Clinical Challenge

A faster heart rate and numbness: Is the patient having a heart attack?

A faster heart rate and numbness: Is the patient having a heart attack?

A 30-year-old woman presents with an increased heart rate, shortness of breath, and tingling in her right arm.

An unusual pelvic mass in a 43-year-old woman

An unusual pelvic mass in a 43-year-old woman

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A woman who is in generally good health presents with a visibly enlarged abdomen with left-sided dominance and increased pelvic pressure that had worsened.

Abnormal Pap test follow-up in a 30-year-old woman

Abnormal Pap test follow-up in a 30-year-old woman

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A 30-year-old Caucasian woman reports a history of abnormal Pap test results with no other complaints.

Vision changes after bariatric surgery

Vision changes after bariatric surgery

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A patient notes concerns with vision difficulty 4 years after undergoing a laparoscopic biliopancreatic diversion with a duodenal switch.

An unusual cause 
of respiratory distress in an infant

An unusual cause 
of respiratory distress in an infant

A congenital condition is found in an infant with respiratory and gastrointestinal symptoms.

Managing nephropathy in a patient with type 2 diabetes

Managing nephropathy in a patient with type 2 diabetes

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A patient with type 2 diabetes presents with elevated microalbumin levels and a recent history of elevated glucose due to bedtime snacking.

Markedly elevated serum transaminase levels

Markedly elevated serum transaminase levels

An incidental finding in an asymptomatic woman is followed by rapid deterioration of her condition.

Painful red spot 
and fever in an infant

Painful red spot 
and fever in an infant

The child and her twin tested positive 
for influenza B infection one week earlier. The child's pulse, respirations, and blood pressure were within normal limits.

Fever and tachycardia after a liver transplant

Fever and tachycardia after a liver transplant

A 29-year-old woman, 12 years post-liver transplant, presents with fever and tachycardia and had recently reported fatigue, weakness, and abdominal pain.

Itchy red rash and 
periorbital swelling

Itchy red rash and 
periorbital swelling

A 38-year-old man presents to an
otolaryngology clinic with itchy eyes,
periorbital swelling, and an itchy red rash on his face and arms.

An adolescent with more than a cold


An adolescent with more than a cold


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A 12-year-old child complains of having a slight sore throat and fatigue, but his mother becomes concerned when the child's symptoms worsen three days later.

Abdominal cramping, foreign body in 
the stool of a child

Abdominal cramping, foreign body in 
the stool of a child

A child presents to the emergency department with a seven-inch live 
worm in his stool.

Unusual use of radiation therapy for pelvic pain

Unusual use of radiation therapy for pelvic pain

A woman suffers cyclic pain after multiple abdominal and pelvic surgeries.

Numbness, tingling, weakness, and coolness in a 'jammed' hand

Numbness, tingling, weakness, and coolness in a 'jammed' hand

A man tells the orthopedics clinic staff about odd sensations in his hand a week after a car accident.

Young man presents with findings suspicious for occult fracture

Young man presents with findings suspicious for occult fracture

A teenager complains of pain in the left wrist, yet manifests no localized swelling and exhibits symmetric bilateral range of motion.

Identifying and addressing infant allergy to cow's milk protein

Identifying and addressing infant allergy to cow's milk protein

Cow's milk protein allergy is relatively common during the first year of life. Unfortunately, the condition is easily missed or mislabeled.

Difficulty lifting the right arm drives a young man to seek help

Difficulty lifting the right arm drives a young man to seek help

An adolescent presented with persistent upper-extremity pain, redness, and 
axillary swelling upon lifting weights.

Hypertension and ­substance abuse mask an underlying condition

Hypertension and ­substance abuse mask an underlying condition

A middle-aged man presents with 
palpitations, tachycardia, tremors, 
and extreme anxiety.

Accidental hand ­amputation requires ­extensive surgery

Accidental hand ­amputation requires ­extensive surgery

A woman is rushed to the ­emergency department after severing her hand in a woodworking accident at home.

Extreme weight loss in an elderly woman over a 24-month period

Extreme weight loss in an elderly woman over a 24-month period

A 65-year-old widow presented with a mass on her right breast and complaints of generally not feeling well.

Sudden neurologic symptom onset 
in an adolescent

Sudden neurologic symptom onset 
in an adolescent

Dizziness, photophobia, nausea and 
an unsteady gait develop following a 
routine annual check up.

Presyncope coupled with an enlarged spleen suggests infection

Presyncope coupled with an enlarged spleen suggests infection

A 69-year-old woman presents with night sweats, dizziness, fatigue and chronic pain in the upper abdomen.

Painful skin ulcer ­develops in older woman on dialysis

Painful skin ulcer ­develops in older woman on dialysis

Metastatic calcification of the left 
breast in a patient with renal failure 
raises suspicion.

A routine check-up 
reveals a significant 
genetic abnormality

A routine check-up 
reveals a significant 
genetic abnormality

A corrections officer came into the primary care office for a routine physical and left with an unexpected diagnosis.

Severe dizziness, nausea and vomiting prompt an ED visit

Severe dizziness, nausea and vomiting prompt an ED visit

The patient's gait was affected 48 hours after onset and any slight head movement intensified the feeling of imbalance.

Symptoms suggesting urolithiasis mask a 
life-threatening ailment

Symptoms suggesting urolithiasis mask a 
life-threatening ailment

Two days after symptom onset, a patient's skin is still mildly diaphoretic, he complains of fatigue and he cannot tolerate food.

A simple case of cellulitis on the third finger is a lot more

A simple case of cellulitis on the third finger is a lot more

A patient presents to the emergency department complaining of pain that originated over the distal tip of the digit.

When a patient falls, the pain 
indicates dislocation

When a patient falls, the pain 
indicates dislocation

Tenderness over the hypothenar eminence, swelling and limited flexion also suggest fracture.

Respiratory distress and pronounced muscular weakness signal trouble

Respiratory distress and pronounced muscular weakness signal trouble

A father is rushed to the emergency department after ingestion of a foreign, powderlike substance.

Acute onset of pain and a noncompressible area in the anterior forearm

Acute onset of pain and a noncompressible area in the anterior forearm

After a high-impact fall, a middle-aged 
firefighter presents with ecchymosis and fixed flexion in the right arm and hand.

A running accident leads to the discovery of a humeral lesion

A running accident leads to the discovery of a humeral lesion

A woman fractured her upper arm in a fall while exercising. A large osteolytic growth was discovered on x-ray.

Severe headache, fever and arm rash after vaccination

Severe headache, fever and arm rash after vaccination

The patient's symptoms indicated that lumbar puncture was required to rule out a meningitis diagnosis.

Kidney mass detected on ultrasound doubles in size over nine months

Kidney mass detected on ultrasound doubles in size over nine months

Imaging was ordered when the patient's clinician could not palpate her ovaries.

The effects of two boat trips linger even after coming ashore

The effects of two boat trips linger even after coming ashore

After vacationing on a houseboat, a woman could not stop feeling like she was rocking, especially when walking.

Burning rash spreads from the trunk to the rest of the body

Burning rash spreads from the trunk to the rest of the body

A Fite stain leads to the correct diagnosis of these lesions in a man originally from Micronesia.

Acute onset of recent memory loss

Acute onset of recent memory loss

Suddenly unable to remember the year or the president's name, an otherwise healthy man is admitted for observation.

Neck rash coupled with refractory neuropathic pain

Neck rash coupled with refractory neuropathic pain

After initial treatment, the rash left a hypopigmented patch.

Palpitations and dyspnea  plus a family history of sudden cardiac death

Palpitations and dyspnea plus a family history of sudden cardiac death

A specialist recommended placement of an implantable cardioverter-defibrillator, but the patient chose to wait and see.

Abdominal mass in a pregnant woman forces induction

Abdominal mass in a pregnant woman forces induction

After developing pancreatitis, the patient was admitted to the hospital and the tumor removed.

Shortness of breath and chest pain worsened by fruits and vegetables

Shortness of breath and chest pain worsened by fruits and vegetables

What first appeared to be infectious esophagitis ended up being a lifelong diagnosis for a young woman.

Silence surrounding a difficult birth adds insult to injury

Silence surrounding a difficult birth adds insult to injury

Respiratory problems lead to neurologic damage for the child and financial ruin for the family.

Mild fatigue follows progressively heavy monthly periods

Mild fatigue follows progressively heavy monthly periods

The patient's family practitioner advised a multivitamin with iron, but she did not comply.

Blisters on the hands and fingers of a woman with discolored urine

Blisters on the hands and fingers of a woman with discolored urine

Mild hypertrichosis and hyperpigmentation of the face were also noted, and plasma porphyrins were grossly elevated.

Vision and balance disturbances initially blamed on aging

Vision and balance disturbances initially blamed on aging

Over a period of three years, the patient's writing worsened, and she had trouble seeing some colors.

Painless bump on the leg for two years' duration

Painless bump on the leg for two years' duration

The boy had no history of pain, rapid growth, or trauma-associated local or systemic abnormalities.

Intermittent ringing in the ear turns constant

Intermittent ringing in the ear turns constant

The patient first suspected wax was the culprit and underwent an MRI to rule out a benign tumor.

Acute onset of pain, numbness in the face, and slurred speech

Acute onset of pain, numbness in the face, and slurred speech

Spontaneous hemiparesis, headache, and involuntary eye movements in a healthy young man raise diagnostic questions.

Intensely itchy rash erupts soon after hemodialysis begins

Intensely itchy rash erupts soon after hemodialysis begins

The man's widespread lesions did not respond to several therapies, including topical corticosteroids.

Unexplained low-back pain in an adolescent with scoliosis

Unexplained low-back pain in an adolescent with scoliosis

Nothing offered more than temporary relief for the aching, constant pain, which was unaccompanied by other symptoms.

Red breast is a red flag in a case of new-onset pain and swelling

Red breast is a red flag in a case of new-onset pain and swelling

Despite a normal exam three months earlier, skin changes and palpable lumps in the axilla were noted.

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