Twelve days after coronary artery bypass graft surgery, a 56-year-old man presented with worsening fatigue and difficulty in reading. Before surgery, he had a long-standing history of hot flashes and decreasing stamina. On examination, the patient had bitemporal hemianopia. The following serum levels were obtained: morning cortisol, 3.6 µg/dL... More »

A previously healthy 26-year-old woman was hospitalized for melena. She denied prior episodes of GI bleeding, fatigue, or dyspnea. The patient was pale. Heart rate was 102 beats per minute, and blood pressure was 100/50 mm Hg. Hemoglobin level was 5 g/dL. Esophagogastroduodenoscopy showed 2 large submucosal tumors in antrum with central... More »

Swelling of the wrists (A) and ankles of 3 months' duration prompted a 33-year-old man to seek medical attention. The swelling was highly migratory, with periods of regression that lasted several days at a time. The patient also had a 3-year history of "breaking out" after contact with water. He had no personal or family history of asthma,... More »

For 6 weeks, a 68-year-old woman had had sharp pain in the left breast that radiated to the left arm and back. The pain was worse on palpation; ibuprofen provided only mild relief. She denied nipple discharge, skin discoloration, and fever. She had no family history of breast cancer. Results of a biopsy of the left breast 6 years earlier were... More »

Six days ago, a 36-year-old man had noticed a dark spot in the field of vision of his left eye. Now the spot more closely resembled a line. He denied other changes in his vision and had not seen any floaters or flashing lights. Two months earlier, the patient had swelling of the ankles and wrists. A complete workup by a rheumatologist was... More »

A 23-year-old man's right chest shows a common congenital muscle anomaly—partial absence of the pectoralis major muscle. The abnormality was noted during a routine preemployment physical examination. The clavicular origin seemed to be intact. There was no apparent decrease in shoulder internal rotation or adduction strength, and the patient... More »

Each year, more than 4.7 million Americans are bitten by a dog. Of those, about 800,000—half of whom are children—seek medical attention.1 The majority of reported animal bites are dog bites. Accordingly, the CDC has named the third week of May National Dog Bite Prevention Week; several suggestions for dog bite prevention are available... More »

This darkly pigmented lesion on the left arm of a 27-year-old man had been present since birth and had slowly enlarged over the past 2 months. Two days earlier, another physician had diagnosed a wart and treated the lesion with liquid nitrogen, which caused erythema of the surrounding skin. This lesion is a congenital nevomelanocytic nevus. This... More »

An 18-year-old girl presented with a red, scaly rash on her cheeks that had been scabbing over, peeling, and draining. She had had similar reactions to earrings and inexpensive jewelry. The appearance of the rash coincided with the use of a new cell phone. An allergy to nickel on the cell phone was suspected. A dimethylglyoxime test (Allertest Ni)... More »

The morning after an 88-year-old woman with symptomatic second-degree type I (Wenckebach) atrioventricular block underwent placement of a dual chamber pacemaker without complication, she awoke with uncomfortable pulsations in her abdomen. The pacing thresholds and impedance had remained unchanged since implantation. An ECG revealed a ventricular... More »

Half way through a 15-minute iontophoresis treatment for de Quervain tenosynovitis of the right wrist, a 42-year-old woman felt exquisite pain but completed the session. After the therapist returned to the room and removed the electrodes, a light gray circular mark about 5 mm in diameter was noted on the skin. The epidermis was gone, and the... More »

Caroli disease had been diagnosed in a 29-year-old man 5 years earlier based on MRI findings of multiple sacculated, dilated intrahepatic ducts with intrahepatic calculi and calculi in the common bile duct. At the time of diagnosis, the patient had no significant medical history and was asymptomatic. Regular follow-up, including annual serial MRI... More »

After a family argument, an 83-year-old woman experienced chest pain, a "racing heart," and a choking sensation and was brought to the emergency department. The chest pain lasted 10 to 15 minutes; was sharp, substernal, and nonradiating; and was associated with dyspnea and a bout of emesis. A sublingual nitroglycerin tablet partially alleviated the... More »

A 26-year-old white man had blurred vision for 4 weeks. A sluggish light reflex was noted in the left eye. Funduscopic examination showed left-sided optic disc swelling with dot hemorrhages and hard exudates. The patient's platelet count was low (10,000/µL), and his partial thromboplastin time was elevated (60 s). Results of further testing for... More »

Dull, intermittent, midepigastric abdominal pain of 1 day's duration prompted a 73-year-old man to seek medical attention. He had no other symptoms. The abdomen was soft and minimally distended, with midepigastric tenderness and tympany. Bowel sounds were hypoactive; there were no peritoneal signs. An upright anteroposterior chest film revealed an... More »

For 2 months, a 30-year-old man with a history of cocaine abuse had had a painful gingival mass (A) and difficulty in eating. Examination revealed a large, fungating mass in the anterior oropharynx that extended posteriorly up to the retromolar region. More »

Black discoloration appeared on the fingernails of a 51-year-old white man who had sustained burns on 15% of his body in a house fire 2 months earlier. The discoloration is a typical side effect of silver nitrate, which was applied to his skin and fingernails during the month he was hospitalized. This topical broad-spectrum bacteriostatic agent is... More »

For 2 months, a 68-year-old man had had progressive weakness, arthralgia, myalgia, and a rash on the arms and legs (A). Closer examination of the rash showed petechial lesions and follicular hyperkeratosis with perifollicular hemorrhage and corkscrew hairs. The patient also had poor dentition and swollen, purple, spongy gingivae. More »

A 59-year-old woman had aphasia and right-sided weakness after a routine total knee replacement. CT and MRI scans revealed a large left middle cerebral artery infarct. A CT angiogram showed no significant disease of the cerebrovascular arteries. More »

A 53-year-old man, who had initially presented with an upper respiratory tract infection, was found to have a stage IV follicular low-grade lymphoma with malignant cells that were positive for CD19, CD20, CD10, surface kappa, and CD45 and negative for CD5. More »