
{"Patient Personal Background": ["He noted a childhood history of plantar warts and believed these lesions to be identical in appearance.", "He had received his third cycle of R-CHOP (rituximab, cyclophosphamide, doxorubicin hydrochloride, vincristine sulfate, prednisone) 2 weeks prior to presentation as well as an injection of granulocyte-colony stimulating factor."], "Patient Symptoms": ["He also complained of a pruritic rash on his left thigh that had started several days before the appearance of his plantar foot lesions.", "It was exquisitely tender to palpation, and the patient was visibly uncomfortable when walking."], "Examination and Results": ["The patient was afebrile, and his vital signs were within normal limits.", "Physical examination revealed grouped, brown, flat-topped papules on his distal plantar left foot (Figure).", "He also demonstrated erythematous papules and plaques on his posterolateral thigh.", "A few areas had shallow erosions.", "Laboratory studies revealed pancytopenia, with a white blood cell count of 2800/\u03bcL, hemoglobin level of 11.6 g/dL, and a platelet count of 81\u2009\u00d7\u2009103/\u03bcL.", "His lactate dehydrogenase level was elevated at 914 U/L, and results of his comprehensive metabolic panel were unremarkable."], "Treatment": ["He was anticipating his fourth cycle of treatment the day of his presentation."], "Others": ["He did not recall any injury or unusual exposure.", "(To convert white blood cell count to \u00d7109/L, multiply by 0.001; to convert hemoglobin to grams per liter, multiply by 10; to convert lactate dehydrogenase to microkatals per liter, multiply by 0.0167."]}
{"Patient Personal Background": ["She had been prescribed total parenteral nutrition prior to referral."], "Patient Symptoms": ["On presentation, her physical examination was remarkable for mild epigastric tenderness."], "Examination and Results": ["The results of laboratory testing, including a complete blood cell count, chemistry values, liver function tests, and amylase and lipase levels, were unremarkable.", "Computed tomography demonstrated focal gastric thickening.", "Esophagogastroduodenoscopy with endoscopic ultrasonography was performed that confirmed a submucosal gastric mass (Figure, A).", "A fine-needle aspiration biopsy revealed benign and reactive glandular cells and debris.", "Magnetic resonance cholangiopancreatography demonstrated a 2.4-cm hypervascular and exophytic mass in the gastric antrum and locoregional lymphadenopathy (Figure, B).A, Endoscopic ultrasonography of the gastric antrum mass reveals an area of gastric thickening (arrowheads) corresponding to computed tomographic findings.", "A fine-needle aspiration biopsy was nondiagnostic, showing gastric antral-type mucosa without pathologic changes (inset).", "B, The coronal image in T2 phase reveals a 1.8\u2009\u00d7\u20092.4\u2009\u00d7\u20091.5-cm hypotense lesion (arrowhead) in the gastric antrum.", "The lesion was also enhanced on T1 arterial phase sequencing."], "Others": ["During endoscopy, this area was visualized grossly as a bulge in the atrium along the incisura."]}
{"Patient Personal Background": ["The patient described a history of sleep apnea, a remote transient ischemic attack with left-sided weakness, and a prior thyroidectomy."], "Patient Symptoms": ["She had increasing fatigue during the last 6 months, as well as worsening anxiety."], "Examination and Results": ["On physical examination, the neck was supple, with no palpable masses or lymphadenopathy, and had a well-healed transverse neck incision.", "Magnetic resonance imaging revealed a 1.1-cm, round, partially enhancing, cystic mass near the tail of the parotid gland that appeared hypointense on T2-weighted imaging (Figure 1).", "An enlarged and distended venous structure that measured up to 7 mm was also visualized in the area.", "Laboratory work revealed no abnormalities.Magnetic resonance images of the parotid gland.", "T1-weighted image (A) and T2-weighted image (B) revealing a round, partially enhancing, cystic mass near the tail of the parotid gland (white and red arrowheads)."]}
{"Patient Personal Background": ["She was not taking any medications because 2 weeks after starting celecoxib, her joint pain resolved and she discontinued use without recurrence of pain.", "The patient had no family history of autoimmune diseases."], "Patient Symptoms": ["She reported no joint swelling or morning stiffness.", "The patient reported no history of fever, weight loss, photosensitivity, malar rashes, skin thickening, oral or nasal ulcers, weakness, Raynaud phenomenon, sicca symptoms, chest pain, shortness of breath, or abdominal pain."], "Examination and Results": ["She previously saw her primary care physician who prescribed celecoxib (for joint pain) and ordered antinuclear antibody (ANA) testing, which was positive at a value of 1:80 (Table).", "On examination, her vital signs, including blood pressure, were normal; and results of skin, thyroid, musculoskeletal, mucus membranes, cardiovascular, pulmonary, and neurologic examinations were all normal."], "Treatment": ["She previously saw her primary care physician who prescribed celecoxib (for joint pain) and ordered antinuclear antibody (ANA) testing, which was positive at a value of 1:80 (Table)."], "Others": ["She was then referred to the rheumatology clinic."]}
{"Patient Personal Background": ["She had a history of type 2 diabetes mellitus, hypertension, hyperlipidemia, and allergic rhinitis.", "Her medications included metformin, lisinopril, and verapamil."], "Examination and Results": ["Her cardiac and pulmonary examinations were normal.", "She had no fever or lymphadenopathy.", "The spleen was palpable 5 cm below the left costal margin.", "Laboratory evaluation revealed a white blood cell (WBC) count of 91 \u00d7103/\u03bcL, with 54% neutrophils, 1% blasts, 2% basophils, 8% metamyelocytes, 23% myelocytes, and 1% promyelocytes (increased immature granulocytes).", "Hemoglobin level was 11.7 g/dL and platelet count was 290\u202f000 (Figure 1)."]}
{"Patient Personal Background": ["His medications included amiodarone, furosemide, nifedipine, insulin glargine, and allopurinol."], "Patient Symptoms": ["The lesions were pruritic at times and the patient reported no improvement with chlorhexidine wash or hydrocortisone, 1%, cream.", "He denied preceding trauma, recent travel, or new medications.A, Red, scaly papules on the patient's forearm."], "Examination and Results": ["He was otherwise asymptomatic, and review of his systems revealed no abnormalities.", "B, Punch biopsy specimen from the center of a papule on the forearm shows pseudoepitheliomatous hyperplasia, spongiosis with vesiculation, intraepidermal neutrophilic microabscesses, focal subepidermal bulla formation, and dermal infiltrate of neutrophils, lymphocytes, and histiocytes (hematoxylin-eosin, original magnification \u00d74).Physical examination revealed numerous red to violaceous scaly papules symmetrically distributed on both forearms.", "Laboratory tests revealed a serum creatinine level of 3.79 mg/dL (normal range, 0.70-1.40 mg/dL) and serum iodine level of 42\u202f305 ng/mL (normal range, 40-92 ng/mL)."], "Treatment": ["The lesions were pruritic at times and the patient reported no improvement with chlorhexidine wash or hydrocortisone, 1%, cream."], "Others": ["A punch biopsy was obtained from the center of a papule on the right forearm (Figure, B)."]}
{"Patient Personal Background": ["On further questioning, the patient noted that between her hospitalizations she had gone home and cleaned her fish tank, played with her pet cat, and gardened in her indoor cactus garden.", "She said she had not recently traveled, and was not taking any immunosuppressive medications."], "Patient Symptoms": ["A few days after that discharge, the patient noticed a painful ulceration on the right distal forearm, at the site where a peripheral intravenous catheter had been inserted during her initial hospitalization."], "Examination and Results": ["On physical examination, the patient had an ulcerated plaque on the right forearm with 2 tender, 1- to 2-cm red nodules in the right antecubital fossa (Figure, A).", "A skin biopsy and culture were performed from the forearm lesion (Figure, B and C).A, An ulcerated plaque on the right forearm.", "Note 2 tender, 1- to 2-cm red nodules in the right antecubital fossa.", "B, Dense neutrophilic infiltrate.", "Note associated tissue necrosis.", "Hematoxylin-eosin, original magnification \u00d720.", "C, Organisms seen on Gram stain."], "Others": ["The patient had been discharged approximately 2 weeks prior, after an admission for congestive heart failure.", "Original magnification \u00d760."]}
{"Patient Personal Background": ["The patient reported using an aluminum-containing antiperspirant spray for years before the onset of the eruption but had since discontinued use of deodorants or antiperspirants without improvement in her lesions.", "Her medical history was significant only for epilepsy, and her daily medications included lamotrigine and cholecalciferol.Physical examination revealed multiple red-brown to purplish follicular papules and nodules in bilateral axillae with focal areas of scarring (Figure 1)."], "Patient Symptoms": ["The areas involved were not itchy or tender but bothered her cosmetically."], "Examination and Results": ["No facial lesions were noted.Clinical examination findings.", "Multiple red-brown papules within the axilla bilaterally.She did not improve with multiple medications, including topical antifungals, topical corticosteroids, oral ketoconazole, topical dapsone, doxycycline (40 mg/d), minocycline (100 mg twice daily), a combination of amoxicillin and clavulanate, and intralesional triamcinolone acetonide."], "Treatment": ["A 4-mm punch biopsy was performed on the right axilla for evaluation."]}
{"Patient Personal Background": ["He had been born at full term and was otherwise healthy.", "His medication regimen included a pediatric multivitamin."], "Patient Symptoms": ["It also appeared to encroach on the visual axis in the downgaze position.", "The parents reported that the patient had started to rub his eyelid intermittently, causing irritation and a minimal amount of associated bleeding.Lesion on the right lower eyelid of an 11-month-old patient."], "Examination and Results": ["On examination, the patient\u2019s pupils were equal in diameter and reactive to light, his ocular motility was full, and the lesion did not obstruct his vision.", "Findings from external examination were significant for a single 3\u2009\u00d7\u20092\u2009\u00d7\u20092\u2013mm, red-brown, raised, solid, fixed papule at the center of the lower eyelid margin.", "There was no madarosis and no evidence of epiphora or conjunctivitis.", "On examination 1 month later, the papule had grown slightly, with a 1\u2009\u00d7\u20091\u2013mm area of ulceration."], "Diagnosis": ["The lesion was initially diagnosed as a hemangioma and the decision was made to monitor it."], "Others": ["There was no history of trauma to the area."]}
{"Patient Personal Background": ["The patient denied any recent illness, travel, viral prodromal symptoms, headache, or skin lesions.", "He reported no exposure to pets or animals."], "Examination and Results": ["A complete review of systems was otherwise negative.At presentation, his visual acuity was counting fingers OD at 1 ft and 20/100 OS, without an afferent papillary defect.", "Slitlamp examination revealed fine inferior keratic precipitates bilaterally, with 3+ anterior chamber cells in the right eye and 2+ anterior chamber cells in the left eye.", "Dilated ophthalmoscopic examination demonstrated numerous confluent creamy yellow lesions in the peripheral retina, with more discrete nummular lesions in the posterior pole in both eyes (Figure 1A).", "No pigmented lesions were noted in the peripheral retina.", "In addition, fine macular striae were present in both eyes, along with subtle optic nerve edema (Figure 1B).Case presentation.", "A, Montage photograph of right eye shows lesions extending from the posterior pole to the retinal periphery.", "B, Enlarged fundus photograph shows nummular macular lesions with mild retina striae and optic disc edema."]}
{"Patient Personal Background": ["His perinatal history was notable for macrosomia, macrocephaly, left-sided failure on newborn hearing screen, and a congenital hypertrichotic patch of the left scalp."], "Patient Symptoms": ["During the first few months, he was observed to frequently tug at his left ear while displaying apparent discomfort and sleeping difficulties.", "Swelling of the left lower part of the face was noted."], "Examination and Results": ["Of note, his length was in the 76th percentile for age, whereas his weight and head circumference were both greater than the 99th percentile for age.", "A nontender, faint blue patch with subtle swelling and thick, coarse overlying hair was present on the left preauricular-temporal part of the scalp (Figure1A).", "Subtle scattered tan patches were present on the trunk and extremities (Figure 1B).A, Blue patch of the left periauricular scalp.", "B, Representative light tan patches with irregular borders on the back.", "Arrowheads indicate the patches."], "Treatment": ["He was treated empirically with multiple antibiotics for presumed otitis media and subsequently had bilateral myringotomy tubes placed.", "The dermatology department was consulted to consider treatment with propranolol.On examination, the patient was afebrile, intermittently irritable, but otherwise well appearing with stable vital signs."], "Diagnosis": ["The differential diagnosis included atypical infantile hemangioma, congenital hemangioma, or venous malformation."], "Others": ["When the left side of his face became more swollen, magnetic resonance imaging was performed at 8 months of age and revealed a left-sided parotid mass.", "He was referred to our institution for further evaluation.Additional magnetic resonance imaging and magnetic resonance angiography of the brain and neck revealed an infiltrative vascular mass of the left parotid, skull base, and deeper facial structures with occlusion of the left internal jugular vein and extension into the external auditory canal.", "Note the difference in the textural quality of the hair overlying the affected area, which the parents trimmed regularly to maintain a more uniform appearance.", "A total of 15 similar lesions were noted on examination."]}
{"Patient Personal Background": ["He had also noted an unintended 3-kg weight loss in the same duration, which he subjectively attributed to the stress of school."], "Patient Symptoms": ["He had experienced occasional blepharospasm and paresthesia in the ipsilateral eye and cheek.", "Mild left-sided buccal weakness was noted."], "Examination and Results": ["Physical examination demonstrated a firm, immobile, irregular mass n the left parotid and approximately 3\u2009\u00d7\u20093 cm in size.", "Otherwise, his cranial nerve function was intact.", "Fine needle aspiration demonstrated medium-size ovoid cells with minimal cytoplasm in crowded groups.", "T2-weighted magnet resonance imaging following the initial computed tomographic (CT) scan demonstrated a poorly marginated mass that was 4 cm in maximum diameter abutting the left superficial parotid with involvement of the masseter (Figure, A).", "Flow cytometry demonstrated phenotypically normal T-cell and B-cell populations.", "Permanent histologic sections demonstrated nests of nonkeratinizing undifferentiated atypical epithelial cells intimately intermingled with a dense lymphoplasmacytic infiltrate (Figure, B).", "Immunohistochemical analysis for cytokeratin AE1/3 was positive in the carcinoma cells (Figure, C).", "In situ hybridization for Epstein-Barr virus\u2013encoded small RNAs (EBERs) was positive (Figure, D).A, T2-weighted coronal magnetic resonance image of the face."], "Treatment": ["A parotidectomy with excision of the tumor was planned."], "Others": ["During the initial exposure of the tumor, an intraoperative frozen section demonstrated a cellular infiltrate, and a diagnosis of lymphoma could not be excluded.", "Given the size and fixed nature of the tumor, the decision was made to stop resection on establishing a definitive diagnosis.", "B-D, Histopathologic images.", "B, Hematoxylin-eosin, original magnification \u00d720.", "C, Cytokeratin AE1/3 immunostain, original magnification \u00d720.", "D, Epstein-Barr virus in situ hybridization, original magnification \u00d720."]}
{"Patient Symptoms": ["It was associated with minimal pain and intermittently fluctuated in size."], "Examination and Results": ["Physical examination revealed a single 1.0\u2009\u00d7\u20090.7-cm mass on the left mid helix that was firm, nontender, nonerythematous, and nonerosive.", "The lesion was found to be superficially located in the dermis and filled with a soft white material that appeared as purple to blue crystals.Histopathologic images.", "A, Specimen shows purple to blue crystals with cystic components.", "B, Cystic structure with amorphous material and granulomatous reaction at the periphery with occasional foreign-body giant cells."], "Treatment": ["Surgical resection was performed."], "Others": ["The resected specimen appeared cystic (Figure, A) with granulomatous reaction at the periphery (Figure, B)."]}
{"Patient Personal Background": ["Her mother had a full-term vaginal delivery without complications and a medical history that was notable only for gastroesophageal reflux disease treated with ranitidine."], "Patient Symptoms": ["The parents first noticed a pea-sized nodule in front of her left ear that was now 3 cm, soft, mobile, and nontender, without overlying skin changes or facial nerve impairment.", "The infant was otherwise well without fevers, feeding well, and growing appropriately."], "Examination and Results": ["Ultrasonography showed a 2.2\u2009\u00d7\u20093.0-cm solid nodule.", "The patient was then referred for magnetic resonance imaging (MRI) with contrast, which showed a 2.9\u2009\u00d7\u20091.6\u2009\u00d7\u20092.3-cm mass with a well-defined capsule arising from within the superficial left parotid gland.", "The mass was largely of fat signal intensity on both T1-weighted (Figure, A) and T2-weighted sequences with heterogeneous soft-tissue enhancement on T1 post-contrast (Figure, B).", "The mass also suppressed relatively uniformly on short T1 inversion recovery (STIR) sequence (Figure, C)."], "Treatment": ["The Figure, D, shows the mass in situ during surgical excision with facial nerve monitoring.Magnetic resonance images of a patient with a left preauricular mass of the superficial parotid lobe."]}
{"Patient Personal Background": ["His medical history was significant for blunt trauma to the left maxilla region approximately 10 years prior to presentation.", "His surgical history was noncontributory."], "Patient Symptoms": ["The pain was exacerbated by eating and prolonged talking.", "He was initially seen at an emergency department, where his symptoms were unsuccessfully treated with antibiotics.", "He stated that he had not experienced hoarseness, weight loss, fever, night sweats, parotid mass, or involuntary facial nerve spasms."], "Examination and Results": ["Physical examination demonstrated a well-developed man in no distress who spoke in a normal tone.", "His vital signs were normal.", "The external auditory canals and the tympanic membranes were intact and clear bilaterally.", "The nasal cavity and the nasopharynx were normal.", "The oral cavity and oropharynx revealed moist mucosa with no lesions or erythema.", "Fiber-optic flexible nasopharyngoscopy and laryngoscopy revealed normal pharyngeal walls and pyriform sinuses.", "The vocal folds were symmetric and mobile bilaterally.", "Computed tomography (CT) of the neck demonstrated a ossified mass (arrowheads) in the left parapharyngeal space (Figure)."], "Treatment": ["He was initially seen at an emergency department, where his symptoms were unsuccessfully treated with antibiotics."]}
{"Patient Personal Background": ["Her medical history was significant for a single episode of lower-extremity deep venous thrombosis during a prior hospitalization, complicated by multiple subsegmental pulmonary emboli.", "At that time, she underwent inferior vena cava filter placement, followed by initiation of anticoagulation therapy.", "She denied any substantial tobacco or alcohol use, and her family history was negative for venous thromboembolic disease.", "Her initial physical examination had unremarkable results, with laboratory evaluation of prothrombin time significant for an international normalized ratio of 2.8."], "Examination and Results": ["Her initial physical examination had unremarkable results, with laboratory evaluation of prothrombin time significant for an international normalized ratio of 2.8.", "Computed tomography (CT) of the chest revealed a large filling defect within the main pulmonary artery, flattening of the interventricular septum, and multiple pulmonary nodules.", "Bedside transthoracic echocardiography demonstrated evidence of severely increased right ventricular systolic pressure, with moderate right ventricular dilation."], "Treatment": ["At that time, she underwent inferior vena cava filter placement, followed by initiation of anticoagulation therapy.", "She was referred for urgent pharmacomechanical interventions, including catheter-directed embolectomy and thrombolysis, for a presumed diagnosis of submassive pulmonary embolism."], "Diagnosis": ["She was referred for urgent pharmacomechanical interventions, including catheter-directed embolectomy and thrombolysis, for a presumed diagnosis of submassive pulmonary embolism."], "Others": ["Following the procedure, she experienced no substantial clinical or radiographic improvement."]}
{"Patient Symptoms": ["The immunoglobulin heavy chain (IgHV) gene mutational status was studied at this time and found to be unmutated, with somatic mutation rate of 0%."], "Examination and Results": ["Immunophenotyping was typical for CLL, showing expression of CD 5, CD 19, CD 23, CD 38, and dim \u03ba light chain restriction.", "Fluorescence in situ hybridization was positive for del (13)(q14) in 63% of her cells.", "Lymphadenopathy was noticed during the initial physical examination and imaging studies.", "Repeated cytogenetic tests showed complex karyotype with del(17)(p13.1) in 35% of her cells as a new abnormality.", "The immunoglobulin heavy chain (IgHV) gene mutational status was studied at this time and found to be unmutated, with somatic mutation rate of 0%."], "Treatment": ["Owing to progressive disease, she was started on therapy with fludarabine and rituximab (FR) 6 months later for 4 cycles, and clinical complete remission was achieved (bone marrow assessment was not done)."], "Diagnosis": ["Immunophenotyping was typical for CLL, showing expression of CD 5, CD 19, CD 23, CD 38, and dim \u03ba light chain restriction.", "Repeated cytogenetic tests showed complex karyotype with del(17)(p13.1) in 35% of her cells as a new abnormality."], "Others": ["However, 2.5 years later she experienced disease relapse.", "Owing to developed worsening fatigue and lymphadenopathy, she wanted to discuss treatment options.The patient is much less likely to respond and have a durable remission with chemoimmunotherapy.The patient is at lower risk of Richter transformation to diffuse large B-cell lymphoma.IgHV-mutated status is defined by more than a 2% sequence difference compared with the germline sequence and can change over the evolution of the disease.The patient is likely to have unfavorable cytogenetic features, positive ZAP-70 protein expression/promoter unmethylated status, and clonal evolution."]}
{"Patient Personal Background": ["The patient did not have abdominal pain, nausea, vomiting, or a history of abdominal surgical procedures and did not use alcohol or tobacco.On physical examination, the patient\u2019s abdomen was soft, nontender, and nondistended, with no palpable masses, and he did not appear jaundiced."], "Examination and Results": ["The patient did not have abdominal pain, nausea, vomiting, or a history of abdominal surgical procedures and did not use alcohol or tobacco.On physical examination, the patient\u2019s abdomen was soft, nontender, and nondistended, with no palpable masses, and he did not appear jaundiced.", "Results of laboratory testing demonstrated a carbohydrate antigen 19-9 level of less than 1 U/mL and a carcinoembryonic antigen level of 6.0 ng/mL (to convert to micrograms per liter, multiply by 1.0).", "A duodenal mass was found using esophagogastroduodenoscopy and biopsies were taken.", "To further evaluate the lesion, the patient underwent a computed tomographic scan of the abdomen and pelvis with contrast dye (Figure 1).A, Cross-sectional computed tomographic scan demonstrating a 4.7\u2009\u00d7\u20092.9-cm, heterogeneous, solid mass involving the ampulla of Vater and the head of the pancreas.", "A heterogeneous soft-tissue nodule can be seen (arrowhead).", "The common bile duct (CBD), duct of Santorini (S), and duct of Wirsung (W) can all be identified traversing the mass compressing the duodenum (D).", "B, Coronal computed tomographic scan demonstrating a polypoid pedunculated ampullary tumor extending into the duodenal lumen."]}
{"Patient Personal Background": ["The patient had undergone laryngectomy with radiation, modified radical neck dissection, and a pectoralis major flap into the right-sided neck wound in 1998.", "This operation was subsequently complicated by right carotid blowout requiring right-sided carotid artery ligation on November 5, 2005."], "Patient Symptoms": ["The patient initially presented to our hospital with a Glasgow Coma Scale score of 3.", "Pertinent findings included an improved Glasgow Coma Scale score of 12 and left arm and leg hemiparesis.", "The right upper arm was cool to the touch below the elbow, with cyanotic right fingers, and the right-sided radial and brachial pulses were absent.", "The patient also presented with a pulsatile mass in the upper chest wall on the right side."], "Examination and Results": ["Findings from computed tomography of the head at the referring hospital showed acute right-hemispheric stroke with left-sided hemiparesis.On examination, the patient was afebrile, with a heart rate of 108 beats/min and blood pressure of 169/91 mm Hg with 100% oxygen saturation.", "Pertinent findings included an improved Glasgow Coma Scale score of 12 and left arm and leg hemiparesis.", "The right upper arm was cool to the touch below the elbow, with cyanotic right fingers, and the right-sided radial and brachial pulses were absent.", "B, Selective angiogram of the innominate artery."], "Others": ["A confirmatory magnetic resonance image of the head is shown in Figure 1A, and a selective angiogram of the innominate artery is shown in Figure 1B.A, Magnetic resonance imaging of the head."]}
{"Patient Personal Background": ["He was adherent to his antiretroviral therapy (ART) regimen (tenofovir/emtricitabine, raltegravir), with a recent CD4 lymphocyte count of 382 cells/mm3 (18%) and HIV RNA below the level of assay detection.", "He reported taking atorvastatin for dyslipidemia and testosterone gel for hypogonadism."], "Patient Symptoms": ["He denied having jaundice, pruritus, abdominal pain, or other gastrointestinal symptoms and reported no alcohol intake or recent use of new medications.", "Shortly thereafter he developed fever to 38.9\u00b0C and a macular rash that involved his palms and soles (Figure)."], "Examination and Results": ["Initial evaluation was unremarkable except for new abnormalities in hepatic laboratory results (alanine aminotransferase, 217 U/L (3.6 \u03bckat/L); aspartate aminotransferase, 149 U/L (2.5  \u03bckat/L); alkaline phosphatase, 610 U/L (10.2 \u03bckat/L); total bilirubin, 2.2 mg/dL (37.6 \u03bcmol/L); and albumin, 3.1 g/dL).", "Test results for hepatitis A, B, and C were negative, as were results for anti\u2013smooth muscle and antimitochondrial antibodies.", "Results of a serum antinuclear antibody test were positive, with a titer of 1:640.", "Liver biopsy demonstrated moderately active interface and lobular hepatitis with plasma cells and periportal cholestasis, findings suggestive of autoimmune hepatitis.", "Physical examination was otherwise normal.Left, Pigmented, macular rash on palmar surface of left hand.", "Right, Pigmented, macular rash on plantar surface of left foot."], "Treatment": ["The patient was started on prednisone and azathioprine."], "Diagnosis": ["Liver biopsy demonstrated moderately active interface and lobular hepatitis with plasma cells and periportal cholestasis, findings suggestive of autoimmune hepatitis."]}
{"Patient Personal Background": ["He had no personal history of cancer, venous thrombosis, recent surgery, trauma, or admission to hospital.", "His medications included fluoxetine, atorvastatin, vitamin D, magnesium, and niacin.On examination, his blood pressure was 164/82 mm Hg; pulse rate, 104/min; and respiratory rate, 18/min."], "Patient Symptoms": ["He described increased anxiety and a pleuritic chest pain that began a few hours prior to his ED visit, but no hemoptysis."], "Examination and Results": ["Oxygen saturation level was 96% in room air.", "His lungs were clear to auscultation bilaterally.", "No extra heart sounds or murmurs were noted.", "Examination of his extremities were unremarkable with no leg symptoms or swelling or pain at calf palpation.", "Laboratory test results showed a hemoglobin level of 160 g/dL (reference range, 14.0-17.5 g/dL), a platelet count of 129\u2009\u00d7\u2009103/\u03bcL (reference range, 150-350\u2009\u00d7\u2009103/\u03bcL), and a serum creatinine level of 1.26 mg/dL (reference range, 0.6-1.2 mg.dL) (111 \u03bcmol/L; reference range, 13-106 \u03bcmol/L).", "His chest film was normal."], "Diagnosis": ["The attending physician\u2019s presumptive diagnosis was pulmonary embolism (PE).", "His pretest clinical probability of PE according to the 2-level Wells score1 was likely (1.5 points for heart rate >100, and 3.0 for other diagnoses less likely than PE)."], "Others": ["Therefore, D-dimer measurement was not performed.", "His computed tomographic pulmonary angiography (CTPA) result is reported in the Table.Rule out PE and perform a work up for alternative diagnoses.Obtain a bilateral lower limb veins compression ultrasonography.Obtain a lung ventilation-perfusion (V\u0307/Q\u0307) scan or pulmonary angiogram."]}
{"Patient Personal Background": ["He moved to Texas from the northeast a few months prior to his illness.", "He denied any exposure to sexually transmitted infections or a history of genital lesions."], "Patient Symptoms": ["He reported that a fraction of the lesions had blistered earlier in the course of his illness.", "The patient also described myalgias and fatigue over the preceding month."], "Examination and Results": ["On examination, the patient had erythematous papules on bilateral palms and soles as well as eroded vesicles on the palate (Figure, A and B).", "Lymphadenopathy was not present.", "A biopsy specimen of a papule on the left sole was obtained for immunohistochemical staining (Figure, C and D).", "A serologic antibody test revealed an elevated coxsackievirus titer of 1:16 (reference range, <1:8; >1:32 indicative of infection).A, Patient\u2019s soles at presentation.", "C, Hematoxylin-eosin\u2013stained section of the biopsy specimen (original magnification, \u00d720).", "D, Immunohistochemistry stain of biopsy specimen (anti\u2013Treponema pallidum polyclonal antibody immunostain; original magnification, \u00d720)."], "Others": ["B, Patient\u2019s palate at presentation."]}
{"Patient Personal Background": ["He stated that he did not have a history of poor wound healing or painful skin ulcers.", "He had a history of type 2 diabetes and an allogenic bone marrow transplant 1 year prior for myelodysplastic syndrome complicated by pancytopenia and chronic graft-vs-host disease."], "Patient Symptoms": ["He reported subjective fevers, as well as increasing erythema and tenderness immediately around the right forearm lesion."], "Examination and Results": ["Physical examination revealed an isolated slightly erythematous, edematous plaque with a prominent central eschar on the right forearm (Figure, A).", "An incisional biopsy at the edge of the eschar was performed, and a specimen was sent for pathological evaluation (Figure, B-D).A, Clinical photograph of a nonhealing ulcer with central eschar on the right forearm.", "B-D, Histopathologic images.", "B, Necrotic debris and fat necrosis with saponification (hematoxylin-eosin, original magnification \u00d740).", "C, Saponification and needle-like clefts within necrotic adipocytes (hematoxylin-eosin, original magnification \u00d7200).", "D, Numerous nonseptate, thick-walled fungal hyphae in the dermis (hematoxylin-eosin, original magnification \u00d7400)."]}
{"Patient Symptoms": ["He reported that the lesions had begun 6 months previously and that they were most bothersome at the end of the day or when he was exposed to the cold and damp environment while out on his boat.", "He applied ice to alleviate the burning, but this worsened the condition."], "Examination and Results": ["Histologic findings from biopsy specimens were also obtained by routine histologic analysis (Figure, B) and direct immunofluorescence examination (Figure, C).A, Clinically, the left ear demonstrates erythema, edema, and focal crusting.", "B, Biopsy specimen from the left ear reveals thrombi within engorged blood vessels but fails to reveal significant inflammation of blood vessel walls (hematoxylin-eosin, original magnification \u00d7200).", "C, Biopsy specimen from the left ear under direct immunofluorescence and stained for anti-IgM highlights thrombi within vessels (original magnification \u00d7200)."], "Treatment": ["A heating pad provided some measure of relief, as did a brief course of systemic corticosteroids.Physical examination revealed that some papular lesions were associated with slight purpura and hemorrhagic crust (Figure, A)."]}
{"Patient Personal Background": ["The older brother had an extensive medical history, including dysphonia, oral mucosal lesions, alopecia, recurrent parotitis, vocal cord swelling, and recurrent vesicular eruptions on his face, trunk, and perineum.", "Two skin biopsies were performed at 2 and 6 years of age, but the findings were considered unremarkable.Findings from ophthalmological examination of the older sibling showed confluent waxy nodular lesions extending from the lashes to the mucocutaneous junction on all 4 eyelids (Figure 1), impairing eyelid closure bilaterally."], "Patient Symptoms": ["There was no history of associated eyelid pain or bleeding.", "The older brother had an extensive medical history, including dysphonia, oral mucosal lesions, alopecia, recurrent parotitis, vocal cord swelling, and recurrent vesicular eruptions on his face, trunk, and perineum.", "Focal trichiasis was associated with superficial punctate keratitis.", "Waxy nodular lesions (arrowheads) are present along the upper and lower eyelids of the patient\u2019s left eye.The younger brother had similar, although less severe, ocular and systemic findings, including eyelid nodules, facial scarring, hyperkeratosis, oral mucosal lesions, and dysphonia."], "Examination and Results": ["Two skin biopsies were performed at 2 and 6 years of age, but the findings were considered unremarkable.Findings from ophthalmological examination of the older sibling showed confluent waxy nodular lesions extending from the lashes to the mucocutaneous junction on all 4 eyelids (Figure 1), impairing eyelid closure bilaterally.", "Focal trichiasis was associated with superficial punctate keratitis.", "There were no other corneal findings.", "There were no lesions on the conjunctiva or iris bilaterally.", "The lenses were clear and no abnormalities were visualized using funduscopy.", "Findings from the remainder of the ocular examination were unremarkable.Clinical appearance of eyelid margin nodules in the older brother.", "Waxy nodular lesions (arrowheads) are present along the upper and lower eyelids of the patient\u2019s left eye.The younger brother had similar, although less severe, ocular and systemic findings, including eyelid nodules, facial scarring, hyperkeratosis, oral mucosal lesions, and dysphonia."], "Others": ["He had seen several medical specialists and had been comprehensively evaluated for these concerns yet remained undiagnosed since birth.", "The patients\u2019 parents denied consanguinity."]}
{"Patient Symptoms": ["Five days later, he developed painless horizontal diplopia and returned to the emergency department.", "Alternate cover testing revealed a 30 prism diopters (\u2206) esotropia on primary gaze that increased to 45\u2206 on lateral gaze."], "Examination and Results": ["Additional evaluation included a repeated computed tomographic scan that showed no infectious involvement of the orbits or petromastoid complexes (Figure).", "Findings from magnetic resonance imaging of the patient\u2019s brain and orbits did not reveal intracranial lesions or extraocular muscle myositis.", "Results of lumbar puncture and cerebrospinal fluid testing, including opening pressure, cell count, and glucose and protein levels, were in the reference range.", "The erythrocyte sedimentation rate and C-reactive protein levels were also in the reference range.", "Findings from neurologic examination did not reveal paresthesias, difficulty with gait, or abnormal tendon reflexes.A, A computed tomographic scan of the face and orbits in coronal sections demonstrating inflammatory changes in the maxillary and ethmoid sinuses without orbital involvement.", "B, An axial computed tomographic scan does not show inflammatory involvement of the petrous apices (digitally processed image).", "A indicates anterior.The patient was then referred for neuro-ophthalmic evaluation.", "Positive findings were limited to a \u22122.5 bilateral abduction deficit.", "His pupils, intraocular pressure, visual fields, and findings from external examination were normal.", "Findings from anterior segment and dilated fundus examinations were also normal."], "Treatment": ["Because of this infection, he went to an emergency department and was prescribed antibiotics for presumed sinusitis.", "Findings from a computed tomographic scan showed diffuse sinusitis that was procedurally drained by an otolaryngologist.", "However, this treatment did not resolve the diplopia and he was subsequently referred to a neurologist."], "Others": ["His best-corrected visual acuity was 20/20 OU."]}
{"Patient Symptoms": ["He had 3 episodes of right-sided ptosis, each of which occurred at 18 months, 3 years, and 5 years of age.", "None of these episodes was preceded by fever.", "During the last 2 episodes, he experienced severe right-sided headache lasting for 6 to 7 days before development of ptosis; he also experienced double vision.", "There was no history of loss of consciousness, seizures, loss of vision or hearing, facial deviation, trouble swallowing, or weakness of the extremities in any of these episodes."], "Examination and Results": ["At the time of the clinic visit, the patient was asymptomatic and results of the neurologic examination were normal.", "Results of brain magnetic resonance imaging performed at 18 months showed thickening of the cisternal part of the right third cranial nerve in the perimesencephalic cistern (Figure, B) with no parenchymal lesions.", "Results of tests on cerebrospinal fluid collected via lumbar puncture were normal.A, The patient\u2019s right-sided ptosis during the first episode at age 18 months."], "Treatment": ["After the first episode, with a presumed diagnosis of acute disseminated encephalomyelitis, he received intravenous pulse methylprednisolone sodium succinate, 30 mg/kg, for 3 days and recovered completely in 3 weeks.", "The patient received intravenous immunoglobulin, 2 g/kg, for 2 days after the subsequent 2 episodes, with a presumed diagnosis of chronic inflammatory demyelinating neuropathy, and recovered fully."], "Diagnosis": ["After the first episode, with a presumed diagnosis of acute disseminated encephalomyelitis, he received intravenous pulse methylprednisolone sodium succinate, 30 mg/kg, for 3 days and recovered completely in 3 weeks.", "The patient received intravenous immunoglobulin, 2 g/kg, for 2 days after the subsequent 2 episodes, with a presumed diagnosis of chronic inflammatory demyelinating neuropathy, and recovered fully."], "Others": ["There was history of migraine on the maternal side of the family.", "There was no family history of autoimmune disorders or cerebral aneurysms.", "The family provided a photograph of the patient\u2019s face at the time of the first episode (Figure, A).", "B, Results of brain magnetic resonance imaging showing thickening of the cisternal part of the right third cranial nerve in the perimesencephalic cistern (white arrowhead)."]}
{"Patient Symptoms": ["He had no nasal obstruction, nasal bleeding, or feeling of aural fullness."], "Examination and Results": ["Fibroscopic evaluation revealed a black nevus\u2013like lesion over the left torus tubarius, without surface necrosis or signs of bleeding when touched.", "Examination of the neck, nasal cavity, and larynx showed no remarkable findings.", "The margins were clearly identified, and laser excision was performed smoothly with only minimal bleeding.", "Microscopy revealed small mixed serous and mucinous glands, normal respiratory epithelia with marked oncocytic cell changes, and abundant eosinophilic granular cytoplasm arranged in a tubular and microcystic pattern (Figure, B).", "Scattered brown pigments were noted in the cytoplasm of most oncocytic cells (Figure, C).", "There was no dyskeratosis.", "The brown pigment was negative for iron stain (Figure, D) and HMB45 stain, but positive for Fontana Masson stain.", "Ki-67 staining revealed low proliferative index in the lesion.", "Some lymphocytic infiltration of the stroma was also noted.A, Endoscopic view of the nasopharynx."], "Treatment": ["It was recommended that he receive laser excision of the lesion under endoscopy.", "During the surgery, the superficial lesion was found to be confined to the left torus tubarius, without invasion of the surrounding structures (Figure, A, arrowhead).", "The surgical specimen was a single black, soft-tissue fragment measuring 0.4\u2009\u00d7\u20090.3\u2009\u00d7\u20090.2 cm."], "Others": ["B-D, Histopathologic images.", "B, Hematoxylin-eosin, original magnification \u00d7100.", "C, Hematoxylin-eosin, original magnification \u00d7200.", "D, Iron stain, original magnification \u00d7100."]}
{"Patient Personal Background": ["There was no other significant medical or surgical history."], "Patient Symptoms": ["On physical examination, severe trismus was present with maximal interdental distance of 1 mm."], "Examination and Results": ["A maxillofacial computed tomographic (CT) examination was performed (Figure).", "A-C, Noncontrast computed tomographic images.", "A, Axial slice from an image of the facial bones.", "B, Coronal slice from an enhanced scan of the facial bones.", "C, Coronal image of the facial bones using a soft-tissue algorithm.", "Asterisk indicates left medial pterygoid artery.", "D, Three-dimensional reconstructed image of the facial bones."], "Treatment": ["Approximately 10 years after onset of symptoms, she was seen by an oral surgeon who attempted mandibular release via a cervical incision.", "The patient was brought to the operating room for excision."], "Others": ["According to the patient, the surgeon was \u201cunable to reach\u201d the affected area, and the operation was unsuccessful."]}
{"Patient Personal Background": ["His medical history was significant for previous nasal endoscopy with biopsy of nasal polyps 6 years previously, with a finding of benign nasal polyps by surgical pathology.", "The patient had then been lost to follow-up."], "Patient Symptoms": ["He now complained of nasal drainage, severe headaches, and long-standing visual loss.", "There had been no acute worsening of headaches or visual loss in the previous months."], "Examination and Results": ["Physical examination showed severe left proptosis, telecanthus, purulent nasal drainage, and nasal polypsis filling the bilateral nasal cavities.", "Ophthalmology consultation revealed no evidence of restriction of gaze or papilledema, and a recommendation was made for endoscopic sinus surgery to remove the source of infection.", "Computed tomographic imaging revealed extensive nasal polyposis, bony remodeling consistent with long-standing inflammation, and massive erosion of the bilateral skull base and orbits (Figure 1A).", "Nasal polyps were present and had a typical appearance superficially (Figure 1B).", "Tissue was sent for histologic evaluation."], "Treatment": ["The patient underwent endoscopic sinus surgery."], "Others": ["However, on deeper dissection, they became increasingly difficult to remove even with powered instrumentation, and an atypical, fibrotic endoscopic appearance was noted (Figure 1C).", "Following this, the dissection was terminated.A, Coronal computed tomographic scan demonstrating extensive nasal polyposis and bony remodeling of bilateral skull base and orbits.", "B, Rigid nasal endoscopy demonstrating superficial appearance consistent with nasal polyps.", "C, Rigid nasal endoscopy following deeper dissection of area in question, demonstrating atypical fibrotic appearance."]}
{"Patient Personal Background": ["She had a history of adenoid cystic carcinoma of the right submandibular gland and had undergone wide tumor excision and postoperative radiation therapy 20 years previously (60 Gy/30 fractions in 1993).", "She also had a history of hyperthyroidism, which was under medical control (with propylthiouracil, 50 mg/d).", "She had no family history of neurofibromatosis."], "Patient Symptoms": ["She stated that she did not have blurred vision, headache, seizures, or trismus."], "Examination and Results": ["A physical examination revealed a bulge in the floor of mouth, limitation of tongue movement, and no palpable lymphadenopathy.", "No neurological deficits were revealed.", "Postgadolinium T1-weighted magnetic resonance imaging disclosed a 7.0\u2009\u00d7\u20094.0\u2009\u00d7\u20093.0-cm, well-defined enhancing mass in the right side of the floor of the mouth, extending posteriorly to the tongue base and medially across the midline (Figure, A).", "The results of laboratory investigations were normal."], "Treatment": ["Transcervical removal of the tumor was performed."], "Others": ["She had no suspicious spots or nodules on the skin.", "The surgical specimen was a 7.2\u2009\u00d7\u20095.8\u2009\u00d7\u20094.3-cm encapsulated tumor composed of a homogeneous, whitish, rubbery, and glistening content (Figure, B).", "Microscopic examination demonstrated oval to eel-like spindle nuclei distributed in a background of generally wavy collagenous fibers and mucinous matrix (Figure, C).", "The specimen showed sparse cellularity and no cellular atypia.", "Neither mitotic figure nor tumor necrosis was found.", "The specimen was immunoreactive for S-100 (Figure, D), focally positive for CD34, but nonreactive for smooth muscle actin.A, Axial T1-weighed gadolinium-enhanced magnetic resonance image of the neck.", "B, Gross image of the surgical specimen.", "C, Histopathologic image.", "Hematoxylin-eosin, original magnification \u00d7200.", "D, Histopathologic image."]}
{"Patient Symptoms": ["She presented with a 1-day history of sore throat, fever, chills, productive cough, globus sensation, dysphagia, and a change in her voice to the point it had become muffled and hoarse.", "Throughout the day she noticed progressive worsening of her symptoms in addition to becoming dyspneic.", "The patient tried using her albuterol inhaler, but this provided no relief of her symptoms."], "Examination and Results": ["The patient was afebrile at presentation, and there were no signs of infection.", "On examination, there was mildly tender right cervical lymphadenopathy but no evidence of peritonsillar exudates.", "Laryngoscopy demonstrated diffuse swelling of the supraglottic structures, particularly the epiglottis and left aryepiglottic fold, with a pale appearance of the mucosa (Figure, A).", "In addition, a neck computed tomographic (CT) scan was obtained, which showed marked swelling of the supraglottic structures with areas of patchy enhancement and narrowing of the airway, as well as enlarged right cervical lymph nodes (Figure, B-D)."], "Treatment": ["Owing to airway compromise, the patient was intubated and received intravenous steroids and ceftriaxone.", "Subsequently, she underwent debulking surgery and carbon dioxide laser ablation of the left arytenoid.A, Laryngoscopic photograph."], "Others": ["B, Axial contrast-enhanced computed tomographic (CT) image through level of the aryepiglottic folds.", "C, Axial contrast-enhanced CT through level of the epiglottis.", "D, Sagittal contrast-enhanced CT image."]}
{"Patient Personal Background": ["Her right eye had been enucleated 40 years before for choroidal melanoma, and she had been fitted with an ocular prosthesis (Figure 1).", "Twenty-six years before presentation, she had received a diagnosis of moderately differentiated, estrogen and progesterone receptor\u2013positive, invasive ductal carcinoma of the left breast (stage II, T2N1M0).", "At that time, she underwent modified radical mastectomy, and 3 lymph nodes were positive for carcinoma.", "She was then treated with 6 cycles of cyclophosphamide, doxorubicin hydrochloride, and fluorouracil, followed by daily tamoxifen citrate for nearly 5 years.", "There was no evidence of recurrent disease after this treatment."], "Patient Symptoms": ["She denied pain, trauma, or changes in vision.", "External examination revealed mild edema, erythema, and ptosis of the left upper lid (Figure 1).", "Best-corrected visual acuity was 20/25, and left ocular motility was full.Photographs of the upper face show the ocular prosthesis (black arrowheads) and asymmetric enlargement, erythema, and ptosis of the left upper eyelid (white arrowheads)."], "Examination and Results": ["External examination revealed mild edema, erythema, and ptosis of the left upper lid (Figure 1).", "Left cervical lymphadenopathy was present.", "Best-corrected visual acuity was 20/25, and left ocular motility was full.Photographs of the upper face show the ocular prosthesis (black arrowheads) and asymmetric enlargement, erythema, and ptosis of the left upper eyelid (white arrowheads)."], "Treatment": ["C, Right side.Recommend eyelid scrubs to the left eyelid for blepharitis.Refer for ophthalmologic examination and orbital computed tomography.Prescribe oral amoxicillin sodium\u2013clavulanate potassium for infectious preseptal cellulitis."], "Others": ["A, Front view.", "B, Left side."]}
{"Examination and Results": ["Small free fluid within the pelvis and 2 large mesenteric masses were discovered adjacent to the liver, pancreas, and stomach (Figure 1).", "During the trauma workup after a motor vehicle crash, 2 large peritoneal tumors were identified in her upper abdomen.", "A, An exophilic mass in segment 3 of the liver invading the distal stomach.", "B, A mass in the lessor sac attaching to the body of pancreas.", "The arrowheads indicate 2 isolated tumors close to the liver, pancreas, and stomach."], "Treatment": ["The patient underwent exploratory laparotomy and en-bloc resection of the intraperitoneal tumors.Computed tomographic images."], "Diagnosis": ["An endoscopic ultrasound-guided fine-needle aspiration of the abdominal mass was obtained and the diagnosis was made."]}
{"Patient Symptoms": ["Physical examination findings were notable for mild abdominal distension and tenderness without guarding or rebound sign."], "Examination and Results": ["He was afebrile and had normal vital signs.", "Abdominal ultrasonography revealed a normal appendix.", "Abdominal radiography (Figure 1A) revealed multiple polygonal calcified lesions in the pelvis and a nonobstructive bowel gas pattern.", "Computed tomography (Figure 1B) revealed a 5.6\u2009\u00d7\u20095.3\u2009\u00d7\u20094.6-cm midline cystic pelvic mass adjacent to the anterior rectal wall that contained several irregularly shaped ossifications.", "Laboratory study results were significant for normal levels of \u03b1-fetoprotein and chorionic gonadotropin and a white blood cell count of 19\u202f700/\u03bcL (reference range, 5500-15\u202f500/\u03bcL; to convert to \u00d7109/L, multiply by 0.001)."], "Treatment": ["The patient was taken to the operating room for an exploratory laparotomy.A, Supine abdominal radiograph reveals multiple polygonal calcified lesions in the pelvis (black arrowhead)."], "Others": ["B, Computed tomographic sagittal image of the abdomen reveals a midline cystic pelvic mass that contains several irregularly shaped ossifications (white arrowhead).", "L indicates left."]}
{"Patient Personal Background": ["His current medications include omeprazole and lorazepam."], "Patient Symptoms": ["The painful ulcers resolve within 2 weeks but recur on different mucosal surfaces.", "He denies new medications, foods, or oral hygiene products and involvement of cutaneous or other mucosal surfaces."], "Examination and Results": ["Intraoral examination demonstrates an ulcer with a pseudomembrane and erythematous halo on the left lateral surface of the tongue (Figure)."], "Treatment": ["He was previously prescribed anesthetic rinses and fluconazole, without benefit."], "Others": ["He is uncertain whether he has a family history of oral ulcers."]}
{"Patient Symptoms": ["His resting oxygen saturation was 94%, declining to 86% after walking for 60 meters."], "Examination and Results": ["A pulmonary examination revealed inspiratory crackles at the bases and diminished breath sounds at the apices.", "A cardiovascular examination showed normal results, without peripheral edema.", "A chest x-ray showed hyperinflation and increased interstitial markings."]}
{"Patient Symptoms": ["She reported a 6.3-kg weight loss, tremor, diaphoresis, and palpitations over the course of 2 months."], "Examination and Results": ["Physical examination revealed tachycardia, tongue and hand tremors, no exophthalmos, a 2-fold diffusely enlarged thyroid gland, and brisk reflexes.Laboratory results showed a thyroid-stimulating hormone (TSH) level of 0.005 mIU/L (normal, 0.45-4.50 mIU/L), free thyroxine level greater than 7.77 ng/dL (100.01 pmol/L) (normal, 0.82-1.77 ng/dL [10.55-22.78 pmol/L]), free triiodothyronine level of 30.6 pg/mL (47.1 pmol/L) (normal, 2.0-3.9 pg/mL [3.08-6.01 pmol/L]), and thyroid-stimulating immunoglobulin index of 5.5 (normal, <1.3).", "Note the increased uptake in the thymus indicating increased metabolic activity."], "Treatment": ["The patient began treatment with methimazole, 20 mg twice daily.A noncontrast computed tomography (CT) scan of the chest (Figure, left) and an 18F-fludeoxyglucose\u2013positron emission tomography (FDG-PET)/CT scan (Figure, right) were completed to evaluate her dyspnea.Left, Noncontrast computed tomography (CT) scan of the upper chest shown in cross section."], "Others": ["Right, 18F-fludeoxyglucose-positron emission tomography/CT scan of the whole body."]}
{"Patient Personal Background": ["The mother had had a normal pregnancy."], "Patient Symptoms": ["The parents reported occasional erosions and crusting that resolved with topical mupirocin, 2%, cream, but with no continued growth."], "Examination and Results": ["Physical examination revealed a firm, exophytic, and flat-topped nodule, with superficial erosion and crust on the right parietal side of the scalp measuring 3 cm in diameter and 1 cm thick (Figure, A).", "No other skin lesions were found.", "Cerebral and abdominal ultrasonography revealed no evidence of visceral involvement."], "Treatment": ["A 4-mm punch skin biopsy was performed, and tissue was sent for pathologic analysis (Figure, B and C)."], "Others": ["The lesion regressed without treatment over a period of 8 months.", "Close follow-up every 3 months was scheduled, and complete involution of the tumor was noted at 10 months of age (Figure, D).A, Nodular lesion on the right parietal scalp at initial presentation.", "B, Histopathologic image of a biopsy specimen (hematoxylin-eosin, original magnification \u00d7200).", "C, Immunohistochemical image of a biopsy specimen (actin stain, original magnification \u00d7100).", "D, Complete regression of tumor at 10 months of age."]}
{"Patient Personal Background": ["His medical history included a heart transplant for ischemic cardiomyopathy in his early 50s, and he was receiving long-term immunosuppressive therapy with cyclosporine, mycophenolate mofetil, and deflazacort."], "Examination and Results": ["He had received a diagnosis of plasmablastic lymphoma 6 months earlier and was being treated with polychemotherapy (cyclophosphamide, doxorubicin hydrochloride, vincristine sulfate, and prednisone [CHOP] regimen).Physical examination revealed a well-demarcated 5\u2009\u00d7\u20095-cm round ulcer with raised border, surrounding erythema, and a base with purulent debris (Figure 1A).", "A punch biopsy specimen from the edge of the ulcer was obtained and sent for histopathologic evaluation (Figure 1B).A, Cutaneous ulcer on the patient\u2019s left leg with a raised erythematous border and a base with purulent debris.", "B, Diagnostic biopsy shows enlarged endothelial cells with intranuclear inclusions surrounded by a clear halo, and some cytoplasmic inclusions.", "Similar findings are detected in some macrophages (hematoxylin-eosin, original magnification \u00d7400)."], "Treatment": ["He had received a diagnosis of plasmablastic lymphoma 6 months earlier and was being treated with polychemotherapy (cyclophosphamide, doxorubicin hydrochloride, vincristine sulfate, and prednisone [CHOP] regimen).Physical examination revealed a well-demarcated 5\u2009\u00d7\u20095-cm round ulcer with raised border, surrounding erythema, and a base with purulent debris (Figure 1A)."], "Diagnosis": ["He had received a diagnosis of plasmablastic lymphoma 6 months earlier and was being treated with polychemotherapy (cyclophosphamide, doxorubicin hydrochloride, vincristine sulfate, and prednisone [CHOP] regimen).Physical examination revealed a well-demarcated 5\u2009\u00d7\u20095-cm round ulcer with raised border, surrounding erythema, and a base with purulent debris (Figure 1A)."], "Others": ["A superficial swab culture sample grew P aeruginosa."]}
{"Patient Symptoms": ["She was initially admitted for altered mental status in the setting of an unwitnessed fall and was noted to have \u201cbruises\u201d on her lower extremities.", "Dermatology was consulted after the development of new lesions on her nose, ear, and the extensor surfaces of her arms bilaterally."], "Examination and Results": ["Admission laboratory test results showed hypercalcemia (calcium level, 11.5 mg/dL) and acute kidney injury (creatinine level, 5.6 mg/dL).On physical examination, the patient\u2019s nose, bilateral cheeks, forehead, and left ear (helical rim and antihelix [Figure, A]) were found to have dusky purpuric macules and patches.", "Her knees, feet, and the extensor surfaces of her arms had reticulated purpuric macules and patches.", "There was skin sloughing off the lesions on her elbows (Figure, B) and knees.", "Four-millimeter punch biopsy specimens were taken from the left ear, right arm, and forehead (Figure, C and D).Clinical and histopathologic images from a case of acral retiform purpura.", "A, Dusky purpuric macules on the helical rim and antihelix of the ear.", "B, Reticulated purpuric patches with focal areas of necrosis on the extensor surfaces of the arms.", "C and D, In specimens from the forehead, multifocal intravascular fibrinoid material consisting of a mix of cryoglobulins and fibrin thrombi with relatively little vessel wall inflammation was seen (hematoxylin-eosin, original magnification \u00d74 [C] and \u00d710 [D])."]}
{"Patient Personal Background": ["Her medical history was significant for Waldenstr\u00f6m macroglobulinemia (WM), and recent laboratory test results showed active WM with bone marrow involvement."], "Examination and Results": ["Results of the eye examination showed best-corrected visual acuity of 20/20 OD and 20/40 OS.", "Anterior segment examination results showed a relatively shallow anterior chamber in the left eye.", "Results of a dilated fundus examination showed a choroidal detachment in the left eye extending circumferentially from the 2-o\u2019clock to the 5-o\u2019clock position and extending posteriorly up to 3 to 4 disc diameters temporal to the macula (Figure, A).", "There was vitreous hemorrhage with a poor view of the posterior pole (Figure, A).A, Ultra-widefield fundus photograph of the left eye showing posterior vitreous hemorrhage (white arrowhead) and a choroidal detachment temporally (yellow arrowheads).", "B, Anterior segment spectral domain optical coherence tomography of the left eye showing the narrow angle from suprachoroidal effusion.Results of fundus fluorescein angiography of the left eye showed hypofluorescence corresponding to vitreous hemorrhage.", "Tortuosity of the temporal vessels was prominent, with diffuse peripheral vascular leakage temporally.", "Choroidal folds were observed 3 disc diameters temporal to the macula, extending to the periphery.", "Peripheral capillary nonperfusion, vascular reorganization, neovascularization, and choroidal detachment were noted.Anterior segment spectral domain optical coherence tomographic results showed a shallow anterior chamber and 360\u00b0 narrow angles in the left eye (Figure, B)."]}
{"Patient Personal Background": ["Eight years earlier, he had sustained a fireworks injury to his right eye followed by globe repair and enucleation within 3 days.", "He had no other significant medical or ocular history.His right eye\u2019s external appearance was normal, and the prosthesis fit well."], "Patient Symptoms": ["He described a history of initially intermittent (lasting hours to days) then constant (for the past 6-8 weeks) central and peripheral blurred vision in the left eye.", "He reported no headaches, numbness, weakness, eye pain, hearing loss, or other neurologic issues."], "Examination and Results": ["Uncorrected visual acuity was Snellen 20/70\u22121 OS (no improvement with pinhole); intraocular pressure was 13 mm Hg.", "Slitlamp examination results of the anterior segment were normal.", "Ophthalmoscopy demonstrated 1+ cells in the anterior vitreous and a serous retinal detachment involving the macula and extending from the 2-o\u2019clock to the 10-o\u2019clock position with pigmentary and atrophic changes in the macula.", "No breaks were noted on scleral depressed examination.", "Fluorescein angiography showed multifocal areas of early hyperfluorescence with late leakage and diffuse retinal vascular leakage predominantly in the inferior retina (Figure 1A).", "Optical coherence tomography (OCT) showed a thickened choroid and subretinal fluid throughout the macula (Figure 1B).", "Enhanced depth imaging showed an enlarged choroid throughout the posterior pole, and ultrasonography confirmed extensive inferior retinal detachment (not shown).A, Fluorescein late-phase angiogram shows multifocal areas of posterior choroidal leakage and diffuse retinal vascular leakage in the inferior (detached) retina.", "B, Optical coherence tomographic en face infrared image (left) and vertical line scan (right) through the fovea show subretinal fluid extending inferiorly with hyperreflective subretinal deposits."]}
{"Patient Symptoms": ["She first became aware of her increased abdominal girth when friends at school asked whether she was pregnant.", "She had noticed her clothing becoming tighter over recent weeks."], "Examination and Results": ["She had not experienced abdominal pain or other symptoms, and there was no history of trauma.", "Physical examination revealed a firm, distended abdomen without bowel sounds.", "Pregnancy test results were negative.", "Results of laboratory studies, including a complete blood cell count, basic metabolic panel, and liver function tests, were within normal limits.", "An abdominal radiograph showed a paucity of bowel gas markings (Figure 1A).", "A subsequent computed tomographic scan of the abdomen and pelvis revealed a 30-cm retroperitoneal cystic structure causing significant mass effect on the abdominal viscera, displacing the right kidney superiorly under the liver causing moderate hydronephrosis (Figure 1B).A, Abdominal radiograph showing a paucity of bowel gas markings."]}
{"Patient Personal Background": ["There was no history of immunocompromise or foreign travel."], "Patient Symptoms": ["He had no clinically significant improvement in symptoms despite multiple courses of oral antibiotics.", "Over the previous 2 months, he had developed progressive right-sided facial swelling, pain, blurred vision, and a 6.8-kg weight loss.", "The patient\u2019s examination was notable for right-sided facial and periorbital swelling, severe pain, and limitation of lateral gaze of the right eye."], "Examination and Results": ["A computed tomographic (CT) scan at an outside hospital showed complete opacification and an invasive process centered in the right maxillary sinus.", "A repeated CT scan was completed (Figure).A-C, Computed tomographic images.", "A, Coronal view of the paranasal sinuses in bone windows showing near-complete opacification of the right maxillary sinus with soft-tissue thickening, a calcific focus, and associated erosion of the bony walls.", "B, Coronal view of the paranasal sinuses in soft-tissue windows.", "C, Axial view of the paranasal sinuses in bone windows."], "Treatment": ["The patient was started on treatment with intravenous antifungal and broad-spectrum antibiotics, and he was transferred for further evaluation and management."], "Diagnosis": ["An endoscopic maxillary antrostomy and biopsy showed inflammatory changes and numerous fungal organisms consistent with Aspergillus species."]}
{"Patient Personal Background": ["He was a tour guide, a profession that requires speech."], "Patient Symptoms": ["Because he experienced voice fatigue frequently, he visited a hospital for professional assistance."], "Examination and Results": ["Fibroscopy showed a well-circumscribed mass of approximately 3\u2009\u00d7\u20093\u2009\u00d7\u20092 cm, with a smooth surface, located at the laryngeal side of the left aryepiglottic fold and covering nearby structures, such as the bilateral vocal cords and left pyriform sinus (Figure 1, A).", "It was composed of adipocytes of various sizes in a fibromyxoid background.", "In the fibromyxoid areas, atypical spindle cells with hyperchromatic and enlarged nuclei were present, as well as scattered lipoblasts without areas of dedifferentiation (Figure 1, B).", "Immunohistochemically, the tumor exhibited substantial nuclear staining for both CDK4 and MDM2 and stains (Figure 1, C)."], "Treatment": ["A biopsy was performed, and the patient visited our institution (Taipei Veterans General Hospital) for further intervention.", "The laryngeal mass was removed through transoral laser microsurgery."], "Others": ["The tumor was at the submucosa with focally ulcerated overlying epithelium."]}
{"Examination and Results": ["A magnetic resonance imaging (MRI) study of the brain and cervical spine obtained to evaluate for demyelinating disease demonstrated a normal brain and cervical cord, but an incidental T2 hyperintense lesion within the right pterygoid muscles was noted.", "A dedicated fifth cranial nerve MRI examination performed to better characterize the lesion revealed a well-defined, lobulated T2 hyperintense lesion within the right pterygoid muscles without mass effect, adjacent edema, or other invasive features (Figure, A).", "There was a small focus of signal void on the T2-weighted images, suspicious for tiny calcification.", "On gadolinium administration, there was sequential increased enhancement on the postcontrast T1-weighted axial images (Figure, B and C).", "Further imaging workup with single-proton emission computed tomography-CT (SPECT-CT) using technetium Tc 99m\u2013labeled red blood cells (RBCs) demonstrated increased tracer pooling within the lesion (Figure, D).A-C, Magnetic resonance imaging studies (axial views) of a teenager with an incidental masticator space lesion.", "D, Single-proton emission computed tomographic image (axial view) using technetium Tc 99m\u2013labeled red blood cells demonstrating increased tracer pooling within the lesion."], "Others": ["The rest of the clinical history and neurological examination was unremarkable.", "On further consultation with the otolaryngology department, the patient stated that she had not experienced any sensation of a mass, and results from a focused otolaryngologic examination were also normal."]}
{"Patient Symptoms": ["The patient continued to experience dysphagia, globus, and a choking sensation when coughing."], "Examination and Results": ["A right pyriform sinus mass was seen on fiber-optic laryngoscopy.", "Computed tomography (CT) and magnetic resonance imaging (MRI) confirmed the finding of a hypopharyngeal mass.", "An MRI scan obtained 1 month postoperatively demonstrated a persistent mass or swelling.", "On fiber-optic examination, right pyriform sinus fullness was visualized.", "An interval MRI demonstrated a 2-cm soft-tissue mass in the cervical esophagus (Figure, A).", "Using rigid suspension laryngoscopy, we identified a large, smooth-walled ovoid mass herniating from the cervical esophageal opening.", "A mucosal stalk anchored the mass to the lateral pyriform sinus wall.", "The tumor was well-defined, solitary, tan-red, and composed of sheets of large, round-to-polygonal cells with marked eosinophilic, granular cytoplasm (Figure, B).", "Most tumor cells exhibited peripherally or centrally located vesicular nuclei with prominent nucleoli.", "Peripheral intracellular vacuoles indenting the cytoplasm were seen, which represent a processing artifact due to intracellular glycogen loss (Figure, C).A, Axial contrast-enhanced spoiled gradient magnetic resonance image."], "Treatment": ["The patient underwent an endoscopic laser excision.", "Endoscopic snare cautery was used to excise the mass."], "Others": ["Immunohistochemical stains revealed tumor cells that were focally positive for myogenin and diffusely positive for desmin and myoglobin.", "During operative laryngoscopy, no mass was identified.", "B and C, Histopathological images.", "B, Hematoxylin-eosin, original magnification \u00d720.", "C, Hematoxylin-eosin, original magnification \u00d740."]}
{"Patient Personal Background": ["He reported a 44\u2013pack-year smoking history and remote alcohol abuse."], "Examination and Results": ["On physical examination he had a 10-cm right-sided facial mass extending under the auricle from the mastoid to the zygoma and inferiorly to the angle of the mandible.", "The mass was firm, mildly tender, but without overlying skin changes or cervical lymphadenopathy.", "Computed tomographic (CT) and magnetic resonance imaging (MRI) scans showed maxillary sinus compression with partial destruction of the zygomatic arch, mandible, and orbital floor (Figure, A and B).", "The mass extended into the right pterygopalatine fossa, disrupting the floor of the middle cranial fossa and widening the foramen ovale.", "A core biopsy specimen revealed spindle cell proliferation with abundant collagen that stained focally with CD34, smooth muscle actin, and Bcl-2.", "The Figure, C, shows a gross pathologic image after excision of the mass.Histopathologic findings demonstrated spindle cells arranged in long fascicles with abundant interstitial collagen (Figure, D).", "Tumor cells exhibited central, oval nuclei, and moderate amounts of pale-pink cytoplasm with indistinct borders.", "There was no increased or atypical mitosis, necrosis, or vascular invasion.", "Immunostaining demonstrated strong nuclear staining for \u03b2-catenin antibody and was positive for smooth muscle actin antibody, while stains for desmin, pan-keratin, S-100, CD34, and Bcl-2 antibodies were negative.", "The Ki67 index was less than 1%.A, Coronal computed tomographic scan of the mass.", "B, Postcontrast axial T1-weighted magnetic resonance image.", "C, Gross pathologic image of the mass."], "Others": ["D, Histopathologic image of excised tissue (hematoxylin-eosin, original magnification \u00d740)."]}
{"Patient Personal Background": ["He had no notable medical or surgical history."], "Patient Symptoms": ["He denied fevers, dizziness, or recent trauma."], "Examination and Results": ["He was afebrile with normal vital signs.", "He was well nourished, alert, and in no acute distress.", "Results of an abdominal examination revealed normoactive bowel sounds, no distention, but tenderness on the left side.", "Computed tomography (CT) of the abdomen and pelvis with intravenous contrast revealed a 12\u2009\u00d7\u200913\u2009\u00d7\u200911-cm left-sided adrenal mass (Figure 1).", "Results of laboratory examination revealed plasma levels of metanephrines, normetanephrines, cortisol, renin, and aldosterone within reference limits."]}
{"Patient Personal Background": ["The patient had a history of multiple episodes of hematemesis attributed to alcoholic gastritis; however, at this admission, he indicated he had not experienced vomiting."], "Patient Symptoms": ["He described the pain as a sharp, left upper-quadrant pain migrating to the epigastric region for 24 hours.", "He admitted to early satiety over the past few months."], "Examination and Results": ["Physical examination revealed a soft nondistended abdomen, but it was very tender in the epigastric region without rebound or guarding.", "Elevated results of liver function tests, as well as amylase and lipase levels consistent with alcoholic pancreatitis, were noted.", "Magnetic resonance imaging, computed tomographic imaging, and upper endoscopy findings are shown in Figure 1.", "A, Computed tomographic scan and magnetic resonance imaging (inset) demonstrating a heterogeneous mass lesion in the fundus and body of the stomach.", "B, Upper endoscopic image directly visualizing the mass intruding into the lumen of the stomach."], "Others": ["There was no palpable mass.", "Biopsy results of the mass were reported as normal gastric mucosa.Diagnostic imaging."]}
{"Patient Personal Background": ["Her medications included bimatoprost, atenolol, atorvastatin, and clopidogrel.A, Upper facial profile showed iris heterochromia and eyelash hypertrichosis."], "Patient Symptoms": ["Her irises were also different colors: the right iris was brown, and the left was hazel (green-brown) (Figure 1).", "The patient had noticed a gradual darkening of her right iris and lengthening of her eyelashes during the last year but denied visual changes or foreign-body sensation."], "Examination and Results": ["B, Right eyelid and eye showed thick, long eyelashes with brown iris."], "Others": ["Her medical history included a cerebrovascular accident, hypercholesterolemia, and hypertension and a remote history of breast cancer treated with lumpectomy and radiation therapy."]}
{"Patient Personal Background": ["His medical history includes a 5-pack-year smoking history but no illicit drug or alcohol use, promiscuous sexual activity, or recent travel outside of the United States.", "He works with Mexican immigrants."], "Patient Symptoms": ["He had tattoos placed 3 years before presentation and noticed skin lesions confined to his tattoos 1 year ago."], "Examination and Results": ["Vital signs revealed temperature, 36.7\u00b0C; heart rate, 76/min; respiratory rate, 17/min; blood pressure, 128/82 mm Hg; and oxygen saturation, 99% on room air.", "Examination revealed a well-appearing patient with clear lungs bilaterally and numerous scattered red to violaceous macules and papules along his tattoos (Figure 1, left).", "Complete blood cell count showed hemoglobin level, 11.3 g/dL; white blood cell count, 4.5 \u00d7103/mm3; and platelet count, 189 \u00d7103/mm3.", "Results of a complete metabolic panel were normal except for elevated levels of blood urea nitrogen (33 mg/dL), creatinine (3.0 mg/dL), and ionized calcium (6.7 mg/dL).", "Urinalysis showed gross hematuria, with 10 to 20 red blood cells per high-power field and 0 to 5 white blood cells per high-power field.", "Chest radiography showed bilateral hilar lymphadenopathy without consolidations, nodules, or cavitary lesions (Figure 1, right).", "Computed tomography of the abdomen showed right-sided hydronephrosis with an obstructive stone.Left, Numerous scattered red to violaceous macules and papules along patient\u2019s tattoos."]}
{"Patient Personal Background": ["His other medications include metformin and amlodipine.", "He is married, has 3 children, and reports a sedentary lifestyle."], "Patient Symptoms": ["He has normal libido but experiences occasional erectile dysfunction, which is being successfully managed with a phosphodiesterase-5 inhibitor."], "Examination and Results": ["His morning total testosterone level (measured by mass spectrometry) was 279 ng/dL (normal reference range for this laboratory, 300-900 ng/dL), prompting his referral.", "On physical examination, his body mass index was 34.7 (calculated as weight in kilograms divided by height in meters squared).He was not cushingoid and his visual fields were normal.", "Acanthosis nigricans was noticed on the neck.", "There was no gynecomastia.", "His testes were normal in size.", "His muscle strength was normal."], "Treatment": ["He has normal libido but experiences occasional erectile dysfunction, which is being successfully managed with a phosphodiesterase-5 inhibitor."], "Others": ["He recently heard on the radio that his symptoms might be due to \u201clow T.\u201d One month ago, he saw his primary care physician and requested measurement of his testosterone level.", "Relevant laboratory tests, including repeat morning total testosterone assessed in an endocrinology clinic, are reported in Table.Further evaluation is required; repeat total testosterone measurement using an immunoassay.The patient has androgen deficiency; no further evaluation is required."]}
{"Patient Personal Background": ["The lesions appeared while she was taking levofloxacin; however, on admission the antibiotic therapy was continued.", "On physical examination, the patient had localized retiform purpura on the right earlobe and bilateral helices that were tender to palpation (Figure, A)."], "Patient Symptoms": ["Initially, the left ear developed very painful lesions that resembled bruises.", "Subsequently, her right ear became involved and developed similar lesions, but she denied any other areas being affected."], "Examination and Results": ["Findings from laboratory tests, including a hypercoagulability workup, complete blood cell count, comprehensive metabolic panel, urinalysis, cryoglobulins, cytoplasmic antineutrophil cytoplasmic antibodies, and complement levels were all unremarkable.", "However, the test result for perinuclear antineutrophil cytoplasmic antibodies (p-ANCAs) was positive.", "A punch biopsy for histopathologic examination was performed (Figure, B and C).A, Retiform purpura on the right helix.", "B, Abundant red blood cell extravasation and fibrin thrombi (hematoxylin-eosin, original magnification \u00d710).", "C, Leukocytoclastic vasculitis and fibrin thrombi (hematoxylin-eosin, original magnification \u00d740)."], "Treatment": ["She had recently been treated for a urinary tract infection with trimethoprim-sulfamethoxazole and levofloxacin.", "Her other medications included propylthiouracil, amlodipine besylate, pravastatin sodium, solifenacin succinate, and gabapentin."]}
{"Patient Personal Background": ["The patient had no notable recent medical illnesses, illicit drug use, or new medications."], "Patient Symptoms": ["The lesions began on the bilateral lower legs and spread to the thighs, buttocks, hands, forearms, and proximal arms.", "Review of systems was notable for episodic muscle cramping and numbness involving the lower extremities."], "Examination and Results": ["Physical examination revealed numerous stellate red-brown patches without induration, scale, or ulceration (Figure, A)."], "Treatment": ["An incisional wedge biopsy was performed on a lesion from the lower extremity, and the specimen was stained with hematoxylin-eosin (Figure, B and C).A, Stellate red-brown patches on the patient's right lower extremity."], "Others": ["B, Specimen from a lower-extremity lesion (original magnification \u00d710).", "C, Same specimen as shown in panel B but at higher magnification (\u00d720)."]}
{"Patient Personal Background": ["There was no personal or family history of malignancy."], "Patient Symptoms": ["The patient noted that the lesion had slowly enlarged over the preceding 5 years from when he first noticed it as a small bump.", "He denied a history of trauma prior to its development.", "The patient denied any spontaneous bleeding, crusting, or itching, and he was primarily concerned about its growth."], "Examination and Results": ["On physical examination, the patient\u2019s left frontal scalp revealed a mobile 1.2-cm mammillated, soft, brown plaque with protruding terminal hairs (Figure, A).", "The remainder of the patient\u2019s skin examination revealed no other concerning lesions.", "There was no lymphadenopathy present.", "Dermoscopically, the lesion was characterized by irregular pigment globules, milialike cysts, and focal arborizing vessels (Figure, B)."], "Treatment": ["A shave biopsy was performed for histopathologic examination (Figure, C and D)."]}
{"Patient Personal Background": ["Her family history revealed that her father was alive and well at approximately age 90 years, and her mother had died at approximately age 80 years with a history of neuropsychiatric disease and gait change.", "There was no history of tobacco, excess alcohol, or recreational drug use."], "Patient Symptoms": ["Her family noted that her first symptoms appeared at age 55, with subtle gait dysfunction and then evident imbalance.", "By age 57, there was concern over progressive withdrawal from social interchange, personality changes, and impairment of judgment.", "By age 59, she was experiencing bouts of inappropriate out-of-context laughter and tears, inattention, daytime fatigue, and frank memory impairment.", "She developed visuoperceptive changes and difficulties using the television remote control device.", "She developed obsessive checking behaviors.", "She started having swallowing difficulties but nonetheless had unexpected weight gain.", "She developed progressively worse motoric problems, with stiffness, abnormal posturing, a left toe pointing upward, and falls."], "Examination and Results": ["General examination findings were noncontributory.", "Neurological examination revealed abnormal mental status, with full orientation and good registration, concentration, digit span, and language function but with poor calculations and constructions (Figure 1A) and decreased short-term memory.", "Nonetheless, her Mini-Mental State Examination score was 28 of 30.", "Cranial nerve examination revealed some decreased upgaze and mild facial masking.", "Motor examination revealed rigidity and dystonic posturing in the left arm and leg, imbalance on gait, decreased arm swing, and retropulsion but no significant tremor.", "Sensory examination findings were normal.", "Reflex examination showed mild left hyperreflexia with an upgoing left toe.", "Blood and urine laboratory study results were within normal limits.", "Cerebrospinal fluid was unremarkable except for biomarkers that showed a mid-range \u03b2-amyloid 42 level of 530 pg/mL and normal total tau and phosphotau levels of 182 and 25 pg/mL, respectively.", "Magnetic resonance imaging of the brain was reported as unremarkable (Figure 1B).", "Positron emission tomography (PET) imaging of the brain revealed right frontotemporoparietal hypometabolism with some sensorimotor sparing (Figure 1C), which was neither typical nor atypical of Alzheimer disease.", "Electroencephalography showed left frontotemporal sharp waves and slowing."], "Others": ["She had continued progressive decline in cognition and motor function and died almost mute and bedridden in her early 60s after a 9-year course of illness.A, Patient testing.", "Constructional apraxia is seen in her copying of the top row template figures, with preserved writing in script.", "B, Brain magnetic resonance imaging at the time of presentation.", "The top panel shows selected sagittal T1-weighted images, and the bottom panel shows selected axial T1-weighted images.", "C, Brain positron emission tomography using fluorodeoxyglucose F 18 tracer in the axial plane.", "Frontal and temporal hypometabolism is seen, more marked on the right, with some apparent sensorimotor sparing bilaterally."]}
{"Patient Symptoms": ["At presentation, she reported occasional photopsias, floaters, and blurred vision but no pain."], "Examination and Results": ["Visual acuity was 20/25\u22122 OD and 20/40 OS.", "Low internal reflectivity and a mass measuring 8.4 mm in height by 12.9 mm across the base (Figure, A and B) were revealed on B-scan ultrasonography.", "A complete blood cell count and results of liver function tests were within reference limits; a computed tomographic scan of the abdomen, chest, brain, and orbits showed no evidence of metastasis.A and B, B-scan ultrasonography of the left eye.", "A, Original scan shows a mass with a height of 8.4 mm and a base dimension of 12.9 mm.", "B, Follow-up scan shows the mass in a transverse 12-o\u2019clock position with a decrease in tumor height to 1.4 mm 4\u00bd years after iodine 125 plaque brachytherapy.", "This lesion corresponds to the site of the choroidal melanoma and plaque placement.A radioactive episcleral iodine 125 (125I) plaque was surgically placed over the lesion and removed 1 week later.", "The tumor height decreased to 2.3 mm by 1 year and remained at less than 2 mm in years 2 through 4\u00bd on B-scan ultrasonography (Figure, B).At her last follow-up, the patient had a 4.5\u2009\u00d7\u20093.0-mm bluish black flat lesion on the sclera (Figure, C).", "Results of a dilated fundus examination showed a grayish black, minimally elevated choroidal lesion with surrounding retinal pigment epithelial atrophy but without subretinal fluid, hemorrhage, or hard exudates."], "Treatment": ["C, An external slitlamp photograph of the left eye shows a bluish black pigmented lesion on the sclera measures 4.5\u2009\u00d7\u20093.0 mm (anterior-posterior by horizontal orientation).", "The tumor decreased in height, and visual acuity remained stable at 20/30 OS."], "Diagnosis": ["Her choroidal melanoma was located at the 11- to 1-o\u2019clock position, anterior to the equator but posterior to the ciliary body."]}
{"Patient Personal Background": ["He was diagnosed as having nephropathy 5 years ago."], "Patient Symptoms": ["He presented with a history of bilateral, painless, progressive visual diminution for 2 years."], "Examination and Results": ["On examination, his best-corrected visual acuity was 20/200 in both eyes.", "He had bilateral posterior subcapsular cataracts.", "Both the corneas were clear.", "Intraocular pressures were 14 and 16 mm Hg in the right and left eyes, respectively, by Goldmann applanation tonometry.", "Dilated ophthalmoscopy revealed a hypopigmented zone in the parafoveal macula (Figure).", "Color vision testing revealed red-green deficiencies in both eyes.Advanced chloroquine retinopathy."], "Diagnosis": ["Color vision testing revealed red-green deficiencies in both eyes.Advanced chloroquine retinopathy.", "Fundus photographs of the right (A) and left (B) eyes showing hypopigmented zones concentric to the fovea consistent with chloroquine retinopathy."]}
{"Patient Personal Background": ["The patient was otherwise healthy with normal development and growth.", "She had no other medical problems and was not taking any medications.", "The patient\u2019s history was otherwise unremarkable; she had no pets, had no recent travel outside the United States, and her vaccinations were up to date.On physical examination, the patient had well-defined, follicular, pink, scaly papules coalescing into thin plaques on her knees (Figure 1A), elbows, and dorsal hands and feet, as well as diffuse, marked orange-red hyperkeratosis and hyperlinearity of her palms with clear demarcation at the wrists (Figure 1B).A, Well-defined follicular, pink, scaly papules coalescing into plaques on the patient\u2019s knees."], "Patient Symptoms": ["The rash started as small pink bumps on her knees and elbows, spreading to her hands and feet and progressively thickening."], "Examination and Results": ["The patient\u2019s history was otherwise unremarkable; she had no pets, had no recent travel outside the United States, and her vaccinations were up to date.On physical examination, the patient had well-defined, follicular, pink, scaly papules coalescing into thin plaques on her knees (Figure 1A), elbows, and dorsal hands and feet, as well as diffuse, marked orange-red hyperkeratosis and hyperlinearity of her palms with clear demarcation at the wrists (Figure 1B).A, Well-defined follicular, pink, scaly papules coalescing into plaques on the patient\u2019s knees."], "Treatment": ["B, Marked orange-red hyperkeratosis of the patient\u2019s palms.Initial treatment with hydrocortisone valerate cream, 0.2%, provided minimal improvement."], "Others": ["A 4-mm skin punch biopsy was performed."]}
{"Patient Personal Background": ["There was no family or personal history of bleeding disorders."], "Patient Symptoms": ["The epistaxis occurred 3 to 4 times a day and resolved with pressure.", "He did not have facial pain, facial paresthesia, or visual changes."], "Examination and Results": ["Nasal endoscopy revealed a large, well-vascularized, polypoid mass filling the right anterior nasal cavity.", "A computed tomographic scan showed a right nasal cavity mass (4.5\u2009\u00d7\u20091.7 cm) extending to the posterior choana with opacification and bony remodeling of the right maxillary sinus.", "The mass had heterogeneous intermediate signal intensity on T2-weighted magnetic resonance imaging (Figure, A).", "Hematoxylin-eosin stain showed a sheet-like proliferation of epithelioid and polygonal cells with pale eosinophilic granular cytoplasm and relatively uniform vesicular nuclei (Figure, B).", "The cells were arranged in nests.", "Branching, staghorn-like blood vessels were scattered throughout the tumor.", "The tumor cells stained positive for smooth muscle actin (Figure, C), muscle specific actin, Bcl-2, INI-1, and transcription factor E3 (Figure, D).", "A, T2-weighted magnetic resonance imaging (MRI) scan of a right nasal cavity mass extending to the posterior choana with heterogeneous intermediate signal intensity.", "B and C, Histopathologic images.", "B, A sheetlike proliferation of epithelioid and polygonal cells with pale eosinophilic granular cytoplasm and relatively uniform vesicular nuclei (hematoxylin-eosin, original magnification \u00d740).", "C, The tumor cells stained positive for smooth muscle actin (original magnification \u00d720)."], "Treatment": ["The patient was taken to the operating room for biopsy and possible excision of the nasal mass.", "However, the lesion was found to have a narrow pedicle of attachment and was resected in its entirety."], "Others": ["As the lesion was biopsied, there was brisk bleeding.", "The mass was based on the superior aspect of the nasal septum and cribriform plate."]}
{"Patient Symptoms": ["His parents reported that he complained of left orbital pain just before they noticed the swelling, and he was treated with cold compresses with only slight improvement.", "He had never experienced these symptoms before.", "The patient had not experienced diplopia, change in visual acuity, nasal obstruction, change in oral intake, weight loss, recent upper respiratory infection, sick contacts, fevers, or chills."], "Examination and Results": ["At the time of presentation, the patient was breathing comfortably and was afebrile.", "Findings from his head and neck examination were significant for a firm mass over the left zygoma and lateral infraorbital rim, 2\u2009\u00d7\u20093 cm in diameter.", "The mass was nontender, nonerythematous, and fixed to the underlying zygoma and lateral infraorbital rim.", "There was no cervical lymphadenopathy.", "Ophthalmology examination revealed intact extraocular movements, bilateral visual acuity of 20/50, and no evidence of afferent papillary defect.", "Computed tomographic (CT) images showed a round, soft-tissue mass with osseous destruction and erosion into the zygoma, infratemporal fossa, inferolateral orbit, and maxillary sinus (Figure, A and B).", "Concern for orbital involvement prompted magnetic resonance imaging (MRI) of the maxillofacial region (Figure, C and D)."], "Treatment": ["He was taken to the operating room the following day for open biopsy."], "Others": ["A and B, Computed tomographic images of the maxillofacial region showing a round, soft-tissue mass.", "A, Coronal view.", "B, Axial view.", "C and D, Magnetic resonance imaging (MRI) scans of the maxillofacial region; C, T2-weighted MRI scan, axial view.", "D, Postcontrast T1-weighted MRI scan, coronal view."]}
{"Patient Personal Background": ["However, he used to wear a cap, which created pressure and friction on the upper part of both ears."], "Patient Symptoms": ["The nodules were painful on touch, especially while the patient was sleeping in a lateral position.", "There was no history of trauma.", "They were tender on palpation."], "Examination and Results": ["On examination, the free border of the helix of both the ears showed a few dull red, dome-shaped, firm nodules 2 to 3 mm in size with central crusting (Figure, A).", "No cervical lymphadenopathy was observed.", "One of the nodules on the right ear was excised; histopathologic features of the nodule are shown in the Figure, B.", "It showed a sharply defined, centrally depressed ulcer covered by a hyperkeratotic parakeratotic scale, occasional bacterial colonies, and plasma.", "The adjacent epidermis showed hyperplasia.", "The base of ulcer showed eosinophilic degeneration of collagen and solar elastosis.", "In addition, there were a few proliferating blood vessels and mild lymphomononuclear infiltrate.", "Underlying cartilage was not seen in the section.", "On serial sectioning, cartilage was seen and found to be normal.A, An ear with dull red, dome-shaped, firm nodules 2 to 3 mm in size with central crusting (arrowheads)."], "Others": ["B, Histopathologic image (hematoxylin-eosin, original magnification \u00d7100)."]}
{"Patient Symptoms": ["She first noticed the mass following an uncomplicated dental procedure.", "It grew slowly for a few years but then stabilized.", "She stated that it was sensitive to cold liquids but was otherwise asymptomatic."], "Examination and Results": ["Results from routine laboratory tests and hematologic markers were normal.", "Examination revealed a roughly 4\u2009\u00d7\u20092.5-cm, nontender, firm mass anterior to the right mandibular parasymphysis.", "The mass was fully mobile relative to the underlying mandible and could be seen bulging into the gingivolabial sulcus.", "There were no overlying skin or mucosal changes, and the skin and mucosa moved freely over the mass.", "Computed tomographic (CT) imaging demonstrated a well-defined, hyperdense, mildly heterogeneous mass with few focal areas of fat attenuation along the inferior aspect of the lesion (Figure, A-C).", "The mass was separate from the right mandibular parasymphysis without evidence of periosteal reaction or erosion into the underlying bone.", "The surrounding soft tissues appeared unremarkable.", "No additional lesions were noted.", "The mass was not fixed to any adjacent structures.A-C, Computed tomographic images.", "Axial views of soft tissue (A) and bony windows (B) demonstrating an ossified hyperdense mass within the right gingivobuccal space with well-defined margins."], "Treatment": ["The patient was taken to the operating theater, where a firm, multilobulated, yellow mass was excised through a gingivolabial incision (Figure, D)."], "Others": ["D, The intraoperative photograph shows the well-defined mass, just prior to removal, arising in the right gingivobuccal space, separate from the underlying mandible."]}
{"Patient Personal Background": ["She was diagnosed with depression and began treatment with antidepressant medication.After 8 months, she had worsening complaints."], "Patient Symptoms": ["At that time, a family member reported that her memory problems had progressed.", "She was no longer able to find misplaced objects, remember appointments, or handle financial affairs.", "She was often subdued, her mood depressed, and her sleeping time increased."], "Examination and Results": ["Clinical examination at that time revealed a flattened affect and a 22 of 30 Mini-Mental State Examination score.", "Findings were otherwise normal, and there were no focal neurologic deficits.", "Basic laboratory workup results were unremarkable.", "She was referred to a neurologist, who ordered contrast-enhanced magnetic resonance imaging (MRI) of the brain.The MRI (Figure) revealed extensive ill-defined areas of FLAIR (fluid-attenuated inversion recovery) and T2 signal abnormalities with additional enhancing nodular foci located within deep white matter structures, the basal ganglia, the caudate, the pons, and the midbrain.", "Also identified was enhancement of the interpeduncular cistern and cerebral peduncles, suggestive of leptomeningeal involvement.Magnetic resonance images (MRIs) of the head obtained 8 months after patient\u2019s first clinical visit.", "A, Axial T2-weighted MRI of the head at the level of the lateral ventricles demonstrates extensive ill-defined areas of increasing signal with only minimal associated mass effect involving the frontal lobe white matter, greater on the left than on the right."], "Treatment": ["She was diagnosed with depression and began treatment with antidepressant medication.After 8 months, she had worsening complaints."]}
{"Patient Symptoms": ["Episodes progressed in frequency and duration, occurring several times daily and lasting for hours.", "His symptoms were prominent after activity and reliably triggered by straining with urination and terminated by lying supine.", "The patient also reported a 1-week history of urinary retention requiring intermittent self-catheterization."], "Examination and Results": ["Neurological examinations both during and between episodes revealed symmetric patellar and Achilles hyperreflexia with bilateral crossed adductor response, but otherwise the results were normal.", "A thoracic spine magnetic resonance imaging scan with fast imaging employing steady-state acquisition (FIESTA) sequences was obtained (Figure).", "A dynamic computed tomographic myelogram demonstrated a lesion compressing the dorsal spinal cord at the T7 level (Video).Magnetic resonance imaging (MRI) of the thoracic spine using fast imaging employing steady-state acquisition (FIESTA) sequences.", "The MRI scan with FIESTA sequences revealed a blurry spinal cord signal alteration at the T7-T8 level with deformation of the cord posteriorly (arrowhead)."]}
{"Patient Personal Background": ["Her medical history included hypertension and gastroesophageal reflux.", "She had no smoking or alcohol history.", "Her only operations in the past were nononcologic, nongastrointestinal procedures.On examination, her heart and lungs were normal."], "Patient Symptoms": ["She reported acute onset of pain that woke her up from sleep, was crampy in nature, and was localized to the right upper quadrant.", "She denied any nausea or vomiting and there was no association with eating.", "She reported similar pain over the previous month but not to the current severity.", "There was no history of fevers/chills, diarrhea, melena, or hematochezia."], "Examination and Results": ["Her abdomen was soft but tender in the right upper quadrant.", "Laboratory evaluation revealed a normal compete blood cell count, including a white blood cell count of 8900/\u00b5L (to convert to \u00d7109 per liter, multiply by 0.001).", "Results from a complete metabolic panel, including lipase, and from carcinoembryonic antigen and carbohydrate antigen 19-9 testing were normal.", "Ultrasonography revealed asymmetric thickening of the gallbladder wall without pericholecystic fluid.", "Computed tomographic scans of the abdomen with oral and intravenous contrast were obtained (Figure 1).Computed tomographic scan with coronal (A) and sagittal (B) views showing a soft-tissue mass associated with the fundus of the gallbladder."], "Others": ["She had never had a colonoscopy."]}
{"Patient Personal Background": ["She had no personal or family history of venous thrombosis and did not have any recent surgery, trauma, or admission to hospital.", "Her long-term medications included fluoxetine, vitamin D, and hydrochlorothiazide.On examination, temperature was 38.3\u00b0C (101\u00b0F), blood pressure was 157/78 mm Hg, pulse rate was 82 beats per minute, and respiratory rate was 20 breaths per minute."], "Patient Symptoms": ["She had no leg swelling and no pain on calf palpation."], "Examination and Results": ["Her long-term medications included fluoxetine, vitamin D, and hydrochlorothiazide.On examination, temperature was 38.3\u00b0C (101\u00b0F), blood pressure was 157/78 mm Hg, pulse rate was 82 beats per minute, and respiratory rate was 20 breaths per minute.", "Oxygen saturation was 97% in room air.", "She had a regular heart rate with a mild systolic murmur; her jugular venous pressure was normal; and  lung auscultation revealed reduced air entry at the left base.", "Laboratory testing results are reported in Table 1.", "The clinical probability of PE was unlikely (Wells score).D-dimer test result is positive."], "Diagnosis": ["The attending physician raised the diagnosis of a pulmonary embolism (PE) among the differentials."], "Others": ["Imaging test is required.D-dimer test result is positive.", "The diagnosis of PE is confirmed.D-dimer test result is positive but below her age-adjusted cutoff.", "PE is ruled out.D-dimer test result is positive due to active malignancy.", "PE is ruled out."]}
{"Patient Personal Background": ["The pain began after the patient began to play competitive basketball and was localized to her mid shin.", "Dietary and menstrual histories revealed no abnormalities."], "Patient Symptoms": ["The pain began after the patient began to play competitive basketball and was localized to her mid shin.", "The single-leg hop test elicited severe localized pain."], "Examination and Results": ["Examination demonstrated focal tenderness along the distal mid shaft of the tibia anteriorly.", "Radiographs were obtained for further evaluation (Figure).Radiography of the right lower leg.", "Left, Anteroposterior view."]}
{"Patient Personal Background": ["He was diagnosed with bronchiectasis of unknown etiology 6 years ago and notes a worsening of his cough and dyspnea over the past few months.", "His medications include albuterol inhaler, fluticasone-salmeterol inhaler, guaifenesin, and loratadine.Left, Axial computed tomography scan of the chest revealing mild bronchiectasis and ground glass inflammation."], "Patient Symptoms": ["He was diagnosed with bronchiectasis of unknown etiology 6 years ago and notes a worsening of his cough and dyspnea over the past few months.", "He has a purpuric plaque on the right medial ankle and dorsal foot, with central vesicles (Figure, right).", "The rash is tender to palpation, and there is associated nonpitting edema of the right foot and ankle."], "Examination and Results": ["A recent computed tomography scan of the chest revealed mild bronchiectasis and ground glass inflammation (Figure, left), and recent pulmonary function tests showed combined obstructive and restrictive defects.", "Right, Purpuric plaque on the right medial ankle and dorsal foot, with central vesicles.On examination, the patient\u2019s vital signs are normal.", "The rash is tender to palpation, and there is associated nonpitting edema of the right foot and ankle.", "Laboratory values are notable for a leukocyte count of 15\u2009700 cells/\u00b5L, with 38% eosinophils (absolute count, 5950 cells/\u00b5L; normal, <350).", "His platelet count was 272\u2009000, and his hemoglobin level was 14.7 g/dL."], "Treatment": ["His medications include albuterol inhaler, fluticasone-salmeterol inhaler, guaifenesin, and loratadine.Left, Axial computed tomography scan of the chest revealing mild bronchiectasis and ground glass inflammation."], "Diagnosis": ["He was diagnosed with bronchiectasis of unknown etiology 6 years ago and notes a worsening of his cough and dyspnea over the past few months."], "Others": ["He has had no fevers, joint pain, recent trauma, or new exposures to the area."]}
{"Patient Symptoms": ["She was otherwise asymptomatic.", "The patient returned 1 week later with worsening cutaneous eruptions and new complaints of fever, weakness, and malaise."], "Examination and Results": ["Findings from physical examination were notable for discrete skin-colored to pink papules coalescing into plaques on her face, trunk (Figure, A and B), and all 4 extremities.", "There was no scale or other epidermal change.", "A punch biopsy for hematoxylin-eosin staining was performed (Figure, C).", "Repeat physical examination revealed splenomegaly and axillary lymphadenopathy.", "A peripheral blood smear (Figure, D) and other diagnostic tests were performed.A, Discrete skin-colored to pink papules on the abdomen.", "B, Discrete papules coalescing into plaques on superior gluteal cleft.", "C, Punch biopsy specimen (hematoxylin-eosin).", "D, Peripheral blood smear (hematoxylin-eosin, original magnification \u00d7100)."]}
{"Patient Symptoms": ["On physical examination, the patient was in severe discomfort with limited movement owing to cutaneous pain.", "He was cachectic and had widespread erosions and tense and flaccid bullae with overlying crust affecting his trunk and extremities (including the palms and soles) but sparing his scalp (Figure, A).", "He had severe stomatitis with localized hemorrhagic lesions, shaggy erosions on the buccal and gingival mucosa, and erythematous macules on his hard and soft palates (Figure, B)."], "Examination and Results": ["Findings from laboratory tests, including a complete blood cell count and a comprehensive metabolic panel, were unremarkable except for mild anemia.", "Results from a computed tomographic scan of the chest and neck showed adenopathy suspicious for lymphoproliferative disorder or potentially metastatic disease.", "A punch biopsy for histopathologic examination (Figure, C) and direct immunofluorescence (DIF) was performed, and serum was tested for indirect immunofluorescence (IIF) on rodent epithelium (Figure, D).A, Erosions, tense and flaccid bullae, and overlying crust over the dorsal side of the foot.", "B, Severe stomatitis and hemorrhagic crust.", "C, Histopathologic image of a biopsy specimen showing suprabasal acantholysis and a dermal infiltrate of lymphocytes, histiocytes, and scattered eosinophils (hematoxylin-eosin, original magnification \u00d720).", "D, Positive indirect immunofluorescence test of rat urinary bladder epithelium."]}
{"Patient Personal Background": ["SLE had been diagnosed ten years previously after she presented with a positive antinuclear antibody titer (most recent titer, 1:1280), arthralgias, leukopenia, oral ulcers, and a malar erythematous eruption.", "There was no history of discoid or tumid lupus lesions."], "Patient Symptoms": ["SLE had been diagnosed ten years previously after she presented with a positive antinuclear antibody titer (most recent titer, 1:1280), arthralgias, leukopenia, oral ulcers, and a malar erythematous eruption.", "Physical examination revealed poorly demarcated erythematous plaques and nodules, tender to palpation, ranging from the distal thigh to the lower leg, adjacent to arthroscopy sites."], "Examination and Results": ["Physical examination revealed poorly demarcated erythematous plaques and nodules, tender to palpation, ranging from the distal thigh to the lower leg, adjacent to arthroscopy sites.", "Lesions around the suture sites appeared more violaceous.", "A punch biopsy of the lesion was performed (Figure, B and C).A, Clinical photograph of right knee demonstrating ill-defined erythematous plaques and nodules adjacent to 2 small incisional scars from previous arthroscopy.", "B and C, Photomicrographs of punch biopsy specimen.", "B, Hematoxylin-eosin, original magnification \u00d74.", "C, Hematoxylin-eosin, original magnification \u00d710."], "Treatment": ["Initially, the lesions were thought secondary to soft-tissue infection and were treated with courses of clindamycin, vancomycin, and doxycycline."], "Diagnosis": ["SLE had been diagnosed ten years previously after she presented with a positive antinuclear antibody titer (most recent titer, 1:1280), arthralgias, leukopenia, oral ulcers, and a malar erythematous eruption."]}
{"Patient Personal Background": ["His ocular history included enucleation of his right eye secondary to a traumatic ruptured globe 6 years previously.", "He denied any systemic medical problems and was not taking any medications."], "Patient Symptoms": ["He reported that he first noticed a small lesion on the nasal conjunctiva of his left eye 6 months earlier; there was rapid growth during the last 2 months.", "The mass became painful 4 weeks earlier and started to affect his vision 2 weeks earlier."], "Examination and Results": ["On examination, his visual acuity was no light perception OD (prosthesis) and light perception OS.", "External examination revealed a well-fitting prosthesis in the right eye with a healthy upper and lower eyelid fornix."], "Treatment": ["An incisional biopsy was performed.Clinical photograph at presentation demonstrating a large, hemorrhagic, necrotic mass obscuring the entire globe and eyelids of the left eye."], "Others": ["The left eye is shown in Figure 1."]}
{"Patient Personal Background": ["Her medical history was significant for stage II breast carcinoma with positive lymph nodes, which was diagnosed and treated 5 years prior."], "Examination and Results": ["Visual acuity was 20/60 OD and 20/20 OS.", "Ophthalmoscopy of the right eye revealed a 6\u2009\u00d7\u20096-mm circumscribed serous macular detachment with turbid subretinal fluid.", "Similar lesions were present in the nasal and inferior midperiphery (Figure, A and B).", "The left eye was unremarkable.", "Fluorescein angiography (FA) showed hyperfluorescent pinpoint hot spots with interspersed hypofluorescent patches in the areas of the lesions (Figure, C-F).", "Notably absent on FA were retinal pigment epithelium (RPE) leakage, a smokestack pattern of subretinal leakage, or RPE gutter defects.", "B-scan ultrasonography demonstrated choroidal thickening nasal to the optic disc (Figure, G); vascularity could not be assessed.", "Optical coherence tomography (OCT) showed a localized serous macular detachment with a focal area of choriocapillaris infiltration and thickening near the nasal edge of the detachment (Figure, H).Fundus photograph (A-B) of the right eye demonstrates a serous macular detachment with yellowish choroidal discoloration.", "A, Similar yellowish choroidal lesions (arrowheads) were present in the nasal and inferior midperiphery.", "B, The enlarged image demonstrates the extent of serous macular detachment (arrowheads).", "C, Wide-angle fluorescein angiography in the late venous phase of the right eye shows an area between the disc and fovea with scattered hyperfluorescent hotspots.", "Magnified views of the macular lesion (D), nasal lesion (E), and inferior lesion (F).", "G, B-scan ultrasonography of the right eye shows a subtle nonspecific choroidal thickening with medium internal reflectivity.", "The arrowhead points to the choroidal infiltration by the metastatic tumor."]}
{"Patient Personal Background": ["The child was otherwise well and no previous skin or nail conditions were known."], "Patient Symptoms": ["Her mother reported a sudden onset of brittle nails with cracks followed by painless sloughing of nails.", "Initially only the fingernails had been affected, but the toenails soon showed the same pathology."], "Examination and Results": ["On clinical examination, most fingernails showed semilunar whitish grooves in the middle of the nail plate (Figure, A).", "The toenails had transverse partial cracks of the proximal nail plate with distal onycholysis but normal proximal nail growth (Figure, B).Findings on clinical examination.", "A, Fingernails showed semilunar whitish grooves in the middle of the nail plate.", "B, Toenails had transverse partial cracks of the proximal nail plate with distal onycholysis."], "Others": ["The family was concerned and suspected an internal disease or vitamin deficiency."]}
{"Patient Personal Background": ["He had no history of sinus disease or surgery and had no epistaxis, weight loss, or visual symptoms."], "Examination and Results": ["Computed tomography showed a 3.1-cm mass in the left ethmoid sinus and nasal cavity (Figure, A).", "Positron emission tomographic scanning showed no evidence of metastasis.", "Nasal endoscopy revealed a friable, polypoid mass in the ethmoid sinus with extension into the nasal cavity and superiorly to the skull base.", "A biopsy specimen showed a heterogeneous tumor with small, angulated, blue cells with hyperchromatic nuclei, apoptosis, and mitosis, malignant glands lined by cuboidal cells with round nuclei, prominent nucleoli, and eosinophilic cytoplasm.", "The glands had luminal mucin production (Figure, B).", "Focally, there were also scattered round cells with abundant eosinophilic, refractile cytoplasm, features of rhabdomyoblasts (Figure, C).", "These latter cells were strongly positive for desmin (Figure, D) and myogenin."], "Others": ["Ethmoid sinus mass.", "A, Computed tomographic scan.", "The arrowhead indicates the mass.", "B, Blastema as indicated by the asterisk and malignant glands as indicated by the arrowhead.", "C, Rhabdomyoblasts as indicated by the arrowheads (hematoxylin-eosin, original magnification \u00d740).", "D, Desmin immunohistochemistry with strong positive staining in the rhabdomyoblasts (original magnification \u00d720)."]}
{"Examination and Results": ["Endoscopic nasopharyngoscopy revealed a large polypoid nasal mass occupying the left nasal roof and completely obstructing the nasal passage.", "Contrast-enhanced T1-weighted magnetic resonance imaging (MRI) revealed a 1.7\u2009\u00d7\u20093.5\u2009\u00d7\u20092.6-cm soft-tissue mass within the left ethmoid cavity, eroding through the cribriform plate with adjacent dural enhancement (Figure, A).", "Intraoperative pathologic examination showed polypoid spindle cell proliferation.", "Histopathologic findings showed respiratory epithelium with submucosal vascular proliferation with no atypia among the lining endothelial cells.", "The Figure, B, shows a central vessel surrounded by lobules of endothelial lined capillaries.", "The Figure, C, highlights the endothelial cells of the numerous capillaries and the central vessel.A, Contrast-enhanced T1-weighted magnetic resonance imaging of a soft-tissue mass within the left ethmoid cavity.", "B, Central vessel surrounded by lobules of endothelial-lined capillaries (hematoxylin-eosin, original magnification \u00d720).", "C, Endothelial cells of the numerous capillaries and the central vessel on CD34 staining (original magnification \u00d720)."]}
{"Patient Symptoms": ["Although she had been experiencing a gradually increasing lumpy feeling on swallowing for at least 6 months, she did not experience of dysphagia, dyspnea, or pain."], "Examination and Results": ["Physical examination revealed a mass measuring approximately 4\u2009\u00d7\u20093 cm and covered with normal mucosa on the posterior oropharyngeal wall.", "This tumor was firm, nontender, and firmly adherent (Figure, A).", "Computed tomography (CT) showed a segmented bony lesion located at the odontoid process and the body of the C2 vertebra (Figure, B).", "This mass showed high signal intensity with a hypointense rim in both T1- and T2-weighted magnetic resonance images (MRI) (Figure, C and D, respectively).", "Polysomnography was performed and showed an apnea-hypopnea index of 58.7/h and a minimal oxygen saturation of 76%, which led to a diagnosis of obstructive sleep apnea."], "Treatment": ["Hence, we performed total excision of the mass using a per-oral approach.A, Photograph of an oropharyngeal mass."], "Diagnosis": ["The mass was considered causative of obstructive sleep apnea."]}
{"Patient Personal Background": ["She was otherwise healthy, with no medical or surgical history."], "Patient Symptoms": ["She had no associated pain, difficulty swallowing, or difficulty breathing."], "Examination and Results": ["Findings from her physical examination were unremarkable with the exception of a 2\u2009\u00d7\u20092-cm firm, nontender, submucosal posterior soft palate mass just left of the uvula.", "There was no overlying ulceration or discoloration.", "Flexible nasopharyngoscopy was normal.", "Prior to presentation, a computed tomographic scan and biopsy had been performed at an outside hospital.", "Magnetic resonance imaging (MRI) of the face with contrast was also performed (Figure, A-C).", "Imaging showed a well-circumscribed solid lesion with no evidence of infiltration of soft-tissue structures, the pterygopalatine fossa, or palatine nerve foramina.", "There was no cervical lymphadenopathy."], "Treatment": ["The lesion was resected via a transoral approach and was easily dissected from the surrounding tissue (Figure, D)."], "Others": ["The overlying mucosa was spared."]}
{"Patient Personal Background": ["The patient had a history of prostate cancer treated with prostatectomy 4 years previously without evidence of recurrence and melanoma of the posterior neck treated with wide local excision, in addition to non\u2013insulin-dependent diabetes mellitus and hyperlipidemia controlled with oral medications.", "He does not smoke and has been in a monogamous marriage for more than 30 years."], "Patient Symptoms": ["The rash initially started 4 years prior as a dime-sized, pink, scaly area in the right inguinal crease and was pruritic.", "Since then, the rash had failed to resolve and the affected area had increased in size to its present dimensions."], "Examination and Results": ["Examination revealed a multifocal scaly, pink-red beefy plaque in the right inguinal crease extending from the superior aspect of the scrotum to the gluteal crease measuring approximately 6\u2009\u00d7\u20097 cm in total area with some areas of excoriation and superficial open wounds.", "An additional area of macular erythema extended superiorly along the inguinal crease toward the medial thigh.", "No lymphadenopathy of the inguinal region was noted."], "Treatment": ["Results of a biopsy at the time were consistent with lichen simplex chronicus, and treatment with topical steroids was initiated."], "Diagnosis": ["Results of a biopsy at the time were consistent with lichen simplex chronicus, and treatment with topical steroids was initiated."]}
{"Examination and Results": ["An abdominal magnetic resonance image is shown in Figure 1A.", "Laparotomy exposed a giant multinodular mass (Figure 1B).A, Abdominal magnetic resonance image."], "Treatment": ["Given the symptoms and magnetic resonance imaging findings, the patient was eventually taken to the operating room."], "Others": ["B,Intraoperative photograph of the giant multinodular mass occupying most of the upper abdomen."]}
{"Patient Personal Background": ["She had previously lived in Beijing, China.", "During that evaluation, the patient reported that she had run in areas with dog feces on the ground and had eaten sheep meat (notably, not organ meat); she denied consuming canine meat."], "Patient Symptoms": ["In 2011, she was evaluated in a Chinese clinic for abdominal bloating and moderate left upper quadrant pain; she was offered a splenectomy, but she declined and pursued a second opinion at a hospital in the United States in 2012."], "Examination and Results": ["Results of serologic tests for Echinococcus antibody IgG were negative.", "Results of a CT scan were remarkable for a 9.7\u2009\u00d7\u20099.0\u2009\u00d7\u200910.5-cm anterior cyst and a smaller posterior cyst measuring 4.6\u2009\u00d7\u20094.7\u2009\u00d7\u20093.8 cm, both with rim calcifications (Figure 1).A large splenic cyst with calcified capsule is present in the anterior aspect of the spleen, with a smaller cyst in the posterior aspect of the spleen, also with calcified capsule.", "Arrowheads indicate the location of the cysts.", "Under higher resolution, debris is noted within the larger cyst."]}
{"Patient Personal Background": ["A glioma of the optic chiasm was treated 20 years prior with chemotherapy and radiation.", "Medications included analgesics, cyclobenzaprine, sumatriptan, ondansetron, divalproex sodium, gabapentin, furosemide, somatotropin, potassium chloride, vitamin D, and estrogen."], "Patient Symptoms": ["Sequelae included chronic headaches, anterior hypopituitarism, and hydrocephalus necessitating a ventriculoperitoneal shunt."], "Examination and Results": ["Blood pressure was 125/87 mm Hg.", "Mucosae were moist and jugular venous pressure was not well seen.", "Her cardiopulmonary and abdominal examinations were normal, peripheral edema was absent, and sensorium was clear."], "Treatment": ["Haloperidol was recently added."], "Others": ["Table 1 shows initial laboratory data."]}
{"Patient Personal Background": ["He reported being diagnosed with dermatitis herpetiformis more than 20 years ago and receiving sulfapyridine and dapsone for treatment.", "He stopped taking these medications because of limited benefit and concern about nephrotoxicity.", "Physical examination revealed diffuse erosions with grouped papules and vesicles on his bilateral extremities, elbow and knee extensors, chest, back, buttocks, face, and scalp (Figure 1)."], "Patient Symptoms": ["Recently, extensive skin disease and pruritus developed.", "He noted 20 years of chronic diarrhea, which improved with a gluten-free diet, in addition to chronic renal insufficiency, hypothyroidism, and aortic stenosis."], "Examination and Results": ["Examination also revealed extensive excoriations, as well as superficial honey-colored crusts."], "Treatment": ["Since then, he was treated with periodic courses of oral antibiotics and oral corticosteroids."]}
{"Patient Symptoms": ["She reported no chest pain, dyspnea on exertion, presyncope, orthopnea, paroxysmal nocturnal dyspnea, or pedal edema.Physical examination demonstrated blood pressure of 140/76 mm Hg and a heart rate of 72/min."], "Examination and Results": ["She reported no chest pain, dyspnea on exertion, presyncope, orthopnea, paroxysmal nocturnal dyspnea, or pedal edema.Physical examination demonstrated blood pressure of 140/76 mm Hg and a heart rate of 72/min.", "Carotid upstrokes were slightly delayed with a transmitted murmur.", "Lungs were clear bilaterally.", "Cardiac examination demonstrated a regular rate and rhythm, normal S1, 3/6 harsh, late-peaking systolic murmur that radiated to the carotids with soft A2, 2/4 diastolic decrescendo murmur at the left lower sternal border, and 2/6 holosystolic murmur at the apex.", "Distal pulses were 2+ bilaterally.", "There was no edema.A 2-D and Doppler transthoracic echocardiogram (TTE) was performed to assess valvular function (Table; Interactive).The patient has functional mitral regurgitation secondary to a dilated cardiomyopathy.The patient has moderate aortic valve stenosis with the severity overestimated by Doppler measurements.The patient has severe aortic valve stenosis with preserved left ventricular systolic function."], "Diagnosis": ["There was no edema.A 2-D and Doppler transthoracic echocardiogram (TTE) was performed to assess valvular function (Table; Interactive).The patient has functional mitral regurgitation secondary to a dilated cardiomyopathy.The patient has moderate aortic valve stenosis with the severity overestimated by Doppler measurements.The patient has severe aortic valve stenosis with preserved left ventricular systolic function."]}
{"Patient Personal Background": ["Past medical history was significant only for well-controlled hypertension treated with irbesartan (300 mg daily) and poor vision in the left eye for many years attributable to presumed inactive ocular histoplasmosis.On presentation, the patient appeared well, with blood pressure of 140/70 mm Hg and a regular heart rate of 75/min."], "Patient Symptoms": ["He also noticed rhythmic pulsing sounds in both ears during the past month."], "Examination and Results": ["Best corrected visual acuity was 20/200 (right eye) and counting fingers at 1 foot (left eye).", "Direct ophthalmoscopy revealed severe bilateral optic disc edema, peripapillary hemorrhages, and absent spontaneous venous pulsations (Figure 1).", "Findings from a full neurologic examination were otherwise normal."]}
{"Patient Personal Background": ["At the time of consultation, the patient was taking oral treatment with duloxetine hydrochloride, clonazepam, oxcarbazepine, fentanyl, sulpiride, zopiclone, omeprazole magnesium, and baclofen.", "He also admitted to self-administering subcutaneous injections of meperidine, 100 mg 4 times per day, for the past 3 years, at different sites, including the deltoid areas and abdomen."], "Patient Symptoms": ["Physical examination disclosed a large and deep, irregularly shaped, cutaneous ulcer on the dorsum of his right forearm.", "Necrotic tissue and muscle exposure was seen at the base of the ulcer (Figure, A).", "Woody induration of skin on both forearms and on the abdominal region was also observed.", "Bilateral contracture of deltoid, triceps, and biceps muscles was noted.", "Active and passive range of motion was restricted at the shoulders and elbows."], "Examination and Results": ["No signs of joint inflammation were seen.", "Growth from culture specimens taken from the ulcer was negative for bacteria, mycobacteria, and fungal organisms.", "His serum creatinine kinase level was raised (192 U/L; reference range, 0-174 U/L), but test results for complete blood cell count; erythrocyte sedimentation rate; antinuclear antibody, rheumatoid factor, aspartate aminotransferase, alanine aminotransaminase, and aldolase levels; and serum electrophoresis were all within normal limits.", "A wedge biopsy from the indurated skin of the abdominal region was performed (Figure, B and C)."], "Treatment": ["(To convert creatinine kinase to microkatals per liter, multiply by 0.0167."], "Others": [")A, Clinical photograph of the large, deep, irregularly shaped, cutaneous ulcer on the dorsum of the right forearm.", "Three small ulcers are seen adjacent to the larger ulcer.", "B and C, Histologic images of a wedge biopsy specimen from the indurated skin of the abdominal region (hematoxylin-eosin).", "B, Original magnification \u00d710.", "C, Original magnification \u00d740."]}
{"Patient Symptoms": ["He recalled that a small lesion had appeared approximately 8 months prior, and over the past several months he had noted significant growth and pain.", "A nonpruritic rash had also become apparent on his forearms and thighs."], "Examination and Results": ["Physical examination showed a 2-cm macerated pedunculated growth on the left buttock within the intergluteal cleft (Figure, A).", "An erythematous rash was noted on the forearms and thighs with fine scale present at the wrists.A, Photograph of a 2-cm macerated pedunculated growth on the left buttock.", "C, Histopathologic image of immunohistochemical staining for spirochetes (original magnification \u00d7400).A shave biopsy specimen of the exophytic growth on the buttock revealed marked epidermal hyperplasia (Figure, B) with a dense dermal infiltrate containing lymphocytes and plasma cells."], "Others": ["B, Histopathologic image of an exophytic growth on the buttock with marked epidermal hyperplasia (hematoxylin-eosin, original magnification \u00d740)."]}
{"Patient Personal Background": ["He denied consuming tobacco or alcohol regularly.", "He had type 2 diabetes mellitus for 2 years, which was well controlled with oral hypoglycemic agents.", "The patient had no systemic complaints.", "There was no history of high-risk behavior for human immunodeficiency virus (HIV) acquisition."], "Patient Symptoms": ["The lesion had started as a small painless mass on the right lateral aspect of the tongue, which gradually grew and subsequently ulcerated.", "It was asymptomatic except for causing mild difficulty in eating."], "Examination and Results": ["On physical examination, there was a single well-defined ulcer measuring 2\u2009\u00d7\u20092 cm on the right lateral aspect of tongue with a clean base and irregular and elevated heaped-up margins (Figure 1A).", "There was no underlying induration, friability, or bleeding on manipulation.", "The rest of the oral cavity was normal.", "B, Biopsy from the ulcer showing a mixed cell infiltrate (hematoxylin-eosin, original magnification \u00d740).", "C, Intracellular yeast forms within the histiocytes  (original magnification \u00d7100)."], "Others": ["The patient could not recall any history of trauma or tongue bite preceding the lesion.", "A 3-mm punch biopsy from the edge of the ulcer was taken and sent for histopathological examination (Figure 1B and C).A, Tongue ulcer."]}
{"Examination and Results": ["His visual acuity was hand motions, and intraocular pressure measurement was deferred in that eye.", "Findings from examination of the left eye showed a penetrating injury with a 3-pronged barbed fishhook, with 1 prong lodged in the anterior chamber and another lodged in the lower eyelid (Figure 1).", "The status of the crystalline lens was unclear owing to corneal edema.", "No hypopyon was visualized."]}
{"Patient Personal Background": ["She had undergone gastric bypass surgery 3 months before presentation, which was complicated by a gastric ulcer and stricture.", "Other medical history included hypothyroidism and thyroidectomy for thyroid cancer diagnosed 10 years ago.", "Her medication regimen included levothyroxine sodium and occasional bariatric chewable vitamins.", "She denied alcohol or tobacco use or drug abuse."], "Patient Symptoms": ["There was a mild abduction deficit in both eyes as well as prominent upbeating nystagmus.", "The amplitude of the nystagmus increased in upgaze and dampened with downgaze.", "She was unable to read the control plate of the Ishihara test."], "Examination and Results": ["Her best-corrected visual acuity was 20/200 OD and 20/400 OS.", "Her pupils were equally reactive, with no relative afferent pupillary defect.", "Findings from an anterior segment examination were unremarkable.", "Findings from a dilated fundus examination revealed disc edema in both eyes with peripapillary nerve fiber layer thickening and large intraretinal hemorrhages (Figure).A and B, Initial presentation of large intraretinal hemorrhages and disc edema in the left and right eye, respectively."], "Others": ["She had lost 34.5 kg since the procedure."]}
{"Patient Symptoms": ["At the time of transfer, the patient was noted to have choking with feeds as well as a large volume of clear oral secretions that required frequent suctioning."], "Treatment": ["He was transported to a local emergency department.", "Following a difficult orotracheal intubation with multiple attempts, the infant was transferred to a pediatric intensive care unit with a presumptive diagnosis of bronchiolitis.", "During the next 2 days, he was weaned off mechanical ventilation and received oxygen via the nasal cannula.", "He began feeding orally and was transferred to the general inpatient floor.", "Based on these clinical findings, oral food and fluids were withheld from the patient and a fluoroscopic video swallowing study (FVSS) was performed (Figure 1 and Video)."], "Diagnosis": ["Following a difficult orotracheal intubation with multiple attempts, the infant was transferred to a pediatric intensive care unit with a presumptive diagnosis of bronchiolitis."]}
{"Patient Personal Background": ["She reported a weight loss of 40 kg during the previous 12 months concomitant with depression.", "The patient had a history of cardiac arrhythmia, hypertension, and sigmoidectomy for diverticulitis.", "Medications included lasilix, amlodipine, amiodarone, and atenolol.On examination, the patient appeared well."], "Patient Symptoms": ["She reported a weight loss of 40 kg during the previous 12 months concomitant with depression.", "A positive Murphy sign was observed."], "Examination and Results": ["Her vital signs were normal.", "The abdomen was soft without distension.", "Her white blood cell count was 11400/\u03bcL (to convert to \u00d7109/L, multiply by 0.001), her hemoglobin level was 11.5 g/dL (to convert to g/L, multiply by 10.0), and her platelet count was 233 \u00d7103/\u03bcL (to convert to \u00d7109/L, multiply by 1.0).", "The C-reaction protein level was elevated to 41 mg/L (to convert to nmol/L, multiply by 9.524).", "The results of renal and liver function, coagulation, blood level of electrolytes, total protein, albumin, antigen carcino embryonnaire, carbohydrate antigen 19-9, carbohydrate antigen 125, and \u03b22 microglobulin tests were normal.", "The patient had a normal esophagogastroduodenoscopy and colonoscopy.", "Ultrasonography revealed a 10\u2009\u00d7\u20098-m mass in the right hypochondrium.", "Abdominal computed tomography scan revealed a thickened gallbladder wall infiltrating the liver parenchyma.", "There were 3 perihepatic lymph nodes.", "Magnetic resonance imaging showed a greatly enlarged gallbladder with a thickened wall without invading adjacent structures, a continuous mucosal line, and a hypoattenuated intramural nodule (Figure 1)."]}
{"Patient Personal Background": ["Findings from the prenatal ultrasound, most recently conducted at 33 weeks\u2019 gestation, were normal."], "Patient Symptoms": ["The infant was active and well perfused, with a soft but distended abdomen and right-sided labial swelling."], "Examination and Results": ["Her Apgar scores at 1 and 5 minutes were 7 and 9, respectively.", "Findings from the remainder of her examination were unremarkable.An abdominal radiograph revealed dilated small-bowel loops (Figure 1A).", "Radiography of the upper gastrointestinal tract with water-soluble contrast showed a normal pattern of rotation.", "Results of a suction rectal biopsy revealed ganglion cells to be present.", "Serial abdominal radiographic images showed retained contrast in the terminal ileum 6 days following the gastrointestinal series (Figure 1B).A, Abdominal radiograph showing distended small-bowel loops with absent gas in the colon and rectum."], "Treatment": ["The infant\u2019s postnatal course was remarkable for a febrile episode that was presumed to be due to chorioamnionitis in the mother and for which antibiotic treatment was initiated."]}
{"Patient Personal Background": ["He reported no other illnesses and was taking only esomeprazole."], "Patient Symptoms": ["The patient noted chronic, left-sided abdominal pain related to his lymphoma and normal passage of stool and flatus."], "Examination and Results": ["He was afebrile and normotensive with a pulse rate of 104/minute.", "A large, firm, tender mass located near the umbilicus was palpable in his abdomen, but there was no rigidity or rebound tenderness.", "Laboratory studies (Table) showed an elevated lactate level of 6.3 mmol/L (reference range, 0.7-2.2 mmol/L) (56.8 mg/dL; reference range, 6.3-19.8 mg/dL).A computed tomographic scan of the abdomen showed diffuse lymphadenopathy and a large mesenteric mass abutting multiple segments of the small intestine and encasing the mesenteric vasculature.", "His tachycardia improved, but blood lactate remained elevated between 4.7-7.2 mmol/L (42.3-64.9 mg/dL)."], "Treatment": ["He received 3 L of intravenous normal saline in the first 24 hours because of concern about volume depletion and sepsis."], "Diagnosis": ["Serial abdominal examination results remained unchanged from the initial presentation.The patient has lactic acidosis from hypovolemic shock.The patient has lactic acidosis from mesenteric ischemia."]}
{"Patient Personal Background": ["She has a history of hypertension and gastroesophageal reflux disease but no history of smoking."], "Patient Symptoms": ["Two hours prior to presentation, she choked on her food while at dinner and received repeated attempts at the Heimlich maneuver with successful dislodgement of a piece of ham.", "The choking episode lasted for approximately 10 seconds, during which the patient was unable to speak.", "On arrival, she was dyspneic and in respiratory distress."], "Examination and Results": ["Oxygen saturation was 80% with ambient air and improved to 99% with supplemental oxygen delivered via nasal cannula.", "A 12-lead electrocardiogram showed normal sinus rhythm without acute ST or T-wave changes.", "Brain natriuretic peptide level was 84 pg/mL.", "The patient received a chest radiograph and a computed tomographic scan of the chest (Figure).", "Transthoracic echocardiography demonstrated preserved systolic function, with no evidence of valve disease.Top left, Chest radiograph, posteroanterior view.", "Top right, Chest radiograph, left lateral view."]}
{"Patient Personal Background": ["During this period, he had been seen by his primary care physician as well as by hematology, dermatology, and cardiology specialists, who had told the patient his lesions were ecchymoses secondary to warfarin anticoagulation.The patient had no history of malignancy or exposure to communicable diseases."], "Patient Symptoms": ["He experienced a 15.8-kg weight loss during the past few months but denied any fevers or night sweats."], "Examination and Results": ["Physical examination revealed numerous slightly raised erythematous nodules throughout the neck, torso, and bilateral upper extremities (Figure, left).", "Inspection of the oral cavity demonstrated 2 discrete erythematous patches with sharply demarcated borders on the soft palate (Figure, right).", "The remainder of the physical examination was unremarkable.", "Laboratory results revealed a prothrombin time of 11.6 seconds, an international normalized ratio of 1.0, a hemoglobin level of 12.1 g/dL, and a platelet count of 106 cells \u00d7103/\u03bcL; results of a basic chemistry panel with liver function tests were within normal limits."], "Others": ["The skin lesion was biopsied, and results are pending.Left, Erythematous nodules on neck and torso (inset, close view)."]}
{"Patient Personal Background": ["Thirty years ago, he had abnormal liver function tests attributed to use of an unknown medication that resolved when the drug was discontinued.", "He reports no jaundice, pruritus, or family history of liver disease and takes no medications.", "He drinks 1 alcoholic beverage daily (\u2248100 g/week)."], "Examination and Results": ["On physical examination, blood pressure was 108/63 mm Hg, pulse rate was 61 beats per minute, and body mass index (calculated as weight in kilograms divided by height in meters squared) was 23.4.", "His liver was 7.0 cm by percussion and nontender, sclera were anicteric, there was no stigmata of chronic liver disease, and splenomegaly was absent.", "The examination was otherwise unremarkable.", "His laboratory values are reported in the Table."]}
{"Examination and Results": ["Screening mammography (Figure, B) performed 4 weeks prior revealed a large grouping of left breast subareolar calcifications extending into the skin and nipple.", "Follow-up ultrasonography demonstrated no discrete abnormal mass or shadowing but did show multiple echogenic foci consistent with findings on mammography.", "B, Mammography of the left breast."], "Treatment": ["An incisional biopsy specimen of the mass was obtained and sent for histopathologic evaluation (Figure, C).A, Firm, irregular, subareolar nodule of left nipple measuring 2 cm in diameter."], "Others": ["C, Biopsy specimen of the subareolar nodule (hematoxylin-eosin, original magnification \u00d720)."]}
{"Patient Personal Background": ["She had 2 older brothers, and the family had no medical history of note.", "Physical and mental developments were normal."], "Patient Symptoms": ["Physical examination revealed mild xerosis with superficial skin erosions and erythematous residual macules from previous erosions.", "Hair, nails, and mucous membranes were normal.", "The mother explained that she often found the child peeling off skin with marked facility.", "Symptoms improved in winter and worsened in summer."], "Examination and Results": ["Some of the lesions had an unusual linear geographic contour and were predominantly located at areas of friction (Figure, A and B).", "Serological markers for celiac disease were negative.", "A skin biopsy was performed (Figure, C).A, Clinical photograph of a disease outbreak.", "Skin fragility can be seen as superficial erosions distributed predominantly around the trunk, some with geometric shape.", "B, Photograph showing localized affectation of the disease.", "Erythemato-desquamative well-demarcated plaque with peeling borders on right foot.", "C, Hematoxylin-eosin staining (original magnification \u00d740) of healthy skin.", "Remarkable detachment of the entire stratum corneum and mild psoriasiform epidermis hyperplasia with no other significant findings."], "Others": ["There was no history of blistering."]}
{"Patient Symptoms": ["She was initially diagnosed with mastitis and received several courses of antibiotics for 2 months without improvement.", "Subsequently she presented with back pain, paresthesias, shooting pain in the mandibular region, and diplopia."], "Examination and Results": ["A skin biopsy specimen from the breast was obtained (Figure, B).", "Laboratory test results highlighted a hemoglobin level of 7.6 g/dL and a platelet count of 80\u2009000/\u03bcL."], "Treatment": ["All of these conditions improved under treatment with oral corticosteroids, but the breast enlargement continued."], "Diagnosis": ["She was initially diagnosed with mastitis and received several courses of antibiotics for 2 months without improvement."], "Others": ["(To convert hemoglobin to grams per liter, multiply by 10; to convert platelets to number of cells\u2009\u00d7\u2009109/L, multiply by 1.0.", ")A, Enlargement and induration of both breasts.", "B, Histopathologic specimen from the breast (hematoxylin-eosin, original magnification \u00d740)."]}
{"Patient Symptoms": ["At age 3 months, the patient was referred for ophthalmologic examination owing to a flat, hypopigmented lesion in the left temporal iris noted by the patient\u2019s father.", "The patient had multiple hypopigmented macules on his scalp, face, neck, back, limbs, and torso (arrowheads)."], "Examination and Results": ["On examination, the patient fixed and followed with both eyes.", "Pupils, motility, and binocular alignment were normal.", "Dilated ophthalmoscopic examination revealed a well-demarcated hypopigmented lesion originating from the retinal nerve fiber layer and protruding into the vitreous cavity of the right eye (Figure 1B).", "A similar lesion was seen along the left inferotemporal arcade (Figure 1C).", "B-scan ultrasonography revealed a 4.0\u2009\u00d7\u20092.9\u2009\u00d7\u20092.2-mm lesion with no calcification, no retinal detachment, and no choroidal involvement (Figure 1D).", "Given the suspected iris hamartoma and retinal astrocytic hamartoma, a systemic workup was commenced.A, Dermatologic manifestations.", "B, A lesion was discovered in the right eye consistent with a retinal astrocytic hamartoma.", "C, A similar smaller lesion was seen in the left eye.", "D, B-scan ultrasonography revealed an elevated lesion emanating from the retina with no calcification or choroidal involvement."], "Diagnosis": ["Because of the constellation of findings, an initial diagnosis of linear epidermal nevus syndrome was made.", "At age 3 months, the patient was referred for ophthalmologic examination owing to a flat, hypopigmented lesion in the left temporal iris noted by the patient\u2019s father."], "Others": ["The family history was negative for any dermatologic or genetic diseases."]}
{"Examination and Results": ["Best-corrected visual acuity was 20/20 OU.", "Results of the pupillary examination, intraocular pressure measurements, motility, and confrontatiol visual field testing were normal in each eye.", "Findings on the anterior slitlamp examination demonstrated rare anterior chamber cells and mild nuclear sclerotic cataracts in both eyes.", "Results of the dilated fundus examination (Figure 1) demonstrated bilateral vitreous cells that were not dense enough to obscure retinal vessel details, as well as optic disc hyperemia, arterial attenuation, arterial and venous sheathing, hard exudates, and focal areas of retinal thinning.", "There was no macular edema in either eye.", "Results of a complete blood cell count were normal.Fundus photograph of the patient\u2019s left eye at presentation."]}
{"Patient Symptoms": ["One month prior to presentation, the patient\u2019s mother noticed multiple annular, scaly patches on the patient\u2019s scalp and upper back.", "Both of the patient\u2019s brothers developed similar patches.", "Two weeks before presentation, the area on the scalp grew in size, becoming a tender nodule with yellow suppurative discharge.Results of the physical examination were notable for a somewhat tired-appearing boy with a 6-cm tender, red nodule on the right frontal scalp (Figure 1)."], "Examination and Results": ["Two weeks before presentation, the area on the scalp grew in size, becoming a tender nodule with yellow suppurative discharge.Results of the physical examination were notable for a somewhat tired-appearing boy with a 6-cm tender, red nodule on the right frontal scalp (Figure 1).", "The nodule had a boggy consistency and thick yellow crust and was draining yellow material.", "There was no hair within this area on the scalp.", "On the patient\u2019s right upper back was an annular scaly patch; significant posterior auricular and cervical lymphadenopathy was noted bilaterally.View on presentation of a boggy, erythematous nodule with suppurative discharge and loss of hair."]}
{"Patient Symptoms": ["Physical examination findings were significant for mild left flank pain, but there was no costovertebral angle tenderness."], "Examination and Results": ["Laboratory results were within normal limits.", "Axial imaging demonstrated an exophytic, retroperitoneal mass with solid and cystic components involving the left kidney, posterior abdominal wall, and mesocolon (Figure 1).", "The mass measured 20 cm in its greatest dimension.", "Findings on colonoscopy and mammography were negative.", "Positron emission tomography\u2013computed tomography did not reveal any other abnormality.Coronal computed tomographic image showing a retroperitoneal mass with a cystic component and involvement of adjacent kidney and mesocolon.", "Red arrowhead indicates descending colon; blue arrowhead, left kidney invaded by mass; and yellow arrowhead, retroperitoneal mass with cystic component."]}
{"Patient Symptoms": ["Physical examination revealed hepatomegaly and left lower abdominal tenderness.", "The night after the procedure, the patient developed generalized peritonitis, and computed tomography revealed abundant free air (Figure 1B).A, Colonoscopic stent placement."], "Examination and Results": ["She was hemodynamically stable.", "Physical examination revealed hepatomegaly and left lower abdominal tenderness.", "She had normal liver function test results and a carcinoembryonic antigen level of 23.8 ng/mL (to convert to micrograms per liter, multiply by 1).", "Computed tomography of the abdomen and pelvis revealed a 9-cm, obstructed sigmoid colon mass with fistulous extensions to the bladder and small bowel and numerous metastases to the liver, peritoneum, and omentum.", "The night after the procedure, the patient developed generalized peritonitis, and computed tomography revealed abundant free air (Figure 1B).A, Colonoscopic stent placement."], "Treatment": ["The patient was referred to a gastroenterologist for stent placement (Figure 1A).", "B, Computed tomogram depicting perforation.The patient went to the operating room for an emergency laparotomy."], "Diagnosis": ["Pathologic analysis of an endoscopic biopsy specimen revealed a moderately differentiated colon adenocarcinoma."]}
{"Patient Personal Background": ["On day 3 of hospitalization, the dermatology service was consulted.The patient had a history of mild psoriasis, which significantly worsened 1 year prior to presentation, necessitating treatment with systemic agents and ultimately leading to a diagnosis of human immunodeficiency virus (HIV) infection."], "Patient Symptoms": ["Linear excoriations were noted diffusely."], "Examination and Results": ["Physical examination was remarkable for severe cachexia and diffuse plaques of thick, tan scale (Figure 1).", "Hyperkeratotic areas were verrucous and fissured over bony prominences, including the elbows, knees, ribs, and clavicles.", "Linear excoriations were noted diffusely.", "Unroofed crust revealed a smooth, red, moist undersurface.Left, Diffuse plaques of thick, tan scale."], "Treatment": ["Dolutegravir and emtricitabine/tenofovir were continued, and diphenhydramine was prescribed for pruritus."], "Diagnosis": ["On day 3 of hospitalization, the dermatology service was consulted.The patient had a history of mild psoriasis, which significantly worsened 1 year prior to presentation, necessitating treatment with systemic agents and ultimately leading to a diagnosis of human immunodeficiency virus (HIV) infection."]}
{"Patient Symptoms": ["He was found to be tachycardic, hypotensive, in severe respiratory distress, and oliguric, and he had peripheral cyanosis and a lactate level of 3.1 mmol/L (reference range, 0.6-1.7 mmol/L) (27.9 mg/dL; reference range, 5.0-15 mg/dL)."], "Examination and Results": ["He was found to be tachycardic, hypotensive, in severe respiratory distress, and oliguric, and he had peripheral cyanosis and a lactate level of 3.1 mmol/L (reference range, 0.6-1.7 mmol/L) (27.9 mg/dL; reference range, 5.0-15 mg/dL).", "The following morning, his central venous pressure was 13, stroke volume variation was 7%, and lactate was 3.0 mmol/L (27.0 mg/dL).", "Mean arterial pressure of 60 to 65 mm Hg was achieved but lactate continued to increase to 4.2 mmol/L (37.8 mg/dL).The patient has epinephrine-induced \u03b22-adrenergic stimulation driving his hyperlactatemia.The patient likely has sepsis, possibly with an uncontrolled infectious source, that requires further workup.The patient has decreased lactate clearance due to liver dysfunction and complicated by Ringer lactate solution.The patient is hypoperfused and requires further fluid and pressor resuscitation."], "Treatment": ["He was intubated, given empirical antibiotics for suspected community-acquired pneumonia, resuscitated with 3 L of Ringer lactate solution, and admitted to the intensive care unit.", "However, blood pressure declined progressively through the night despite further fluid resuscitation and the addition of vasopressors (norepinephrine, vasopressin, and epinephrine) and hydrocortisone."], "Diagnosis": ["Mean arterial pressure of 60 to 65 mm Hg was achieved but lactate continued to increase to 4.2 mmol/L (37.8 mg/dL).The patient has epinephrine-induced \u03b22-adrenergic stimulation driving his hyperlactatemia.The patient likely has sepsis, possibly with an uncontrolled infectious source, that requires further workup.The patient has decreased lactate clearance due to liver dysfunction and complicated by Ringer lactate solution.The patient is hypoperfused and requires further fluid and pressor resuscitation."]}
{"Patient Personal Background": ["He has a history of pancreatitis several years prior, recent repair of a tibial fracture, ankle osteoarthritis, cholelithiasis, seizure disorder, and bipolar disorder.", "He has a family history of type 2 diabetes in his father and brother.", "His current medications include phenobarbital, levetiracetam, quetiapine, lorazepam, fluoxetine, tramadol, aspirin, celecoxib, and gabapentin, none of which were started in the past few months."], "Patient Symptoms": ["The rash is nonpruritic but is associated with burning pain."], "Examination and Results": ["Skin examination reveals hundreds of bright pink papules with central yellow hue distributed symmetrically over his dorsal hands, elbows, shoulders, and thighs (Figure 1).", "The remainder of the examination is unremarkable.Left, Erythematous pink-and-yellow papules on the wrists."], "Others": ["The patient has had no fevers, shortness of breath, recent viral syndromes, or recent travel."]}
{"Patient Personal Background": ["She currently takes no medications."], "Patient Symptoms": ["For the past 6 months, she noted when lying on her left side an inability to hear the television or her baby crying.", "She also noted right-sided aural fullness and occasional right-sided headache."], "Examination and Results": ["Otoscopic examination results were normal.", "A 512-Hz tuning fork examination showed a left-sided lateralization when the vibrating tuning fork was placed on the center of her forehead (Weber test) and bilateral air greater than bone conduction with the vibrating tuning fork placed in front of her ear canal vs her mastoid tip (Rinne test).", "Facial motor and sensory function were intact and symmetric.", "The rest of the head and neck examination was unremarkable."], "Diagnosis": ["An audiogram was ordered (Figure).This audiogram depicts sensorineural hearing loss (SNHL) consistent with early Meniere disease.This audiogram depicts a right-sided SNHL and impaired speech discrimination, which necessitate further investigation.This audiogram depicts a right-sided conductive hearing loss (CHL) with a notch at 2000 Hz, consistent with otosclerosis."]}
{"Patient Symptoms": ["He also complained of multiple tender red lesions on his bilateral ankles and legs that appeared 2 days prior to admission."], "Examination and Results": ["Findings from a review of systems were negative for cough, sore throat, history of hepatitis, tuberculosis, sarcoidosis, inflammatory bowel disease, or sulfonamide use.Physical examination revealed several ill-defined, exquisitely tender erythematous subcutaneous nodules on his bilateral shins, medial feet, ankles, and right lower thigh without overlying ulceration, necrosis, or drainage (Figure, A and B).", "A punch biopsy was performed, demonstrating pathognomonic histopathologic findings (Figure, C and D)."]}
{"Patient Personal Background": ["His medical history included severe peripheral arterial disease and a remote history of ruptured abdominal aortic aneurysm."], "Examination and Results": ["Physical examination of the left flank showed a well-defined 5\u2009\u00d7\u200912-cm purpuric patch with a darker stellate patch within it (Figure, A).", "Two punch biopsy specimens were obtained (Figure, B and C).A, Photograph of a purpuric patch on the left flank.", "B, Biopsy specimen 1 (hematoxylin-eosin, original magnification \u00d740) showing needle-shaped clefts within the lumen of a blood vessel with minimal perivascular inflammation.", "C, Biopsy specimen 2 (hematoxylin-eosin, original magnification \u00d740).", "Eccrine ducts show cellular dyshesion and necrosis."], "Treatment": ["Three months before presentation, he underwent percutaneous endovascular stenting of a left popliteal artery aneurysm."]}
{"Patient Personal Background": ["His medical history was notable for diabetes mellitus and hypertension, which was well controlled with a stable regimen of lisinopril and atenolol for several years.", "He denied using any new medications or supplements or making recent dose adjustments in existing medications.", "There was no history of a prior bullous eruption.", "Physical examination revealed numerous small intact bullae and large erosions on the lateral feet, soles, and toes (Figure, A)."], "Patient Symptoms": ["He denied having pruritus or spontaneous bleeding but reported discomfort from the pressure of intact bullae.", "The extent of the bullae led to difficulty with ambulation."], "Examination and Results": ["There were also intact vesicles on the lateral palms along with erosions demonstrating evidence of previous bullae formation.", "There were no vesicular or bullous lesions on the trunk, arms, legs, or mucosal surfaces.", "Hematoxylin-eosin staining of a biopsy specimen obtained from a bulla on the foot was performed (Figure, B).A, Numerous small bullae in various stages of healing and large erosions on the feet with areas of denuded pink dermis on clinical presentation."], "Others": ["B, Biopsy specimen obtained from a bulla on the foot (hematoxylin-eosin, original magnification \u00d7600)."]}
{"Patient Symptoms": ["He was previously diagnosed with conjunctivitis and treated empirically with artificial tears, ofloxacin drops (0.3%), and prednisolone acetate drops (1%) 4 times a day, without improvement.His visual acuity was 20/20 OD.", "In addition, the patient had a right-sided intranasal mass.A, Slitlamp photograph of the patient\u2019s right eye at presentation."], "Examination and Results": ["Examination findings of the anterior segment of the right eye revealed a raised, nonmobile, engorged perilimbal nodule in the inferotemporal sclera that was tender to palpation and did not blanch with phenylephrine drops (2.5%) (Figure, A).", "The ultrasonogram demonstrated a noncystic, regular, dome-shaped lesion with medium to high reflectivity localized to the sclera without intraocular involvement (Figure, B).", "The remaining results of the right-eye examination and the entire left-eye examination were within the reference range.", "B, Anterior segment ultrasonography of the right eye at presentation.Laboratory test results demonstrated elevated inflammatory markers, with an erythrocyte sedimentation rate of 38 mm/h (reference range, 0-20 mm/h) and a C-reactive protein level of 190 mg/L (reference range, 0.08-3.1 mg/L) (to convert to nanomoles per liter, multiply by 9.524).", "Results of serum antineutrophil cytoplasmic antibody (ANCA), rheumatoid factor, antinuclear antibody, angiotensin-converting enzyme, fluorescent treponemal antibody absorption, rapid plasma reagin, and tuberculosis skin testing were within their reference ranges.", "Results of urine microscopy had 4+ red blood cells per high-power field.", "His blood urea nitrogen and creatinine levels were within their reference ranges."], "Treatment": ["He was previously diagnosed with conjunctivitis and treated empirically with artificial tears, ofloxacin drops (0.3%), and prednisolone acetate drops (1%) 4 times a day, without improvement.His visual acuity was 20/20 OD."]}
{"Patient Personal Background": ["The patient\u2019s history was negative for travel, recent vaccinations, or systemic illnesses.", "The patient reported exposure to cats at home but had no recollection of direct trauma."], "Patient Symptoms": ["He denied having fever, nausea, headache, or other influenzalike symptoms.A, Unilateral isolated disc edema at initial presentation."], "Examination and Results": ["His best-corrected visual acuity was 20/20 OD and 20/200 OS.", "Findings on pupillary, motility, and slitlamp examination of the anterior segment were unremarkable.", "Findings on dilated fundus examination of the right eye were normal.", "Figure 1A depicts the fundus findings in the left eye.", "B, Development of macular edema with exudates 1 week after initial presentation.Findings on magnetic resonance imaging of the brain and orbits showed subtle enhancement of the left optic nerve.", "No masses or demyelinating lesions were found.One week later, he presented to the ophthalmology office.", "His best-corrected visual acuity had improved to 20/40 OS.", "His examination was notable for the fundus finding shown in Figure 1B."]}
{"Patient Personal Background": ["He had normal growth and development and no illnesses or fevers prior to presentation.", "He had no contact with sick persons or with household members with similar skin lesions, and there was no history of recent sun exposure.", "There was no family history of autoimmune disease, and the mother denied symptoms of dry eyes, dry mouth, cavities, or photosensitivity.A physical examination revealed a well-appearing afebrile male neonate with 5 annular plaques located on the frontal and posterior scalp."], "Patient Symptoms": ["The plaques emerged on day 17 of life and did not change in appearance or increase in number."], "Examination and Results": ["The thin red border had fine scaling and several pinpoint pustules.", "In addition, there were faintly pink patches with scaling on the medial eyebrows and mesolabial folds.", "There was no cervical or postauricular lymphadenopathy."]}
{"Patient Personal Background": ["She was a current smoker and was taking aspirin and statin medication at the time of presentation."], "Patient Symptoms": ["Her most recent presentation was 1 week prior for a minor stroke with amaurosis fugax, slurred speech, right-sided weakness, and facial droop lasting longer than 24 hours."], "Examination and Results": ["Magnetic resonance imaging of the brain demonstrated subacute infarctions involving the left frontal and parietal hemispheres.", "Workup at another facility prior to transfer included computed tomographic angiography of the neck, which showed chronic occlusion of the right ICA and 95% stenosis of the left ICA.On examination, the patient was afebrile with a heart rate of 69 beats/min and blood pressure of 134/69 mm Hg.", "Pertinent findings included no carotid bruit, a regular cardiac rhythm, and equally palpable upper extremity pulses bilaterally.", "The patient was neurologically intact, save for 4/5 motor strength in her right upper extremity.", "Computed tomographic angiography of the head and neck was performed (Figure 1).Sagittal view demonstrates the left internal carotid stenosis (A indicates anterior; P, posterior) (A) and the distal extent of the findings (arrowhead) (B)."]}
{"Patient Personal Background": ["She underwent total thyroidectomy 15 years earlier for papillary thyroid cancer and is taking levothyroxine suppression therapy without evidence of recurrence.", "She has well-controlled hypertension and hyperlipidemia.", "Her other medications include losartan, atorvastatin, and ezetimibe.", "She has no history of low trauma fractures (occurring from falls at standing height or less) or nephrolithiasis.", "She has no family history of hypercalcemia."], "Patient Symptoms": ["She feels well and reports no concerns."], "Examination and Results": ["Serum calcium levels before her thyroidectomy were normal.", "Physical examination demonstrated no palpable thyroid tissue."], "Diagnosis": ["Her laboratory values are reported in the Table.The patient has hypercalcemia from thyroid suppression therapy."]}
{"Patient Personal Background": ["He did report a history of injection drug use, opioid drug snorting, and tobacco abuse.", "He also reported working as a gardener and having 2 dogs as pets."], "Patient Symptoms": ["He originally developed a pustule inside the nares, which gradually spread to involve the nose (Figure 1A).", "The patient reported no fever, chills, headache, diplopia, cough, dyspnea, or hemoptysis."], "Examination and Results": ["Physical examination revealed an erythematous and deformed nose with small pustules and a perforated nasal septum.", "A complete blood cell count showed a white blood cell count of 19\u2009000 cells/\u00b5L; a chemistry panel showed a serum creatinine level of 1.7 mg/dL (150.3 \u03bcmol/L) and mildly elevated liver enzyme levels.", "Results of a human immunodeficiency virus screening test were negative.", "A computed tomography scan of the head, facial sinuses, and chest showed soft tissue swelling of the nose and several large cavitary lesions in the lungs (all lobes), with multiple bilateral nodular opacities (Figure 1B), but no intracranial lesions.A, Patient with pustulonodular lesion on nose and a Penrose drain."]}
{"Patient Personal Background": ["His medical history was unremarkable and he was not taking regular medications."], "Patient Symptoms": ["The lesions appeared approximately 8 hours after taking two 25-mg doses of diclofenac, which was prescribed for low back pain.", "He initially noticed itching over both hands and feet, followed by a burning sensation and the subsequent development of generalized purplish lesions.", "He reported history of a similar though less severe eruption 4 months earlier at similar sites following diclofenac ingestion."], "Examination and Results": ["A clinical examination revealed multiple well-circumscribed, round to oval, purplish patches, erosions, and blisters on his trunk and feet (Figure).", "Crusting over the lips and dusky red erosions and plaques on the penis, scrotum, and lower limbs were also noted (Figure)."], "Treatment": ["The lesions appeared approximately 8 hours after taking two 25-mg doses of diclofenac, which was prescribed for low back pain."]}
{"Patient Personal Background": ["The patient used standard finger sticks to test his blood glucose levels daily.", "However, he had pricked his fingers for decades without incident."], "Patient Symptoms": ["The lesions were persistent, asymptomatic, and without aggravating or alleviating factors.", "A review of symptoms was positive only for intermittent bloating and diarrhea."], "Examination and Results": ["Physical examination revealed multiple petechiae in a linear arrangement extending from the volar and lateral aspects of the fingers to the finger pads (Figure, A).", "Results from initial laboratory tests, including a complete blood cell count, comprehensive metabolic panel, antinuclear antibody, erythrocyte sedimentation rate, rheumatoid factor, and cardiolipin antibody, were unremarkable.", "Results from a urinalysis and transthoracic echocardiogram were also unremarkable.", "Punch biopsies for histopathologic examination (Figure, B) and direct immunofluorescence (Figure, C) were performed.A, Petechial eruption on the fingers.", "B, Histopathologic image showing subtle collections of neutrophils within the dermal papillae (hematoxylin-eosin, original magnification \u00d7200).", "C, Direct Immunofluorescence revealing granular IgA deposition within the dermal papillae and at the dermoepidermal junction (original magnification \u00d7400)."]}
{"Patient Symptoms": ["He also reported easy bruising with minor trauma."], "Examination and Results": ["Physical examination showed trachyonychia (rough accentuated linear ridges) on 8 fingernails (Figure, A), thin and brittle toenails, diffuse nonscarring alopecia, and multiple purpuric patches on the forehead, scalp, chest, and arms.", "He had substantial laxity of the skin on finger pads (Figure, A), and both sides of the gluteal cleft revealed soft, nontender, rugated, skin-colored linear kissing plaques with no vesicles, bullae, ulcers, or erosions present.A, Nail and cutaneous findings including trachyonychia of the fingernails and cutaneous laxity of the fingerpads.", "B, Histopathologic specimen of the nail bed showing orange, amorphous and extracellular material deposited in the subungual dermis of the nail bed (Congo red special stain, original magnification \u00d710).", "C, Same specimen under polarized light microscopy revealed intense apple-green birefringence of the amorphous material in the subungual dermis (lower half of the photomicrograph) (Congo red special stain, polarized light microscopy, original magnification \u00d710)."]}
{"Treatment": ["On arrival to the emergency department, the patient was intubated and resuscitated.", "He underwent emergent chest, bilateral upper and lower extremity escharotomies, and a decompressive laparotomy for abdominal compartment syndrome.", "Once the patient was hemodynamically stable he was taken to the operating room and underwent 4 operations for debridement and grafting, with the initial operation taking place 10 days after admission.", "All were successfully treated with antibiotics.A, Newly excised burn wound with stitches at the amputation site and a large white nodule."], "Others": ["B, Close-up view of a burn wound newly excised to the subcutaneous tissue with black, plaque-shaped growth.", "C and D, Histopathologic images, original magnification \u00d750.", "C, Hematoxylin-eosin.", "D, Gomori methenamine silver stain."]}
{"Examination and Results": ["On external examination, a pink, fleshy, pedunculated lesion with telangiectatic vessels on the surface was seen over the left caruncle (Figure 1).", "Her best-corrected visual acuity was 20/20 OU.", "Her ocular motility was intact in both eyes."]}
{"Patient Personal Background": ["The patient wears spectacles for myopia but has no other ocular history and denies a history of trauma.", "Her medical history is unremarkable, and her review of systems was negative, except for occasional back pain for which she takes tramadol hydrochloride orally."], "Patient Symptoms": ["The patient noticed the lesion when looking in a mirror 3 years prior to presentation.", "The patient has had no visual changes or other symptoms but thinks the lesion may have grown slightly since first detected."], "Examination and Results": ["On examination, her corrected acuity was 20/20 OD and 20/25+ OS.", "The results of pupil, motility, and confrontational visual field examinations were normal.", "The intraocular pressure was 17 mm Hg OD and 18 mm Hg OS.", "The patient\u2019s manifest refraction was \u221214.50\u2009+\u20092.50\u2009\u00d7\u2009089 diopters OD and \u221216.00\u2009+\u20094.00\u2009\u00d7\u2009077 diopters OS.", "The results of an anterior segment examination are that both the right eye and the left eye, except for the lesion identified (Figure 1), are normal."]}
{"Patient Personal Background": ["She reported a pruritic, painful rash on her hands and feet and multiple painful joints.Animal exposures included 3 new puppies and rodent infestation in the home and neighborhood cats."], "Patient Symptoms": ["She reported a pruritic, painful rash on her hands and feet and multiple painful joints.Animal exposures included 3 new puppies and rodent infestation in the home and neighborhood cats.", "She did not report recent travel or arthropod bites.On examination, her right elbow and left knee were swollen and warm.", "She reported pain with passive movement of the right shoulder and left wrist.", "Petechial and pustular lesions were present on both hands and palms (Figure, A).", "Her feet, including the soles, had many petechial lesions and a few purpuric lesions (Figure, B).A, Numerous scattered erythematous papules and petechiae with a few pustules on the palm and fingers of the left hand."], "Examination and Results": ["She did not report recent travel or arthropod bites.On examination, her right elbow and left knee were swollen and warm.", "Petechial and pustular lesions were present on both hands and palms (Figure, A).", "Her feet, including the soles, had many petechial lesions and a few purpuric lesions (Figure, B).A, Numerous scattered erythematous papules and petechiae with a few pustules on the palm and fingers of the left hand.", "B, Many petechiae on the dorsum of the feet.Results of laboratory testing were significant for a white blood cell count of 5050/\u03bcL (to convert to \u00d7109/L, multiply by 0.001) and a platelet count of 55\u00d7103 (to convert to \u00d7109/L, multiply by 1).", "Results of urinalysis and comprehensive metabolic panel were unremarkable ."]}
{"Patient Symptoms": ["She also lost more than 30 kg of weight during this period."], "Examination and Results": ["Physical examination revealed acute cachexia with conjunctival pallor and an immobile nontender mass in the left upper abdomen.", "Her laboratory test results revealed a microcytic anemia and hypoalbuminemia.", "The patient was scheduled for exploratory laparotomy and resection.A large central necrotic mass is shown in this computed tomography image of the abdomen."], "Treatment": [], "Others": ["Abdominal computed tomography was performed (Figure 1)."]}
{"Patient Personal Background": ["He had a long-standing history of gastroesophageal reflux disease that was only partially controlled with proton pump inhibitor therapy."], "Patient Symptoms": ["The symptoms were exacerbated by cessation of proton pump inhibitor medication, and he reported an associated 9-kg weight loss."], "Examination and Results": ["Results of laboratory testing were significant for iron deficiency anemia (hematocrit, 31% [to convert to proportion of 1.0, multiply by 0.01]) and hemeoccult-positive stool.", "Upper and lower endoscopy, computed tomography enterography, PillCam capsule endoscopy, and a Meckel scan failed to identify a source of GI bleeding.", "The patient received a retrograde double-balloon enteroscopy that showed an outpouching in the distal ileum (Figure, A) with an accompanying ulceration of the adjacent mucosa (Figure, B)."], "Treatment": ["Exploratory laparotomy with small-bowel resection was performed, and the gross specimen is shown in Figure, C.A, Outpouching of the distal ileum."], "Others": ["B, Ulceration adjacent to the outpouching of the distal ileum.", "C, Resected distal ileum revealing an ulceration of the mucosa.", "Arrowhead indicates site of ulceration."]}
{"Patient Personal Background": ["She did not report any previous abdominal surgery."], "Patient Symptoms": ["The colicky pain did not migrate during that period and occurred in paroxysms at 9- to 10-minute intervals.", "The patient was afebrile and had no nausea or vomiting."], "Examination and Results": ["Physical examination revealed mild tachycardia (96/min) and moderate abdominal distension without signs of peritonism; the bowel sounds were hyperactive.", "Careful examination ruled out incarcerated hernias in the groin, femoral triangle, and obturator foramen.", "Blood analysis results showed mild leukocytosis (total white blood cell count, 10.5\u2009\u00d7\u2009103/\u03bcL [to convert to \u00d7109 per liter, multiply by 0.001]) without elevation of the C-reactive protein level (<3 mg/L [to convert to nanomoles per liter, multiply by 9.524]).", "Serum electrolyte levels were within the normal range.", "Computed tomography of the abdomen was conducted (Figure).Computed tomographic images of the abdomen."], "Others": ["A, Axial imaging.", "B, Coronal imaging."]}
{"Patient Symptoms": ["She had evidence of bilateral carpal tunnel syndrome (positive Phalen test and Tinel sign bilaterally) and reduced deep tendon reflexes in the upper and lower extremities bilaterally."], "Examination and Results": ["On physical examination, she had no pallor, lymphadenopathy, or organomegaly.", "Laboratory test results for complete blood cell count, serum calcium, serum creatinine, blood glucose, serum thyroid-stimulating hormone, and serum B12 were within normal limits."], "Diagnosis": [], "Others": ["Because of unexplained neuropathy, a workup to detect an underlying monoclonal gammopathy was done, including serum protein electrophoresis, immunofixation, and free light chain assay (see Table).The patient most likely has monoclonal gammopathy of undetermined significance (MGUS).This patient most likely has light chain monoclonal gammopathy."]}
{"Patient Personal Background": ["During the prior 5 months, she experienced mild diarrhea, which was ultimately diagnosed as Crohn disease by colonoscopy with biopsy.Skin lesion progression and histopathological changes (hematoxylin-eosin, original magnification \u00d7200).Physical examination reveals a pale, febrile patient with left leg edema and a rounded, swollen, and tender 10\u2009\u00d7\u200910-cm ulceration on her left medial malleolus."], "Patient Symptoms": ["The lesion began as 2 sesame seed\u2013sized violaceous, papulovesicular rashes with an erythematous halo on her left medial malleolus 12 days prior to presentation.", "Within 1 week, more papulovesicles appeared, merged, and ulcerated spontaneously (Figure, A and B).", "The ulceration expanded outwardly at a rapid pace, with increasing pain and a hemorrhagic exudative discharge (Figure, C [left panel]).", "The ulceration has a raised rugged surface with thick hemorrhagic exudates and a surrounding violaceous-greyish necrotic border (Figure, C [left panel]).Laboratory tests show moderate anemia, hypoalbuminemia, and fecal occult blood."], "Examination and Results": ["The ulceration has a raised rugged surface with thick hemorrhagic exudates and a surrounding violaceous-greyish necrotic border (Figure, C [left panel]).Laboratory tests show moderate anemia, hypoalbuminemia, and fecal occult blood.", "Histopathology of skin lesions shows dermal edema with dense infiltration of neutrophils and vascular fibrinoid necrosis (Figure, C [right panel]).", "Results of acid-fast staining, periodic acid\u2013Schiff staining, bacterial and mycological cultures of skin biopsy specimens, and blood cultures are negative."], "Treatment": ["The lesion did not respond to treatment with systemic antibiotics, including vancomycin and meropenem."], "Diagnosis": ["During the prior 5 months, she experienced mild diarrhea, which was ultimately diagnosed as Crohn disease by colonoscopy with biopsy.Skin lesion progression and histopathological changes (hematoxylin-eosin, original magnification \u00d7200).Physical examination reveals a pale, febrile patient with left leg edema and a rounded, swollen, and tender 10\u2009\u00d7\u200910-cm ulceration on her left medial malleolus."]}
{"Patient Personal Background": ["She reported nonadherence to blood pressure medications."], "Patient Symptoms": ["She described the pain as \u201csomeone sitting on her chest\u201d and reported associated diaphoresis and shortness of breath."], "Examination and Results": ["On physical examination, the heart rate was 99 beats per minute and blood pressure was 247/130 mm Hg.", "An electrocardiogram showed sinus rhythm with left ventricular hypertrophy (LVH) and inferior T-wave inversion.", "Laboratory values are shown in Table 1.An echocardiogram showed moderate LVH with preserved left ventricular systolic function and no segmental wall motion abnormalities.", "The following day she underwent coronary angiography, which revealed only mild nonobstructive coronary artery disease with a 20% stenosis of the proximal left circumflex coronary artery.Chronic elevation in cardiac troponin T (cTnT) due to left ventricular hypertrophy.Type I non\u2013ST-segment elevation myocardial infarction (MI) due to atherosclerotic plaque rupture.Type II non\u2013ST-elevation MI related to acute increase in myocardial oxygen demand."], "Diagnosis": []}
{"Patient Personal Background": ["He was divorced 10 years previously and has since had multiple sexual partners.", "He reports sex only with women."], "Patient Symptoms": ["His dysuria resolved and he now feels well."], "Examination and Results": ["His examination is normal, including the genitalia and skin.", "He has no neurologic deficits.", "Screening for other sexually transmitted infections reveals hepatitis B virus serologies consistent with previous immunization, a negative human immunodeficiency virus (HIV) enzyme immunoassay (EIA), and reactive syphilis test results (Table 1).The patient does not recall prior syphilis diagnosis or treatment."], "Treatment": ["He was diagnosed with gonococcal urethritis and treated with intramuscular ceftriaxone and oral azithromycin."], "Diagnosis": ["He was diagnosed with gonococcal urethritis and treated with intramuscular ceftriaxone and oral azithromycin.", "The local health department has no record of syphilis testing for him.The patient has latent syphilis and requires 2.4 million U intramuscularly of benzathine penicillin G weekly for 3 doses (total 7.2 million U penicillin).The patient has low titers representing the serofast state and does not require treatment.The patient has falsely elevated titers and should undergo repeat testing.The patient needs a lumbar puncture to assess for asymptomatic neurosyphilis."]}
{"Patient Personal Background": ["She reports no new medications, foods, or oral hygiene products.", "She has a history of hypertension, hypothyroidism, type 2 diabetes, gastroesophageal reflux disease, and seasonal allergies.", "Her medications are valsartan-hydrochlorothiazide, levothyroxine sodium, metformin, insulin, and loratadine."], "Patient Symptoms": ["The lesions cause pain and difficulty brushing her teeth."], "Examination and Results": ["Intraoral examination shows generalized erythema and sloughing of the maxillary and mandibular gingiva, without evidence of dental plaque, calculus, or both, and white striae (Wickham striae) affecting the gingiva and mucosa (Figure 1)."], "Others": ["She reports no involvement of other cutaneous or mucosal surfaces and no family history of oral lesions."]}
{"Patient Personal Background": ["Her medical history was significant for hypothyroidism, seizures, and functional heart murmur.", "Medications included levothyroxine sodium, mometasone furoate, levocetirizine, and benzonatate."], "Patient Symptoms": ["She reported that at the time of initial onset, multiple painful ulcers had appeared on the anterior maxillary gingiva.", "She stated that the lesions had resolved spontaneously without treatment but recurred 8 years later as swelling and ulceration of the maxillary and mandibular gingiva.", "She denied involvement of cutaneous surfaces and reported a history of ligneous conjunctivitis since childhood (Figure, A).", "Review of systems was significant for easy bruising and prolonged bleeding."], "Examination and Results": ["Intraoral examination revealed generalized mild edema with rolled margins of the maxillary and mandibular gingiva accompanied by nodular ulceration of the left maxillary gingiva (Figure, B).", "Biopsy specimens were obtained from the gingival ulcer (Figure, C and D) and buccal mucosa for routine histological and direct immunofluorescence analysis, respectively.", "Also obtained were a complete blood cell count with differential and comprehensive metabolic panel; no abnormal findings were identified.A, Pseudomembranous masses affecting conjunctival mucosa of the left eye consistent with ligneous conjunctivitis."], "Others": ["B, Edema with rolled margins and nodular ulceration of the left maxillary gingiva.", "C and D, Punch biopsy specimen from the maxillary gingiva showing aggregates of relatively amorphous, eosinophilic material beneath the epithelium and around blood vessels (C, hematoxylin-eosin, original magnification \u00d7100; D, hematoxylin-eosin, original magnification \u00d7200)."]}
{"Patient Personal Background": ["The mother, initially unavailable for examination because she remained at the facility where she had given birth, reported via telephone that she was healthy except for a urinary tract infection for which she had taken a 7-day course of nitrofurantoin monohydrate approximately 3 to 4 weeks before delivery.", "She denied a history of herpesvirus infection, blistering disorder, or autoimmune disease."], "Examination and Results": ["On physical examination, the neonate exhibited extensive erosions rimmed by purulent vesicles involving the groin, neck, scalp, fingers, and left side of the upper chest (Figure, A and B).", "Mucous membranes were spared.", "Biopsy specimens were obtained, with results as shown in the Figure, C and D.A, Erosions rimmed with flaccid turbid vesicles involving the groin, thighs, and abdomen.", "B, Large erosion with a rim of flaccid purulent vesicles and crusting on the left side of the chest.", "C, Histopathologic analysis of truncal skin sample demonstrating suprabasilar acantholysis with an eosinophil-rich infiltrate (hematoxylin-eosin, original magnification \u00d740).", "D, Direct immunofluorescence of perilesional skin from the right side of the chest demonstrates IgG in an intracellular \u201cchicken wire\u201d pattern involving the lower spinous layer (original magnification \u00d740)."]}
{"Patient Personal Background": ["The patient was not taking any medications at the time and denied any recent international travel.Physical examination revealed multiple annular plaques with raised erythematous-violaceous borders on the face, distributed mainly along the forehead and temporal region (Figure, A)."], "Patient Symptoms": ["The eruption began on his upper back, at which time he felt well.", "After returning from his trip, he noted that the eruption had become more prominent on his back and had spread to his face.", "In addition, he began to have a febrile illness with joint pain and swollen nodes, which subsequently resolved without treatment.", "The lesions continued to rapidly enlarge without scaling, and his plaques were not associated with itching or pain."], "Examination and Results": ["There were similar coalescing lesions found on back (Figure, B).", "No other mucocutaneous findings were noted, and the rest of examination was unremarkable.", "A punch biopsy specimen was obtained from a plaque on the right upper back and submitted for pathologic review (Figure, C and D).A, Multiple annular plaques with raised erythematous-violaceous borders are distributed mainly along the frontal and temporal region of the head.", "B, Similar findings are seen on the patient\u2019s face with more central clearing and attenuated coloring.", "C, This pathologic specimen from a lesion on the upper back depicts distended sebaceous lobules with associated follicular dilatation and a mild chronic perivascular and perifollicular lymphomononuclear infiltrate.", "D, This pathologic specimen from the upper back exhibits sebaceous lobules with sebocyte necrosis and an associated neutrophilic infiltrate that also includes scattered lymphomononuclear cells."], "Others": ["He then received significant sun exposure while on a 7-day trip to Miami, Florida."]}
{"Patient Personal Background": ["He had undergone numerous chemotherapeutic regimens over the past 3 years, all of which had failed.", "He acknowledged a mild, untreated seasonal rhinitis but otherwise had enjoyed good health prior to his cancer diagnosis."], "Patient Symptoms": ["He denied the use of heating pads but admitted to sitting on the hearth, directly in front of his fireplace, for long periods because of the cold weather and chills presumably from his underlying malignant neoplasm."], "Examination and Results": ["Physical examination revealed a large, reticulated, erythematous plaque with micaceous and silvery scale localized to the mid-back (Figure, A).", "A punch biopsy was performed (Figure, B-D).A, Large, reticulated, erythematous plaque with silvery scale localized to the mid-back.", "B-D, Punch biopsy specimens.", "B, Mild hyperkeratosis overlying an epidermis with dysmaturation and apoptotic cells, increased small blood vessels, pigment incontinence, and perivascular inflammation with lymphocytes and eosinophils (hematoxylin-eosin, original magnification \u00d720).", "C, Keratinocyte dysmaturation demonstrated by large keratinocytes with hyperchromatic nuclei and prominent nucleoli, and increased mitoses with starburst cells (arrowheads) (hematoxylin-eosin, original magnification \u00d760).", "D, Squamous metaplasia and apoptosis of the eccrine ducts (hematoxylin-eosin, original magnification \u00d760)."], "Treatment": ["For the past 4 months he had been receiving oral etoposide (daily for the first 3 weeks of each 4-week cycle), daily pancrelipase, and monthly octreotide acetate intramuscular injections."]}
{"Patient Personal Background": ["Ocular history included penetrating keratoplasty with intraocular lens exchange and Descemet stripping automated endothelial keratoplasty in the right eye."], "Patient Symptoms": ["He described it as a central \u201cband\u201d of absent vision just below center."], "Examination and Results": ["On examination, visual acuity measured 20/40 OD and 20/60 OS, improving to 20/40 with pinhole.", "A complete blood cell count, results of a comprehensive metabolic panel, erythrocyte sedimentation rate, C-reactive protein level, and computed tomography of the head without contrast were all normal.", "Four days later in the Retina Clinic, visual acuity was unchanged.", "Slitlamp examination of the anterior segment was normal.", "Ophthalmoscopy revealed no vitreous cells, a posterior vitreous separation, cup-disc ratio of 0.3, normal retinal vessels, and a superior parafoveal crescent of translucent retina without associated edema or hemorrhage.", "The peripheral retina was normal.", "Fundus autofluorescence and fluorescein angiogram showed abnormalities in the superior macula (Figure 1).A, Fundus autofluorescence shows a superior parafoveal and perifoveal dark crescent at presentation, corresponding to the hypofluorescent region in part B."], "Others": ["Review of systems was negative."]}
{"Patient Symptoms": ["Ophthalmology was consulted urgently in the recovery room because of complaints of vision loss and ophthalmoplegia in the right eye."], "Examination and Results": ["On examination, visual acuity was no light perception (NLP) OD and 20/20 OS.", "Pupils were equal and round, with a 3+ relative afferent pupillary defect in the right eye.", "Intraocular pressure was within normal limits in both eyes.", "There was complete ophthalmoplegia in the right eye with no signs of restriction on forced ductions and normal motility in the left eye.", "Visual field was full to confrontation in the left eye.", "The right eye also demonstrated mild fullness of the orbit, right cheek skin erythema, trace proptosis, and trace conjunctival chemosis.", "Posterior examination was significant for diffuse retinal whitening with a cherry-red spot in the macula in the right eye (Figure 1A).", "There were no other neurologic deficits identified on examination.Case presentation.", "B, Immediate postoperative magnetic resonance imaging showing enlarged extraocular muscles on the right side (arrowheads).A computed tomography scan without contrast did not show an acute intracranial hemorrhage and demonstrated diffuse enlargement of the right extraocular muscles.", "Magnetic resonance imaging of the brain and orbits with contrast again showed enlargement and abnormal signal of the extraocular muscles on the right (Figure 1B); there was no evidence of cavernous sinus pathology."], "Others": ["A, Fundus photograph of right eye showing diffuse retinal whitening with a cherry-red spot."]}
{"Patient Personal Background": ["She was born at 38.3 weeks via spontaneous vaginal delivery after an uncomplicated pregnancy to a 35-year-old, G3, now P2 mother with no significant medical history.", "Results of maternal prenatal laboratory tests were all unremarkable.", "She received regular prenatal care, and routine ultrasonography revealed no anomalies."], "Examination and Results": ["The Apgar scores were 9 at 1 minute and 9 at 5 minutes.", "No resuscitation was required in the delivery room.", "The newborn was already breastfeeding well, voiding, and stooling by the time of the initial examination.", "Physical examination revealed a 3.5\u2009\u00d7\u20094-cm mobile mass on the right lateral trunk at the midaxillary line at levels approximately T4 to T6.", "The mass was firm and round, although when palpated it was not homogeneous or smooth.", "There was no discoloration of the overlying skin.", "Results of the remainder of the physical examination were normal."]}
{"Patient Personal Background": ["The patient denied any history of abdominal surgery."], "Patient Symptoms": ["He reported only mild abdominal pain.", "On examination, he was mildly distended and tender focally on the right side."], "Examination and Results": ["In the emergency department, a nasogastric tube was placed, yielding a moderate amount of dark, foul-smelling output.", "Laboratory results were significant for a white blood cell count of 13\u2009300/\u03bcL (to convert to \u00d7109 per liter, multiply by 0.001) (bands 20%).", "A contrast-enhanced computed tomographic scan of the abdomen and pelvis  demonstrated dilated small intestine (measuring up to 4.7 cm), with air-fluid levels extending to the terminal ileum (Figure 1A and B).", "The entire colon was collapsed.", "There were several loops of normal-caliber bowel proximal to the area of concern.", "Dilated small intestine with air-fluid levels extending to the terminal ileum (A and B)."], "Treatment": ["The decision was made to take him to the operating room for exploration given the lack of any previous abdominal surgical procedures and no other explanation for his symptoms.", "Intraoperatively, a large portion of the small intestine was involved in dense adhesions.", "After performing careful lysis on the distal involved bowel, a tightly coiled and twisted segment was encountered (Figure 1C).", "At this point, further attempts to separate loops of small intestine would have been difficult, and the decision was made to resect this segment (approximately 110 cm) and perform a primary anastomosis.Cross-sectional computed tomographic scan of the abdomen."], "Others": ["C, Intraoperative image of involved small intestine.", "Tightly coiled and twisted small bowel with adhesive bands."]}
{"Patient Personal Background": ["His surgical history was notable for a coronary artery bypass graft 9 months earlier and \u03b3-knife resection of an acoustic neuroma 10 years ago.Physical examination revealed a soft, nontender abdomen without obvious palpable masses."], "Patient Symptoms": ["He had been having recurrent gastrointestinal bleeding and melena during the past year.", "He reported a 6.75-kg weight loss during the past few months but did not have abdominal pain, nausea, vomiting, fevers, or chills."], "Examination and Results": ["Inspection of the patient\u2019s skin demonstrated multiple fleshy, soft cutaneous nodules (Figure 1A).", "The patient\u2019s laboratory testing was only notable for anemia with a hemoglobin level of 10.4 g/dL (reference range, 12-16 g/dL).", "A prior extensive examination, including upper and lower endoscopy, upper gastrointestinal series with small-bowel follow-through, and capsule endoscopy did not reveal a diagnosis.", "A computed tomography image of the abdomen and pelvis is shown in Figure 1B.A, Multiple cutaneous nodules and pigmented spots are evident on physical examination.", "B, Cross-sectional imaging reveals a large, complex, septated, right-upper-quadrant abdominal mass."]}
{"Patient Personal Background": ["In the past 2 years, she was thought to have a urinary tract infection (UTI) on 8 occasions and received antibiotic therapy 6 times."], "Patient Symptoms": ["Symptoms that triggered an evaluation for UTI included increased confusion, urinary frequency, cloudy urine, lethargy, hallucinations, and falls.", "The patient reports no dysuria or abdominal pain but does chronically complain of voiding frequently.", "She is afebrile with no abdominal, suprapubic, or flank tenderness, but her urine has a foul odor."], "Examination and Results": ["A catheterized urine specimen is obtained and results of urinalysis are reported (Table).", "The urine culture reveals more than 100\u2009000 colony-forming units (CFUs) per milliliter of Escherichia coli, which is sensitive to all antibiotics except ampicillin.The patient has a UTI because of chronic incontinence and a positive urine culture.A positive urinalysis and urine culture are always a UTI.Since the patient has a history of recurrent UTIs, these urine test results indicate that she has another UTI."], "Others": ["On this occasion, the family reports that she \u201cdoesn\u2019t look right,\u201d but the nursing staff states she is not confused."]}
{"Patient Personal Background": ["He is a former smoker with a 12 pack-year history, having quit 40 years ago.He is afebrile, and other vital signs are normal."], "Patient Symptoms": ["The facial droop and leg weakness developed 3 weeks ago, while he was vacationing in upstate New York.", "His symptoms have not progressed since initial onset.", "He reports no rash, headache, joint pain, visual changes, fevers, night sweats, or weight loss."], "Examination and Results": ["On physical examination he has a left lower facial droop with sparing of the forehead muscles.", "Lower extremity strength is preserved and reflexes are normal; however, he has a subtle gait abnormality characterized by slight dragging of his left leg with ambulation.", "His white blood cell count is normal.", "Tests for toxoplasma, Lyme disease, cryptococcal antigen, and human immunodeficiency virus are negative.", "T1-weighted magnetic resonance imaging (MRI) of his brain demonstrates multiloculated ring-enhancing fluid collections involving the right basal ganglia, insula, and frontal lobe (Figure)."], "Others": ["His cancer screening is up to date and unremarkable."]}
{"Patient Personal Background": ["The patient recently returned from a trip to Puerto Rico.", "He has no significant past medical history."], "Patient Symptoms": ["He noticed the lesions approximately 1 week after his return."], "Examination and Results": ["On physical examination, the patient is in overall good health.", "Notable findings include 3 red, serpiginous lesions on the heel (Figure, A), lateral area of the midfoot (Figure, B), and ankle, some with vesicles.", "Vesicles were also noted over the Achilles tendon.Serpiginous lesions on the heel (A) and lateral area of the midfoot (B) of the patient."]}
{"Patient Personal Background": ["The patient is from India and arrived in the United States 1 month ago for graduate studies.", "She reports no significant medical history and is unaware of any tuberculosis (TB) exposures.", "She received the BCG vaccine as a child."], "Patient Symptoms": ["She has no symptoms."], "Examination and Results": ["Laboratory testing showed normal chemistry and hematology values and a negative HIV test.", "The TST reveals an induration of 20 mm.", "Because of the TST result, the patient has a chest radiograph performed, which was unremarkable.", "The patient asks whether the positive TST result could be due to her BCG vaccination and wants further testing before beginning therapy.", "Blood is drawn for an interferon-\u03b3 release assay (IGRA; see Figure for results).aExplanation of values: nil (the interferon-\u03b3 concentration in plasma from blood incubated without antigen [negative control]); TB antigen minus nil (the interferon-\u03b3 concentration in plasma from blood stimulated with 3 relatively specific TB peptides) minus nil; and mitogen minus nil (the interferon-\u03b3 concentration in plasma from blood stimulated with mitogen minus nil).", "The TB response (TB antigen minus nil) is calculated as the difference in interferon-\u03b3 concentration in plasma from blood stimulated with TB antigens minus the interferon-\u03b3 concentration in plasma from blood incubated without antigen (nil)."], "Treatment": ["Treatment for latent TB infection (LTBI) was recommended based on the positive TST, negative chest radiograph, and recent US arrival from a high-TB\u2013incidence country."], "Diagnosis": ["Data are based on package insert available at http://www.quantiferon.com/irm/content/PI/QFT/2PK/US.pdf.cFor negative, positive, and indeterminate results, the probability of Mycobacterium tuberculosis infection is not likely, likely, and uncertain, respectively.The patient does not have LTBI."], "Others": ["The mitogen tube contains a mitogen (phytohaemogglutin-P) that is a nonspecific stimulator of T-cells.", "It is used as a positive control to ensure the capacity to respond to antigens and also serves as a control for correct blood handling and incubation.bFor this IGRA, 1 mL of blood is drawn into each of 3 tubes (nil [negative control], mitogen [positive control], and TB antigens tube).", "A positive IGRA test result occurs when all of the following criteria are met: (1) the nil value is less than 8 IU/mL; (2) the TB antigen minus nil response is greater than or equal to both 0.35 IU/mL and 25% of the nil value; and (3) there is a positive mitogen response.", "No further evaluation is needed.The patient needs further evaluation for active TB disease."]}
{"Patient Personal Background": ["His medical history included Parkinson disease, for which he took no medication."], "Patient Symptoms": ["Three months prior, he had noticed a small nodule on his calf, with no overlying skin changes or tenderness.", "This progressed to a tender, nodular plaque while other lesions appeared.", "The patient denied other signs or symptoms."], "Examination and Results": ["Laboratory findings showed an elevated lactate dehydrogenase (LDH) level at 439 U/L (reference range, 118-242 U/L) (to convert LDH to microkatals per liter, multiply by 0.0167).", "Results from serum chemical analyses, complete blood cell count, and tests of liver functions were normal.", "Physical examination revealed a healthy-appearing man with a 4.0\u2009\u00d7\u20094.0-cm pink, firm, tender nodular plaque on his left calf (Figure, A), a 5.0-cm firm, subcutaneous mass on his right thigh, and a 0.5\u2009\u00d7\u20090.5-cm subcutaneous nodule on his left cheek.", "There was no cervical, axillary, or inguinal lymphadenopathy.", "A punch biopsy specimen was obtained from each lesion (Figure, B and C).A, Clinical photograph of the nodular plaque on the left lateral calf.", "B and C, Histopathologic images from the punch biopsy specimen demonstrating angiocentrism.", "B, The large atypical lymphoid cells can be seen infiltrating a vessel (outlined by arrowheads) (hematoxylin-eosin, original magnification \u00d7400).", "C, Histopathologic image from the punch biopsy specimen showing positive EBER in situ hybridization."]}
{"Patient Personal Background": ["She had a medical history of hypertension, hyperlipidemia, and tobacco abuse, requiring treatment with losartan and atorvastatin.Physical examination revealed punctate, blanchable telangiectasias coalescing to form large, retiform patches on her bilateral lower extremities, feet, and upper extremities (Figure, A)."], "Patient Symptoms": ["They had first appeared on her lower legs 15 years ago and were slowly increasing in number and spreading to involve her feet and bilateral upper extremities.", "The patient denied tenderness, pruritus, and edema."], "Examination and Results": ["There was no conjunctival or mucosal involvement.", "Histologic findings from a biopsy specimen are shown in the Figure, B.A, Multiple telangiectasias coalescing to form large, retiform patches on the bilateral lower extremities.", "B, Dilated, ectatic vessels in the superficial dermis with no associated inflammation or fibrinoid necrosis (hematoxylin-eosin, original magnification \u00d7200)."], "Others": ["She reported no family history of this problem and denied any personal history of anemia, epistaxis, hematemesis, melena, hematochezia, or hemoptysis.", "The patient reported no dermatographism or purpura."]}
{"Patient Personal Background": ["Her medical history was unremarkable, and she was not taking any medications at the time of presentation."], "Patient Symptoms": ["She reported pain, pruritus, and serous discharge associated with the plaques but denied any systemic symptoms."], "Examination and Results": ["Results of a physical examination revealed well-demarcated, moist, erythematous plaques and erosions in the bilateral inframammary regions (Figure 1A) and the intertriginous regions of the groin and scattered excoriated papules on the scalp.", "A punch biopsy specimen of the plaque along the left inframammary region was sent for pathologic evaluation (Figure 1B-D).A, Well-demarcated erosive plaques on the bilateral inframammary region.", "B, Abundant atypical cells within the epidermis and papillary dermis (hematoxylin-eosin, original magnification \u00d710).", "C, Abundant atypical cells with reniform nuclei within the epidermis and papillary dermis (hematoxylin-eosin, original magnification \u00d740).", "D, Immunohistochemical analysis (original magnification \u00d710)."], "Treatment": ["Previous treatment with multiple courses of topical and systemic antifungals, topical and systemic corticosteroids, and oral antibiotics had failed."]}
{"Patient Symptoms": ["The patient reported loss of consciousness and face trauma secondary to airbag deployment.", "At the 10-week follow-up appointment, the patient reported that she was \u201cmiserable\u201d because of vision loss; Snellen best-corrected visual acuity was 20/30 OD."], "Examination and Results": ["Visual acuity measured 20/200 OD and 20/40 OS.", "No afferent pupillary defect was noted.", "In the right eye, external examination revealed ecchymosis and periorbital edema.", "The anterior segment was within normal limits.", "Examination of the posterior segment in the right eye demonstrated whitening of the macula with a central red spot consistent with posterior pole commotio retinae.", "Flame-shaped hemorrhages and cotton-wool spots were noted (Figure 1A).", "Optical coherence tomography (OCT) revealed subfoveal debris (Figure 1B).", "Posterior segment examination was within normal limits.A, Fundus photograph of the right eye demonstrates whitening of the macula with a central red spot.", "Flame-shaped hemorrhages and cotton-wool spots are present in the nasal macula and surrounding the superior arcade.", "B, Optical coherence tomography of the right eye demonstrates subfoveal debris with distortion of the normal foveal architecture."], "Treatment": ["The patient was observed with serial examinations."]}
{"Patient Personal Background": ["She denied any medication use and had no history of ocular surgery or known ophthalmic disorders."], "Examination and Results": ["Best-corrected visual acuity was counting fingers at 1 ft OD and 20/300 OS.", "There was no afferent pupillary defect.", "Slitlamp examination revealed fine keratic precipitates bilaterally, with 2+ anterior chamber cells in her right eye and 0.5+ cells in her left eye.", "Dilated fundus examination of the right eye demonstrated a creamy white lesion emanating superiorly from the optic nerve associated with areas of intraretinal hemorrhage and extensive perivascular sheathing along the vascular arcades into the midperiphery (Figure 1A).", "Ophthalmoscopic examination of the left eye showed a peripapillary preretinal gliotic lesion exerting mild traction on the macula with fine retinal striae and a macular star configuration of exudates (Figure 1B).", "Spectral-domain optical coherence tomography revealed significant cystoid macular edema with associated subretinal fluid in the right eye and hard exudates without evidence of cystoid macular edema in the left eye.Baseline montage color fundus photographs.", "A, Right eye demonstrates retinal whitening superior to the optic nerve adjacent to several pigmented chorioretinal scars.", "B, Left eye demonstrates a preretinal gliotic lesion with a macular star."]}
{"Patient Personal Background": ["Medical history revealed no other medical problems."], "Patient Symptoms": ["Her mother reported the lesion appeared at age 3 months, was previously diagnosed as a hemangioma, and was treated with observation.", "She also reported the lesion originated as a \u201ccystlike papule\u201d that had continuously expanded.", "In addition to causing cosmetic concerns, the lesion seemed to be irritated by clothing and would occasionally bleed and swell.", "Since its appearance at 3 months of age, several abscesses formed underneath the region of concern requiring incision and drainage."], "Examination and Results": ["On physical examination, at the proximal posterior thigh, there was an 11\u2009\u00d7\u200910-cm cobblestoned, gray plaque composed of numerous purplish, vesicular papules with surrounding satellite papules.", "No swelling was present.", "A 4-mm punch biopsy was performed (Figure, B and C).Translucent papules and histologic examination in a child.", "A, Clinical examination shows numerous grouped translucent papules.", "B and C, Dilated thin-walled vascular spaces containing valvelike papillary projections in the superficial dermis."], "Treatment": ["Since its appearance at 3 months of age, several abscesses formed underneath the region of concern requiring incision and drainage."], "Diagnosis": ["Her mother reported the lesion appeared at age 3 months, was previously diagnosed as a hemangioma, and was treated with observation."]}
{"Patient Personal Background": ["Her medical history was significant for hypertension and a previous laparoscopic cholecystectomy approximately 6 years ago.Coronal computed tomographic (CT) image of abdominal mass (arrowhead) (A) and axial CT image of peritoneal implant (arrowhead) (B)."], "Examination and Results": ["She underwent a metastatic workup.", "High-resolution computed tomography revealed a 3\u2009\u00d7\u20094-cm circumferential lesion in the second and third portions of the duodenum involving the pancreatic head (Figure 1).", "Multiple nodules were noted along the peritoneal reflection of the right paracolic gutter.", "The results of a biochemical analysis were remarkable with a total bilirubin level of 6.8 mg/dL (to convert to micromoles per liter, multiply by 17.104), an aspartate aminotransferase level of 394 U/L, an alanine transaminase level of 746 U/L, and an alkaline phosphatase level of 1146 U/L (to convert the last 3 analytes to microkatals per liter, multiply by 0.0167)."]}
{"Patient Personal Background": ["Medical history was significant for a total thyroidectomy for papillary thyroid cancer 7 years before as well as a strong family history of malignant breast cancer on the maternal side and colon and liver cancer on the paternal side.Physical examination revealed an 8\u2009\u00d7\u20098-cm, tender, firm posterior right-flank mass that was mobile but fixed to the abdominal wall musculature.", "Her case was presented at the soft tissue tumor board, and given that the patient was asymptomatic and pregnant, the decision was made to closely watch the progression of this lesion with serial imaging with a planned resection after delivery.Unfortunately, she developed premature rupture of membranes and lost the pregnancy."], "Examination and Results": ["Laboratory examination revealed no abnormalities.", "Ultrasonography demonstrated a hypoechoic lesion measuring 3.3\u2009\u00d7\u20093.6 cm with internal echoes and no significant flow (Figure 1A).", "A noncontrast magnetic resonance image (MRI) revealed this to be a well-circumscribed T2 hyperintense lesion with diffuse surrounding soft tissue edema within the adjacent muscular and subcutaneous tissues abutting the posterior margin of the right chest wall and external oblique muscle at the level of the T11 to T12 intercostal space (Figure 1B and C).A, Ultrasonography demonstrating a hypoechoic mass in the musculature of the right flank.", "B and C, T1- and T2-weighted images demonstrating an enhancing right-flank mass within the right-flank musculature.Because of the concern of malignancy, an ultrasonography-guided core biopsy was performed and demonstrated a myofibroblastic proliferation with immunostains positive for actin and negative for S100 and desmin.", "Follow-up computed tomography was not able to identify the lesion but MRI showed that it was still present but decreased in size (2.4\u2009\u00d7\u20091 cm) with interval resolution of surrounding inflammatory changes."], "Treatment": ["B and C, T1- and T2-weighted images demonstrating an enhancing right-flank mass within the right-flank musculature.Because of the concern of malignancy, an ultrasonography-guided core biopsy was performed and demonstrated a myofibroblastic proliferation with immunostains positive for actin and negative for S100 and desmin.", "She subsequently underwent wide local resection of the lesion."]}
{"Patient Personal Background": ["None of these therapies was of benefit.The patient reported no significant medical history and was not taking other medications."], "Patient Symptoms": ["He reported nasal congestion and pain, bleeding, and minor sloughing of nasal mucosal tissue."], "Examination and Results": ["On examination he had an erythematous plaque without ulceration on the right side of the neck (Figure, left).", "Examination also revealed erythema and swelling of the left nasal ala extending to the infratip lobule (lowermost portion of the nasal tip directly above the nostril openings) and left alar rim as well as disruption of the nasal architecture with crusting of the left nare (Figure, right).", "Cervical lymphadenopathy was present and most pronounced on the right side.", "A biopsy of the nasal tissue revealed pseudoepitheliomatous hyperplasia, a lymphoplasmocytic inflammation, with no organisms found using special staining.Left, Erythematous plaque with crusting on the right side of the neck."], "Treatment": ["He was seen by 2 dermatologists, a family physician, and an otolaryngologist in Venezuela as well as 2 dermatologists, 2 family physicians, a nurse practitioner, and an infectious diseases specialist in the United States.", "These 10 clinicians collectively prescribed oral amoxicillin, cefadroxil, cephalexin, azithromycin, clindamycin, and cefdinir as well as intramuscular ceftriaxone and topical bacitracin, mupirocin, and polymyxin B."], "Others": ["The remainder of the physical examination was unremarkable."]}
{"Patient Personal Background": ["He had type 2 diabetes mellitus treated with insulin, metformin, glyburide, and pioglitazone.", "He also had coronary artery disease complicated by a myocardial infarction and coronary artery bypass graft surgery 6 years ago."], "Patient Symptoms": ["He has had occasional night sweats but reported no fevers, weight loss, or change in appetite."], "Examination and Results": ["The general physical examination was unrevealing, as were oropharyngeal, cardiac, respiratory, abdominal, and lymph node examinations.", "A complete blood cell count (CBC) showed a hemoglobin level of 14.6 g/dL and a white blood cell count of 24.1\u2009\u00d7\u2009103/\u03bcL with 25% neutrophils and 69% lymphocytes; platelet count was 189\u2009\u00d7\u2009103/\u03bcL.", "A peripheral blood smear (Figure) showed red blood cells with mild anisocytosis (unequal size) and poikilocytosis (variation in shape).", "The platelets were normal in number and appearance.", "White blood cells were increased, with a lymphocytic predominance.", "The lymphocytes were mature and appeared somewhat heterogeneous.", "Smudge cells were noted (Figure, Left panel, lower right corner; Right panel, center)."]}
{"Patient Personal Background": ["She also had fine-textured hair, present since childhood with thinning noted in the past 7 years.", "At the time, she denied a family history of similar skin findings but recently reported similar hand and foot findings in her mother."], "Patient Symptoms": ["Many of the papules were depressed centrally.", "The lesions on her hands first developed in her 40s and were exacerbated by alcohol-based hand sanitizer at work.", "They became more prominent with exposure to water but remained asymptomatic.", "Two punch biopsies were performed from the left thenar eminence (Figure, C).A, Clinical photograph of the palm showing dozens of flesh-colored to translucent palmar papules."], "Examination and Results": ["There was no extension onto the dorsal aspect of the hands.", "There were similar translucent papules over the margins of her feet, particularly her great toes, and hyperkeratotic yellow plaques with scattered pits over her bilateral soles, concentrated in areas of pressure.", "B, Closer clinical view of the palmar papules over the thenar eminence, some with central depression.", "C, Histologic image from a skin biopsy specimen from the thenar eminence (hematoxylin-eosin, original magnification \u00d740)."], "Treatment": ["Occasional application of urea cream to her feet did not lead to significant improvement."], "Others": ["She had no history of eczema."]}
{"Patient Personal Background": ["She had a history of type 2 diabetes mellitus, hypothyroidism, and hypercholesterolemia.", "Her regular medications included metformin, insulin, rosuvastatin calcium, levothyroxine sodium, and aspirin."], "Patient Symptoms": ["She also had bilateral injected conjunctivae with periorbital swelling."], "Examination and Results": ["Examination revealed edematous labia and multiple perivulvar tender nodules on violaceous and indurated plaques sparing the vaginal mucosa and inguinal creases (Figure, A).", "A punch biopsy of the perivulvar lesions was performed for histopathologic analysis (Figure, B and C) and tissue culture.A, Perivulvar plaques and nodules that developed after chemotherapy for acute myeloid leukemia.", "Edematous labia with perivulvar violaceous plaques and nodules.", "B and C, Skin histologic images from perivulvar plaques and nodules.", "B, Spongiosis and hyperplasia of the epidermis with neutrophilic infiltrate within the dermis (hematoxylin-eosin, original magnification \u00d710).", "C, Necrotic collagen and eccrine gland destruction (hematoxylin-eosin, original magnification \u00d710)."]}
{"Patient Personal Background": ["He reported no history of cutaneous diseases.", "He had undergone heterologous bone marrow transplantation for chronic myeloid leukemia 18 years before and had hypertension controlled with lisinopril and hydrochlorothiazide and type 2 diabetes mellitus controlled by diet."], "Examination and Results": ["Physical examination revealed multiple hyperkeratotic purplish brown papules and plaques, more confluent in the perianal area, with well-demarcated keratotic prominent margins (Figure, A and B).", "Dermoscopy showed structureless brownish pigmentation and erythema in the center, demarcated by a white-yellow hyperkeratotic scale at the periphery.", "Therefore, 2 skin biopsies were performed (Figure, C).A, Multiple hyperkeratotic purplish brown papules and plaques on both buttocks, more confluent in the perianal area, with well-demarcated slightly elevated keratotic margins.", "B, Detail of the clinical lesions."], "Treatment": ["Because of suspicion of lichen planus annularis, the patient was treated intermittently with intramuscular triamcinolone acetonide depot and topical treatments such as corticosteroids, antifungal agents, pimecrolimus, and retinoic acid, resulting in subjective pruritus relief; however, the lesions did not show satisfactory improvement in 2 years\u2019 follow-up."], "Others": ["C, Biopsy specimen (hematoxylin-eosin, original magnification \u00d7400)."]}
{"Patient Personal Background": ["He denied any family history of similar eruptions and was not taking any medications aside from whey protein supplementation.", "He was eating a normal diet."], "Patient Symptoms": ["He felt well otherwise, denying fever, gastrointestinal upset, or any antecedent illness or exposure."], "Examination and Results": ["The cutaneous eruption had continued to spread despite topical and oral corticosteroid therapy, and diphenhydramine provided no relief from the pruritus.A, Initial clinical presentation of bullae on an erythematous base in a reticular pattern on the back.", "B, Biopsy specimen from the mid-abdomen showing dense infiltration of the epidermis by numerous eosinophils (hematoxylin-eosin).", "C, Biopsy specimen from the back showing abrupt necrosis of the epidermis and an intraepidermal blister filled with neutrophils and eosinophils.", "The blister correlates with the bulla seen clinically.", "The upper dermis showed a mixed infiltrate of lymphocytes, eosinophils, and neutrophils (hematoxylin-eosin).A complete blood cell count and comprehensive metabolic panel revealed only a minor lymphopenia (lymphocyte percentage, 16.8%; lymphocyte count, 1000/\u03bcL [normal, 1300-3600/\u03bcL]), a high monocyte percentage (13.6%; normal, 4.0%), but a normal absolute monocyte count.", "(To convert lymphocyte count to \u00d7109/L, multiply by 0.001.)", "Results from assays for herpes simplex virus IgG, antinuclear antibodies, glucagon, and zinc were all within normal limits.On clinical examination, vesicles and bullae were found coalescing into large reticulated plaques with background erythema on the upper neck, inframammary areas, groin, mid back, and extending down onto the upper buttocks.", "The bullae were eroded in some areas with hemorrhagic crust (Figure 1A).Punch biopsy specimens from characteristic lesions were obtained and sent for hematoxylin-eosin (H&E) examination (Figure 1B and C)."], "Treatment": ["The cutaneous eruption had continued to spread despite topical and oral corticosteroid therapy, and diphenhydramine provided no relief from the pruritus.A, Initial clinical presentation of bullae on an erythematous base in a reticular pattern on the back."], "Others": ["No evidence of ketosis was noted."]}
{"Patient Personal Background": ["The patient\u2019s medical history was notable for rheumatoid arthritis that had been well controlled with methotrexate for 15 years."], "Patient Symptoms": ["The lesion was first noted 6 months prior to presentation and was initially diagnosed as a chalazion.", "The nodule increased in size during the next several months despite conservative measures including warm compresses.", "Despite an initial decrease in lesion size, 6 weeks postinjection, new-onset ipsilateral extraocular motility deficits and palpable preauricular lymphadenopathy were noted."], "Examination and Results": ["A magnetic resonance image revealed an infiltrative process in the involved eyelid and lymphadenopathy (Figure, B and C).", "Findings from systemic evaluation, including complete blood cell count, serum protein electrophoresis, serum lactate dehydrogenase, and whole-body positron emission tomography, were unremarkable.A, Swollen right upper eyelid.", "Magnetic resonance images demonstrating diffuse eyelid infiltration (B, arrowhead) and lymphadenopathy (C, arrowhead)."], "Treatment": ["Intralesional triamcinolone was then administered."], "Diagnosis": ["A biopsy revealed a mixed inflammatory infiltrate without evidence of neoplasia, supporting a diagnosis of chalazion.", "A second biopsy of the eyelid lesion revealed large, atypical lymphocytes diffusely positive for CD20 and negative for CD5 and Bcl-1 (Figure, D-G), supporting a diagnosis of diffuse large B-cell lymphoma (DLBCL)."]}
{"Patient Personal Background": ["He had undergone trabeculectomy in the right eye with mitomycin C 4 years earlier."], "Examination and Results": ["On examination, his best-corrected visual acuity was 6/60 (\u22122.5 diopters sphere/0.5 diopters cylinder\u2009\u00d7\u200990) and 6/6 (0.5 diopters sphere) OD and OS, respectively.", "His IOP was 36 mm Hg and 12 mm Hg OD and OS, respectively, while receiving the maximum-tolerated antiglaucoma medications.", "Fundus examination was normal (Figure 1A and B), and B-scan ultrasonography revealed no mass lesion in the right eye.", "The left eye was normal.A and B, Right eye at presentation showing marked red glow of the fundus (A) compared with the left eye (B).", "On the first postoperative day, the anterior chamber was flat with corneolenticular touch (Figure 1C) and serous choroidal effusion.", "The Ahmed glaucoma valve tube was ligated a week later, following which the IOP stabilized and choroidal effusion subsided.After 9 months, the IOP rose to 30 mm Hg, which could not be controlled medically.", "Postoperatively, it again led to hypotony and a shallow anterior chamber.", "The accompanying choroidal effusion was now associated with exudative retinal detachment, with retina-lenticular touch (Figure 1D) and the patient did not respond to conservative management."], "Treatment": ["C, First postoperative day following Ahmed glaucoma valve implantation in the right eye with a flat anterior chamber.", "Note the iris plugging the opening of the Ahmed glaucoma valve tube.", "D, Large serous retinal detachment and choroidal effusion following fibrous capsule excision.He underwent Ahmed glaucoma valve implantation in the right eye.", "The anterior chamber repeatedly flattened despite viscoelastic injection, and the choroidal effusion persisted.", "There was a tense fibrous capsule encapsulating the Ahmed glaucoma valve plate, which was excised."]}
{"Patient Personal Background": ["The patient\u2019s mother noted that both the pregnancy and the delivery were uncomplicated.", "She denied ever having a miscarriage and had another healthy male child at home without any similar lesions.", "The mother had a history of varicella as a child; she did not have a history of herpes simplex virus and had no oral or genital lesions at the time of delivery."], "Patient Symptoms": ["These papules had been present at birth and were persistent at the time of the patient\u2019s initial hospital discharge.", "Because no resolution had been noted over the next few days, the patient was taken to his primary care physician for evaluation and then sent to the emergency department for further workup."], "Examination and Results": ["The patient was afebrile.", "On examination, the patient was noted to have 2- to 3-mm vesicles on the left upper extremity in a linear, bandlike distribution (Figure, A), and similar 2- to 3-mm deep-seated vesicles on his left medial thigh in a whorled configuration, approximately 4\u2009\u00d7\u20093 cm in total size (Figure, B).", "In addition, the patient had a 1-mm vesicle on his abdomen.A, Vesicles (2-3 mm in diameter) on the left forearm are in a linear, bandlike distribution.", "B, Deep-seated vesicles on left medial thigh are in a whorled configuration."]}
{"Patient Personal Background": ["Her medical history included a partial oophorectomy of a right ovarian cyst, hypertension, and vomiting and abdominal pain once a year that started 10 years earlier.", "She had always been diagnosed as having adhesive ileus, and her symptoms always improved within a day after hospital admission."], "Patient Symptoms": ["She had always been diagnosed as having adhesive ileus, and her symptoms always improved within a day after hospital admission.", "A physical examination at admission revealed that her abdomen was slightly distended and tender to palpation on the right side of the paraumbilical point without muscle guarding."], "Examination and Results": ["The hematologic findings revealed slight anemia and amylasemia; her hemoglobin level was 9.3 g/dL (to convert to grams per liter, multiply by 10.0), and her amylase level was 168 U/L (to convert to microkatals per liter, multiply by 0.0167).", "Abdominal computed tomography (CT) with intravenous contrast agent revealed a mass on the right side of the paraumbilical point (Figure 1).Contrast-enhanced computed tomographic scan through the abdomen showing a mass on the right side of the paraumbilical point."]}
{"Patient Personal Background": ["Her medical history included gastroesophageal reflux disease, irritable bowel syndrome, hypothyroidism, hypertension, asthma, and obesity."], "Examination and Results": ["On palpation, the mass extended superiorly to the costal margins and inferiorly to the anterior-superior iliac spine; no fascial edge was palpable medially.", "A computed tomographic (CT) scan demonstrated abdominal contents\u2014including liver, ascending colon, and omental fat\u2014protruding through a 12-cm defect."], "Treatment": ["Weight loss was counseled and 8 weeks allowed for optimization before exploration."]}
{"Patient Personal Background": ["In addition to chronic hepatitis B, her medical history was notable for hypertension and her surgical history was significant for a recent liver biopsy."], "Patient Symptoms": ["The patient was symptomatic with intermittent left upper quadrant abdominal pain that was associated with nausea and constipation."], "Examination and Results": ["Physical examination revealed a soft, nontender, minimally distended abdomen with no palpable masses and no costovertebral angle tenderness.Laboratory test results at presentation revealed complete blood cell count, comprehensive metabolic panel, and amylase values within the reference ranges and a hepatitis B virus quantification level of 1590 IU/mL.", "A computed tomographic scan of the abdomen and pelvis using intravenous contrast was obtained (Figure 1).Coronal computed tomographic imaging on initial presentation."], "Others": ["She reported no other gastrointestinal, genitourinary, or overall symptoms."]}
{"Patient Personal Background": ["The patient did relate having many prior episodes of epistaxis since childhood."], "Patient Symptoms": ["Multiple red papules on the tongue (Figure 1), trunk, and limbs were noted during the physical examination.", "The patient stated she had not noticed the red papules before."], "Examination and Results": ["Computed tomography (CT) of the brain showed a ring-enhanced lesion with surrounding edema on the left frontoparietal lobe.", "There was no suggestion of otitis media or parasinusitis and no history of craniotomy, open head injury, or cyanotic heart disease."], "Treatment": ["Blood cultures were obtained when the patient was first seen, and the patient received ampicillin/sulbactam empirically.Multiple red papules on the tip and sides of the tongue.Consult a neurosurgeon to evaluate the brain CT finding; obtain a CT scan of the lung and abdomen and offer genetic counseling for the patient and her family.Consult a neurosurgeon to evaluate the brain CT finding; obtain a dermatology consultation and refer the patient to interventional radiology."], "Others": []}
{"Patient Personal Background": ["He was a graduate student who was doing well until he developed decompensated cirrhosis with variceal hemorrhage."], "Patient Symptoms": ["When he first presented, he had hypovolemic shock from acute blood loss related to variceal hemorrhage that was treated with many blood transfusions and variceal banding procedures.", "He did not have any confusion, insomnia, or decreased mental alertness.", "Jaundice was noted on the physical examination but he was alert and oriented with normal cognitive function."], "Examination and Results": ["He had a serum ammonia level measured as part of the routine liver transplant evaluation.", "No tenderness was noted on his abdominal examination and he had mild ascites."], "Treatment": ["When he first presented, he had hypovolemic shock from acute blood loss related to variceal hemorrhage that was treated with many blood transfusions and variceal banding procedures.", "The Table lists results of laboratory analyses performed at admission and on hospital days 25 and 38.The patient has hepatic encephalopathy and should be treated.The patient has subclinical hepatic encephalopathy and should be treated.The patient is at high risk for developing hepatic encephalopathy and should be prophylactically treated.The patient does not have hepatic encephalopathy so no treatment is necessary."], "Others": ["When he was transferred to the liver unit on hospital day 25, his liver test abnormalities had mostly recovered and he had no further gastrointestinal bleeding.", "During the inpatient liver transplant evaluation, his cognitive capacity and mental status remained stable and he had no symptoms of encephalopathy.", "He received oral diuretics for the management of his ascites."]}
{"Patient Personal Background": ["His myelofibrosis had been treated 2 years earlier with a splenectomy and allogeneic peripheral hematopoietic stem cell transplantation from a single-antigen mismatched unrelated donor.", "A busulfan-based myeloablative regimen was used for preconditioning before the transplant.", "He had received tacrolimus, but that was tapered off 4 months before his current problems began.", "His only current medication is daily oral acyclovir.Vital signs were normal."], "Patient Symptoms": ["Subsequently, he noted development of a nonpruritic rash on his face, trunk, and extremities.", "The rash was associated with intermittent fever, muscle pain, and weakness."], "Examination and Results": ["There were well-demarcated erythematous to violaceous scaly plaques on his forehead and cheeks, sparing the nasolabial folds and periocular regions (Figure, A).", "Diffuse areas of reticulated hyperpigmentation were present across his chest and upper back (Figure, B).", "There were violaceous, thin, flat-topped papules bilaterally on the dorsal surfaces of his hands (Figure, C) and the lateral soles of his feet.", "Musculoskeletal examination revealed impaired ability to dorsiflex the wrists while bringing the palms together (\u201cprayer sign\u201d).A, Well-demarcated erythematous to violaceous scaly plaques on the forehead and cheeks with notable sparing of the nasolabial folds and periocular regions.", "C, Violaceous, thin, flat-topped papules bilaterally on the dorsal surfaces of the hands.Results of liver function tests revealed an aspartate aminotransferase level of 41 U/L (0.68 \u03bckat/L); alanine aminotransferase, 68 U/L (1.14 \u03bckat/L); alkaline phosphatase, 147 U/L (2.45 \u03bckat/L); and total bilirubin, 0.7 mg/dL (11.97 \u03bcmol/L)."], "Others": ["After the transplant, he experienced acute graft-vs-host disease predominantly manifested by gastrointestinal symptoms."]}
{"Patient Personal Background": ["His medical history was significant for hypertension, gastroesophageal reflux, and prostate cancer."], "Examination and Results": ["On examination, uncorrected visual acuity was 20/25 OU, pupils were equal and reactive to light without afferent defect, confrontational fields were normal, and ocular motility was full.", "External examination was significant for decreased sensation in the distribution of the ophthalmic branch of the left trigeminal nerve.", "A palpable mass was appreciated at the left supratrochlear notch.", "There was 4 mm of proptosis and 2 mm of inferior globe dystopia, with increased resistance to retropulsion in the left eye.", "Magnetic resonance imaging of the orbits demonstrated an infiltrating superomedial mass involving the extraconal and intraconal space on the left side (Figure 1).Magnetic resonance imaging of the orbits."], "Others": ["An 86-year-old man presents with an infiltrating mass of the left superomedial orbit demonstrated on T1-weighted axial (A) and coronal (B) images."]}
{"Patient Symptoms": ["He denies any other ocular discomfort."], "Examination and Results": ["His best-corrected visual acuity is 20/30 OD and 20/20 OS.", "His pupil, intraocular pressure, motility, and confrontational visual field are normal in each eye.", "The results of an external examination and a slitlamp examination of the anterior segment of both eyes are unremarkable.", "A dilated fundus examination reveals clear vitreous in each eye and small yellow-white retinal lesions in the right eye.", "The patient denies any history of recent illnesses (Figure 1).A, Color fundus photograph shows subtle yellow-white punctate lesions deep in the retina.", "Fluorescein angiograms demonstrate hyperfluorescent lesions during the early and late phases and late optic nerve staining (arterial [B], venous laminar [C], and late [D] phase)."]}
{"Patient Personal Background": ["Three months prior to presentation, he had received a diagnosis of pneumonia; his condition improved after a course of azithromycin.", "He denied ever having a fever, weight loss, contact with any sick persons, or sexual activity; using illicit drugs; or traveling outside of southern California.Examination revealed mildly tender, fluctuant masses at the base of his neck, each measuring 4 cm in diameter (Figure, A)."], "Patient Symptoms": ["The left-sided mass had been spontaneously draining straw-colored fluid for 5 days."], "Examination and Results": ["Laboratory values included a white blood cell count of 13/\u03bcL (to convert to \u00d7109 per liter, multiply by 0.001) (69% neutrophils, 21% lymphocytes, and 2.3% eosinophils [to convert to proportion of 1.0, multiply by 0.01]), a hemoglobin level of 12.3 g/dL (to convert to grams per liter, multiply by 10.0), and a platelet count of 337\u2009\u00d7\u2009103/\u03bcL (to convert to \u00d7109 per liter, multiply by 1.0).", "The results of a screening antibody test for human immunodeficiency virus and of a Mantoux tuberculin skin test were negative.", "A chest radiograph revealed bilateral hilar adenopathy (Figure, B).", "An excisional lymph node biopsy of the left-sided mass was performed (Figure, C).A, Bilateral level IV (low jugular) cervical adenopathy.", "B, Chest radiograph showing bilateral hilar adenopathy.", "C, Histological examination of the excised lymph node showing multiple spherules containing endospores (arrowheads) (hematoxylin-eosin, original magnification \u00d7200)."]}
{}
{"Patient Personal Background": ["Three months prior, he had an episode of native aortic valve endocarditis, necessitating aortic valve replacement with a pericardial bioprosthesis.", "He developed postoperative acute renal failure, which progressed to chronic renal failure requiring dialysis via tunneled catheter."], "Examination and Results": ["Transesophageal echocardiography demonstrated a vegetation on his prosthetic aortic valve.", "However, on postprocedure radiography, the tip of the triple-lumen catheter was not in the expected location (Figure 1)."], "Treatment": ["Owing to his dialysis needs, a temporary dialysis catheter was placed in the right internal jugular vein.", "As intravenous access was required for vasoactive medications and intravenous antibiotics, a triple-lumen central catheter was placed in the left internal jugular vein under ultrasonographic guidance.", "The catheter was removed, and a new-stick insertion of a new catheter was attempted under ultrasonographic guidance.Chest radiograph showing left internal jugular catheter placement (arrowhead)."], "Diagnosis": ["On this admission, he was found to have methicillin-resistant Staphylococcus aureus (MRSA) bacteremia.", "He was diagnosed as having MRSA prosthetic valve endocarditis and admitted to the cardiovascular surgical intensive care unit prior to surgical intervention.In the setting of MRSA bacteremia, his tunneled dialysis catheter had been removed."], "Others": ["The catheter went in easily without resistance, was drop tested to confirm venous placement, and flushed and drew easily, and venous waveforms and pressures were transduced."]}
{"Patient Personal Background": ["The patient had no history of oral or genital herpes lesions."], "Patient Symptoms": ["Her lesions improved with prednisone but recurred when treatment was discontinued.", "No inciting factors were identified except a possible relation to her menstrual cycle.", "She also reported concurrent painful oral lesions."], "Examination and Results": ["Erythematous, hyperpigmented, annular papules with dusky centers and bullae were observed on her arms and legs bilaterally (Figure, A, B, C).", "Oral lesions were also observed and consisted of erythematous, crusted papules with superficial ulceration, gingival hyperplasia, and superimposed thrush (Figure, D).", "Results of herpes simplex virus (HSV) 1 and 2 IgG serologic testing were positive.", "Test results for pemphigus antibody panel, antinuclear antibodies, human immunodeficiency virus, and rapid plasma reagin were negative."], "Treatment": ["Her lesions improved with prednisone but recurred when treatment was discontinued."]}
{"Patient Symptoms": ["The patient reports experiencing no fevers or chills since the plaque developed."], "Examination and Results": ["On examination the bright reddish, irregularly shaped plaque measures 4.0\u2009\u00d7\u20091.5 cm and has erosions on the surface (Figure 1).", "The physical examination is otherwise unremarkable."]}
{"Patient Personal Background": ["His blood pressure was 183/116 mm Hg despite taking lisinopril (40 mg/d) and verapamil (180 mg/d).", "He had previously taken hydrochlorothiazide, which was discontinued due to hypokalemia approximately 1 month ago, as well as atenolol, which was stopped 2 months earlier."], "Examination and Results": ["As part of the workup for secondary hypertension, plasma aldosterone concentration and plasma renin activity were measured (Table 1).Primary aldosteronism is suggested; imaging is required for confirmation.Primary aldosteronism is suggested; confirmation requires an aldosterone suppression test.The results are unreliable; ARR should be measured 1 month after discontinuing lisinopril."], "Treatment": ["His blood pressure was 183/116 mm Hg despite taking lisinopril (40 mg/d) and verapamil (180 mg/d)."], "Diagnosis": [], "Others": []}
{"Patient Symptoms": ["Soon thereafter, she was noted to be more forgetful and unsteady.", "She was seen by an otolaryngologist for left-sided hearing loss and diagnosed as having Meniere disease.", "She was treated for aseptic meningitis but continued to decline."], "Examination and Results": ["Head computed tomography findings were negative and the following day, the headache subsided.", "Subsequently, brain magnetic resonance image findings showed numerous foci of enhancement throughout the brain (Figure 1).", "Cerebrospinal fluid analysis results were normal except for mildly elevated protein (108 mg/dL).", "Findings from cerebrospinal fluid Gram stain and cultures were negative.", "No oligoclonal bands were found.", "Test results for human immunodeficiency virus, syphilis, enterovirus, West Nile virus, herpes simplex virus types 1 and 2, hepatitis, Cryptococcus, Lyme disease, Rickettsia, and Ehrlichia were negative.", "Erythrocyte sedimentation rate and C-reactive protein findings were normal.", "Results from antinuclear antibody, extractable nuclear antigen, rheumatoid factor, and antineutrophil cytoplasmic antibody tests were negative.", "Chest x-ray showed no hilar adenopathy.", "On examination, the patient had visual acuity of 20/20 OU.", "Pupils, intraocular pressure, motility, and confrontational visual fields were normal.", "External and anterior segment examinations were unremarkable."], "Treatment": ["Symptoms mildly abated with meclizine hydrochloride and a brief course of steroids.", "Ophthalmology was consulted to evaluate the patient when she began to experience transiently blurred vision."], "Diagnosis": ["She was seen by an otolaryngologist for left-sided hearing loss and diagnosed as having Meniere disease."], "Others": ["She was subsequently admitted to the hospital.", "Dilated fundus examination findings were unremarkable.Axial brain magnetic resonance imaging.", "A, Diffusion-weighted imaging.", "B, Corresponding apparent diffusion coefficient image."]}
{"Patient Personal Background": ["She was taking glatiramer acetate and tizanidine hydrochloride for MS."], "Patient Symptoms": ["The patient also noted decreased peripheral vision and pain on eye movements of the left eye.", "She described a recent episode of gastroenteritis prior to the onset of visual complaints."], "Examination and Results": ["Her initial visual acuity was 20/50 in both eyes with a 1+ relative afferent pupillary defect in the right eye.", "The patient had red desaturation in the left eye, and her color vision, which was determined by use of an Ishihara test, was decreased in both eyes.", "Intraocular pressure and ocular motility were normal, and the results of an external examination, an anterior segment examination of both eyes, and a posterior segment examination of the right eye were unremarkable."]}
{"Patient Symptoms": ["This was his third hospitalization for these symptoms; the previous admissions were 2 and 4 months earlier, with no symptoms in the intervals.", "However, within 24 hours after admission, our patient developed left chemosis with eyelid edema and erythema.", "Extraocular movements were limited in all directions in both eyes, with a larger deficit in the right eye.Adolescent boy with eyelid swelling, redness, and pain."], "Examination and Results": ["During the prior admissions, treatment included antibiotics for orbital cellulitis and corticosteroids for suspected antibiotic allergies.Physical examination was notable for right upper and lower eyelid edema and erythema, conjunctival hyperemia, chemosis, and proptosis (Figure, A).", "His vision and pupillary responses were normal.", "Fundus examination revealed mild blurring of the disc margins only on the right side.", "Slitlamp examination identified numerous cells in the right anterior chamber.", "A, Swelling of the right orbital (white arrowhead) and periorbital (black arrowhead) tissues and proptosis, with mild swelling of the left upper eyelid (blue arrowhead).", "B, Maxillofacial computed tomography with intravenous contrast showed severe right proptosis with stretching of the right optic nerve (white arrowhead) and thickening of the rectus muscles and soft tissues (black arrowhead).", "Mild enlargement of the lacrimal gland on the left side can also be seen (blue arrowhead).", "C, Maxillofacial magnetic resonance imaging with intravenous contrast.", "Coronal (left) and axial (right) views showed inflammation involving the intraconal fat and perineural soft tissues (white arrowhead), as well as the inferior and lateral extraocular muscles, on the right side."], "Treatment": ["During the prior admissions, treatment included antibiotics for orbital cellulitis and corticosteroids for suspected antibiotic allergies.Physical examination was notable for right upper and lower eyelid edema and erythema, conjunctival hyperemia, chemosis, and proptosis (Figure, A)."], "Others": ["The left eye appeared normal at admission.", "The black arrowheads indicate the muscles in the coronal and axial views.Computed tomography (Figure, B) and magnetic resonance imaging (MRI) (Figure, C) of the orbit were performed."]}
{"Patient Personal Background": ["Her medical history was unremarkable; in particular, she had no history of endometriosis."], "Patient Symptoms": ["She had visited the emergency department of another hospital 2 weeks before with the same symptoms and had received conservative treatment.", "A mass was palpable in the lower right abdominal quadrant."], "Examination and Results": ["On physical examination in the present visit, she had lower abdominal tenderness but no sign of peritoneal irritation.", "The results of routine blood investigations, including white blood cell count, hemoglobin concentration, and C-reactive protein level, were within normal limits, as they had been in the previous hospital.", "Abdominal ultrasonographic examination was performed, followed by abdominal computed tomography; the results were suggestive of an ileal intussusception (Figure, A).", "A colonoscopy revealed the presence of a bulge in the cecal lumen (Figure, B).A, Abdominal computed tomography suggesting the presence of an ileal intussusception."]}
{"Patient Personal Background": ["Of note, the patient\u2019s son has a history of neurofibromatosis 1."], "Patient Symptoms": ["He denied having pelvic pain, urinary symptoms, or bowel symptoms."], "Examination and Results": ["However, on surveillance computed tomography, he was noted to have a new pelvic mass that was concerning for a recurrent malignant neoplasm.", "His prostate-specific antigen level was undetectable.", "Subsequent magnetic resonance imaging revealed a heterogeneously enhancing mass within the prostatic bed, which had central necrosis (Figure).", "The mass measured 4.8\u2009\u00d7\u20095.5\u2009\u00d7\u20095.0 cm and was contiguous with the right obturator internus.", "No appreciable lymphadenopathy was noted.", "Computed tomography\u2013guided biopsy revealed spindle cells with a low mitotic index.", "The result of immunohistochemical staining was diffusely positive for desmin and smooth muscle actin, as well as focally positive for pan-keratin and S100.", "The staining result was negative for CD34 and CDK4.", "Fluorescence in situ hybridization failed to demonstrate MDM2 (OMIM 164785) gene amplification.Magnetic resonance imaging of the pelvis reveals a large heterogeneously enhancing mass within the prostatic bed.", "Axial (A and B) and sagittal (C and D) views reveal that the mass has T1 isointensity to hypointensity and T2 hyperintensity, suggesting internal areas of necrosis.", "A marked mass effect is seen on the anterior-inferior bladder, which displaces the bladder superiorly.", "The mass is contiguous with the right anterior aspect of the obturator internus and with the inner cortex of the midline superior pubic rami, which demonstrate erosion of the midline but no appreciable enhancing marrow signal."]}
{"Patient Personal Background": ["His medical history included hypertension and diabetes mellitus; he had no recent travel."], "Patient Symptoms": ["The mass was associated with increasing pain as it grew rapidly, starting from the size of a dime and increasing to extend 15 cm.", "The patient reported spontaneous drainage of pus from the mass and an unexplained weight loss."], "Examination and Results": ["Physical examination revealed a large palpable mass with central fluctuance and surrounding erythema.", "The mass extended from the subcostal region to the anterior superior iliac spine on palpation and was tender to touch.", "No active drainage was noted; however, multiple pustules were present (Figure 1A).", "Computed tomography of the chest, abdomen, and pelvis showed a large (10 \u00d7 15 cm) soft-tissue mass in the right lateral abdominal wall, extending from the level of the diaphragm to the iliac crest (Figure 1B and C).", "The mass appeared to directly invade the liver and extend through intercostal spaces with multiple small areas of calcification."], "Treatment": ["The patient was then taken to the operating room where an excisional biopsy was performed.A, Right flank mass on initial presentation."], "Others": ["Core needle biopsy showed inconclusive results, and a recommendation was made for a fresh tissue biopsy."]}
{"Patient Symptoms": ["She denies fever, cough, orthopnea, weight loss, and appetite change."], "Examination and Results": ["Physical examination reveals tenderness at the location of the left fifth rib and reduced left chest expansion.", "There is no chest wall deformity.", "Chest radiography (Figure 1) shows left lower lobe opacification obscuring the left hemidiaphragm and blunting of the left costophrenic angle.Left, Anteroposterior chest radiograph."], "Treatment": ["She has been treated with analgesia and physiotherapy."]}
{"Patient Symptoms": ["The lesion appeared as a small reddish-brown macule 3 years ago and has gradually increased in size.", "During the past several months, the lesion has become indented and increasingly tender.", "The patient denies systemic symptoms, including fevers and chills, and is primarily concerned about the changing appearance of the lesion and the new-onset tenderness."], "Examination and Results": ["Cutaneous examination reveals a 3-cm sclerotic reddish brown patch with central yellow deposits (Figure 1).", "Laboratory evaluation includes a random blood glucose level of 217 mg/dL (12 mmol/L)."]}
{"Patient Personal Background": ["Three years earlier, red cell scintigraphy documented a splenic hemangioma, which remained stable on periodic computed tomography (CT) scans.There is no history of abdominal trauma, melena, or hematochezia."], "Patient Symptoms": ["The patient had lost 6.75 kg (15 lb) and experienced increasing fatigue during a period of 1 month."], "Examination and Results": ["On physical examination, vital signs are normal.", "The spleen edge is palpable 6 cm below the left costal margin (increased from 1 month prior).", "There is no hepatomegaly or lymphadenopathy.", "On rectal examination there is no gross blood, and no stool to perform a guaiac test.", "Laboratory studies show a hemoglobin level of 6.8 g/dL (from 12 g/dL 2 months earlier and 8 g/dL 1 week earlier), white blood cell (WBC) count of 15.76\u2009\u00d7\u2009109/L, and platelet count of 266\u2009\u00d7\u2009109/L.", "A CT scan of the abdomen was performed (Figure 1).Computed tomography scan of the abdomen."], "Others": ["A, Axial view.", "B, Coronal view."]}
{"Patient Personal Background": ["He had a distant history of contact lens wear but terminated use owing to recurrent corneal abrasions.", "The patient was unemployed and denied cigarette smoking, alcohol use, or drug use.", "Current medications included insulin, nasal spray, and aspirin."], "Patient Symptoms": ["The patient reported redness in his eye for 2 days.", "He denied pain, itchiness, or recent ocular trauma.", "Review of systems was positive for stiff joints of the hands and back pain."], "Examination and Results": ["On examination, uncorrected visual acuity was 20/40 in the right eye and 20/100 in the left eye.", "Findings from Schirmer testing without anesthesia for 2 minutes were 20 mm OD and 15 mm OS.", "Corneal sensation was bilaterally decreased to a level of 2/4.", "There were inferior corneal epithelial defects, with significant corneal thinning bilaterally, and an inferonasal Descemetocele of the right eye.", "The anterior chambers possessed 3 to 4+ cells, with bilateral hypopyons (Figure).", "Serology was sent owing to concern regarding the patient\u2019s joint pain, need for a Crohn disease workup, and presence of bilateral corneal thinning with anterior uveitis.", "Significant results included an elevated rheumatoid factor of 27 IU/mL (normal, 0-14 IU/mL), while all other laboratory results were within normal limits.", "Results from corneal cultures were positive for pansensitive coagulase-negative Staphylococcus, which was likely a contaminant from the eyelids.A, Slitlamp photograph of the right eye demonstrating a paracentral neurotrophic ulcer with anterior uveitis and a hypopyon."], "Others": ["His medical history was significant for uncontrolled type 2 diabetes mellitus, leading to bilateral below-the-knee amputations, and osteomyelitis.", "The patient reported that results from a workup for Crohn disease were negative."]}
{"Examination and Results": ["An ophthalmologic examination revealed visual acuity without correction of 20/20 in both eyes, and slitlamp examination findings of the right eye identified a unique lesion that was oval in shape, measured 2 mm in thickness by 2 mm in diameter, was translucent and brown, and changed its location with head posture.During gonioscopy, we observed a nonpigmented wide angle without other findings that suggested adhesions between the lesion and the structures of the camerular angle.", "The patient had a clear cornea without pathologic findings, and the intraocular pressure with Goldman tonometer was 10 mm Hg in both eyes."]}
{"Patient Personal Background": ["She has a known allergy to infliximab and had not been exposed to this drug recently.", "She lives in a heavily wooded area with 2 dogs and 3 cats, although she did not recall a tick bite.Photograph of the left buttock depicting one of the annular pink-violaceous patches."], "Patient Symptoms": ["The patient noticed the rash 1 day prior to presentation.", "The rash was asymptomatic with no pain or pruritus.", "Since that time, the patient reported low-grade fever and 1 week of headache for which she had been taking ibuprofen.", "She also reported fatigue.", "She denied any preceding upper respiratory tract symptoms.Physical examination revealed a well-nourished girl in no acute distress with approximately 10 pink-violaceous nummular and annular patches ranging from 1 to 4 cm in diameter (Figure)."], "Examination and Results": ["These patches were located on the trunk, buttocks, and thighs bilaterally."], "Others": ["Fourteen days prior to presentation, the patient was seen in the emergency department for a temperature greater than 102\u00b0F."]}
{"Patient Personal Background": ["He had no prior chronic medical conditions.", "His family history was positive for a brother with kidney stones.", "He was a former smoker but denied current drug or alcohol use."], "Patient Symptoms": ["The pain was associated with morning nausea and was worsened by food and alcohol.", "Review of systems was positive for dry throat, gastroesophageal reflux, and frequent headaches."], "Examination and Results": ["Physical examination was notable for a faintly palpable midabdominal mass slightly to the left and above the umbilicus with localized discomfort to palpation.", "Ultrasonography of the abdomen showed a hypoechoic, hypervascular, solid mass left of the midline (Figure, A).", "A subsequent computed tomography scan of the abdomen and pelvis demonstrated a left adrenal myelolipoma and a 4.4\u2009\u00d7\u20093.7-cm hypervascular soft tissue mass just left of the midline within the mesentery in close approximation with the small bowel, centered at the level of the L3-L4 intervertebral disc (Figure, B)."], "Treatment": ["He was given trials of proton pump inhibitors and dicyclomine with no relief.", "A laparotomy was performed and a round, well-circumscribed soft tissue mass located approximately 90 cm distal to the ligament of Treitz at the base of the mesentery was removed intact without the need for bowel resection (Figure, C)."], "Others": ["Pathologic photomicrograph of the specimen is shown (Figure, D).Preoperative imaging of the mesenteric mass and gross surgical specimen and histopathologic analysis.", "A, Preoperative ultrasonography showing a hypoechoic, solid mass.", "B, Preoperative computed tomography scan showing a hypervascular soft tissue mass.", "C, Gross surgical specimen.", "D, Histopathologic analysis of the mesenteric mass (hematoxylin-eosin)."]}
{"Patient Personal Background": ["Her medical history was significant only for asthma.Computed tomography revealed a large amount of free fluid throughout the abdomen and pelvis with an area of focal density consistent with a hematoma in the left midabdomen that measured 7.3\u2009\u00d7\u20096.1\u2009\u00d7\u20097.5 cm (Figure 1)."], "Patient Symptoms": ["The patient had diffuse lower abdominal pain with nausea and one episode of emesis."], "Examination and Results": ["Her vital signs were notable for a blood pressure of 108/69 mm Hg and a heart rate of 124 beats/min.", "Physical examination findings revealed tachycardia and a distended, diffusely tender abdomen without evidence of a seatbelt sign or peritonitis.", "Her laboratory findings were unremarkable except for a hemoglobin level of 10.5 g/dL (to convert to grams per liter, multiply by 10) and a white blood cell count of 21\u2009300/\u03bcL (to convert to \u00d7109/L, multiply by 0.001).", "There was also an area of free fluid in the right lower quadrant with irregularity of the right gonadal vein and a heterogeneous and bulky uterus.Computed tomographic image (sagittal view).", "Image shows a large amount of free fluid throughout the abdomen and pelvis with an area of focal density consistent with hematoma in the left midabdomen that measured 7.3 \u00d7 6.1 \u00d7 7.5 cm."]}
{"Patient Personal Background": ["Digital rectal examination revealed no stool in the vault and gross blood and pelvic examination were negative.Surgical history was notable only for a previous cesarean delivery.", "Medical history was significant for 2 years of waxing and waning generalized abdominal pain and a hospital admission for small-bowel obstruction 11 months prior that was managed conservatively."], "Patient Symptoms": ["Medical history was significant for 2 years of waxing and waning generalized abdominal pain and a hospital admission for small-bowel obstruction 11 months prior that was managed conservatively."], "Examination and Results": ["Physical examination demonstrated a soft, nontender, and nondistended abdomen without peritoneal signs or palpable masses.", "Digital rectal examination revealed no stool in the vault and gross blood and pelvic examination were negative.Surgical history was notable only for a previous cesarean delivery.", "Endoscopic evaluation revealed multiple polyps in the colon, stomach, and duodenum consistent with a diagnosis of juvenile polyposis syndrome.Admission laboratories demonstrated a lactate level of 18 mg/dL (to convert to millimoles per liter, multiply by 0.111), white blood cell count of 6000/\u03bcL (to convert to \u00d7109/L, multiply by 0.001), and hemoglobin level of 13.3 g/dL (to convert to grams per liter, multiply by 10).", "Amylase and lipase levels and chemistry findings were normal."], "Diagnosis": ["Endoscopic evaluation revealed multiple polyps in the colon, stomach, and duodenum consistent with a diagnosis of juvenile polyposis syndrome.Admission laboratories demonstrated a lactate level of 18 mg/dL (to convert to millimoles per liter, multiply by 0.111), white blood cell count of 6000/\u03bcL (to convert to \u00d7109/L, multiply by 0.001), and hemoglobin level of 13.3 g/dL (to convert to grams per liter, multiply by 10)."], "Others": ["Computed tomography with oral and intravenous contrast was obtained and is shown with imaging from her initial presentation 11 months prior (Figure 1).Axial and coronal views of computed tomography imaging on initial presentation (A) and 1 year later (B)."]}
{"Patient Personal Background": ["He had been seen by his mother 1 hour earlier and was previously fit and well and up to date with immunizations.An ambulance was called and paramedics noted a reduced Glasgow Coma Scale score of 3, trismus with normal respiratory effort, and a scalp hematoma on the left forehead."], "Patient Symptoms": ["His Glasgow Coma Scale score had improved to 14, but he had no recollection of events.", "His left leg was flexed, and he cried whenever this limb was examined.", "On closer inspection, his left foot was warm, with generalized mild erythema and swelling.", "There were bullae on the dorsum of the first and second toes and a cluster of painless, dry, black punctate lesions laterally (Figure, left)."], "Examination and Results": ["On arrival in the emergency department he was afebrile, normotensive with a heart rate of 120 beats/min, and had a respiratory rate of 20 breaths/min.", "Similar, paler lesions were clustered symmetrically on the left (Figure, right) and right forearms.Venous blood gas analysis revealed severe lactic acidosis (pH, 6.9; Pco2, 4.9 kPa; Po2, 11.8 kPa; bicarbonate, 7.1 mEq/L; base excess, \u221226 mEq/L; and lactate, 171.17 mg/dL [19 mmol/L]).", "Values for serum glucose and ketones were 342.3 mg/dL (19 mmol/L) and 0 mmol/L, respectively.", "Other laboratory investigations were unremarkable apart from a creatinine kinase level of 3000 U/L (50.1 \u03bckat/L) and a white blood cell count of 20\u2009\u00d7\u2009109 cells/L with lymphocytosis."]}
{"Patient Symptoms": ["The patient developed paroxysmal tachycardia on the third postoperative day.", "He had no chest pain or mental status alteration."], "Examination and Results": ["On physical examination, his pulse was 130/min and irregularly irregular, blood pressure was 126/59 mm Hg, and breath sounds were diminished in bibasilar lung fields.", "A bedside 12-lead electrocardiogram showed atrial fibrillation with rapid ventricular response and no ST-segment elevation.", "Portable chest x-ray showed pulmonary edema."], "Treatment": ["He was scheduled for a laparoscopic right hemicolectomy.", "Immediately before surgery, sequential compression devices were placed on his legs to reduce the risk for venous thromboembolic disease.", "Following his uncomplicated operation, pulse oximetry showed oxygen desaturation requiring supplemental oxygen."], "Diagnosis": ["Upon evaluation, guaiac-positive stools were found and follow-up colonoscopy revealed an invasive adenocarcinoma of the cecum."]}
{"Patient Personal Background": ["He has no other medical history or symptoms.", "This surgery was performed in Nigeria, and he does not know why or what was done.", "He is a construction project manager and does not smoke, drink alcohol, or use illicit drugs."], "Patient Symptoms": ["In the past month, the mass significantly enlarged and became more red and painful, and he can no longer close his eye."], "Examination and Results": ["His best-corrected visual acuity was 20/20 in the right eye and 20/25 in the left.", "His pupils were round and reactive with no afferent pupillary defect.", "His intraocular pressure was 12 mm Hg in the right eye and 13 mm Hg in the left.", "Extraocular movements were normal in both eyes.", "Slit lamp examination of the anterior segment of the right eye was unrevealing.", "The anterior chamber, iris, and lens of the left eye were normal."], "Treatment": ["He underwent ocular surface surgery, presumably for a pterygium, on the left eye 1 year ago."], "Others": ["He does not take any medications.", "Figure 1 shows the left eye."]}
{"Patient Symptoms": ["The parents had noted a white pupillary reflection in the left eye for the past 2 months."], "Examination and Results": ["On ophthalmologic examination, the visual acuity of the right eye was 6/7.5 (equivalent to 20/25) and the left eye did not follow an object.", "The remainder of the physical examination was unremarkable."]}
{"Patient Personal Background": ["His medical history included squamous cell carcinoma of the lung diagnosed 1 year prior, which was resected."], "Patient Symptoms": ["C, Fundus photograph of the left eye with retinitis, serous retinal detachment, and disc hyperemia.The patient returned with loss of vision in his right eye.", "One week later, he had vision loss in both eyes."], "Examination and Results": ["On examination, his visual acuity was 20/30 OD and 20/25 OS and he had  mutton fat keratic precipitates and 1+ cells in both eyes.", "The vitreous and retina revealed no signs of inflammation.", "The result revealed mild to moderate diffuse lymphadenopathy in the neck, axillae, mediastinal, and inguinal regions.", "The symmetric pattern favored a diagnosis of sarcoidosis; metastatic disease was less likely.", "A lymph-node biopsy showed lymphoid follicular hyperplasia and nonnecrotizing granulomatous inflammation, consistent with sarcoidosis.", "The results of special stains were negative for bartonella, fungal organisms, and mycobacterial infection (Figure 1A).A, Hematoxylin-eosin stain of the lymph-node biopsy, low (top) and high (bottom) power (original magnification \u00d72).", "B, Fundus photograph of the right eye with 3+ vitreous haze and retinitis.", "On examination, his visual acuity was counting fingers OD and 20/30 OS.", "He was treated with prednisone, 60 mg daily, for sarcoid panuveitis.", "His visual acuity was hand motions OD and counting fingers OS."], "Treatment": ["The patient started treatment with prednisolone acetate, 1%, 4 times daily in both eyes.", "He had 2+ cells in the anterior chamber and 3+ vitreous haze (Figure 1B)."], "Diagnosis": ["The symmetric pattern favored a diagnosis of sarcoidosis; metastatic disease was less likely.", "Because the scan was consistent with a diagnosis of sarcoidosis in this patient with granulomatous anterior iritis, no further laboratory testing was pursued.", "A lymph-node biopsy showed lymphoid follicular hyperplasia and nonnecrotizing granulomatous inflammation, consistent with sarcoidosis."], "Others": ["The day before, he had undergone a positron emission tomography scan to look for evidence of metastatic lung cancer.", "There was no evidence of lymphoma."]}
{"Patient Personal Background": ["He did not take any medications, had never been hospitalized, and had never had any major surgical procedures."], "Patient Symptoms": ["It had evolved from a flat discoloration since the age of 3 years, which continued to slowly enlarge and thicken.", "The patient denied spontaneous bleeding or ulceration, and he had full range of motion and use of his extremity."], "Examination and Results": ["On inspection, there was a 4.5 cm\u2009\u00d7\u20093.5 cm, verrucous plaque with underlying fullness on the right medial thigh.", "There were also punctate vessels evident on the hyperkeratotic surface.Close-up of lesion at presentation."], "Others": ["Neither he nor his family members reported a history of similar lesions on their body.", "His upper and lower extremities were otherwise normal.", "A verrucous, vascular plaque with underlying fullness on the right medial thigh."]}
{"Patient Personal Background": ["He had a history of simultaneous pancreas-kidney transplantation 15 years ago and both grafts had been functioning well."], "Examination and Results": ["On examination, he was in no distress, had a temperature of 37\u00b0 C, and blood pressure of 91/44 mm Hg.", "Two days after presentation, a computed tomographic scan of the abdomen and pelvis was obtained (Figure).", "It showed an air-containing abscess and a stent in the common iliac artery.A stent can be seen in the right common iliac artery (A and C, arrowheads).", "A gas-containing phlegmon was also evident (B and C, asterisks)."], "Treatment": ["Two days prior to presentation, he had a peripheral angiogram done to evaluate a nonhealing left foot ulcer by an interventional cardiologist, at which time a stent graft was deployed to the right common iliac artery for a pseudoaneurysm that was incidentally discovered."]}
{"Patient Symptoms": ["The pain was initially transient and colicky, but had increased in intensity and became constant.", "She denied having fevers, chills, or change in bowel habits.", "On postoperative day 11 she returned with symptoms of fever and increasing right lower quadrant pain.", "Weeks later, she presented to an outside facility with spotting and cramping."], "Examination and Results": ["During examination, the patient had significant focal tenderness to palpation, but displayed no peritoneal signs.", "Her laboratory results were unremarkable, without any findings for leukocytosis or bandemia.Computed tomograpy (CT) scan and ultrasonography were inconclusive and revealed only mild haziness in the right lower quadrant and an abnormal-appearing cecum.", "The appendix was not visualized.", "Magnetic resonance imaging of the abdomen was then performed to further investigate the area surrounding the cecum (Figure, A).", "Arrowhead points at the suspicious structure within the cecum.", "B, Histologic slide of the resected appendix shows positive progesterone receptor immunostaining (original magnification x400).The patient recovered well and was discharged home.", "Imaging revealed an abscess near the ileocolic anastomosis, which was successfully treated with percutaneous drain placement."], "Treatment": ["Given these symptoms and findings, the decision was made to explore this patient laparoscopically.", "After careful intraoperative evaluation, it became evident that she would require an ileocecectomy.", "The removed specimen was sent to pathology for analysis.", "The patient recovered and was discharged."], "Others": ["The histologic analysis is presented in Figure, B.A, Abdominal magnetic resonance imaging.", "Intrauterine fetal demise was noted and the patient underwent an emergency dilation and curettage."]}
{"Patient Personal Background": ["He does not wear dentures and denies trauma, use of tobacco products, poor nutrition, and risky sexual practices."], "Patient Symptoms": ["He denies pain and discomfort but is concerned because the mass has increased in size during the past year."], "Examination and Results": ["Physical examination reveals a healthy appearing male with a nontender, symmetric, nodular bony protuberance on the midline of the hard palate.", "Two prominent protuberances are also noted at the bilateral maxillary tuberosities (Figure)."], "Others": ["Family history is noncontributory."]}
{"Patient Personal Background": ["Past medical history and family history are unrevealing.Distal left middle finger."], "Patient Symptoms": ["She first noticed a black streak down the middle of her nail 10 years prior to presentation.", "Subsequently, the pigmented band on the nail plate widened and darkened, with pigment spreading to the proximal nail fold and distal acral hyponychial skin.", "She has no associated symptoms, including nail splitting, bleeding, or pain, and no history of acute or recurrent trauma."], "Examination and Results": ["The nail examination is illustrated in the Figure.", "Examination of all other nails is unremarkable."], "Others": ["Several years previously, she was reassured that her nail pigmentation was benign.", "A, Dorsal clinical view.", "B, Dorsal dermoscopic view.", "C, Distal clinical view.", "D, Distal dermoscopic view.Reassure patient that this is benign nail pigmentationRecommend punch biopsy of the nail bed through intact nail plateRecommend removal of the entire nail plate with representative biopsy of all areas of pigmentSend clippings of the free edge of the nail plate for histopathology and culture."]}
{"Patient Personal Background": ["Her home medication regimen consisted of ribavirin, rifaximin, lactulose, furosemide, spironolactone, peginterferon alfa-2a, and levothyroxine sodium."], "Examination and Results": ["Corrected visual acuity was recorded as 20/40 OU.", "Her pupils, intraocular pressure, motility, and confrontational visual fields were normal in each eye.", "Anterior slitlamp examination demonstrated mild nuclear sclerotic cataracts in both eyes.", "Dilated fundus examination (Figure 1) demonstrated multiple peripapillary and macular cotton-wool spots in both eyes, dot hemorrhages in both eyes, peripapillary flame hemorrhage in the right eye, and a disc hemorrhage in the left eye.Fundus photograph of the patient\u2019s right eye at presentation."], "Others": []}
{"Patient Symptoms": ["The rash was asymptomatic and started as red bumps that then evolved into pustules and blisters.", "All other family members had significant improvement with the treatment; however, our patient\u2019s lesions continued to worsen during the subsequent 2 weeks."], "Examination and Results": ["On physical examination, the patient had numerous erythematous macules, papules, and pustules on her back.", "Many of the lesions had superimposed hemorrhagic crust and surrounding scale.", "In addition, several grouped papules were noted, including some in a linear array (Figure 1A and B).", "The rest of her cutaneous examination results were unremarkable except for a few fading pink papules noted on her left abdomen (Figure 1C).Numerous erythematous papules and pustules on the back, many with overlying hemorrhagic crust and surrounding scale (A) and (B), and few erythematous papules on the left lower abdomen (C)."], "Treatment": ["Shortly after the onset of the outbreak, the patient and all family members were treated with 2 once-weekly doses of permethrin, 5%, cream."], "Others": ["On further questioning, it was discovered that the patient\u2019s father worked in a nursing home that had experienced a recent outbreak of scabies."]}
{"Examination and Results": ["Abdominal ultrasonography showed a well-defined hypoechoic lesion abutting the pancreas.", "Further imaging by contrast-enhanced computed tomography (CT) and 3-dimensional reconstruction revealed a well-circumscribed, 3-cm lesion surrounding the common hepatic artery (Figure, A and B).", "The lesion demonstrated patchy arterial enhancement, and a small irregularity of the common hepatic artery was present within the lesion.", "Endoscopic ultrasonography demonstrated a hypoechoic, well-defined mass; fine-needle aspiration showed no abnormal cells within the paucicellular specimen.", "Surgical exploration revealed a firm, ovoid lesion surrounding the hepatic artery at the origin of the gastroduodenal artery (Figure, C).", "Following resection, the lesion was bisected to reveal a smooth white arterial lumen surrounded by grayish fibrotic tissue with punctate hemorrhagic foci.", "Histologic sections of the specimen demonstrated small, singly dispersed vessels embedded in a background of fascicles of spindled cells with monotonous, fusiform nuclei and abundant eosinophilic cytoplasm.", "Focally, areas of myxoid degeneration were present.", "Despite extensive sampling, no mitotic activity, cytologic atypia, or areas of necrosis were identified.", "There was strong, diffuse cytoplasmic staining for desmin (Figure, D), and staining results for S100 were negative.", "Furthermore, CD34 stained strongly positive in vessels but failed to highlight the intervening stroma.A, Computed tomography of an enhancing mass (dotted circle) surrounding the common hepatic artery with emanating gastroduodenal artery, right hepatic artery, and left hepatic artery (arrowheads).", "B, 3-Dimensional reconstruction of the location of the lesion (dotted circle) with relation to the involved vessels and surrounding structures.", "C, Intraoperative view of a 3-cm mass surrounding the common hepatic artery just prior to the trifurcation of the gastroduodenal artery, right hepatic artery, and left hepatic artery.", "D, The tumor cells showed strong cytoplasmic expression of the smooth-muscle marker desmin."]}
{"Patient Personal Background": ["She had a history of hypertension and depression and was receiving omeprazole and paroxetine."], "Patient Symptoms": ["The mass had appeared 2 days before presentation and was associated with vomiting.", "Additionally, the patient had not passed stools or had intestinal gas for 2 days."], "Examination and Results": ["On physical examination, the mass was exteriorized through the anal canal.", "It was covered by hypoxemic rectal mucosa, but no digestive lumen could be identified inside the mass (Figure 1).", "Furthermore, the patient had a distended abdomen, absent bowel sounds, and no tenderness to palpation.", "No abdominal scar was visible, and no groin hernia was palpable.", "Her blood pressure was 160/80 mm Hg and her temperature was 37.8\u00b0C.", "Results of complete blood cell count, coagulation tests, and basic chemistry panel were all within normal limits.", "An abdominal radiograph showed several air-fluid levels without pneumoperitoneum, confirming an intestinal occlusion.View of the mass exteriorized through the anus."]}
{"Patient Personal Background": ["She does not take any prescribed or over-the-counter medications."], "Patient Symptoms": ["Review of systems is noncontributory, and she denies fevers, chills, shortness of breath, cough, and genital lesions."], "Examination and Results": ["Vital signs are normal, and physical examination reveals shallow erosions with hemorrhagic crusts on the lips and widespread targetoid macules with dusky centers on the palms (Figure).", "The remainder of the examination is unremarkable.A, Shallow erosions with hemorrhagic crusts on the lips of a 22-year-old woman."]}
{"Patient Personal Background": ["He was not aware of any lower leg injury but did note that the shin rash had started as a \u201cbump\u201d that developed a central scab."], "Patient Symptoms": ["One week before admission, he noticed tender skin eruptions adjacent to the anus and on the left shin.", "The patient reported no fevers or chills.", "He had no history of eczema and had not used any special wipes or cleansing agents in the perianal area.", "He did not recall having skin lesions of this type previously.On physical examination an erythematous, indurated plaque with a central black hemorrhagic crust surrounded by yellow pustulovesicles was seen on the left shin."], "Examination and Results": ["Adjacent to and surrounding the anus there was an area of erythema with irregular margins and superficial exfoliation (Figure).Obtain a skin biopsy of the affected area on the left shin and apply a topical antibiotic to both the perianal area and the shin area until the pathology result is available.Obtain bacterial culture from both areas and start a systemic antibiotic.Obtain both bacterial culture and fungal culture of the affected areas and administer both a systemic antibiotic and a systemic antifungal agent.Obtain fungal culture from both affected areas and initiate systemic antifungal therapy."], "Treatment": ["He received high-dose intravenous methylprednisolone when he entered the hospital.", "His physician had prescribed a combination cream of betamethasone diproprionate and clotrimazole for these lesions."]}
{"Patient Personal Background": ["She had no significant medical history or prior ocular problems."], "Examination and Results": ["Best-corrected visual acuity was 20/20 OD and 20/25 OS, with eccentric fixation and trace exophoria in the left eye.", "Pupils were equally round and reactive.", "Anterior segment examination revealed an enlarged right corneal nerve.", "The left macula had a fibrotic-appearing epiretinal membrane (Figure 1A).", "There were 2 small, flat, pigmented lesions along the arcades of the right fundus (Figure 1B), likely atypical congenital hypertrophy of the retinal pigment epithelium (CHRPE) lesions, or pigmented ocular fundus lesions (POFLs).", "Observation was elected.", "B-scan ultrasonography and biometric A-scan showed bilaterally clear vitreous without retinal detachment.", "Fluorescein angiography showed hyperfluorescence around the macula lesion without leakage, consistent with staining (Figure 1E), in the left eye."], "Treatment": ["On follow-up, optical coherence tomography showed focal macular thickening in the left eye, most likely a retinal hamartoma (Figure 1C), and intraretinal abnormalities between the retinal pigment epithelium (RPE) and photoreceptor layer in the right eye, consistent with POFLs and likely representing combined retina-RPE hamartomas (Figure 1D)."]}
{"Patient Personal Background": ["Her medical history includes asthma and acne.", "Her medications included minocycline hydrochloride (for 25 months for acne), ranitidine hydrochloride, contraceptive pills, and iron supplements.An initial physical examination revealed mild synovitis in both ankles and an erythematous, raised papule overlying the distal aspect of the right anterior tibia."], "Patient Symptoms": ["The lesion first appeared as a skin-colored papule and, within a week, developed an erythematous halo.", "Seven weeks later, the original skin lesion evolved into an ulcer with erythematous, raised borders (Figure 1).", "The case patient had new eruptions of nonindurated, violaceous, nontender, reticulated patches overlying the skin on the bilateral anterior tibias, consistent with livedo reticularis."], "Examination and Results": ["Treatment with prednisone acetate (10 mg daily) was initiated.", "She denies any previous episodes, and the results of a review of mitigating factors were negative.Ulcer with raised border and erythematous halo in distal right shin.A laboratory workup revealed a positive antinuclear antibody 1:640 nucleolar pattern, an elevated erythrocyte sedimentation rate, and elevated C-reactive protein and serum IgG levels.", "The results of the following laboratory studies were negative or normal: complete blood cell count, urinalysis, liver profile, Lyme disease, parvovirus B19, Monospot test, uric acid, rheumatoid factor, antistrepolysin antibody, anti-Scl70, antihepatitis C virus, hepatitis B surface antigen, hepatitis B core antibody, cytomegalovirus antibody, and human T-lymphotropic viruses 1 and 2 antibody.", "Culture results of the skin lesion were negative.", "The results from chest radiography were normal."], "Treatment": ["Treatment with prednisone acetate (10 mg daily) was initiated."], "Others": ["To our knowledge, there is no family history of this condition."]}
{"Examination and Results": ["Routine laboratory values were within normal limits.", "The patient underwent ultrasonography of the abdomen, and 2 cystic lesions were discovered in the liver.", "Magnetic resonance imaging of the abdomen revealed 2 multiloculated cystic lesions in segments IV and V of the liver (Figure, A).", "Additional laboratory values included normal carcinoembryonic antigen and cancer antigen 19-9 levels."], "Treatment": ["Percutaneous aspiration with a biopsy of one of the cystic lesions was performed that revealed atypical cells suspicious for malignancy.", "The patient was then referred for management to our institution, where she underwent an exploratory laparotomy and enucleation of these 2 complex multiloculated cystic lesions (Figure, B).A, Axial image from abdominal magnetic resonance imaging."]}
{"Patient Personal Background": ["Her medical history was significant for hypertension and left breast invasive ductal carcinoma in 2007 treated with lumpectomy and adjuvant radiation as well as synchronous rectal cancer after neoadjuvant chemoradiation and abdominoperineal resection.", "As part of her treatment course, the patient received a total dose of 50.5 Gy pelvic irradiation and 60 Gy irradiation to the left breast and axillary basin."], "Examination and Results": ["On physical examination, she had a hard, well-circumscribed, fixed mass in the upper, outer quadrant of her left breast.", "The lesion was not tender to palpation nor was there any associated axillary or supraclavicular lymphadenopathy.", "Examination of the nipple as well as the contralateral breast and axilla was unremarkable.", "Computed tomography of the thorax revealed a 6.7\u2009\u00d7\u20094 cm mass arising from the left chest wall distinct from the left breast with extent to the pleural surface of the left thorax (Figure, A).", "Positron emission tomography revealed metabolic activity within the mass but did not reveal any distant disease.", "Core needle biopsy confirmed the diagnosis and the patient was offered resection with reconstruction.A, Computed tomographic axial section of the thorax illustrating a left chest wall mass measuring 6.7\u2009\u00d7\u20094 cm apparently distinct from the left breast parenchyma with possible pleural invasion."], "Treatment": ["Lung parenchyma adjacent to the chest wall reveals stippling and fibrosis consistent with previous irradiation.The patient underwent a left radical mastectomy including resection of the pectoralis major and minor and resection of the adjacent chest wall resulting in a chest wall defect spanning ribs 2 through 4 (Figure, B).", "The patient underwent immediate reconstruction of the chest wall with 2-mm-thick expanded polytetrafluoroethylene and latissimus dorsi pedicle flap reconstruction of the soft tissue defect and breast mound.B."], "Diagnosis": ["B, Postresection wound including chest wall."], "Others": ["The patient denied any antecedent trauma or infection.", "The patient was followed up with yearly computed tomography of the abdomen and pelvis in addition to yearly digital mammography.", "Her last mammogram, 5 months prior to presentation, was unremarkable."]}
{"Patient Personal Background": ["He has a history of hepatitis B, hepatocellular carcinoma, and idiopathic pancreatitis."], "Patient Symptoms": ["The lesions are initially very painful and slow to resolve.", "New lesions tend to appear with, or immediately after, episodes of acute pancreatitis."], "Examination and Results": ["Laboratory evaluation reveals elevated levels of serum lipase (2700 IU/L) and amylase (3400 IU/L).", "Examination of the skin reveals erythematous subcutaneous nodules symmetrically distributed on the bilateral lower and upper extremities, primarily on the lower legs and feet.", "One of the largest nodules has a small amount of yellow, oily discharge."], "Treatment": ["Previous treatments have included incision and drainage of a nodule on the right foot as well as oral and intravenous administration of antistaphylococcal antibiotics for presumed cellulitis."]}
{"Patient Symptoms": ["Treatment with desonide, 0.05%, ointment twice daily proved to be ineffective.", "The patient\u2019s rash also failed to clear with a therapeutic trial with griseofulvin liquid (125 mg/5 mL), 5 mL daily, and econazole, 1%, cream twice daily for 2 weeks and later ciclopirox, 0.77%, cream twice daily for 2 weeks, although the patient reported some improvement.", "Three weeks later, the patient presented with 2 slowly expanding, hyperpigmented, ringlike lesions with a tendency toward central clearing and peripheral scaling and erythema on the right cheek (Figure 1).A 4-year-old girl presenting with two 5-cm-diameter annular patches (arrowheads) slowly increasing in size over 3 weeks on the right cheek."], "Examination and Results": ["Test results for antinuclear antibody and rheumatoid factor were negative."], "Treatment": ["Treatment with desonide, 0.05%, ointment twice daily proved to be ineffective.", "The patient\u2019s rash also failed to clear with a therapeutic trial with griseofulvin liquid (125 mg/5 mL), 5 mL daily, and econazole, 1%, cream twice daily for 2 weeks and later ciclopirox, 0.77%, cream twice daily for 2 weeks, although the patient reported some improvement.", "The presence of persistent acneiform papules on the cheeks with postinflammatory hyperpigmentation led to a therapeutic trial of erythromycin, 400 mg/5 mL, 1.3 mL orally twice a day, with food."]}
{"Patient Personal Background": ["He has been unemployed and bedridden for the last 3 years owing to his skin disease.", "He has a history of ischemic heart disease, familial Mediterranean fever, and arthropathy."], "Patient Symptoms": ["On presentation, he noted anorexia and reported a 10-kg weight loss during the last 8 months."], "Examination and Results": ["On physical examination, he appeared cachectic.", "His abdomen was soft with no palpable mass.", "A macular rash with multiple infected ulcerated areas and diffuse lower limb edema was noticed (Figure 1).", "The remainder of his physical examination results were unremarkable."], "Treatment": ["He was treated with nonsteroidal anti-inflammatory drugs for pain relief and steroids for the skin disease."], "Diagnosis": ["Except for the skin rash, he was newly diagnosed as having diabetes mellitus."]}
{"Patient Personal Background": ["He had undergone hemodialysis for the past year and had a brachiocephalic fistula in his left arm.", "His medical history was also significant for peripheral vascular disease, hypertension, and antiphospholipid antibody syndrome for which he was receiving warfarin sodium since 2010.", "His other medications were epoetin alpha, ferrous gluconate, cinacalcet hydrochloride, paricalcitol, sevelamer carbonate, amlodipine besylate, labetalol hydrochloride, lisinopril, simvastatin, pentoxifylline, and Humalog and Lantus insulin.", "He did not smoke.The patient had a temperature of 37.6\u00b0C and a grade II/VI systolic ejection murmur."], "Patient Symptoms": ["He had necrosis and eschar formation involving his fingers (Figure 1A), toes (Figure 1B and C), and left posterior medial calf (Figure 1D).", "He had violaceous skin with central eschar on the posterior medial aspect of his right leg (Figure 1E) that was exquisitely tender with gangrenous change."], "Examination and Results": ["He did not smoke.The patient had a temperature of 37.6\u00b0C and a grade II/VI systolic ejection murmur.", "He had normal femoral pulses with no distal pulses palpable.", "Both feet were warm with good Doppler signals in the dorsalis pedis and posterior tibial arteries.", "He had a palpable pulse and thrill in the brachiocephalic fistula in his left upper arm.", "There was also a weak distal radial pulse.", "He had good Doppler signals over the radial, ulnar, and palmar arch arteries bilaterally.Photographs of necrosis and eschar formation involving fingers (A), right (B) and left (C) toes, left posterior medial calf (D), and violaceous skin with central eschar on the posterior medial aspect of the right leg (E).Laboratory studies revealed a white blood cell count of 13\u2009900/\u03bcL (to convert to \u00d7109 per liter, multiply by 0.001), a hemoglobin level of 7.7 g/dL (to convert to grams per liter, multiply by 10.0), a platelet count of 309\u2009\u00d7\u2009103/\u03bcL (to convert to \u00d7109 per liter, multiply by 1.0), an international normalized ratio of 2.4, a blood urea nitrogen level of 88 mg/dL (to convert to millimoles per liter, multiply by 0.357), a creatinine level of 9.9 mg/dL (to convert to micromoles per liter, multiply by 88.4), a calcium level of 7.5 mg/dL (to convert to millimoles per liter, multiply by 0.25), an albumin level of 2.4 g/dL (to convert to grams per liter, multiply by 10), and an intact parathyroid hormone level of 349.7 pg/mL (to convert to nanograms per liter, multiply by 1.0).", "A skin biopsy specimen of the calf showed epidermal necrosis, dermal hemorrhage, focal dermal intravascular thrombi, and subcutaneous intravascular and extravascular calcifications."]}
{"Patient Personal Background": ["Previously she was able to run 5 to 6 miles per day.", "She has no other cardiovascular risk factors.", "Her blood pressure is 124/76 mm Hg bilaterally.", "There is a high-pitched systolic bruit over the right subcostal region and the umbilicus."], "Patient Symptoms": ["Exercise tolerance has worsened over the past year and is now limited to several blocks."], "Examination and Results": ["There is a high-pitched systolic bruit over the right subcostal region and the umbilicus.", "Peripheral pulses are normal.", "The ankle brachial index (ABI) at rest is borderline normal (0.91) on the right and normal (1.03) on the left.", "The remainder of the examination is normal.After physical therapy and nonsteroidal anti-inflammatory agents failed to improve symptoms, a computed tomography angiogram (CTA) is performed, revealing a \u201cbeaded appearance\u201d in the right renal artery and a long-segment stenosis of the right external iliac artery.", "There is no atherosclerosis."], "Treatment": ["A catheter-based angiogram confirms the CTA findings (Figure).Perform angioplasty and stenting of the right renal and external iliac arteries.Manage medically with antihypertensive agents and a walking program.Perform angioplasty of the right renal artery and angioplasty with stenting of the right external iliac artery.Administer cilostazol for claudication and continue lisinopril for hypertension."], "Others": []}
{"Patient Personal Background": ["Thirteen days before delivery, she visited the emergency department with flulike symptoms.", "The infant was born at 40 weeks\u2019 gestation by forceps delivery."], "Patient Symptoms": ["During admission, the infant developed violaceous skin lesions with edema in inguinal and axillary regions (Figure).", "Lesions became ulcerated within 3 to 4 days, with infarcted necrotic areas."], "Examination and Results": ["Blood tests showed leukopenia (white blood cell count, 2460/\u03bcL) with neutropenia (neutrophil count, 220/\u03bcL) (to convert both to \u00d7109 per liter, multiply by 0.001).", "Intravenous floxacillin was started, followed by surgical debridement due to progression of the major lesions.Axillary inflammatory nodule (A) and inguinal inflammatory plaques with violaceous hue (B).His mother was addicted to drugs, she had a known hepatitis C virus infection, and the pregnancy was unsupervised."], "Treatment": ["Intravenous floxacillin was started, followed by surgical debridement due to progression of the major lesions.Axillary inflammatory nodule (A) and inguinal inflammatory plaques with violaceous hue (B).His mother was addicted to drugs, she had a known hepatitis C virus infection, and the pregnancy was unsupervised."], "Others": ["Routine infectious screening revealed negative serology for syphilis, hepatitis B virus, and human immunodeficiency virus (HIV) types 1 and 2 by enzyme-linked immunosorbent assay (ELISA)."]}
{"Patient Symptoms": ["In addition, the patient had worsening lower back and lower extremity pain, treated as sciatica on an outpatient basis, for 3 months.", "The patient had constipation, urinary incontinence, and generalized weakness but no fever, nausea or vomiting, or change in bowel movements."], "Examination and Results": ["Physical examination revealed a firm, nonpulsatile, slightly tender mass in the left lower quadrant and significant perineal ecchymosis.", "Vital signs were normal.", "Laboratory test results were remarkable for white blood cell count (13\u2009800/\u03bcL [to convert to \u00d7109 per liter, multiply by 0.001]), blood urea nitrogen level (72 mg/dL [to convert to millimoles per liter, multiply by 0.357]), creatinine level (4.2 mg/dL [to convert to micromoles per liter, multiply by 88.4]), hemoglobin level (9.8 g/dL [to convert to grams per liter, multiply by 10.0]), and international normalized ratio (2.7).", "Computed tomography of the abdomen and pelvis was performed (Figure).Computed tomographic images of the abdomen and pelvis.", "A, Axial imaging shows that the bladder (black arrow) is displaced to the right, and a Foley catheter is located anteriorly.", "The rectum (white arrow) is compressed posteriorly.", "B, Coronal imaging shows that the bladder (arrow) is severely displaced, and a Foley catheter is located medially."], "Treatment": ["In addition, the patient had worsening lower back and lower extremity pain, treated as sciatica on an outpatient basis, for 3 months."]}
{"Patient Personal Background": ["He had a 50-year history of cigarette smoking and had stopped smoking 5 months prior to being seen.When the symptom of hemoptysis occurred 5 months earlier, chest radiography and computed tomography (CT) revealed a ground-glass opacity in the left upper lobe."], "Patient Symptoms": ["However, about 1 month later, hemoptysis reoccurred and increased volume and frequency over the following 4 months.After treatment with an antifibrinolytic agent, a ball-like mass with an air crescent sign in the left upper lobe was noted.On physical examination, sonorous rhonchi were audible in the bilateral lungs."], "Examination and Results": ["Chest CT revealed a cavitary lesion with a central contrast-enhanced ball-like mass at the site of the prior ground-glass lesion.", "Sputum examinations for acid-fast bacilli smear and culture, fungal culture, and cytology showed negative results.", "Fiberoptic bronchoscopy revealed blood clots over the orifice of the left upper lobe bronchus, but no endobronchial lesion was detected.The chest CT finding, characteristic of a fungus ball-like shadow with an air crescent sign, highly suggested a pulmonary aspergilloma.", "However, the contrast enhancement was present within the mass, and lung malignancy could not be excluded."], "Treatment": ["The patient was treated with an antifibrinolytic agent (tranexamic acid), and the hemoptysis gradually improved and follow-up chest radiography showed resolution of the lesion (Figure 1).", "However, about 1 month later, hemoptysis reoccurred and increased volume and frequency over the following 4 months.After treatment with an antifibrinolytic agent, a ball-like mass with an air crescent sign in the left upper lobe was noted.On physical examination, sonorous rhonchi were audible in the bilateral lungs.", "A whitish, firm nodule about 2 cm was noted in a cavity in the left upper lung."], "Diagnosis": ["Fiberoptic bronchoscopy revealed blood clots over the orifice of the left upper lobe bronchus, but no endobronchial lesion was detected.The chest CT finding, characteristic of a fungus ball-like shadow with an air crescent sign, highly suggested a pulmonary aspergilloma."]}
{"Patient Symptoms": ["In the weeks before her hospital admission, she developed subacute cognitive deterioration and progressive headaches.", "On presentation she has difficulties initiating speech (nonfluent aphasia) and responds slowly and inconsistently to questions."], "Examination and Results": ["Otherwise, her physical examination is unremarkable.", "Laboratory studies reveal an elevated erythrocyte sedimentation rate (ESR) (135 mm/h), anemia (hemoglobin level, 9.5 g/dL), and high serum levels of soluble interleukin 2 receptor (sIL2R) (36\u2009551 pg/mL), lactate dehydrogenase (LDH) (448 U/L), and \u03b22-microglobulin (3.1 mg/L), with normal renal function, liver enzyme levels, and serum immunological and microbiological findings.", "Analysis of the cerebrospinal fluid (CSF) demonstrates a mildly increased leukocyte count (11\u2009\u00d7\u2009106/L) and total protein concentration (0.10 g/dL).", "Magnetic resonance imaging of the brain shows multiple infarctions, and digital subtraction angiography of the intracranial vessels demonstrates abnormalities suggestive of vasculitis (Figure 1).", "An electrocardiogram, computed tomography scans of the chest and abdomen, 18-fluorodeoxyglucose positron emission tomography, transesophageal echocardiography, inspection of the skin, and ophthalmologic evaluation are unremarkable.A, Axial MRI using fluid-attenuated inversion recovery (left) demonstrating hyperintense multifocal lesions involving mainly the subcortical white matter; axial diffusion-weighted MRI (right) showing hyperintense lesions consistent with recent infarctions."], "Treatment": ["B, Digital subtraction angiography of the intracranial vessels showing widespread areas of vessel wall irregularity, which consist of zones of focal stenosis and luminal tapering in many third-order and fourth-order branches.Initiate secondary preventive treatment for multiple infarctions with antiplatelet agents.Postpone treatment; obtain a brain biopsy including the leptomeninges.Postpone treatment; obtain random skin biopsies and a bone marrow biopsy."]}
{"Patient Personal Background": ["He denies any travel or illicit drug use.", "He has received appropriate immunizations, has no relevant family history, and has never experienced similar episodes."], "Patient Symptoms": ["The eruption began in his scalp and subsequently spread over 9 days\u2019 time to his neck, back, and chest.", "The patient otherwise feels well, without fever, chills, or systemic symptoms."], "Examination and Results": ["The physical examination is notable for numerous grouped vesicles and relatively monomorphic tense bullae, coalescing into markedly annular plaques, superimposed on erythematous bases with central clearing and scale.", "The eruption is generalized and symmetric but predominates on his posterior neck, back, chest and upper arms (Figure 1), and inner thighs.", "He is otherwise afebrile and appears well.A, Grouped vesicles and tense bullae in a generalized distribution on the trunk and extremities of patient."], "Treatment": ["He had been seen in the emergency department and prescribed oral cephalexin for the eruption, with no improvement."], "Others": ["He denies any other use of medication (including prescription or over-the-counter medications, herbal supplements, and vitamins) in the days, weeks, or months prior to onset."]}
{"Patient Symptoms": ["On examination, visual acuity measured 20/50 OD.", "Three months later, at the Illinois Eye and Ear Infirmary, she reported an improvement in her vision but noted negative images of dots when her right eye was closed."], "Examination and Results": ["Her local ophthalmologist considered a white dot syndrome and recommended a systemic workup.", "Results of a complete blood cell count, comprehensive metabolic panel, antinuclear antibodies (including DNA and ribosomal SSA/Ro), positron emission tomography and magnetic resonance imaging (MRI) of the brain, mammography, and chest radiography were normal.", "Dermatologic examination revealed a nevus on the left arm, a nevus on her left shoulder, and seborrheic keratosis on her left shoulder.", "Visual acuities measured 20/30 OD and 20/20 OS.", "Slitlamp examination findings were normal; there were no anterior chamber or vitreous cells.", "Funduscopic examination revealed yellow-white, multisized, subretinal, creamy lesions clumped in various portions of her retina, including the periphery (Figure 1).", "The lesions were smaller in the posterior pole and larger in the periphery.", "Subretinal serous fluid was present overlying some of the prominent lesions inferiorly, without associated exudate or hemorrhage.Fundus photograph shows yellow-white, multisized, subretinal, creamy lesions in the right eye."], "Others": ["Review of systems was negative."]}
{"Patient Personal Background": ["The patient otherwise had no significant medical history and was in good health."], "Patient Symptoms": ["At puberty, the lesion expanded in size, became irritated, and developed a papillated, rough texture."], "Examination and Results": ["On physical examination, there was a 3.6-cm\u2009\u00d7\u20091.5-cm verrucous skin-colored to light-brown plaque on the right nasal sidewall (Figure).Clinical photograph of a 3.6-cm\u2009\u00d7\u20091.5-cm verrucous skin-colored to light-brown plaque on the right nasal sidewall."]}
{"Patient Personal Background": ["She had no comorbidities, such as diabetes mellitus or hypertension, and no previous admission to the hospital.", "She is married and has 4 children; her last child was born 40 days prior to her presentation to the hospital."], "Patient Symptoms": ["The pain was usually generalized but sometimes radiated to the right iliac fossa.", "The pain got worse with meals and was associated with nausea but no vomiting.", "In the last 2 days, the pain was associated with loose stools, but there was no mucus or blood."], "Examination and Results": ["On examination, her vital signs were normal (temperature, 37.1\u00b0C; pulse, 86 beats/min; and blood pressure, 121/86 mm Hg).", "Her abdomen was soft and lax.", "There was mild tenderness in the right iliac fossa, but no lump or lumps were felt.", "Bowel sounds were not exaggerated.", "Her white blood cell count was 8500/\u03bcL (to convert to \u00d7109 per liter, multiply by 0.001), her hemoglobin level was 1.3 g/dL (to convert to grams per liter, multiply by 10.0), and her platelet count was 361\u2009\u00d7\u2009103/\u03bcL (to convert to \u00d7109 per liter, multiply by 1.0).", "The results of renal and liver function tests were normal.Abdominal ultrasonography revealed a 4.2\u2009\u00d7\u20094.2-cm mass in the midabdominal region lateral to the gall bladder fossa.", "The mass has the \u201cdonut sign\u201d with central echogenicity (Figure 1A).", "An abdominal computed tomographic scan (Figure 1B) showed a 8.2\u2009\u00d7\u20094\u2009\u00d7\u20092.6-cm tubular thin-walled filling defect in the cecum and lower part of ascending colon.", "The oral contrast agent can be seen around, proximal, and distal to the defect, with no obstruction noted.Abdominal ultrasonographic image revealing a 4.2\u2009\u00d7\u20094.2-cm mass with central echogenicity, the \u201cdonut sign\u201d (A)."]}
{"Patient Personal Background": ["The patient denied any previous medical or surgical history."], "Patient Symptoms": ["On examination, the patient had mild right upper quadrant tenderness to palpation without signs of peritonitis."], "Examination and Results": ["Her imaging results from the outside hospital included abdominal magnetic resonance cholangiopancreatography revealing a cystic abnormality in the region of the porta hepatis (Figure 1A).", "Routine laboratory values were within normal limits, except for a mildly elevated amylase level.", "A computed tomographic scan was obtained to further delineate the abnormality (Figure 1B).Magnetic resonance cholangiopancreatography (A) and abdominal computed tomography (B) revealing a cystic lesion in the region of the porta hepatis (arrowheads)."], "Others": ["F indicates feet; H, head; L, left; and R, right."]}
{"Patient Personal Background": ["She had received the bisphosphonate zoledronate for treatment of metastatic renal carcinoma for several months before the lesion appeared."], "Patient Symptoms": ["The patient reports no trauma or acute process around the area."], "Examination and Results": ["On examination, the teeth are mobile, and an area of exposed bone tissue in the mandible is detected (Figure).", "There is no tenderness on palpation or profound gingival bleeding."]}
{"Patient Personal Background": ["She does not take any medications.", "She is currently working and lives at home with her male partner and her pets.", "She is a nonsmoker and drinks alcohol socially."], "Patient Symptoms": ["She describes it as a black lace over her field of vision that she first noticed after waking 8 days prior to presentation.", "Owing to worsening vision, she was referred to us for further evaluation."], "Examination and Results": ["Her best-corrected visual acuity is 20/200 in the right eye and 20/20 in the left eye, with a right relative afferent pupil defect.", "The results of a slitlamp examination of the intraocular pressure, motility, and anterior segment in both eyes are unremarkable.", "Dilated examination findings of the left eye are normal."], "Others": ["She has no systemic symptoms and no past ocular or systemic health problems."]}
{"Patient Personal Background": ["There was no history of teratogenic exposure, no family history of congenital defects, and no history of consanguinity."], "Patient Symptoms": ["There was mucus discharge from the opening."], "Examination and Results": ["There was no other craniofacial anomaly and bilateral nasal cavities were normal.", "The trunk was 2.5 cm in length connected with a thin pedicle.", "Computed tomography (CT) scan and magnetic resonance imaging (MRI) showed no other associated craniofacial abnormality.Full-term, 10-day-old girl with a trunklike projection from the medial canthus of the left eye."]}
{"Patient Personal Background": ["Her only significant medical history was a routine cesarean section 4 years earlier."], "Examination and Results": ["Physical examination findings revealed a firm, mobile, nontender, midline abdominal mass.", "A computed tomographic (CT) scan was performed, which showed a well-circumscribed, 10-cm mass (Figure 1).", "A large, well-circumscribed mass (white arrow) is shown on the cross-sectional image."], "Treatment": ["The patient was scheduled for elective exploratory laparotomy and resection.Scout (A) and cross-sectional (B) images from a computed tomographic scan of the abdomen."], "Others": ["Several different physicians had evaluated the patient previously without a definitive diagnosis or treatment."]}
{"Patient Symptoms": ["The patient had been experiencing early satiety and heat intolerance."], "Examination and Results": ["Physical examination was significant for orthostatic hypotension and an immobile, nontender abdominal mass.", "An abdominal computed tomographic scan was obtained (Figure, A).", "Based on these findings, the patient underwent surgical resection (Figure, B).Coronal imaging illustrating a large heterogeneous mass in the left abdomen (A)."], "Treatment": ["Specimen after resection (B)."]}
{"Patient Symptoms": ["The lesion began 4 years ago as a crusted papule following a puncture wound, caused by the tip of a wooden stick, that resulted in some mild bleeding.", "The lesion then gradually increased in size and was slightly pruritic on occasion.", "The patient reports experiencing no fevers or chills since the development of the rash."], "Examination and Results": ["On physical examination, a dark red plaque measuring 3.0\u2009\u00d7\u20094.0 cm is observed on the right upper quadrant of the back.", "The plaque is irregularly shaped with a defined border and includes several black or brown dot-like petechiae.", "The plaque appears elevated and infiltrative, with a rough surface covered in waxy white crusts."], "Treatment": ["He was initially diagnosed with eczema in a local clinic and has been treated with intermittent topical application of 2.5% hydrocortisone cream over the last 3 months, with no improvement."], "Others": ["The physical examination is otherwise negative."]}
{"Patient Symptoms": ["She presented for evaluation because new lesions of similar appearance appeared on the upper limbs, trunk, vulva, and perineum despite antibiotic therapy.", "Also the vulva and perineum had an intense erythematous rash."], "Examination and Results": ["Physical examination revealed many large, tense bullae filled with clear fluid, rounded with an erythematous base and \u201crosette-like\u201d blisters (Figure).", "She was apyretic and vital parameters were normal.", "Laboratory tests showed a normal white blood cell count and lymphocyte subpopulations, erythrocyte sedimentation rate, and C-reactive protein level.", "Test results for anti-transglutaminase and antiendomysial antibodies were negative."], "Treatment": ["She had been treated with topical mupirocin and oral amoxicillin\u2013clavulanate potassium for a suspected superficial skin infection."]}
{"Patient Personal Background": ["His symptoms followed a 1-day discharge from a recent hospital admission for a viral illness.", "He denied any history of trauma, and the remaining medical history was unremarkable."], "Patient Symptoms": ["At the time of evaluation, he reported associated left shoulder pain and was in noticeable distress."], "Examination and Results": ["Physical examination revealed a distended abdomen with associated diffused peritoneal signs.", "He was afebrile, with a heart rate of 77 beats/min, blood pressure of 96/46 mm Hg, oxygen saturation of 100% in room air, and a respiratory rate of 16 breaths/min.", "Abdominal ultrasonography was performed (Figure 1).Ultrasonography image of the right (A) and left (B) upper quadrants of the abdomen."]}
{"Examination and Results": ["On examination, he tested positive for the Blumberg sign.", "Blood analysis showed leucocytosis, neutrophilia, and an increased level of C-reactive protein.", "Ultrasonographic (Figure, A) and computed tomographic images (Figure, B) showed a thickened wall outpouching arising from a discreetly thickened appendix and inflamed surrounding fat.", "Right-sided colonic diverticulosis was also seen.", "The patient underwent an appendectomy with gross findings as shown in Figure, C.Ultrasonographic image of the right lower quadrant (A) and sagittal reformatted computed tomographic image (B), both showing a thickened wall outpouching (arrow) arising from the vermiform appendix (arrowheads) with inflammatory changes in the surrounding mesenteric fat (asterisk)."], "Treatment": ["C, Gross findings of excised appendix (arrowheads) reveal an inflamed wall outpouching (arrow) and mesenteric fat (asterisk)."]}
{"Patient Personal Background": ["She denies use of alcohol or illicit substances."], "Patient Symptoms": ["She denies fevers, chills, and other systemic symptoms."], "Examination and Results": ["Physical examination reveals necrotic black eschars and scattered stellate purpuric patches on the lower extremities (Figure, A and B).", "All areas are exquisitely tender to palpation.", "The remainder of the examination is unremarkable.A, Necrotic black eschars on the lower extremities.", "B, Stellate purpuric patches on the lower extremity.Laboratory investigation demonstrates a creatinine level of 1.9 mg/dL (168.0 \u03bcmol/L), elevated from her baseline level of 1.2 mg/dL (106.1 \u03bcmol/L) 1 month ago.", "Lupus anticoagulant level (60.9 seconds [normal value, <43.1 seconds]), prothrombin time (14.2 seconds [normal range, 11-13.2 seconds]), and partial thromboplastin time (35.4 seconds [normal range, 21-33 seconds]) are slightly elevated."], "Treatment": ["Her cancer was diagnosed 6 months ago, and she was treated with primary surgical debulking, with partial omentectomy, loop ileostomy, and 4 cycles of chemotherapy with paclitaxel\u2009+\u2009carboplatin and panitumumab\u2009+\u2009gemcitabine."]}
{"Patient Personal Background": ["The cancer was well controlled for 31 months, when his tumor recurred and he was switched to erlotinib (150 mg/d)."], "Patient Symptoms": ["One month later, he developed a few erythematous follicular papules with focal scaling on the scalp, which intermittently improved and worsened and were reasonably well controlled with topical corticosteroids.", "Subsequently, the number of scalp lesions increased, accompanied by pustules and hair loss.", "Paronychia, pruritus, and dry skin were also present, but the pustular eruption was limited to the scalp."], "Examination and Results": ["Numerous pustules with an erythematous base were observed on the scalp vertex (Figure 1)."], "Treatment": ["One month later, he developed a few erythematous follicular papules with focal scaling on the scalp, which intermittently improved and worsened and were reasonably well controlled with topical corticosteroids.", "The cancer was well controlled for 31 months, when his tumor recurred and he was switched to erlotinib (150 mg/d)."], "Others": ["Neither pustules nor hair loss was noted.", "Neither fever nor other constitutional symptoms were noted."]}
{"Patient Personal Background": ["The mother was 22 years old, gravida 3, para 3, without significant comorbid conditions.", "She received prenatal care during the pregnancy and was negative for hepatitis B surface antigen, human immunodeficiency virus, and reactive rapid plasma reagin.", "She denied a history of sexually transmitted infections, cold sores, or genital lesions."], "Patient Symptoms": ["Multiple 7- to 8-mm vesicles with erythematous bases, some with hemorrhagic crusting and others filled with clear fluid, were scattered over the chest, back, and extremities (Figure 1)."], "Examination and Results": ["Physical examination of the neonate demonstrated a preterm, nondistressed, healthy-appearing patient, with normal vital signs.", "Oropharyngeal lesions and neurologic deficits were not present."], "Treatment": ["During prenatal care she tested positive for group B streptococcus and received appropriate treatment."]}
{"Patient Personal Background": ["She reported a normal eye examination by an optometrist 6 months prior and no history of corrective lens wear."], "Examination and Results": ["Her visual acuity without correction in each eye was count fingers at 5 ft with pinhole improvement to 20/200.", "The pupils were 4 mm OU and unreactive.", "On slitlamp examination, the anterior chambers were shallow and the angles on gonioscopy were closed in each eye (Figure).", "The undilated fundus examination revealed normal-appearing optic nerves with cup-to-disc ratios of 0.2.", "Intraocular pressures were 48 mm Hg OD and 49 mm Hg OS.", "When given a \u22126.50 D sphere trial lens, her visual acuity improved to 20/20 OD and 20/25 OS."]}
{"Patient Personal Background": ["He had been undergoing a maintenance chemotherapy regimen consisting of vincristine sulfate, 6-mercaptopurine, methotrexate, and high-dose prednisone.", "He did not undergo bone marrow or stem cell transplant as part of his treatment."], "Patient Symptoms": ["A and B, Multiple tiny, spiny, follicular hyperkeratotic papules on the face.", "Alopecia was also noted involving the eyebrows and the eyelashes, but the scalp was spared."], "Examination and Results": ["Multiple topical medications including keratolytics were applied to the affected areas without effect.Skin examination and microscopy analysis of punch biopsy specimen.", "C and D, Microscopy showed abnormal maturation of anagen hair follicles with excessive inner root sheath differentiation (original magnification \u00d74 [C] and \u00d740 [D]).Skin examination revealed multiple 1- to 3-mm, spiny, follicular, flesh-colored to erythematous hyperkeratotic papules predominantly on the face and to a lesser extent on the trunk, and extremities, with fine hairlike spicules emanating from most of them (Figure, A and B).", "A punch biopsy specimen was taken (Figure, C and D)."]}
{"Patient Symptoms": ["The pain was localized to her right abdomen, both upper and lower quadrants, with acute tenderness to palpation.", "She had some nausea and vomiting."], "Examination and Results": ["The pain was localized to her right abdomen, both upper and lower quadrants, with acute tenderness to palpation.", "Ultrasonographic findings gave concern for acute cholecystitis.", "A computed tomographic scan was ordered by her primary care physician after admission to the hospital (Figure)."], "Diagnosis": ["Ultrasonographic findings gave concern for acute cholecystitis."]}
{"Patient Symptoms": ["One day after the onset of pain, he presented to the emergency department.", "The patient described his pain intensity as 8 on a scale of 1 to 10.", "He also described having some nausea but no anorexia, and he experienced a single episode of emesis in the emergency department."], "Examination and Results": ["He was afebrile, and his heart rate was 86 beats/min; blood pressure, 128/86 mm Hg; and body mass index, 28 (calculated as weight in kilograms divided by height in meters squared).", "Bilateral lower abdominal and supraumbilical tenderness was present, as was lower abdominal voluntary guarding to palpation.", "Deep palpation of the left lower quadrant did not elicit pain over the right lower quadrant (ie, negative Rovsing sign).", "Internal and external rotation of the flexed right leg did not elicit pain (ie, negative obturator sign).", "Dorsiflexion of the right thigh against the examiner\u2019s hand resulted in right lower quadrant pain (ie, positive psoas sign).", "Rectal examination was unrevealing.", "Levels of liver function enzymes, amylase, and bilirubin were normal, as was a complete blood cell count, except for leukocytosis of 14\u2009000 cells/mm3.", "Urinalysis was unremarkable.", "A computed tomography (CT) scan was obtained (Figure 1).Computed tomography scan in the case patient."], "Others": ["A, Axial view.", "B, Coronal view.", "C, Sagittal view."]}
{"Patient Personal Background": ["The patient\u2019s medical history was notable for a 30-year history of hypertension and diabetes."], "Patient Symptoms": ["The bulge was more prominent on standing, coughing, and straining.", "Neither fever nor chills were reported."], "Examination and Results": ["Physical examination revealed a reducible protrusion in the left flank, with several red to light brown macules on the overlying skin (Figure).", "Computed tomography (CT) of the abdomen showed convexity of the left lower abdominal wall compared with the right and did not reveal any mass, hernia, or accumulation of fluid in the abdominal cavity.A, Lateral view showing hyperpigmented macules on the overlying skin of the left flank bulge."], "Treatment": ["Antiviral agents were not administered when he first developed zoster because the diagnosis was established more than 72 hours after first presentation of the disease."]}
{"Patient Symptoms": ["The patient had a persistent dry cough."], "Examination and Results": ["On primary and secondary survey, he had a patent airway, was hemodynamically stable, and had a single entrance wound over the right mandible.", "No exit wound was visible.", "The appearance of his oropharynx was unremarkable.", "The trachea was in midline, and breath sounds were clear and equal in all lung fields.", "Radiography of the chest showed a foreign body in the right side of the chest (Figure, A).", "After this initial imaging, the patient was log-rolled onto his left side, and a computed tomography (CT) scan of the chest was obtained (Figure, B).A, Anteroposterior chest radiograph taken in the trauma bay on arrival."]}
{"Patient Personal Background": ["She has no ophthalmic or medical history and denies recent travel or abnormal exposures."], "Patient Symptoms": ["She denies ocular discomfort or systemic symptoms."], "Examination and Results": ["Her uncorrected acuity is 20/60 OD without improvement with pinhole and 20/20 OS.", "Her pupils, intraocular pressure, motility, and confrontational visual fields are normal in each eye.", "Results of the external examination and slitlamp examination of the anterior segment of both eyes are unremarkable.", "Dilated examination findings of the left eye are normal."]}
{"Patient Personal Background": ["He had no history of perinatal infections, sick contacts, recent travel, or pets.", "The family lives in an apartment in New York City.On physical examination, the patient had fewer than 20 pink papulovesicles, some with hemorrhagic crust, scattered on the upper chest, abdomen, lower back, and extremities (Figure, A and B)."], "Patient Symptoms": ["His parents reported several pink papules that first appeared on his trunk and spread to his extremities within 24 hours.", "His increasing irritability and poor oral intake led to his admission for further evaluation."], "Examination and Results": ["His palms, soles, and oropharynx were otherwise unremarkable.Clinical and histologic images of papulovesicles.", "The clinical images show scattered pink papulovesicles, some with overlying hemorrhagic crust (A and B).", "C, A histologic section (hematoxylin and eosin, original magnification \u00d710) of a papule shows a focally eroded epidermis (asterisk) with a relatively dense and diffuse perivascular and interstitial dermal infiltrate (arrow) of predominantly mononuclear cells and a few neutrophils, with changes indicative of a mild vasculitis.Laboratory test results were notable for a mild leukopenia with a white blood cell count of 4.6\u2009\u00d7\u2009109/L (normal, 6.0-18.0\u2009\u00d7\u2009109/L) with 18% monocytes.", "C-reactive protein was slightly elevated at 3.38 mg/L (normal, <2.9 mg/L)."], "Treatment": ["Blood, urine, and wound cultures were taken, and a skin punch biopsy was performed (Figure, C)."], "Others": ["The patient\u2019s vaccinations were up to date.", "He was started treatment with intravenous ceftriaxone and intravenous acyclovir."]}
{"Patient Personal Background": ["She had a complicated medical history that was significant for non-Hodgkin lymphoma, chronic diarrhea, myelodysplastic syndrome treated with chemotherapy, and Beh\u00e7et syndrome treated with prednisone acetate (6 mg daily).", "Her surgical history was significant for a previous right-sided hemicolectomy due to recurrent right-sided diverticulitis."], "Patient Symptoms": ["The patient had some accompanying cough, nausea, and arthralgias but denied having dyspnea, emesis, and chest or abdominal pain."], "Examination and Results": ["On examination, she was alert and awake with appropriate mental status.", "Her vital signs were as follows: blood pressure of 150/59 mm Hg, heart rate of 127 beats per minute, respiratory rate of 20 breaths per minute, temperature of 38.5\u00b0C (101.3\u00b0F) (oral), and an oxygen saturation as measured by pulse oximetry of 99% in room air.", "The physical examination was unremarkable.", "Significant laboratory data included a white blood cell count of 2700/\u03bcL (reference range, 4800-10\u2009800/\u03bcL; to convert to \u00d7109 per liter, multiply by 0.001), a lactic acid level of 19.8 mg/dL (to convert to millimoles per liter, multiply by 0.111), and a platelet count of 72\u00d7103/\u03bcL (to convert to \u00d7109 per liter, multiply by 1.0).", "Urinalysis showed trace blood, positive nitrite, +1 leukocyte esterase, and a white blood cell count of 2000/\u03bcL to 5000/\u03bcL.", "A urine culture came back positive for Klebsiella pneumonia, and a blood culture came back positive for Enterobacter sakazakii (now know as Cronobacter sakazakii)."], "Treatment": ["There was concern about the source of the bacteremia, so an infectious disease consult was ordered, and a computed tomographic scan of the abdomen/pelvis with contrast was performed.", "The patient was scheduled for surgery, and the findings are shown in Figure 2."], "Others": ["Figure 1 shows a coronal, reformatted image of the scan."]}
{"Patient Symptoms": ["She denied any history of hematemesis or hematochezia."], "Examination and Results": ["On abdominal examination, an irregular mass measuring 20\u2009\u00d7\u200910 cm without tenderness was found, and no bruit was heard on auscultation.", "No other vascular anomalies were detected on systemic examination.", "All laboratory test results were within normal limits.", "Upper gastrointestinal endoscopy showed normal gastric mucosa.", "Nonenhanced computed tomography of the abdomen showed a partially well-circumscribed, mixed cystic and solitary mass that partially enveloped the stomach and compressed adjacent organs, likely arising from the stomach (Figure 1).Axial nonenhanced computed tomographic image showing a mixed cystic and solitary mass that partially enveloped the stomach."]}
{"Patient Personal Background": ["His history included lumbar spine surgery and chronic back pain leading to continued requirement for opiate analgesia."], "Examination and Results": ["Endoscopy revealed food stasis throughout the esophagus, large diverticula in the lower esophagus, no resistance at the lower esophageal sphincter, and extensive candidiasis.", "A barium swallow was diagnostic (Figure 1).", "Esophageal manometry demonstrated 100% hypertensive propagated pressure waves in the distal esophagus, with a mean esophageal pressure of 335 mm Hg, a maximum pressure of 701 mm Hg, and normal relaxation of the lower esophageal sphincter."], "Treatment": ["The patient was treated with antifungal therapy and received a 1-month course of calcium channel antagonists, but symptoms were unchanged and weight loss progressed."]}
{"Patient Personal Background": ["He has no relevant medical history and does not take any\r\nmedications."], "Examination and Results": ["Apart from the lesions, the physical\r\nexamination is unremarkable.", "Skin examination reveals disseminated sharply demarcated, dome-shaped,\r\nred-brown papules and nodules with a shiny, waxy surface.", "These 0.1- to 0.8-cm lesions are on his\r\nface, scalp, ears, neck, trunk, shoulder (Figure 1A),\r\nupper extremities (Figure 1B), lower extremities\r\nincluding the palms and soles, and scrotum.", "The mucous membranes and periorbital area are spared.", "A\r\nshave biopsy reveals a yellow appearance of the base of the papule.", "Hematoxylin-eosin stains reveal\r\na diffuse inflammatory infiltration of the upper and middle dermis with lymphocytes, plasma cells,\r\nnumerous foamy histiocytoid cells, and a large number of multinucleated cells.", "Emperipolesis\r\n(engulfed lymphocytes) is present within the histiocyte cytoplasm.", "There is rare nuclear atypia.", "Electron microscopy shows indented nuclei and emperipolesis in histiocytes."], "Others": ["No family members have similar symptoms."]}
{"Patient Personal Background": ["His medical history was significant for pharyngitis associated with scarlet fever that he had a month before; the pharyngitis was treated by his general practitioner with clarithromycin (500 mg twice daily for a week).", "No throat culture or rapid antigen test for group A streptococci was performed at that time."], "Patient Symptoms": ["He complained of nausea, vomiting, and asthenia as well."], "Examination and Results": ["On physical examination, he presented with mild right upper abdominal quadrant tenderness.", "He met all the criteria for systemic inflammatory response syndrome, and his blood tests showed a marked increase in inflammatory markers.", "Blood and urine cultures were obtained, and the results were negative.", "His chest radiograph was normal.", "An abdominal ultrasonographic examination revealed a 6-cm, solid, inhomogeneous mass in liver segment 6.", "A contrast-enhanced computed tomographic scan of the abdomen (Figure 1) showed that the lesion was hypodense with numerous septa without contrast enhancement.", "Magnetic resonance imaging (Figure 2) evidenced a mixed solid-liquid lesion, with some septa delimiting large areas of necrosis.", "The results of a serological detection test for echinococcosis were negative.", "His carcinoembryonic antigen, carbohydrate antigen 19-9, and \u03b11-fetoprotein blood levels were normal.", "Serological markers for hepatitis B virus, hepatitis C virus, and human immunodeficiency virus were negative.", "A study of leukocyte populations and immunoglobulin electrophoresis did not reveal any disorder of the immune system.Computed tomographic scan showing a large, hypodense, multiloculated lesion in liver segment 6.Magnetic resonance imaging scan showing an heterogeneous, capsulated lesion, with numerous septa delimiting large areas of necrosis."], "Treatment": ["Empirical antibiotic therapy with ampicillin sodium/sulbactam sodium was started."]}
{"Patient Personal Background": ["Medical and family histories were unremarkable and no abnormalities were found on physical examination."], "Examination and Results": ["A radiograph of the right knee showed osteolytic lesions in the distal femur and the head of the tibia.On magnetic resonance imaging, the epiphyseal lesions were visualized as cystic and nonsclerotic and extended to the articular surface of the distal femur and proximal tibia (Figure 1).", "Soft tissue extension was suspected from the tibia.", "Laboratory test results showed normal blood cell count, renal function, and concentration of C-reactive protein.Aneurysmatic bone cysts were suspected and a biopsy was performed.", "Histopathological examination detected spindle cell infiltrates with hemorrhages, fragmented trabecular bone, and numerous osteoclastic giant cells proliferating at a rate of 10% suggesting an aggressive giant cell lesion.Since it was still not determined whether the lesions were malignant, flourodeoxyglucose F 18 positron emission tomography/computed tomography was performed and found additional lesions in the left distal femur and the left mandible.", "Biopsy of the mandible showed the same type of tissue as seen in the right femur and tibia."], "Treatment": ["Laboratory test results showed normal blood cell count, renal function, and concentration of C-reactive protein.Aneurysmatic bone cysts were suspected and a biopsy was performed."]}