The patient is a 38-year-old man with cough and body ache that started 3 days ago.  He had fever and chills at the beginning and has low grade fever at the time of visit. He feels tired and sleepy. His body ache and myalgia get better after using Tylenol. The PCR test for Covid is positive. His vital signs are within normal limits with a body temperature of 37.9 C. There is no lymphadenopathy or white exudates in the pharynx.


A 41-year-old woman comes to the dermatology clinic complaining of facial redness, especially on her forehead and cheeks. She noticed that the redness gets worse in the summer and after sun exposure. She is otherwise healthy. On physical examination, she has multiple papules and pustules present on her forehead, cheeks, and nose on a background of erythema and telangiectasias. There are no other lesions or nodules. The patient is married and has 2 children who are 5 and 9 years old. She has IUD and doesn't wish to have more kids. She does not smoke or drink alcohol. Her vital signs are normal, and BMI is 21.


A 50-year-old woman comes to the clinic complaining of difficulty swallowing both liquids and solid foods, as well as occasional cough while eating.  She also has difficulty lifting her arms above her head and getting up from a chair. The weakness seems to get worse gradually. The patient has no prior medical problems and takes no medications.  Vital signs are normal.  Physical examination shows an erythematous rash on the upper eyelids. There are some red papules over joints of her hands. The rest of the physical examination is unremarkable. Antinuclear antibodies, anti-Jo-1 antibodies and anti-MDA5 antibody are positive.  Muscle biopsy shows perifascicular inflammation and atrophy of the fascicle and surrounding blood vessels.


A 19-year-old male came to clinic with some sexual concern.  He recently engaged in a relationship and is worried about the satisfaction of his girlfriend. He has a "baby face" according to his girlfriend's statement and he is not as muscular as his classmates.  On physical examination, there is some pubic hair and poorly developed secondary sexual characteristics. He is unable to detect coffee smell during the examination, but the visual acuity is normal. Ultrasound reveals the testes volume of 1-2 ml. The hormonal evaluation showed serum testosterone level of 65 ng/dL with low levels of GnRH.


A 32-year-old woman comes to the hospital with vaginal spotting.  Her last menstrual period was 10 weeks ago. She has regular menses lasting for 6 days and repeating every 29 days. Medical history is significant for appendectomy and several complicated UTIs. She has multiple male partners, and she is inconsistent with using barrier contraceptives. Vital signs are normal.  Serum β-hCG level is 1800 mIU/mL, and a repeat level after 2 days shows an abnormal rise to 2100 mIU/mL.  Pelvic ultrasound reveals a thin endometrium with no gestational sac in the uterus.


A 51-year-old man comes to the office complaining of fatigue and some sexual problems including lack of libido. The patient doesn't smoke or use any illicit drug.  Blood pressure is 120/80 mm Hg and pulse is 70/min.  Oxygen saturation is 99% on room air.  BMI is 24 kg/m2.  Skin examination shows increased pigmentation. Genotype testing is consistent with homozygosity for the C282Y mutation. Laboratory study shows transferrin saturation of 55% and serum ferritin of 550 μg/L. He is diagnosed as a case of hemochromatosis.


A 61-year-old man comes to the clinic due to nonproductive cough and progressive dyspnea.  The patient's medical conditions include hypertension, hypercholesteremia and peptic ulcer disease.  He smokes 2 packs of cigarettes daily for the past 30 years.  On examination, there are decreased breath sounds and percussive dullness at the base of the left lung.  Other vital signs are normal. Abdomen is soft without tenderness. CT scan shows a left-sided pleural effusion and nodular thickening of the pleura. The plural fluid was bloody on thoracentesis. Biopsy shows proliferation of epithelioid-type cells with very long microvilli.


A 7-month-old boy is brought to emergency by his parents due to irritability and inability to defecate for the past 3 days.  The patient has had constipation and discomfort with bowel movements since birth.  His symptoms worsened after eating semi-solid foods.  Vital signs are normal.  Abdominal examination shows distension and tenderness to palpation with presence of bowel sounds.  Xray with barium shows a narrow rectum and rectosigmoid area.  The rest of the colon proximal to this segment is dilated. Digital rectal exam revealed burst of feces out of the anus. The biopsy showed absence of submucosal ganglia in the last segment of the large intestine.


A 67-year-old woman comes to the clinic due to recent episode of choking, dysphagia, and cough.  Her other medical problems include hypertension, dyslipidemia, and osteoarthritis.  She does not smoke or use alcohol. She lives with her husband and she is able to do her own daily activities. She used to teach elementary school. Blood pressure is 135/80 mm Hg.  The patient's breath smells bad. Other physical examinations are normal.  A barium swallow study reveals an abnormality in the upper esophagus with an outpouching at the junction of the lower part of the throat and the upper portion of the esophagus.


A 47-year-old man comes to the office for routine checkup. He is complaining of chronic cough and occasional but progressive dyspnea.  Other medical conditions include hypertension and osteoarthritis.  The patient smokes a pack of cigarettes daily and does not use alcohol or illicit drugs.  He used to be a construction worker. On examination, there are decreased breath sounds and percussive dullness at the base of both lungs.  Chest CT scan reveals a mild bilateral pleural effusion and diffuse thickening of the pleura. The patient's documents show chronic exposure to asbestosis. The specimen of the lungs reveled  pulmonary fibrosis that is most predominant in the lower lobes, characterized  by the presence of asbestos bodies (golden-brown beaded rods with translucent centers).


A 24-year-old man comes to the office complaining of infertility.  He and his wife have been trying to conceive for the last 18 months.  Medical records of his wife showed no abnormalities.  The patient doesn't smoke and takes no medications.  Height is 185 cm and weight is 77 kg.  Heart and lung sounds are normal.  There is bilateral gynecomastia and bilateral descended firm testes.  The lower extremities appear abnormally long. His karyotype evaluation shows 47, XXY consistent with Klinefelter syndrome.


A 39-year-old woman comes to the clinic complaining of arthralgias and nodules on her legs.  She has no fever or other skin rashes. The prior medical condition is unremarkable, and she takes no medications.  On physical examination, there is moderate hepatomegaly. The lesions on her legs are tender and present predominantly on the anterior surface of the lower extremities. She doesn't smoke and drinks alcohol occasionally. The patient has 2 male sexual partners. Vital signs are normal. Chest x-ray demonstrates enlarged hilar lymph nodes, and laboratory testing reveals an elevated ACE level. Biopsy of the skin lesion shows noncaseating granulomas that stain negative for fungi & acid-fast bacilli.


A 2-year-old boy is brought to the office by his parents due to a rash that started 1 week ago.  A similar red, itchy rash on the cheeks, trunk, and arms has occurred intermittently since infancy.  The patient has had a few upper respiratory infections but no major illnesses.  Vaccinations are up to date, and he takes no medications. He is on a balanced diet, and he is healthy in appearance.  Vital signs and milestone examination are within normal limits.  Similar findings are observed on the cheeks and proximal upper extremities.  The diaper area is clear, and no mucosal lesions are present.


A 7-year-old girl is brought to the emergency department by her parents for generalized rash.  The mother reports that she was playing outside wearing a skirt and felt a sharp pain in her arm while seating on a mat, plying with her doll.  Her mother suspects that something had stung her.   The patient's blood pressure is 75/55 mm Hg and her heart rate is 122/min.  Physical examination shows erythematous, raised plaques over the trunk, extremities, and face.  Lung auscultation reveals bilateral expiratory wheezes.


A 15-year-old boy with mild intellectual disability is brought to the office by his parents for a routine physical examination.  The boy is going to a school for students with learning disabilities.  The patient was adopted, and his immunizations are up to date.  Review of the patient's medical records is notable for cytogenetic studies that showed a small gap near the tip of the long arm of the X chromosome, which is consistent with fragile X syndrome, an X-linked disorder. The defect is an unstable expansion of trinucleotide repeats (CGG) in the fragile X mental retardation 1 (FMR1) gene, located on the long arm of the X chromosome. He is not using any medications and vital signs are within normal levels. His blood chemistry analysis as bellow:
Blood Chemistry Value      Normal Range     Patient Value
Glucose                    90-120 mg/dl     95 mg/dl
BUN (Blood Urea Nitrogen)  7-24 mg/dl       10 mg/dl
Creatinine                 0.7-1.4 mg/dl    0.8 mg/dl
Calcium                    8.5-10.5 mg/dl   9 mg/dl
Sodium                     134-143 mEq/L    135 mEq/L
Potassium                  3.5-4.5 mEq/L    3.7 mEq/L
Chloride                   95-108 mEq/L     98 mEq/L
CO2                        20-30 mEq/L      25 mEq/L
Blood pH                   7.38-7.42        7. 39


A 66-year-old woman comes to the office due to joint pain in the hands and periodic morning stiffness that lasts less than 15 minutes.  The pain is moderately severe and worsens with daily activity. The patient used Tylenol with minimal relief.  Past medical history is notable for hypertension and hypercholesteremia.  Physical examination shows firm nodules over the distal interphalangeal joints, bilaterally. The patient has pain in her knees as well. The knees are stiff in the morning for less than 30 minutes and become worse with climbing stairs. She has some sensation of bone friction during activity. X-ray shows narrowing of the joint space, subchondral bone sclerosis and osteophyte formation along the joints.


A 23-year-old man comes to the emergency department following an episode of syncope.  He was working out when he felt dizzy and passed out without head injury.  He has had 3 other episodes of light-headedness over the last year, all happening during physical activity. He never had this experience while resting. He has no other medical conditions.  The patient does not use tobacco, alcohol, or illicit drugs.  His father died suddenly at age 35.  Vital signs are within normal limits.  On physical examination, the patient has a harsh systolic murmur.  The lungs are clear with no peripheral edema. Echocardiography shows asymmetric interventricular septal hypertrophy.


A 3-year-old girl is brought to the clinic by her parents for assessment of her short stature. Physical examination reveals short limbs and a relatively large head. She has a flat nasal bridge and a small midface. The girl's father exhibits similar physical features; however, her mother looks normal. The genetic testing reveals an autosomal dominant point mutation in the fibroblast growth factor receptor 3 (FGFR3) gene consistent with achondroplasia in both father and the child. The girl has not received any treatment yet, and it is her first visit after immigration to the US. The other mental and developmental examinations are unremarkable.


A 19-year-old girl comes to the clinic due to a left wrist mass.  She noticed swelling on the top of her wrist about 4 months ago and came to the clinic due to cosmetic concerns.  Examination shows a nontender, rounded mass on the dorsal wrist that transilluminates with a penlight. Vital signs are normal. The patient needs to type on her computer almost all day. She is left-handed. She does not smoke or use illicit drugs. She is in sexual relationship with two male partners and uses condoms.


A 63-year-old man comes to the clinic for recent unintentional weight loss. The patient also has epigastric discomfort after meals. He has no known medical problems and takes no medications. His blood pressure is 130/75 and pulse rate is 88/min. He is not febrile. Upper endoscopy shows a lesion in the stomach that shows typical features of diffuse-type adenocarcinoma presenting with signet ring cells that do not form glands.


A 39-year-old man comes to the emergency department with an acute onset of severe left toe pain.  The toe is red and exhibits swelling. The patient is not febrile, and does not remember any recent trauma. Medical history is not significant except for the similar attacks and the diagnosis of gouty arthritis. His medication history includes Allopurinol to prevent gouty attacks. His father has the same medical condition. However, his older brother who is 41 years old is healthy with no history of gouty arthritis. Physical examination shows a swollen, tender first metatarsophalangeal joint.  Aspiration of the joint showed high leukocyte count, negative Gram stain, and numerous needle-shaped crystals, which is compatible with gouty arthritis.


An 8-year-old boy is brought to the clinic by his parents because of weakness and difficulty of standing up from a sitting position. The mother is healthy but had a brother who died in his 20th after being disabled and using wheelchairs in the last few years of his life. Physical examination shows 3/5 lower extremity muscle strength and enlarged calf muscles. The other physical examination and vital signs are unremarkable. Muscle biopsy showed absence of dystrophin protein. The patient is diagnosed with DMD.


A 67-year-old man comes to the clinic with slowly worsening vision in both eyes.  He is not able to drive at night, as the symptoms are worse at night. His pupils are normal in diameter both in the light and darkness. Other medical history is unremarkable.  Ocular examination shows loss of the red reflex and blurry vision.  Acuity testing shows 50/100 vision in both eyes with normal visual field testing. His blood pressure is 130/70 and pulse is 68/min. the other physical examinations are normal.


A 49-year-old man comes to the office because of the bulging in his groin.  Physical examination shows a swelling above the inguinal ligament. When the patient is asked to cough, the size of the bulge increases.  His medical history is significant for mild dyslipidemia, which is under control by lifestyle modifications. He does not smoke, but drinks alcohol occasionally. His vital signs and other physical examinations are unremarkable. He is referred to a surgeon and scheduled to undergo elective laparoscopic hernia repair.


A 4-year-old boy comes to the office for the follow up of his confirmed oculocutaneous albinism.  The patient was born at 38 weeks gestation with no complications.  Vital signs are normal.  Weight and height are at the 50th percentile.  On examination, iris transillumination is present, and there are no apparent foveae on funduscopic examination.  Optic nerves are small and gray.  All the hairs including eyebrows and lashes are white.


A 33-year-old woman comes to clinic complaining of progressive fatigue, decreased appetite, and 11-lb weight loss in the past 2 months.  She uses levothyroxine because of the previously diagnosed Hashimoto disease. She has no other medical conditions and does not use tobacco, alcohol, or illicit drugs.  Physical examination shows a generalized increase in pigmentation of the skin.  Measurement of serum cortisol before and after administration of exogenous adrenocorticotropic hormone (ACTH) shows no difference in the levels. Stable glucocorticoid replacement therapy starts for her with the diagnosis for primary adrenal insufficiency (Addison disease)


A 23-year-old woman comes to the emergency department with a history of nosebleeds lasting for 1 hour. She has a history of heavy menses as well as occasional gum bleeding following dental procedures. Her mother also has a history of menorrhagia. Laboratory tests reveal increased bleeding time and slightly increased partial thromboplastin time. She has no other medical conditions and is otherwise healthy. Her coagulation study shows CB = 0.30 IU/mL and FVIII:C = 0.37 IU/mL. She is not smoking or using any kind of illicit drugs. She uses alcohol occasionally and is in ra elationship with her boyfriend for the past 2 years.


A 47-year-old woman comes to the office complaining of pain in the calf and knee when she bends down. The pain limits her activity. Her medical history is significant for osteoarthritis, for which she uses nonsteroidal anti-inflammatory drugs (NSAIDs) for the past two years. She is living with her husband and has 3 children. She doesn't smoke but drinks alcohol occasionally. Her vital signs are normal. On physical examination, there is a small effusion in the right knee. The effusion grew a little larger and she developed a tender swelling in the popliteal fossa and calf. Both the pain and swelling worsened as she bent and straightened her knee.


A 25-year-old woman comes to the clinic with her roommate.  The roommate says that the patient has twice fallen asleep while they were talking.  The patient has regularly fallen asleep in the afternoon while reading or watching television but typically feels refreshed after a brief nap.  She also reveals that she sometimes hears a voice prior to falling asleep.  She also complains of some episodes of clumsiness that cause her to drop objects or fall. MSLT showed that the sleep latency was less than 8 min and that the patient enters rapid eye movement (REM) sleep almost immediately.


A 17-year-old male comes to the office due to several months of right elbow pain.  The pain is worse with activity and limits his workouts and activities.  He has tried over-the-counter medications with limited relief.  Medical history is notable for eczema, and current medications include a topical hydrocortisone ointment.  He is sexually active with his girlfriend and uses condoms. He does not smoke or drink alcohol. He plays tennis most of the days of the week. The comprehensive evaluation shows pain on the lateral side of the elbow, made worse by pressure applied on the lateral epicondyle of the humerus and when making a fist with the elbow joint straightened. The patient has this pain since last year and had several courses of physical therapy.


A 43-year-old woman, gravida 3 para 3, comes to the clinic complaining of recently painful menstrual cycles.  The patient's last menstrual period was 2 weeks ago. Urine β-hCG is negative. Menarche was at age 12, and menstrual periods occur every 28 days and lasts for 5 days.  She is sexually active with her husband and does not have pain with intercourse. BMI is 23 kg/m2 and Vital signs are normal.  On physical examination, the uterus is uniformly enlarged and tender. She is candidate for hysterectomy with the diagnosis of adenomyosis.


A 60-year-old man comes to the clinic complaining of hand tremor that started few months ago.  It is most bothering when he wants to drink from a glass or pour from a bottle. He does not smoke, but drinks occasionally. He recently started consuming more alcohol as his tremor subsides somewhat when he drinks small amounts of alcohol.  Family history is significant for similar problems in his mother.  Vital signs are normal and the patient has no other medical conditions.  Neurologic examination shows bilateral tremor in the upper extremities. The diagnosis of essential tremor is confirmed.


A 55-year-old white woman comes for a routine checkup.  She has no significant medical history and does not use tobacco, alcohol, or illicit drugs.  The patient's only medication is an over-the-counter multivitamin.  Family history is notable for a hip fracture in her mother.  Blood pressure is 130/80 mm Hg and pulse is 112/min. She has occasional back pain and lives a sedentary lifestyle with the BMI of 24 Kg/m2. Plain X-ray of the spine shows mild compression fracture at the level of T10. X-ray absorptiometry studies demonstrate abnormally low bone density in the lumbar vertebrae and T-score values below -2.5, which confirms the diagnosis of osteoporosis.


A 61-year-old man comes to the emergency department complaining of an acute vision disturbance. He had an episode of vision disturbance in the right eye that occurred suddenly and resolved spontaneously in 15 minutes. He also has right jaw pain while chewing.  He also complains of fatigue and hip muscle aches over the last several months.  The patient has a history of mild hyperlipidemia that has been controlled by diet and lifestyle modifications.  On examination, his blood pressure is 130/70 mm Hg and pulse is 66/min.  Neurological examination is unremarkable.  Visual examination is also normal. ESR is 103 mm/h. Temporal artery biopsy shows multinuclear giant cells and internal elastic membrane fragmentation.


A 48-year-old man comes to the office complaining of heartburn and acid reflux.  He has taken over-the-counter antacids but sees no relief.  Other medical history is unremarkable.  The patient does not use tobacco, alcohol, or illicit drugs.  Vital signs are within normal limits.  BMI is 31 kg/m2.  Physical examination is  positive for mild tenderness in upper stomach. Chest x-ray shows an air-fluid opacity behind the heart.  A barium swallow study reveals approximately 1/3 of the stomach herniating through the esophageal hiatus.


A 15-week-old infant brought to the clinic for the follow up. The infant has flat facies, small ears, a single palmar crease, and upward slanting eyes. He was born on 39th week to a 39-year-old woman who didn't have prenatal care. The medical record confirms the trisomy of chromosome 21 (Down syndrome). The infant is otherwise healthy.


A 20-year-old man comes to the emergency due to bleeding after a tooth extraction.  The bleeding has persisted for approximately 30 minutes despite constant direct pressure.  He is a known case of Hemophilia type A treated with FVIII. Blood pressure is 95/60 mm Hg and pulse is 105/min. His weight is 70 Kg. Family history is positive for Hemophilia type A in his maternal uncle. He also has a lipoma on his left arm which he plans to remove surgically. His FVIII activity is 40%.


A 70-year-old man comes to the office accompanied by his wife.  The patient has experienced progressive memory loss over the last years.  He needs help with some of his routine activities, such as paying bills.  The patient's wife says, "He used to be such an independent person, but now he needs help with many things, even finding direction to home!"  Medical history includes hypertension, hyperlipidemia, and type 2 diabetes mellitus.  Family history includes Alzheimer disease in his father.  MRI reveals diffuse cortical and hippocampal atrophy. The diagnosis of AD is made using the National Institute on Aging and the Alzheimer's Association (NIA-AA) criteria.


Patient is a 45-year-old man with a history of anaplastic astrocytoma of the spine complicated by severe lower extremity weakness and urinary retention s/p Foley catheter, high-dose steroids, hypertension, and chronic pain. The tumor is located in the T-L spine, unresectable anaplastic astrocytoma s/p radiation. Complicated by progressive lower extremity weakness and urinary retention. Patient initially presented with RLE weakness where his right knee gave out with difficulty walking and right anterior thigh numbness. MRI showed a spinal cord conus mass which was biopsied and found to be anaplastic astrocytoma. Therapy included field radiation t10-l1 followed by 11 cycles of temozolomide 7 days on and 7 days off. This was followed by CPT-11 Weekly x4 with Avastin Q2 weeks/ 2 weeks rest and repeat cycle.


48 M with a h/o HTN hyperlipidemia, bicuspid aortic valve, and tobacco abuse who presented to his cardiologist on [**2148-10-1**] with progressive SOB and LE edema. TTE revealed severe aortic stenosis with worsening LV function. EF was 25%. RV pressure was 41 and had biatrial enlargement. Noted to have 2+ aortic insufficiency with mild MR. He was sent home from cardiology clinic with Lasix and BB (which he did not tolerate), continued to have worsening SOB and LE edema and finally presented here for evaluation.
During this admission repeat echo confirmed critical aortic stenosis showing left ventricular hypertrophy with cavity dilation and severe global hypokinesis, severe aortic valve stenosis with underlying bicuspid aortic valve, dilated ascending aorta, mild pulmonary artery systolic hypertension. The patient underwent a preop workup for valvular replacement with preop chest CT scan and carotid US (showing moderate heterogeneous plaque with bilateral 1-39% ICA stenosis). He also underwent a cardiac cath with right heart cath to evaluate his pulm art pressures which showed no angiographically apparent flow-limiting coronary artery disease.


A 32 yo woman who presents following a severe 'exploding' headache. She and her husband report that yesterday she was in the kitchen and stood up and hit her head on the corner of a cabinet. The next morning she developed a sudden 'exploding' headache. She came to the hospital where head CT showed a significant amount of blood in her right ventricle. NSGY evaluated her for spontaneous intraventricular hemorrhage with a concern for an underlying vascular malformation. Cerebral angiogram was done which showed abnormal vasculature with a draining vein from L temporal lobe penetrating deep white matter consistent with AVM. The patient did continue to have a headaches but they were improving with pain medication. The patient refused PT evaluation but was ambulating independently without difficulty. She was discharged to home with her husband on [**2155-12-6**].


This is a 44 year old female with PMH of PCOS, Obesity, HTN who presented with symptoms of cholecystitis and was found incidentally to have a large pericardial effusion. A pericardiocentesis was performed and the fluid analysis was consistent with Burkitt's lymphoma. Pericardial fluid was kappa light chain restricted CD10 positive monotypic B cells expressing FMC-7, CD19, CD20, and myc rearrangement consistent with Burkitt's Lymphoma. A subsequent lumbar puncture and bone marrow biopsy were negative for any involvement which made this a primary cardiac lymphoma. A cardiac MRI showed a mass that was 3cm x 1cm on the lateral wall of the right atrium adjacent to the AV junction.
Past Medical History:
1. Rare migraines
2. HTN
3. Obesity
4. PCOS/infertility
5. Viral encephalitis/meningitis-->ICH-->seizure/stroke ([**2137**]) =- from severe sinus infxn, caused mild non-focal residual deficits
6. CSF leak w/ meningitis s/p lumbar drain placement
7. R LE DVT s/p IVC filter placement
8. Knee surgery


74M hx of CAD s/p CABG, EF 60% prior CVA (no residual deficits), HTN, HL, DMII, Moderate to Severe PVD was referred to cardiology for evaluation of PVD, and on examination patient was found to have carotid bruits. Upon further review of symptoms the pt reports + Occasional dizziness, no prior syncope occasional HA, Denies CP/SOB. No sensory or motor defects. He recalls that he might have had a stroke 10-15 years ago without any residual deficit. Prior to CABG he only had diaphoresis.
Further review of systems is notable for absence of chest pain, dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, palpitations, syncope or presyncope. He underwent Carotid U/S that showed significant bilateral carotid stenosis, L>R. Angiography revealed an 80% stenosis of the R ICA and a 90% L ICA stenosis. Cerebral angiography further revealed patent right ACA and MCA and patent left ACA and left MCA.
Past Medical History:
CAD s/p CABG in [**2154**] ([**Hospital1 112**])
Prior CVA
Bilateral carotid artery disease
Anemia
PVD
Hypertension
Diabetes c/b retinopathy and peripheral neuropathy
Cataracts s/p surgery
Thyroid nodule
Colon polyps s/p resection
Intermittent Lower back pain
Proteinuria
s/p right elbow fracture as a child
Arthritis


Patient is a 55yo woman with h/o ESRD on HD and peritoneal dialysis who presented with watery, non bloody diarrhea and weakness. She has a history of 2 prior C diff infections, the most recent just 1 month ago. Recent antibx use in the last month on prior admission. Was also txd for Cdiff at that time for 14 d. course with po vanco. Pt was initially admitted to the ICU and was septic on pressors (levophed) until the morning of [**8-26**] with leukocytosis but no fever. C diff assay positive on admission, and pt had leukocytosis consistent with C diff. Patient was placed on Vanco po, Flagyl IV and Flagyl po initially, and when patient improved she was transitioned to Vanco oral and Flagyl oral on [**8-29**]. Patient was treated with Vanco for an extended course of 6 weeks given her recurrent C diff. Pt was also encouraged to take probiotics and to bleach her home when she was discharged.


60 yo M with Hep C cirrhosis, grade II esophageal varices, recent admission for UGIB [**2-9**] NSAID gastritis, referred for admission throught the ED by hepatology clinic for new slurred speech and tangential thought process. Patient also describes new imbalance leading to a fall during which he may have hit his head on. Per last liver clinic note has been off ETOH for a year (corroborated with pt), utox was negative for alocohol. CT was within normal limits, and neuro evaluation determined this was not ischemic infart. Patient was given a presumptive diagnosis of hepatic encephalopathy and started on lactulose. Liver function tests showed a striking increase in his total and direct bilirubin since last visit. Another worrisome feature was the increase in the patient's AFP. This could be progression of cirrhosis as he failed interferon twice. He is to follow-up as an outpatient to work this up.
Past Medical History:
HCV Cirrhosis (tx with interferon x2 with no response)
Portal Gastropathy
Grade II Esophageal varices
HTN
Recent admission [**4-/2150**]: UGIB [**2-9**] non-steroidal induced
gastritis


This is a 57-year-old gentleman with CLL and large cell transformation. He presented with his disease back in [**10/2119**] with an elevated white count and LDH. He was without any splenomegaly or any cytopenias at that time. He did have some bulky lymphadenopathy. He then completed four cycles of FCR therapy, which he completed back in 09/[**2119**]. He had an excellent response to therapy and was monitored off treatment for approximately two years. He then presented in [**7-/2122**] with a rising white count, approximately 50% lymphocytes, and a mildly elevated LDH. He also had some mild worsening palpable lymphadenopathy. He then received four cycles of PCR, but did not have much in the way of response and his treatment regimen was switched to R-CVP of which he received two cycles. He did again not have a significant response, though continued to have an excellent performance status, and he was ultimately switched to Campath therapy. He did have resolution of his lymphocytosis, and his white count has come down nicely, but did not have much in the way of response in terms of reducing his bulky lymphadenopathy. He then eventually had developed an enlarging left cervical node which was biopsied and was found to have Richter's transformation.


41 year old man with history of severe intellectual disability, CHF, epilepsy presenting with facial twitching on the right and generalized shaking in at his NH which required 20 mg valium to cease seizure activity. Per outside medical patient was felt to have focal epilepsy with secondary generalization, likely due to anoxic brain injury at birth, and probably related to the atrophic changes seen on MRI, particularly in the left temporal lobe.
The patient first developed seizures at age 13 found by family to have a generalized convulsion. He had a second seizure two years after his first episode. He was maintained on Dilantin and phenobarbital. The patient went 20 years without another seizure. He was recently tapered off Dilantin, and it was felt that perhaps this medication was necessary to maintain him seizure free. The patient had no further events during the hospital course and was back at his baseline at the time of discharge. Full EEG reports are pending at the time of dictation.
Past Medical History:
Epilepsy as above, CHF, depression


Pt is a 22yo F otherwise healthy with a 5 yr history of the systemic mastocytosis, with flares normally 3/year, presenting with flushing and tachycardia concerning for another flare. This is patient's 3rd flare in 2 months, while still on steroid taper which is new for her. She responded well to 125 mg IV steroids q 8 hrs and IV diphenydramine in addition to her continuing home regimen. CBC was at her baseline, w/normal differential. Serum tryptase revealed a high value at 84. The patient failed aspirin challenge due to adverse reaction. She was stabilized on IV steroids and IV benadryl and transferred back to the medical floor. She continued on her home histamine receptor blockers and was transitioned from IV to PO steroids and benadryl and observed overnight and was discharged on her home meds, prednisone taper, GI prophylaxis with PPI, Calcium and vitamin D, and SS bactrim for PCP.


A 75 yo M w/ metastatic papillary thyroid cancer s/p XRT 19 sessions who presented with 2 days of worsening dysphagia for solids, poor oral intake, weight loss 20 pounds over last several weeks and some lethargy.
Papillary thyroid cancer dx w/ right neck mass
--s/p neck mass resection; unable to perform thyroidectomy
--high bleed risk, proximity to trachea and recurrent laryngeal nerve and large tumor size
--s/p XRT to neck
--s/p RAI ablation
--Metastatic to lymph nodes and adrenal glands
* s/p hernia repair
* s/p tonsillectomy


34 year old woman with Marfan's syndrome and known severe mitral valve prolapse with regurgitation, who was planned for a MV repair but was lost to follow-up. She remains symptomatic and is now prepared to undergo mitral valve repair/replacement surgery. EF of 65% on TTE.
Past Medical History:
Marfans Syndrome
MVP with severe mitral regurgitation
Gastric reflux disease
History of gestational diabetes mellitus
Hypertension with pregnancy
Obesity
c-section x 2
laser eye surgery
cataract surgery
foot surgery (shorten bone length)


70 y/o with COPD on 2.5-3.5L O2 at baseline, OSA and obesity hypoventilation syndrome, dCHF, discharged [**2132-8-24**] now presents with agitation and altered mental status with hypoxia and O2 sats 70s on BipAp with 5L. Pt agitated then somnolent at initial presentation. Daughter reported increased agitation and altered mental status x 2-3 days with O2 sats 60s-70s at home. Daughter has also noted increased LE edema and weight gain which prompted a phone call to her PCP and increased lasix dose from 80daily to 100mg daily with some mild improvement in edema. She has had decreased appetite, PO intake, energy level at home with difficulty with ADLs. No recent history of fever, cough, chills, sputum production, CP, abd pain, or other complaints other than chronic right thigh pain last 1-2 months. Daughter also reports med compliance and compliance with BiPap at night.
Past Medical History:
- CAD; s/p 4 vessel CABG in [**2119**]
- CHF; EF 55%, mild AS
- obesity hypoventilation syndrome
- obstructive sleep apnea
- DM2
- ventricular tachycardia; s/p ICD in [**2127**]
- hypothyroidism
- schizophrenia
- COPD
- Pneumona treated in [**4-7**] at [**Hospital1 **]


62 yo male with hx of CVA, neurogenic bladder with indwelling suprapubic catheter with multiple prior admissions for UTIs, altered mental status, and urosepsis presents to the hospital in urosepsis now resolved after treatment with vanc/meropenem. Per CT there is a non-obstructing stone in the L ureter, no evidence of urethral strictures. Significant leaking around suprapubic cath site. Started on ditropan changed over to detrol. Urologist not concerned with leaking and will f/u with pt next week.
s/p CVA
Neurogenic bladder s/p suprapubic cath
Recurrent UTIs with Klebsiella/Pseudomonas
Non-hodgkins Marginal Zone Lymphoma of the left orbit Dx in 03
(s/p R-CHOP x 6 cycles)
Bells Palsy
BPH
Hypertension
Partial Bowel obstruction s/p colostomy
Hepatitis C
Cryoglobulinemia
SLE with transverse myelitis, anti-dsDNA Ab+
Insulin Dependant Diabetic
Fungal Esophagitis Stage IV?
Urinary Tract Infections-pseudomonas & enterococcus


70 year-old woman with a history of CAD recently noted abdominal mass who presents with fevers/rigors and bandemia. Over the last few weeks leading up to admission, she has been experiencing mid-abdominal pain, radiating to the left flank. It lasts throughout the day is not increased by eating though there is associated vomiting and is worsened with coughing. CT abdomen without contrast was then performed on [**4-20**] showing a large 9.5 x 7.5 x 6.0-cm heterogeneous left upper abdominal mass. Patient underwent a EUS with biopsy. The results of the biopsy were consistent with pancreatic adenocarcinoma at the head of pancreas. Splenic flecture/pancreatic tail mass was also seen on CT, likely diverticular abscess given the patients recent likely history of diverticulitis this was thought to be an infected fluid collection or abscess. She was treated with IV antibiotics (Zosyn, then ceftriaxone and flagyl) and will continue on them until seen by ID as an outpatient.
Past Medical History:
1. Coronary artery disease with history of angioplasty in [**State 108**] one year ago
2. Mitral valve prolapse
3. Atrial fibrillation
4. Hyperlipemia
5. Hypertension
6. Chronic kidney disease (SCr 2.1 in [**3-17**])
7. Hypothyroidism? (TSH 10 in [**3-17**])
8. Anemia (HCT 30.7 in [**3-17**])


79 yo F with multifactorial chronic hypoxemia and dyspnea thought due to diastolic CHF, pulmonary hypertension thought secondary to a chronic ASD and COPD on 5L home oxygen admitted with complaints of worsening shortness of breath. Cardiology consult recommended a right heart cath for evaluation of response to sildenafil but the patient refused. Pulmonary consult recommended an empiric, compassionate sildenafil trial due to severe dyspneic symptomology preventing outpatient living, and the patient tolerated an inpatient trial without hypotension. Patient to f/u with pulmonology to start sildenifil chronically as outpatient as prior authorization is obtained.
Past Medical History:
- Atrial septal defect repair [**6-17**] complicated by sinus arrest with PPM placement.
- Diastolic CHF, estimated dry weight of 94kg
- Pulm HTN (RSVP 75 in [**11-24**]) thought secondary to longstanding ASD
- COPD on home O2 (5L NC) with baseline saturation high 80's to low 90's on this therapy.
- OSA, not CPAP compliant
- Mild mitral regurgitation
- Microcytic anemia
- Hypothyroidism
- S/p APPY, s/p CCY ('[**33**])
- Gallstone pancreatitis s/p ERCP, sphincterotomy
- Elevated alk phos secondary to amiodarone


64yo woman with multiple myeloma, s/p allogeneic transplant with recurrent disease and with systemic amyloidosis (involvement of lungs, tongue, bladder, heart), on hemodialysis for ESRD who represents for malaise, weakness, and generalized body aching x 2 days. She was admitted last week with hypercalcemia and treated with pamidronate 30mg, calcitonin, and dialysis. Patient was Initially treated with melphalan and prednisone, followed by VAD regimen, and autologous stem cell transplant. With relapse of her myeloma, she received thalidomide velcade and thalidomide, which were eventually also held due to worsening edema and kidney function.


This is a 78 year-old male with h/o BPH s/p multiple urological procedures, including s/p Suprapubic prostatectomy. He was noted to have low urine output and bladder scan showed 360cc residual. It was impossible for staff to pass a foley. Urology was consulted, performed a flexible cystoscopy in the ICU and found severe 2cm bulbar urethral stricture. They were able to pass small catheter through and left in place. The patient leaked around the catheter, the catheter eventually came out but he continued to have good urine output and post-void bladder scans were performed q4h to ensure he did not have high residual volume. Urology suggested that when patient is stable he will have to be taken to the OR to have the stricture surgically fixed.


65 yo man with history of CAD and prior MI, HLD, HTN, ventricular tachycardia, and syncope was admitted earlier today evaluation of syncope and ventricular arrhythmias. He was recently discharged after a negative work-up for syncope which included the implantation of a cardiac monitoring device. It was interrogated at the OSH and per report the monitor read from yesterday: 40 seconds of VT and then bradycardia with a rate of 39 shortly thereafter corresponding with his symptoms. Overnight, the patient went into monomorphic VT on telemetry. The patient was found to be unresponsive. CPR was initiated, unclear if the patient had a pulse. Within one minute the patient returned to sinus rhythm. The patient does not report any symptoms prior to this episode. Currently, the patient feels presyncope and nausea, but denies chest pain. Patient is to be transferred to the CCU for catheterization and EPS.


A 35-year-old woman presents with history of acne and mild hirsutism. The primary evaluation revealed elevated testosterone levels. She recently noticed gradual enlargement of her hands and feet and recognized that her ring is getting small for her finger. There is some irregularity in her menstrual cycle as well as some nipple discharge. She also has positive history for snoring and headache. The physical examination revealed subtle facial features of acromegaly and prognathism. Visual fields are normal by confrontation. Hirsutism, soft tissue thickening and diaphoresis of the hands and feet are noted.  Laboratory evaluation in the fasting state reveals IGF-1 of 968 ng/mL and random GH of 19.7 ng/mL. MRI reveals a macroadenoma with no invasion. She is on stable doses of octreotide LAR since her diagnosis was confirmed. She is married and has 2 children. She is using IUD as her contraceptive method.


The patient is a 57-year-old man with abdominal pain and vomiting. The pain started gradually about 20 hours ago in the epigastric and periumbilical regions, radiating to his back. He drinks around 60 units of alcohol per week and smokes 22 cigarettes per day. He is healthy with no history of allergies or using any medications. His family history is positive for type 2 diabetes (his father and sister). He lives alone and has no children. The abdomen is tender and soft. His bowel sounds are normal. His heart rate is 115/min and blood pressure 110/75 mmHg. The lab results are remarkable for leukocytosis (19.5), urea of 8.5, high CRP (145), high amylase (1200) and Glc level of 15. Cross-sectional imaging was negative for obstructive pancreatitis.


The patient is a 31-year-old woman complaining of abdominal pain. The pain started last night as diffuse abdominal discomfort. She had poor appetite as well as malaise. The pain worsened in intensity and became sharp in the morning. The pain became localized to the right lower quadrant in the morning. The temperature is within the normal limits with normal vital signs. Focal tenderness and guarding were observed during palpation of the right lower quadrant. Palpation of the left lower quadrant causes pain on the right. Her lab work is remarkable for leukocytosis.
Computed Tomography of the abdomen with contrast shows the presence of a distended appendix with thickened appendiceal wall without perforation, abscess or gangrene.
She is a candidate for laparoscopic appendectomy under general anesthesia.


A 39-year-old man came to the clinic with cough and shortness of breath that was not relieved by  his inhaler. He had these symptoms for 5 days during the past 2 weeks. He doubled his oral corticosteroids in the past week. He is a chef with a  history of asthma for 3 years, suffering from frequent cough, wheezing, and shortness of breath and chest tightness. The symptoms become more bothersome within 1-2 hours of starting work every day and worsen throughout the work week. His symptoms improve within 1-2 hours outside the workplace. Spirometry was performed revealing a forced expiratory volume in the first second (FEV1) of 63% of the predicted. His past medical history is significant for seasonal allergic rhinitis in the summer. He doesn't smoke or use illicit drugs. His family history is significant for asthma in his father and sister.  He currently uses inhaled corticosteroid (ICS) and fluticasone 500 mcg/salmeterol 50 mcg, one puff twice daily.


The patient is a 55 year old man visiting his primary care physician for lower urinary tract symptoms including frequency, urgency, weak stream, incomplete emptying and intermittent flow for the past 9 months. Further evaluation revealed:
IPSS score : 15
Post-void residual: 70 mL
Prostate volume (TRUS): 60 mL
Prostate-specific antigen (PSA) level: 3.2 ng/mL
10 mL/sec of maximum flow rate when urine volume was 130 mL
He is otherwise healthy only using Vit D 1000 units daily. His recent blood chemistry (3 days ago) was normal:
Hgb: 13.5 g/dl
WBC: 135000 /mm3
Plt: 350000 /ml
PT: 11 second
PTT: 35 second
INR: 0.9
Creatinine: 0.5 mg/dl
BUN: 10 mg/dl
U/A:
Color: yellow
Appearance: cloudy
PH: 5.3
Specific gravity: 1.010
Glc: 100
Nitrite: negative
Ketone: none
Leukocyte esterase: negative
RBC: negative
WBC: 2 WBCs/hpf
U/C: negative


The patient is a 42 year-old postmenopausal woman who had a screening sonogram which revealed an abnormality in the right breast. She had no palpable masses on breast exam. Core biopsy was done and revealed a 1.8 cm infiltrating ductal breast carcinoma in the left upper outer quadrant. Lumpectomy was done and the surgical margins were clear. The tumor was HER2-positive and ER/PR negative. Axillary sampling revealed 1 positive lymph node out of 12 sampled. CXR was unremarkable. She is using “well women” multivitamins daily and no other medication. She smokes frequently and consumes alcohol occasionally. She is in a relation with only one partner and has a history of 3 pregnancies and live births. She breastfed all three children.


A 45-year-old woman was referred to the emergency department with abdominal pain lasting about 4 days accompanied by nausea and 2 episodes of vomiting. The pain is localized to the epigastric region and radiates to the right upper quadrant. The pain is worsening after eating fatty food. The patient experienced similar pain twice in the past year. Her past medical history is remarkable for hypercholesterolemia and two C/sections. She has 2 children, and she is menopausal. She doesn't smoke, drink alcohol, or use illicit drugs. She is mildly febrile. Her BP is 150/85, HR 115, RR 15, T 38.2, SpO2 98% on RA. On palpation, she experiences epigastric tenderness  and  tenderness in the right upper quadrant without rebound. Bowel sounds are normal. Laboratory analysis is remarkable for elevated ESR and leukocytosis with a left shift. The ultrasound revealed several gallstones and biliary sludge. The largest gallstone is 0.7cm. Surgery consultation recommends elective cholecystectomy.


A 53-year-old man presents with chronic HCV infection for the past 2 years. His past medical history is only significant for inguinal hernia surgery when he was 20 years old. He is on IFN (100 mg/week) plus RBV (400 mg/day) combination therapy for the past 9 months. Direct antiviral drugs were added to his treatment 6 months ago. His medical record shows previous positive HCV RNA tests as well as positive enzyme immunoassay for anti-HCV-antibodies. The recent biopsy was negative for hepatocellular carcinoma and was only remarkable for chronic inflammation compatible with a chronic viral hepatitis. There is no evidence of alcoholic liver disease, bleeding from esophageal varices, hemochromatosis, autoimmune hepatitis or metabolic liver disease. He is an alert male with no acute distress. His BP: 130/75, HR: 90/min and BMI: 27. His abdomen is soft with no ascites or tenderness. The lower extremities are normal with no edema.


The patient is a 60-year-old Spanish man presenting with shortness of breath about a day before. The symptoms began acutely and progressively worsened. He is a known case of COPD since 2 years ago. The spirometry revealed post-bronchodilator FEV1/FVC = 60% of predicted values. He smokes 20 cigarette per day. His past medical history is remarkable for BPH and he is using Flomax for that. His family history is positive for HTN in his brother. His medication includes Duo-Neb inhaled q4 hr PRN, Vit D3 1000 units per day and Flomax for his PBH. He is an obese man who is acutely ill but oriented and conscious. The vital signs are as bellow:
BP: 135/80
RR: 25/min
HR: 75 bpm
BMI: 40
O2sat: 90%


The patient is a 24-year-old man who has had type 1 diabetes for 11 years. He presents to the emergency room with hyperglycemia and concern for possible diabetic ketoacidosis after not taking his insulin for 3 days. The patient reports that he is currently homeless and has lost his supply of insulin, syringes, glucometer, and glucose testing supplies. The patient states that at the time of his initial diagnosis with type 1 diabetes he was hospitalized with a glucose value >1000 mg/dL. At the time, he was experiencing polyuria, polydipsia, and polyphagia. He reports that he has been on insulin since the time of his diagnosis, and he has never been prescribed oral agents for diabetes management. Most recently, he has been using insulin glargine 55 units once daily, and insulin aspart sliding scale 3 times daily. The patient has had previous episodes of diabetic ketoacidosis, for which he was hospitalized. With this episode of hyperglycemia, he is not experiencing any nausea, vomiting, or abdominal discomfort, and he appears well. His lab studies showed:
A1c: 11.3%
Creatinine: 0.9 mg/dL with eGFR >60 mL/min
Aspartate aminotransferase (AST): 17 U/L
Alanine aminotransferase (ALT): 14 U/L
Beta-hydroxybutyrate: 0.1 mmol/L
Bicarbonate: 25 mEq/L
Anion Gap: 14 mEq/L


The patient is a 33-year-old woman complained of fatigue, weight gain and abnormal spotting between menses. No hirsutism or nipple discharge was detected. Her BMI was 34. Her lab results were remarkable for high TSH level (13 mU/L) and low free T4 level (0.2 ng/dl). Her anti-TPO levels were extremely high (120 IU/ml). She was diagnosed with Hashimoto's thyroiditis. Her aunt, brother and mother have the same disease. After  starting 250 mcg Levothyroxine per day, her symptoms improved significantly and her periods are normal. She is still overweight with BMI of 31. Her most recent thyroid profile revealed all results except for anti-TPO within the normal range:
TSH: 2.35 mU/L
Free T4: 2.7 ng/dl
Anti-TPO: 75 IU/ml


The patient is a 37-year-old woman who came to the clinic for a routine Pap smear. The test revealed stage 1B of cervical cancer. The patient tested positive for HPV 16. She has three sexual partners and   four children. She underwent tubal ligation. She smokes 30 packs/year and drinks alcohol frequently. She is otherwise healthy. She was offered a radical hysterectomy.


The patient is a 47-year-old Asian woman complaining of persistent feelings of sadness. She lost interest in activities she used to enjoy. She states that her mood is mostly depressed for the past 3 weeks. She also lost her appetite , which led to about 5kg weight loss. She complains of loss of energy and feelings of worthlessness nearly every day. She is not using any drugs and she does not smoke. She doesn't drink alcohol. She used to exercise every day for at least 30 min. But she doesn't have enough energy to do so for the past 3 weeks. She also has some digestive issues recently. She is married and has 4 children. She is menopausal. Her husband was recently diagnosed with colon cancer and he is starting his chemotherapy. There is nothing remarkable in her past medical history and her drug history is only positive for Vit D3 1000 units daily. Her family history is negative for any psychologic problems. Her HAM-D score is 20.


The patient is a 32-year-old obese woman who came to the clinic with weight concerns. She is 165 cm tall and her weight is 113 kg.  She is complaining of sleep apnea, PCO and dissatisfaction with her body shape. She is a high-school teacher married for 5 years. She doesn't use any contraceptive methods for the past 4 months and she had no prior pregnancies. She doesn't smoke or use any drugs. She likes to try diets and exercise to lose weight. She completed the four square step test in 14 seconds. Her BP: 130/80, HR: 195/min and her BMI is: 41.54. Her labs:
FBS: 98 mg/dl
TG: 150 mg/dl
Cholesterol: 180 mg/dl
LDL: 90 mg/dl
HDL: 35 mg/dl
Her cardiac assessment is normal. Her joints and ROM are within  normal.


The patient is a 35-year-old woman with myasthenia gravis, class IIa. She complains of diplopia and fatigue and weakness that affects mainly her upper limbs. She had a positive anti-AChR antibody test, and her single fiber electromyography (SFEMG) was positive. She takes pyridostigmine 60 mg three times a day. But she still has some symptoms that interfere with her job. She is a research coordinator and has 3 children. Her 70-year-old father has hypertension.  She does not smoke or use illicit drugs. She drinks alcohol occasionally at social events. Her physical exam and lab studies were not remarkable for any other abnormalities.
BP: 110/75
Hgb: 11 g/dl
WBC: 8000 /mm3
Plt: 300000 /ml
Creatinine: 0.5 mg/dl
BUN: 10 mg/dl
Beta hcg: negative for pregnancy


A 3-day-old Asian female infant presents with jaundice that started a day ago. She was born at 38w3d of gestation, after an uncomplicated pregnancy. The family history is unremarkable. The baby is breastfed.
Vital signs are reported as: axillary temperature: 36.3°C, heart rate: 154 beats/min, respiratory rate: 37 breaths/min, and blood pressure: 65/33 mm Hg. Her weight is 3.2 kg, length is 53 cm, and head circumference 36 cm. Her sclera are yellow and her body is icteric. No murmurs or any other abnormalities are  detected in the heart and lung auscultation. Her liver and spleen are normal on palpation.
Laboratory results are as follows:
Serum total bilirubin: 21.02 mg/dL
Direct bilirubin of 2.04 mg/dL
AST: 37 U/L
ALT: 20 U/L
GGT: 745 U/L
Alkaline phosphatase: 531 U/L
Creatinine: 0.3 mg/dL
Urea: 29 mg/dL
Na: 147 mEq/L
K: 4.5 mEq/L
CRP: 3 mg/L
Complete blood cell count within the normal range.
She is diagnosed with uncomplicated neonatal jaundice that may require phototherapy.


A 57-year old farmer was diagnosed with Parkinson's disease a year ago. He experiences slowness of movement and tremors. His past medical history is significant for hypertension and hypercholesterolemia. He lives with his wife. They have three children. He used to be active with planting and taking care of their farm animals before his diagnosis. The patient complains of shaking and slow movement. He had difficulty entering through a door, as he was frozen and needed guidance to step in. His handwriting is getting smaller. He is on Levodopa and Trihexyphenidyl. He stated his medications help with shaking and slow movement. But he still has difficulty initiating movements, stiffness and slowness in general. He is an alert and cooperative man who doesn't have any signs of dementia. He doesn't smoke or use any illicit drugs.


The patient is a 14-year-old boy complaining of scoliosis and back pain. He has no other medical condition. He used to be able to play routine activities such as basketball and soccer, however, he recently has problem doing them. The pain is in his leg and back and aggravated by physical activities. He prefer lying down most of the time. He is not happy with his body gesture and complaints of shoulder imbalance and shifting his head to right. Patient is a well-dressed and well-nourished adolescent who is alert and cooperative. The left shoulder is slightly higher than the right shoulder. The scoliotic curve is measured as 45 degree. The patients is candidate for scoliosis surgery according to perioperative MEP monitoring


Patient A is a 30-year-old male who was admitted to the hospital after 10 days of cough, profuse nocturnal sweating and loss of appetite. He had traveled to India 1 months ago and has not any positive history of TB vaccination. He is a previously healthy man, working as an engineer in a high tech company. He doesn't smoke o use any illicit drugs. He was febrile (38 c) with heart rate of 115 b/min, respiratory rate of 22, BP of 125/75 mmHg and O2 sat of 97%. Chest X-ray showed infiltrate in the middle of left lung with diameter of 1.8 cm with signs of cavitation. The sputum smear revealed positive sputum culture for Mycobacterium tuberculosis which are sensitive of the first-line TB drugs (isoniazid, streptomycin, rifampicin and ethambutol). Lab study is reported bellow:
Hgb: 13 g/dl
WBC: 14000 /mm3
Plt: 300000 /ml
AST: 13 U/L
ALT: 15 U/L
Alk P: 53 U/L
Bill total: 0.6 mg/dl
Na: 137 mEq/l
K: 4 mEq/l
Creatinine: 0.5 mg/dl
BUN: 10 mg/dl
ESR: 120 mm/hr


A 62-year-old African-American man presented with left upper and lower extremity weakness, associated with dark visual spot in right eye, right facial numbness, facial drop and slurred speech. He denied dyspnea, headache, palpitations, chest pain, fever, dizziness, bowel or urinary incontinence, loss of consciousness. His medical history was significant for hypertension, hyperlipidemia and hypothyroidism. He smokes cigarette 1 pack per day for 40 years and alcohol consumption of 5 to 6 beers per week. He is not aware about his family history. He is using Levothyroxine, Atorvastatin and HTCZ. His vital signs were stable in the primary evaluation. Left-sided facial droop, dysarthria, and left-sided hemiplegia were seen in the physical exam. His National Institutes of Health Stroke Scale (NIHSS) score was calculated as 7. Initial CT angiogram of head and neck reported no acute intracranial findings. Intravenous recombinant tissue plasminogen activator (t-PA) was administered as well as high-dose statin therapy. The patient was admitted to the intensive care unit to be monitored for 24 hours. MRI of the head revealed an acute 1.7-cm infarct of the right periventricular white matter and posterior right basal ganglia.


A 12 year old girl came to the clinic with her mother, complaining of short stature, delayed in puberty and developmental delay. Her karyotype study revealed 45X and confirmed the diagnosis of Turner syndrome. She is treating with GH since 6 months ago without estrogen therapy to avoid menarche and reach the ideal height. She is an obese, mentally retarded girl in the physical exam. Her breast bulb were in stage 1 with no course hair in the pubic or axillary. Her TSH was 3 and FBS was 75 in the latest lab study.


A 34 year old man comes to the clinic complaining of dizziness and severe diarrhea since yesterday. He has returned from an international trip few days ago and was living in a camp in Sudan for a month. He developed abdominal pain followed by bloating and nausea as well as loose bowel movements. Soon he was having profuse watery diarrhea without odor. The stool is watery and white but the patient has no fever. Blood pressure is 95/62 lying down and drops to 75/40 standing. The skin turgor has reduced. HR is 110 and he looks ill with dry mucosa. V. cholerae was seen in dark-field microscopy of a fresh stool specimen. The lab study is as bellow:
Sodium                           137 meq/L
Potassium                      2 meq/L
Chloride                         94meq/L
CO2                                 15 meq/L
Fecal leukocytes           None seen
Fecal occult blood        Negative


A 57-year-old man was admitted to the clinic because of weight loss and persistent dry cough 4 months ago. Chest computed topography showed bilateral multiple infiltrates in the upper lobes and thickened bronchial walls. There is a documented positive serum MPO-ANCA in his medical record. Transbronchial biopsy revealed necrotic granulomas with multinucleated giant cells and the Wegener's granulomatosis was diagnosed for him. He is treating with corticosteroid and cyclophosphamides since 4 months ago. His Birmingham Vasculitis Activity Score (BVAS) is above 4 since the beginning of his disease. His last physical exam and lab study was performed yesterday and showed the results bellow:
A wellbeing, well-nourished man, non-icteric, cooperative and alert
Weight: 73 kg
Height: 177
BP: 120/80
HR: 90/min
RR: 22/min
Hgb: 13 g/dl
WBC: 8000 /mm3 (Neutrophil: 2700/mm3)
Plt: 300000 /ml
AST: 40 U/L
ALT: 56 U/L
Alk P: 147 U/L
Bill total: 1.2 mg/dl
ESR: 120 mm/hr
MPO-ANCA: 153 EU


The patient is a 41-year-old man and a known case of Acromegaly who underwent transsphenoidal surgery 4 months ago. He came to the clinic for the follow up lab studies after his primary resection surgery. His lab study shows the IGF-1 level of 4.5 ULN adjusted by sex and age. His random GH level is 4 ug/L. The recent brain MRI confirmed the residual pituitary tumor. His past medical history is only significant for acromegaly due to pituitary adenoma and the recent surgery. After his surgery he takes only vitamin D and multivitamins.


The patient is a 17-year-old boy complaining of severe migratory pain in the right lower quadrant of his abdomen that started four days ago. The pain is accompanied by nausea and vomiting. He was febrile with tenderness, rebound tenderness and guarding on palpation. His WBC was elevated with dominant neutrophils. CT scan showed evidence of acute perforated appendicitis with free fluid in the pelvis. Diagnostic laparoscopy revealed phlegmon with no other abdominal abnormalities. He is now a candidate for emergent laparoscopic appendectomy under general anesthesia.


A 17 year old boy  complains of vomiting, non-bloody diarrhea, abdominal pain, fever, chills and loss of appetite for the past 3 days. He ate a salad at a restaurant prior to his diarrhea onset. Physical exam was remarkable for pallor, jaundice, and diffuse abdominal tenderness. Lab results were as follows:
Hemoglobin: 9.7 g/dL
Platelet: 110,000 /cu.mm
Creatinine: 3.6 mg/dL
blood urea nitrogen (BUN): 73 mg/dL
direct bilirubin: 2.4 mg/dL
lactate dehydrogenase (LDH): 881 IU/L (normal: 110-265 IU/L)
Peripheral blood smear showed a moderate number of schistocytes and helmet cells.  Shiga-like toxin-producing E. coli (STEC) stx1/stx2 were found in stools.
He has no other underlying disease and he is not on any medications.


A 42-year-old healthy woman came to the clinic to have her flu shot in early October. She works in a rehab center and has no underlying disease. It's her first time getting the vaccine  this  year. She is married for 5 years and uses barrier methods of contraception. Her menstrual cycle is irregular. She does not smoke. She is not on any medications. She exercises regularly for 30 minutes a day at least 5 days a week. She has no history of allergies to any food or drugs. Her past surgical history is significant for tonsillectomy and she is otherwise healthy.


The patient is a 15 year old girl with the history of recurrent bilateral headache. The attacks come 2 times or more per week and each episode lasts around a day or a half. The pain is pulsating in quality and severe in intensity, causing trouble in her routine physical activity. The attacks are associated with nausea and photophobia. She recently noticed that that there are more attacks around her menstrual period. She is diagnosed with the migraine headache and is under treatment.
She is a high-school student and living with her both parents. She is a book worm and spend her free time in a public library near her home. She is also interested in writing stories and has several short stories in English. She rarely does exercise. Her BMI is 21 with the BP of 100/60. There is nothing remarkable in her physical exam.


The patient is a 20 year old Caucasian female presents to the clinic with one-sided vision lost and facial weakness, dysarthria and numbness lasting for 1 day. She visited her PCP and underwent brain MRI which revealed a single plaque in the brainstem. After few months, she experienced lower extremities weakness led to balance problem. The second MRI revealed another lesion in the left cerebral hemisphere. The diagnosis of Relapsing Remitting Multiple Sclerosis (RRMS) is confirmed after the second MRI. Her past surgical history is significant for a C-section 2 years ago and she has a one child. She is divorced and is not currently in any sexual relationship. She smokes 10 cigarettes per day and drinks alcohol occasionally. She is working as an editor in a publisher company and she is happy that she can keep working from home most of the time. She is under the treatment of RRMS from 7 months ago.


The patient is a 60 year old man complaining of frequent headaches, generalized bone pain and difficulty  chewing that started 6 years ago and is  worsening. Examination shows bilateral swellings around the molars. The swellings have increased since his last examination. Several extraoral lesions are detected in the head and face. The swellings are non-tender and attached to the underlying bone. Further evaluation shows increased uptake of radioactive substance as well as an increase in urinary pyridinoline. His serum alkaline phosphatase is 300 IU/L (the normal range is 44- 147 IU/L). His family history is only significant for hypertension in his mother and DM type 2 in his father. The diagnosis of Paget's Disease of Bone was confirmed and  Bisphosphonate will be started as first-line therapy.


19 yo Hispanic female G1P1 at 32+ 6 weeks of gestational age presented to the OB clinic for routine follow up complaining of mild headache and leg swelling. Primary evaluation revealed BP of 146/99 and urine dipstick with 3+ proteins. Her BP and U/A were normal in previous visit. Repeat BP a few hours later is 150/100 mmHg. Laboratory studies showed a normal hematocrit, platelet count, and liver transaminase levels. She is complaining of fatigue but no fever or chills. She is also suffering of headaches with no vision changes. No shortness of breath, cough, chest pain, orthopnea and palpitations or skin rash were observed. Her physical exam was negative for abdominal pain, change in bowel habits, nausea, vomiting, dysuria, frequency, hematuria or frothy urine. Leg swelling was observed with no arthralgia or back pain.
She has no specific past medical issues and only uses prenatal vitamins. Her family history is positive for DM type 2 and HTN. She is a social alcohol consumer with the negative history of smoking or drug use. She is only have one partner in past 2 years and didn't have any contraceptive methods since 2 years ago. Her BMI was 24 at the first visit when she was at 6 weeks of gestational age. She is getting weight normally during her pregnancies.


The patient is a 60-year-old woman admitted to the stroke department with a recent history of a second course of intravenous antibiotics for aspiration pneumonia. She is febrile and complained of abdominal pain and diarrhea (bowel movements eight times in 3 hours, large volumes of greenish, liquid stool each time).
The patient's abdomen is generally tender and distend with hyperactive bowel sounds. She is febrile (38.4°C), tachycardic (113/min) and hypotensive (80/40 mmHg). The stool samples must were positive for Clostridium difficile toxin.


The patient is a 34-year-old African American man with the known history of Sickle cell disease comes to the clinic with severe bone pain. The patient had severe pain in his lower back that radiated to both thighs scored 9 out of 10. The patient has had positive history of sickle cell crises since childhood. He also had the same symptoms in past two weeks treated with oxycodone which was not beneficial to his pain. His PCP sent him to the emergency department to receive intra venous pain modulators. The patient is afebrile within the normal blood pressure. No splenomegaly was detected in the physical exam. He has no positive history of drug allergy. He won't smoke or uses any illicit drugs. The lab study is as bellow:
Hgb: 8 g/dl
WBC: 10000 /mm3
Plt: 300000 /ml
MCV: 106 fL
Hemoglobine electrophoresis: 91% HbS 6%HbF 3%HbA2
AST: 22 U/L
ALT: 43 U/L
Alk P: 53 U/L
Ferritin: 1200 ng/ml


Fernandez is a 41 year man who is a professional soccer player. He came to the clinic with itchy foot. Physical exam revealed localized scaling and maceration between the third and fourth of his right toe. It became inflamed and sore, with mild fissuring. The dorsum and sole of the foot was unaffected. There is no pus or tearing in the affected area. He didn't use ant topical ointment on the lesion and has no positive history for any underlying disease such as DM. He smokes 15 cigarettes per day and drinks a beer per day. His family history is positive for hyperlipidemia in her mother and MI in her father. He is in relation with several partners and use condom during the intercourse. His physical exam and lab studies were normal otherwise. Tinea pedis infection confirmed as his diagnosis by the observation of segmented fungal hyphae during a microscopic KOH wet mount examination.


A 5 months old male brought to the pediatrics surgery clinic with the complaint of empty scrotum at the right side. The baby boy is a first child who was born at the age of 38 weeks with NVD from a healthy mother. The mother had a normal pregnancy with no complication. The baby boy weighted 3200 gr with the height of 50 cm. He is breast feeding and now weighted as 6.5 kg with the height of 62 cm. He has no developmental delay in the physical assessment. There is a palpable testis is the left scrotum with non-palpable testis in the right scrotum. The penis is normal in shape and size and he is not circumcised. The diagnostic laparoscopy showed an abdominal undescended testis.


The patients is a 25-year-old G1 P1 pregnant woman who is 24W3D gestational old who developed a sudden unset of fever and chills, accompany with nausea and vomiting. She also complains of dysuria, urgency and frequency. She also reports some severe pain in the flank. Her vital signs are: T = 39.7ºC, P = 117, R = 20, and BP = 113/74 mm Hg. Physical examination reveals tenderness on palpation of both costovertebral angles. She has no history of recurrent UTI prior to her pregnancy or any other underlying disease. The urine culture showed Gram-negative rod-shaped bacterial cells, leukocytes, and leukocyte casts. The blood culture is negative. A CBC shows Hb 12.9 g/dL, Hct 39%, MCV 76 fL, WBC count 14,120/µL.


Patient is a 34-year-old woman from Jordan who comes to clinic with some general and non-specific bones and joints pain. She is married and has 3 children. Her past medical and drug history are unremarkable. Her BMI is 23, BP: 120/75, HR: 75/min. Her laboratory study is remarkable for Vit D: 14ng/ml and otherwise healthy. (Ca: 9.2mg/dl, Phosphorus: 3.2mg/dl, PTH: 28pg/ml)


A 22-year-old Caucasian man came to the Clinic with a history of tremors since a year ago. The tremor was first in his right hand while holding something. Later the tremor became continuous and extended to both hands and legs and even at rest. The Kayser-Fleischer' ring was detected in the ophthalmologic exam. The physical exam revealed jaundice, hepatosplenomegaly and hypotonia of the upper limbs. He had a constant smile on his face, however, he has aggressive behavior according to his parents' explanation. His laboratory study was significant for a low serum caeruloplasmin (0.05 g/l), and a raised 24 hour urine copper excretion (120 μg/24 h). Wilson disease was confirmed by high liver copper concentration (305 μg/g dry weight of liver).


The patient is a 41-year-old obese woman coming to the emergency room with abdominal pain and vomiting. The pain that started gradually yesterday is located in the epigastric and periumbilical regions, radiating to her back. She drinks alcohol frequently and does not smoke. She has no history of allergies and uses only multivitamins daily. Her family history is positive for hypertension (her mother). She lives with her husband and has 3 children. The abdomen is tender and soft. Her bowel sounds are normal. Her heart rate is 115/min and blood pressure 110/75 mmHg. The lab studies are remarkable for leukocytosis (19.5), urea of 8.5, high CRP (145), high amylase (1200) and Glucose level of 15. Her abdominal CT scan revealed acute edematous interstitial pancreatitis with enlarged common bile duct and intrahepatic duct confirming gall stone pancreatitis. Her pregnancy test is negative and she is not breastfeeding.


The patient is a 15-year-old boy with asthma diagnosed a year ago. He presents with shortness of breath, chest tightening and cough. According to his mother, he didn't respond to the usual corticosteroid inhaler. He was admitted to the emergency department with diagnosis of severe asthma exacerbation. He is a candidate for general corticosteroid therapy. Spirometry revealed a forced expiratory volume in the first second (FEV1) of 60% of the predicted. His past medical history is non-significant. His family history is significant for asthma in his mother and his uncle. He used to be treated with combination of inhaled corticosteroids and Zafirlukast.


The patient is a 63-year-old man presenting to the Emergency Department with a history of acute urinary retention in the past 2 days. Abdominopelvic CT scan revealed a large prostate and a bladder filled with urine. He is a candidate for urethral catheterization and TURP. Further evaluation revealed:
Post-void residual: 71 mL
Prostate volume (TRUS): 63 mL
Prostate-specific antigen (PSA) level: 3.5 ng/mL
His recent blood chemistry (3 days ago) was normal:
Hgb: 13.6 g/dl
WBC: 133000 /mm3
Plt: 370000 /ml
PT: 12 second
PTT: 34 second
INR: 0.9
Creatinine: 0.5 mg/dl
BUN: 10 mg/dl
U/A:
Color: yellow
Appearance: cloudy
PH: 5.3
Specific gravity: 1.010
Glc: 100
Nitrite: negative
Ketone: none
Leukocyte esterase: negative
RBC: negative
WBC: 2 WBCs/hpf
U/C: negative


The patient is a 45-year-old postmenopausal woman with cytologically confirmed breast cancer. A core biopsy revealed a 3 cm invasive ductal breast carcinoma in the left upper outer quadrant. The tumor is  HER2-positive and ER/PR negative. Axillary sampling revealed 5 positive lymph nodes. CXR was remarkable for metastatic lesions. The patient is using multivitamins and iron supplements. She does not smoke or consume alcohol. She is not sexually active and has no children. She is a candidate for tumor resection and agrees to do so prior to chemotherapy.


A 46-year-old man presents with dizziness and frequent headaches. He has a family history of CAD, but no other cardiovascular risk factors such as smoking, high blood pressure, and diabetes mellitus and is physically active. The patient's LDL-C and HDL-C levels were 545 and 53 mg/dL, respectively. His fasting glucose and triglyceride levels (85 and 158 mg/dL, resp.) were within normal limits.
The patient reported no use of lipid-lowering medications.
Neck auscultation revealed a systolic murmur 3+/6+ in the neck, radiating to the skull. Ultrasonography of the carotid arteries, revealed severe stenosis in the left internal carotid artery (LICA),  as well as moderate stenosis in the right internal carotid artery (RICA) estimated between 40% and 50%. For the LICA, the peak-systolic (PSV) and end-diastolic velocity (EDV) cutoff values were 208.5 cm/s and 54.5 cm/s, respectively; RICA PSV was 91.72 cm/s and RICA EDV was 37.37 cm/s. Plaque was observed in the anterior and posterior walls of the internal carotid artery and common carotid artery, which were characterized as bulky plates extending to the middle third of the internal coronary arteries (ICAs) and as predominantly echogenic and hyperechoic, with less than 50% of the area being echolucent with uneven surfaces.


A 54-year-old obese woman admitted to the emergency department with abdominal pain that started 4 days ago with nausea and vomiting. The epigastric pain radiates to the right upper quadrant, getting worse after eating fatty food. The patient experienced similar pain twice in the past year. Her past medical history is remarkable for hypercholesterolemia and 2 NVDs. She has 2 children, and she is menopausal. She does not smoke, drink alcohol, or use illicit drugs. She is mildly febrile. Her BP is 150/85, HR 115, RR 15, T 38.2, SpO2 98% on RA. She is an obese woman with no acute distress. On palpation, she experiences epigastric tenderness and tenderness in the right upper quadrant without rebound. Bowel sounds are normal. Laboratory analysis is remarkable for elevated ESR and leukocytosis with a left shift. The ultrasound revealed several gallstones, biliary sludge and CBD stones. The smallest stone is 14mm.


The patient is a 55-year-old man diagnosed with HCV 2 years ago and the recent coinfection with HBV. His past medical history is non-significant. He is on IFN, RBV and direct antiviral drugs for the past 6 months. The patient takes no other medications. His medical records show previous positive HCV RNA tests and a positive enzyme immunoassay for anti-HCV-antibodies. The recent biopsy was negative for hepatocellular carcinoma and was only remarkable for chronic inflammation compatible with a chronic viral hepatitis. There is no evidence of alcoholic liver disease, bleeding from esophageal varices, hemochromatosis, autoimmune hepatitis, or metabolic liver disease. He is an alert male with no acute distress. His BP: 130/75, HR: 90/min and BMI: 27. His abdomen is soft with no ascites or tenderness. The lower extremities are normal with no edema.


The patient is a 25-year-old man with type 1 diabetes confirmed with molecular analysis 7 years ago. He presents to the clinic with shortness of breath and fatigue during activities. He claims mild dyspnea after climbing 3 floors, no dyspnea at rest and no angina (New York Heart Association class 2). He is diagnosed with cardiomyopathy that will be treated with ACE inhibitors and Beta blockers. His takes 70/30 Insulin and vitamin D supplements. His past medical history is not significant for any other medical issues. His family history is positive for DM type 1 in his uncle and his grandfather. His lab study is as bellow:
FBS: 100 mg/dl
HbA1c: 6.5%
Cholesterol: 190 mg/dl
TG: 140 mg/dl
LDL: 125 mg/dl
HDL: 40 mg/dl


A 16-year-old girl came to the clinic complaining of weight gain and abnormal menstrual cycles. Her BMI was 24, but she has gained 5 kg in the past few weeks. She gets tired more frequently and does not have energy to go dancing with her friends. Her lab results were remarkable for high TSH levels (15 mU/L) and low free T4 levels (0.18 ng/dl). Her anti-TPO levels were extremely high (136 IU/ml). She was diagnosed with Hashimoto disease. She does not smoke and she is not sexually active.


A Pap smear in a 54-year-old woman revealed abnormal cervical squamous intraepithelial/glandular lesion. She tested positive for HPV 16. She is sexually active with her husband and has 4 children. She is menopausal and uses no contraception. She smokes and drinks alcohol frequently. She is otherwise healthy. She was offered conization.


The patient is a 23-year-old man who came to the hospital with high blood pressure (175/95 mmHg) and signs of septicemia. He developed respiratory failure requiring mechanical ventilation and renal failure requiring hemodialysis. His blood smear showed microangiopathic hemolytic anemia and thrombocytopenia. His blood tests revealed elevated lactate dehydrogenase and reduced human complement C3 levels with a normal coagulation profile. He was diagnosed with atypical hemolytic uremic syndrome. He was treated with plasma exchange and corticosteroids. He has been previously vaccinated with meningococcal group ACWY conjugate vaccine and meningococcal group B vaccine. The genetic survey revealed ADAMTS13 >10%.


A 67-year-old healthy woman came to the clinic to have her flu shot in early October. She works at a rehab center and has no underlying disease. It is her first vaccination this year. she is menopausal and has 4 children. She does not some. She takes daily multivitamins and anti-hypertensive drugs. She exercises regularly for 30 minutes a day at least 5 days a week. She has no allergies to any food or drugs.


A 46-year-old Asian woman  with MDD  complains of persistent feelings of sadness and loss of interest in daily activities. She states that her mood is still depressed most of the days. She complains of loss of energy and feelings of worthlessness nearly every day. She is on anti-depressants for the past 6 months, but the symptoms are still present. She does not drink alcohol or smoke. She used to exercise every day for at least 30 min., but she doesn't have enough energy to do so for the past 3 weeks. She also has some digestive issues recently. She is married and has 4 children. She is menopausal. Her husband was diagnosed with colon cancer a year ago and is undergoing chemotherapy. Her past medical history is unremarkable. Her family history is negative for any psychologic problems. Her HAM-D score is 20.


The patient is a 34-year-old obese woman who comes to the clinic with weight concerns. She is 165 cm tall, and her weight is 113 kg (BMI: 41.5).  In the past, she unsuccessfully used  antiobesity agents and appetite suppressants. She is complaining of sleep apnea, PCO and dissatisfaction with her body shape. She is a high-school teacher. She is married for 5 years. She doesn't use any contraceptive methods for the past 4 months and she had no prior pregnancies. She rarely exercises and movement seems to be hard for her. She is not able to complete  the four-square step test in less than 15 seconds. She does not smoke or use any drugs. Her BP: 130/80, HR: 195/min and her BMI is: 41.54. Her lab results:
FBS: 98 mg/dl
TG: 150 mg/dl
Cholesterol: 180 mg/dl
LDL: 90 mg/dl
HDL: 35 mg/dl
She is considering a laparoscopic gastric bypass.


The patient is a 16-year-old girl recently diagnosed with myasthenia gravis, class IIa. She complains of diplopia and weakness affecting in her upper extremities. She had a positive anti-AChR antibody test, and her single fiber electromyography (SFEMG) was positive. She is on acetylcholinesterase inhibitor treatment combined with immunosuppressants. But she still has some symptoms. She does not smoke or use illicit drugs. She is not sexually active, and her menses are regular. Her physical exam and lab studies are not remarkable for any other abnormalities.
BP: 110/75
Hgb: 11 g/dl
WBC: 8000 /mm3
Plt: 300000 /ml
Creatinine: 0.5 mg/dl
BUN: 10 mg/dl
Beta hcg: negative for pregnancy


The patient is a 53-year-old man complaining of frequent headaches, generalized bone pain and difficulty   chewing that started 6 years ago and is getting worse. Examination shows bilateral swellings around the molars. The swellings have increased since his last examination.  Several extraoral lesions of the head and face are detected. The swellings are non-tender and attached to the underlying bone. Further evaluation shows increased uptake of radioactive substance as well as an increase in urinary pyridinoline. The serum alkaline phosphatase is 300 IU/L (the normal range is 44- 147 IU/L). The patient's sister had the same problems.  She was diagnosed with Paget's disease of bone when she was 52 years old. The diagnosis of Paget's Disease of Bone is confirmed and Bisphosphonate will be started as first-line therapy.


The patient is a 3-day-old female infant with jaundice that started one day ago. She was born at 34w of gestation and kept in an incubator due to her gestational age. Vital signs were reported as: axillary temperature: 36.3°C, heart rate: 154 beats/min, respiratory rate: 37 breaths/min, and blood pressure: 65/33 mm Hg. Her weight is 2.1 kg, length is 45 cm, and head circumference 32 cm. She presents with yellow sclera and icteric body. Her liver and spleen are normal to palpation.
Laboratory results are as follows:
Serum total bilirubin: 21.02 mg/dL
Direct bilirubin of 2.04 mg/dL
AST: 37 U/L
ALT: 20 U/L
GGT: 745 U/L
Alkaline phosphatase: 531 U/L
Creatinine: 0.3 mg/dL
Urea: 29 mg/dL
Na: 147 mEq/L
K: 4.5 mEq/L
CRP: 3 mg/L
Complete blood cell count within the normal range.
She is diagnosed with neonatal jaundice that may require phototherapy.


The patient is a 55-year-old man who was recently diagnosed with Parkinson's disease. He is complaining of slowness of movement and tremors. His disease is ranked as mild, Hoehn-Yahr Stage I. His past medical history is significant for hypertension and hypercholesterolemia. He lives with his wife.  They have three children.  He used to be active with gardening before his diagnosis. He complains of shaking and slow movement. He had difficulty entering through a door, as he was frozen and needed guidance to step in.  His handwriting is getting smaller. He is offered Levodopa and Trihexyphenidyl. He is an alert and cooperative man who does not have any signs of dementia. He does not smoke or use any illicit drugs.