MSD01.Abdominal Pain in a 26-Yr-Old Pregnant Woman

A 26-year-old woman comes to the office because of a 3-day history of lower abdominal pain. She is 18 weeks pregnant by dates. The patient describes the pain as sharp, steady, and radiating across her lower abdomen bilaterally. Last night she developed new nausea and vomiting. She has not been able to keep down any food or drink this morning. She had a normal bowel movement yesterday. She says she felt cold and shivering this morning, followed by feeling warm; however, she did not check her temperature. She denies vaginal bleeding. 

MSD02. Anemia in a 42-year-old woman 

A 42-year-old woman comes to the office for evaluation of significant anemia. She was diagnosed the previous week at an urgent care center during an evaluation for a 2-week history of progressive fatigue and dyspnea on exertion. She had a negative workup for cardiac and pulmonary disease, including normal pulse oximetry, chest x-ray, ECG, and point-of-care cardiac ultrasound. However, at that visit her hemoglobin was discovered to be 7.0 gm/dL (70 gm/L). Today in the office, she is still dyspneic with exertion, is unable to climb a flight of stairs without stopping, but she denies any other current symptoms. She has noted no bloody or dark stools or excessive vaginal bleeding. Her menses are regular, lasting 4 days, and she describes them as "not heavy." She has been told in the past that she had a "low blood count" that her previous doctor attributed to her periods and her vegetarian diet. She was sometimes treated with iron supplements but has had no other treatment or workup. 

MSD03.Back Discomfort in a 12-Year-Old Boy 

A 12-year-old boy is brought to the office by his mother for a well-child checkup. The patient and his mother both state that the patient has been otherwise well except for occasional mild pain and stiffness in the upper back. Symptoms began gradually about a year ago and are present intermittently. The pain and stiffness do not bother him significantly or limit his activities, and they have never awakened him from sleep. He denies any trauma or overuse. He is not currently playing any organized sports although he is able to be normally active with friends and siblings. 

MSD04.Chest Pain in 74-Yr-Old Man 

A 74-yr-old man comes to the Emergency Department (ED) because of a several-month history of increasing exertional chest pain. He states that after walking a few feet he feels left-sided chest pressure that radiates down his left arm. Lately, the pain has been associated with dyspnea and nausea. The pain is relieved by rest within a few minutes. He saw his primary care physician a few days ago. At that time, he was given a prescription for sublingual nitroglycerin as a therapeutic trial and was scheduled for an outpatient stress test in a few weeks. He comes to the ED today because the episodes have been occurring more frequently and with less exertion. He says today that when he takes the sublingual nitroglycerin, it does relieve his symptoms. 

MSD05.Chest Pain in a 62-yr-old Man 

A 62-yr-old man comes to his primary care clinic with the chief complaint of chest pain. He has no pain currently. He first noticed the pain 2 mo ago but attributed it to indigestion. He describes the pain as a pressure sensation in the middle of his chest that does not radiate anywhere else. It seems to come only with exertion and not at rest. He noticed it more last week when he had to shovel snow; he has had no pain since then. He says the pain usually lasts 10 to 15 min and goes away if he takes a break. When present, the pain is not worsened by movement or breathing. The last time he got the pain, he took an aspirin, which he thinks helped. The pain is not associated with shortness of breath, nausea, or diaphoresis. He denies any recent fever, cough, or infectious symptoms. 

MSD06.Chest Pain in a 49-yr-old Woman 

A 49-yr-old woman comes to the emergency department because of chest pain. She says she was in her usual state of health until the day before, when she awoke at 6 am with the sudden onset of sharp left-sided chest pain. Pain has been constant and radiates to the center of her chest. It is not worsened by exertion, movement, food, activity, or respiration. She also had shortness of breath and chills but no cough, nausea, or diaphoresis. She took 400 mg of naproxen without relief. The pain has persisted, prompting her to come to the emergency department now. She has never had chest pain before this episode and has no known history of cardiac or pulmonary disease. 

MSD07.Cough in a 2-yr-old Boy 

A 2-yr-old boy is brought to the emergency department by his parents because of a 1-day history of cough and difficulty breathing. The parents state that the boy appeared normal until the previous night when he began coughing shortly after dinner. The cough stopped after about an hour; the child felt better and went to bed. In the morning, the cough returned and he began to have difficulty breathing, which the parents think is worsening. No one else at home is ill. 

MSD08.Chronic lethargy in a 68 yo woman 

A 68-yr-old woman comes to the office with her daughter because of a 4-mo history of gradually increasing lethargy and worsening memory. Her daughter is concerned because the mother has stopped remembering whether she has taken her regular medications. The daughter is worried that her mother might not be safe to live on her own. Prior to 4 mo ago, the woman had been very busy with community activities, which she has since stopped, and her daughter had not noticed any memory difficulties. The daughter is not aware of any recent illnesses or injuries. 

MSD09.74 YO Woman with an episode of confusion 

A 74-yr-old woman is brought to the emergency department by her husband because of an episode of confusion. The day prior to her visit she attended a wedding at which she had "2 or 3" glasses of wine and afterwards felt extremely tired whereby she left early. When she got home, she went straight to bed without even undressing. She awoke about 3 h later and didn’t remember going to bed or that she had just been at a wedding. Both arms were painful when she awoke, and she noticed blood in her mouth. Her husband says she had been "tossing around in bed." She returned to bed and awoke in the morning several hours past her usual time. She and her husband thought these events were very unusual, and although she felt back to normal except for some slight soreness in her arms, she decided to go the emergency department. 

MSD10.Cough in 47-yr-old woman  

A 47-yr-old woman comes to the office because of an 8-wk history of a cough. She says the cough is never productive, occurs at all times of the day (including at night), and is independent of activity. She is not sure whether she had an upper respiratory tract infection preceding the cough. She does recall that a new neighbor, who is a smoker, moved into a downstairs apartment at the time the cough began. The neighbor frequently smokes outside the patient's apartment window, triggering the cough.

She has not noticed any heartburn or runny nose. One month after the cough started, she noticed pain at the right side of her breastbone occurring with stretching and deep breathing. At that same time, she also noted that she has been wheezing during exertion. She has never had wheezing before. She has had no shortness of breath. 

MSD11.Cough in a 54-yr-old Man   

A 54-yr-old man comes to the office because of a 3-day history of worsening cough that produces a moderate amount of yellowish, nonbloody sputum. He says the cough causes sharp pain in the right side of his chest, and the cough and pain have been causing difficulty sleeping. He has not had anything like this before. 

MSD12.Dyspnea and Back Pain in a 24-yr-old Man   

A 24-yr-old man comes to the emergency department (ED) because of sudden onset of shortness of breath and back pain. Yesterday, the patient was completing a 2-mile run, which he does 2 times/wk, when he suddenly experienced shortness of breath and sharp pain in his spine and on the right side of his back. The pain is constant, mild, and nonradiating and does not worsen during movement. His shortness of breath continued throughout the night and caused difficulty sleeping. The shortness of breath is worse this morning, prompting him to come to the ED. 

MSD13.Exertional Dyspnea in a 76 YO Man    

A 76-year-old man comes to the office because of shortness of breath. He is presently being managed for end-stage renal disease on hemodialysis. Today, the patient states that over the past 6 months he has noted increasing difficulty breathing when he exerts himself. He is relatively sedentary but does climb a flight of stairs to his bedroom at night; he says he used to be able to do this without any problem, but now he reports he needs to stop halfway up the stairs to rest. Occasionally he has mild substernal chest pressure along with the shortness of breath. The chest pressure does not radiate and is not accompanied by nausea or diaphoresis. He has noted increased swelling in his legs. He denies any shortness of breath at rest, orthopnea, or paroxysmal nocturnal dyspnea. He denies any episodes of palpitations, lightheadedness, or syncope. He denies any cough, fever, chills, or night sweats. 

MSD14.Fatigue and Palpitations in a 53-year-old woman 

History of Present Illness

A 53-yr-old woman comes to the office because of palpitations. She is a current patient there and has a history of well-controlled hypertension, type 2 diabetes, and tension headaches. She states that she has noticed intermittent palpitations over the past 2 mo. She describes the episodes as a sensation of irregular and racing heartbeats that are accompanied by fatigue. She denies any chest pain, shortness of breath, light-headedness, or syncope. The episodes last from 10 min to several hours, occur once or twice/wk, and resolve on their own. The last episode was 3 days ago. She cannot identify any particular triggers. She is generally active and walks 3 miles several days/wk without any exertional symptoms including chest pain and dyspnea. She has no family history of early cardiac disease or sudden death. She denies any recent fever or infectious symptoms.

MSD15.Headache and dizziness in a 54-year-old man 

History of Present Illness

A 54-year-old man comes to the office complaining of dizziness, along with a headache and a ringing sensation in his right ear. He says these symptoms began gradually about 3 weeks ago and have been progressively worsening. He describes the dizziness as a sensation that he is veering to one side, causing difficulty keeping his balance while walking and preventing him from riding his bicycle. The headache is mild, diffuse, and non-throbbing. He denies visual symptoms, or focal motor or sensory deficits. He has no nausea or vomiting. He was diagnosed with classical migraine 10 years ago and has been treated successfully with sumatriptan. He says he initially thought these symptoms were a migraine, but he usually has visual auras before his headaches and there were no visual disturbances with the current episodes. In addition, sumatriptan did not help, and he has not previously had tinnitus or vertigo with his headaches. He is uncertain about hearing loss, but he says, "My wife and daughter say I don't hear them when they are riding in the passenger seat of the car—which is not necessarily a bad thing."  

MSD16.Hyperglycemia in a 56-Year-Old Woman  

History of Present Illness

A 56-year-old woman who is a long-time patient returns to the office for scheduled follow up of her type 2 diabetes and chronically elevated blood glucose. At her last visit 3 months ago, her HbA1C was 7.6%, where it had been for several visits. You recommended beginning treatment with insulin, which she refused because of her fear of needles. You then increased her dose of glimepiride from 4 mg to 8 mg once a day and advised her to more strictly follow her diet and exercise regimen, which she claims to be doing. Since the last visit, her home fingerstick glucose levels have ranged from 119 mg/dL to 263 mg/dL (6.6 to 14.6 mmol/L) and her weight on her home scale is unchanged at about 98 kg. She describes increased thirst and urination but denies blurry vision, nonhealing ulcers, or lethargy.

Per office protocol, a fingerstick glucose test on arrival today shows glucose level of 221mg/dL (12.27 mmol/L) and hemoglobin A1C 8.1%; urine dipstick is normal.  

MSD17.Hypernasalilty and Ptosis in a 48-yr-old Wom 

History of Present Illness

A 48-yr-old woman comes to the office because of a nasal-sounding voice. She has been treated in the past for chronic sinusitis and asthma. A year ago, she had balloon rhinoplasty to enlarge her sinuses. Today, she says that she first noticed the nasal-sounding voice a week after surgery, but it has become more apparent over the last 3 mo.

Today, she says it feels as though air escapes through her nose while speaking, giving it a nasal quality. Her voice is better in the morning and worse later in the day. She says she does not have dysphagia but notes occasional nasal regurgitation of liquids but not food. She denies diplopia, drooping eyelids, loss of smell or taste, and difficulty with balance or gait. She denies having arm and leg weakness and numbness.  

MSD18.Left Scrotal Pain in an 18-yr-old Man 

History of Present Illness

An 18-yr-old man comes to the emergency department because he has had left scrotal pain for several hours. He says the pain is accompanied by nausea and began suddenly while he was shoveling snow. He continued shoveling, and the pain and nausea suddenly disappeared after a few minutes. Toward the end of shoveling, the pain and nausea returned and his scrotum started to swell, so he decided to seek medical care.  

MSD19.Leg Pain in a 62-yr-old Man  

History of Present Illness

A 62-yr-old man comes to the emergency department in December because he has had 2 days of progressively worsening pain in his right lower leg between the knee and ankle. He says that several hours before arrival in the emergency department, he began to feel generally ill and aching all over. He thought he had a fever but did not take his temperature. He had been in his usual state of generally good health until 2 days ago. He denies any recent injury to the right leg although he notes that since his coronary artery bypass graft (CABG) surgery, that leg is often slightly swollen at the end of the day but is never painful.  

MSD20.Lethargy in a 65-yr-old Man 

History of Present Illness

A 65-yr-old man is brought to the emergency department (ED) because his neighbors noted that he was lethargic and confused. When emergency medical services (EMS) arrived at the man's home, they found an empty oxycodone pill bottle next to him, and they noted that he had pinpoint pupils. The neighbors stated that the patient has a history of chronic pain. In the ED, he is given naloxone 0.4 mg IV, resulting in prompt improvement in his mental status. Thereafter, the patient is able to answer questions and states that he wanted to die and had taken an overdose of several of his medications in an attempt to end his life. He is not sure exactly which medications he took. 

MSD21. Left-sided Abdominal Pain in a 45-yr-old Ma 

History of Present Illness

A 45-yr-old man comes to the emergency department because of a 6-h history of acute-onset left-sided lower abdominal pain. He describes the pain as starting over his left flank and radiating down toward his groin. The pain comes and goes but is intense when present. He has had some mild nausea without vomiting. The pain does not change with eating. The pain is less when he walks around than when he sits or lies down flat. He has not had any bloody stools, black stools, or change in bowel habits. He denies having diarrhea and constipation. He has noticed his urine looks "dark" but denies pain during urination and urinary frequency. He says that he swims several times a week for exercise, and this pain started immediately after swimming. He also notes that several days ago, his son ran into his left side while playing football. He took some acetaminophen, which minimally relieved his discomfort. He now presents for evaluation at the emergency department because the pain has not subsided. He says he has never experienced pain like this. 

MSD22. Leg Tingling in 20-yr-old Woman 

History of Present Illness

A 20-yr-old woman comes to the office because of a 1-wk history of a feeling she describes as "novocaine wearing off" extending from her waist to her toes on both sides of her body. She says this feeling has been worsening. She has had no prior viral illness and has not received any recent vaccinations or had any recent injuries. She has no weakness in her arms or legs, but says she may be tripping more than usual; however, she has not fallen. She thinks her fingertips feel "funny" as well. She has no headache, face pain, face numbness, double vision, or other visual complaints. She does not have dysarthria, dysphasia, or difficulty swallowing. She says that when wiping her perineal region, it feels "funny." She had an episode of left leg numbness 2 yr ago that lasted 3 wk and that resolved by itself. 

MSD23-Loss of Consciousness in a 50-yr-old Man  

History of Present Illness

A man who appears to be in his 50s is brought to the emergency department. The history is given by emergency medical technicians (EMTs), who state they were called to a store for a 50-yr-old man who possibly had a stroke. At the store, they found him lying on the ground unconscious but breathing normally. After their arrival, the patient awoke but was unable to give coherent responses to questions or commands.

Store employees who saw the patient reported to EMTs that he fell to the ground suddenly from a sitting position, then began drooling, and his arms and legs shook for what seemed to be a long time, but they cannot quantify how long. They state he had not appeared ill before the event. 

MSD24. 31-year-old woman with nausea and increased 

History of Present Illness

31-year-old woman comes to the emergency department because of a 3-week history of nausea, reduced appetite, and increased thirst. She says that she is now drinking 3 to 4 liters of water per day with subsequent polyuria. 

MSD25.Nipple discharge in a 31 yo female 

A 31-year-old woman comes to the office because of a 6-month history of nipple discharge. She has noticed that her breasts are tender and both nipples produce milky discharge on applying mild pressure. She has not noted any bloody or clear nipple discharge, breast lumps, or skin changes. She also states she has not had a menstrual period for 6 months, and her periods had been irregular for 8 months before they stopped altogether. Prior to her menstrual irregularities, her menses occurred at a normal frequency and duration. She is sexually active with a single partner and is trying to conceive. 

MSD26.Nocturia in a 70-Yr-Old Man 

A 70-yr-old man comes to his internal medicine physician with a complaint of waking to urinate. This has been present for several years but has gradually increased in frequency from 2 times/night to 6 times/night. He is not urinating more during the day. He states that when he does urinate, he has to strain to initiate a stream and that his stream is "not like it was when he was 20 years old." He denies incontinence, dysuria, hematuria, flank pain, fevers, or any other complaints. He is otherwise relatively healthy and has not seen a physician in several years. 

MSD 27.Reccurent Headaches in a 31-yr-old Woman 

History of Present Illness

A 31-yr-old woman comes to the emergency department because of a severe headache in the occipital region. She says the headache began suddenly about 1 h ago, and she describes it as "the worst headache of my life." She says the pain is constant and is accompanied by nausea but not vomiting. She denies visual symptoms, focal weakness, and problems with gait and balance.

She has frequently had similar headaches beginning about 2 yr ago. The headaches have increased in frequency this past week, and this episode is by far the worst. She says the headaches start suddenly, last about an hour, and are associated with palpitations, unexplained anxiety, and light-headedness. She has also had nausea and occasional swelling of the neck during these episodes. The headaches are usually associated with exertion or with straining during bowel movements but sometimes occur without any provocation. She has not been evaluated for these headaches before. 

MSD28.Right Testicular Mass in a 28-yo Man 

History of Present Illness

A 28-yr-old man comes to the outpatient clinic for evaluation of a lump in his right testis. About 1 month ago, while taking a shower, he noted a hard area in his right testis that felt "like a marble." He had never noticed this before and decided to wait and see if anything would change. When the mass did not go away, he scheduled this appointment. Today, he states the lump is not painful or tender to the touch and has not changed in size. He has had annual physical exams and was never told that a lump was present. Four years ago, he had a scrotal ultrasound following a brief episode of scrotal discomfort after competing in a bicycle race; the result of the ultrasound was normal. 

MSD29.Scrotal pain in a 10-Yr-Old Boy 

History of Present Illness

A 10-year-old boy is brought to the emergency department because of constant right-sided scrotal pain. The pain began several hours prior to presentation and awoke him from sleep. He is an otherwise healthy boy who states he has never experienced pain like this before. He denies a history of genital trauma or any sexual activity, and he has not noticed any swelling or lumps in his groin. He has not had any fevers, chills, urinary frequency, dysuria, hematuria, or urethral discharge. 

MSD30.Shortness of breath in a 68 y/o man 

History of Present Illness

A 68-year-old man with a recent diagnosis of mild heart failure comes to the office because of a 1-week history of dyspnea on exertion. He is relatively sedentary but is usually able to climb a flight of stairs without stopping. Now he must stop every few steps to rest because of dyspnea but not chest discomfort. He also complains of lower extremity edema, 2-pillow orthopnea, cough with occasional production of white phlegm, wheezing, and a 3-kg weight gain. He denies chest pain or discomfort, palpitations, syncope or near syncope. He has had no fever or upper respiratory symptoms. He states he has been compliant with his medications and denies any changes to his diet. He was seen by another physician two times in the past few months for similar symptoms; both times he had an ECG and chest x-ray and was told he had "mild heart failure." He was treated with an increased dose of furosemide without any other workup. 

MSD31.Scrotal pain in a 21 yo male 

History of Present Illness

A 21-year-old man comes to the emergency department because of a 3-day history of progressively worsening right scrotal pain. He says the pain started 3 days ago when he woke up. At first, the pain was a minor annoyance, but it has gradually increased in intensity to the point that it is now somewhat uncomfortable to walk. He has also noted a gradual swelling of his right scrotum but denies penile discharge, urinary frequency, dysuria, hematuria, or fevers. He denies any trauma to the area. He competed in a basketball game the previous evening but did not feel as though he strained himself during the game. He denies experiencing anything like this in the past. He has taken acetaminophen for the scrotal pain without any relief. 

MSD32.Syncope in an 80-yr-old Woman 

History of Present Illness

An 80-yr-old woman is brought to the emergency department by emergency medical services (EMS) personnel because of a syncopal episode at home. She had been in the shower, suddenly felt weak, and collapsed to the floor. Her husband heard her fall and found her awake, lying on the bathroom floor. He called EMS who, when they arrived in the patient’s home, found her to be tachycardic and hypotensive. On arrival in the emergency department, she is confused and has difficulty answering questions. Her husband states she has hypertension, dyslipidemia, and mild dementia and, 1 wk ago, had a transcatheter aortic valve replacement for severe aortic stenosis. He was told the procedure had been uncomplicated and states that his wife had been feeling well during her recovery. She has never had an event like this one before. 

MSD33.Vaginal bleeding in a pregnant 32-year-old  Woman 

History of Present Illness

A 32-year-old woman comes to the emergency department with painless vaginal bleeding that began earlier in the day. She is at 36 weeks gestation in her 3rd pregnancy; she has had one previous full-term delivery and one spontaneous 1st-trimester abortion. She noticed a small amount of brown discharge on the toilet paper while wiping this morning. Later in the day, she noticed dark red blood on her underwear and decided to come to the emergency department. She denies fluid discharge, abdominal pain, or cramping, and she is feeling usual fetal movement. She has had no abdominal trauma. She has received all routine prenatal care and reports that everything has been normal until now. 

MSD34.54-year-old man with weight gain and muscle 

History of Present Illness

A 54-year-old man comes to the office because of a 10-kg weight gain in the past 3 months despite no significant change in his diet. He also reports bilateral leg weakness, especially when standing up from sitting or when climbing stairs. On questioning, he complains of lethargy and difficulty in getting up in the morning despite getting 8 hours of sleep. He was recently diagnosed with type 2 diabetes and was started on metformin; however, good glycemic control has not been achieved. At a visit 2 months ago, he also complained of low mood for which citalopram was prescribed but with no significant improvement. He tells you today that his wife has left him because she could not tolerate his lack of motivation and mood swings. 

MSD35. Weight loss and dizziness in a 29-year-old  

History of Present Illness 

A 29-year-old man comes to the office because he has had weight loss, lethargy, and postural dizziness for the past 2 months. He says his symptoms began just after surgery to repair a diaphragmatic hernia caused by a stab wound to the chest 6 months ago. He first went to the emergency department 3 weeks after surgery because of sharp right-sided chest pain. At that time, CT scan of the chest was obtained to rule out pulmonary embolism, which was suspected because he was found to have low blood pressure along with his chest pain. No evidence of pulmonary embolism was noted on CT scan. He was discharged home on an antiemetic and acetaminophen. Today he says that, since the operation, he has had gradually worsening lethargy, morning nausea with occasional vomiting, and generalized abdominal pain. He feels very dizzy when he stands up and has lost 12 kg in the last 2 months. 

MSD36. 41 year old man with weight loss and palpit 

History of Present Illness 

A 41-year-old man comes to the office because of a 10-kg weight loss over the past 2 months. He also reports a 1-month history of sweating and palpitations during mild exercise, loose stools, and feeling irritable. Because of these symptoms, he is no longer able to concentrate on his work as an accountant. He also mentions that his eyes recently feel sore, as if somebody has thrown sand in them.