Patient profile A 58-year-old woman presents with 40 minutes of pressure-like discomfort in the upper abdomen and lower chest. The symptoms began while she was carrying groceries upstairs. She reports nausea, sweating, unusual fatigue and mild shortness of breath. Medical history ● Type 2 diabetes mellitus ● Hypertension ● Dyslipidemia Medications ● Metformin ● Losartan ● Atorvastatin Vital signs ● Temperature: 36.8°C ● Blood pressure: 154/92 mmHg ● Heart rate: 102/min ● Respiratory rate: 22/min ● Oxygen saturation: 94% on room air Physical examination The patient appears anxious and diaphoretic. Cardiac rhythm is regular. Lungs are clear. The discomfort is not reproduced by chest-wall palpation.

Patient profile A 34-year-old woman presents with sudden shortness of breath and right-sided pleuritic chest pain. She returned from a 10-hour flight two days ago. Medical history ● No previous cardiopulmonary disease ● No recent infection Medications ● Combined estrogen-progestin oral contraceptive Vital signs ● Temperature: 37.2°C ● Blood pressure: 108/68 mmHg ● Heart rate: 118/min ● Respiratory rate: 28/min ● Oxygen saturation: 90% on room air Physical examination Breath sounds are equal bilaterally. The right calf is swollen and tender and measures 3 cm larger than the left calf.

Patient profile A 69-year-old man develops sudden difficulty speaking and weakness of the right arm while eating breakfast. His spouse states that he was normal 35 minutes earlier. Medical history ● Hypertension ● Atrial fibrillation ● Type 2 diabetes mellitus Medications ● Metformin ● Amlodipine ● The patient stopped taking his anticoagulant two months ago Vital signs ● Temperature: 36.7°C ● Blood pressure: 182/98 mmHg ● Heart rate: 106/min, irregularly irregular ● Respiratory rate: 18/min ● Oxygen saturation: 96% Physical examination The patient has right facial droop, right-arm weakness and expressive aphasia.

Patient profile A 23-year-old man reports abdominal pain that began near the umbilicus approximately 14 hours ago. The pain has migrated to the right lower quadrant. He has anorexia, nausea and one episode of vomiting. Vital signs ● Temperature: 38.0°C ● Blood pressure: 122/76 mmHg ● Heart rate: 98/min ● Respiratory rate: 18/min Physical examination There is localized tenderness and guarding at McBurney point. Coughing increases the pain.

Patient profile A 28-year-old woman presents with sudden left-sided pelvic pain, vaginal spotting, dizziness and pain near the right shoulder. Her last menstrual period was approximately seven weeks ago. Medical history ● Previous pelvic inflammatory disease Vital signs ● Temperature: 36.6°C ● Blood pressure: 88/58 mmHg ● Heart rate: 124/min ● Respiratory rate: 24/min Physical examination She appears pale and distressed. The abdomen is tender with guarding.

Patient profile A 21-year-old university resident presents with severe headache, fever, vomiting and photophobia. His roommate reports that he has become increasingly confused over the last two hours. Vital signs ● Temperature: 39.6°C ● Blood pressure: 96/60 mmHg ● Heart rate: 126/min ● Respiratory rate: 24/min Physical examination The patient is drowsy and has marked neck stiffness. A non-blanching petechial rash is present on the lower extremities.

Patient profile A 52-year-old man presents with severe low-back pain following heavy lifting. The pain initially radiated down the left leg. During the last 12 hours, he has developed bilateral leg weakness and numbness around the perineum. Vital signs ● Temperature: 37.0°C ● Blood pressure: 136/84 mmHg ● Heart rate: 94/min ● Respiratory rate: 16/min Physical examination There is reduced bilateral ankle strength and diminished lower-extremity reflexes.

Patient profile A 66-year-old woman presents with rapidly progressive pain and swelling of the right knee. She cannot bear weight and reports fever and chills. Medical history ● Type 2 diabetes mellitus ● Rheumatoid arthritis ● Right knee prosthesis Medications ● Methotrexate ● Prednisone ● Metformin Vital signs ● Temperature: 39.0°C ● Blood pressure: 104/66 mmHg ● Heart rate: 116/min ● Respiratory rate: 22/min Physical examination The right knee is hot, swollen and erythematous. Both active and passive range of motion cause severe pain.

Patient profile A 42-year-old painter reports gradually worsening right-shoulder pain over three months. The pain is aggravated by overhead work and when lying on the affected side. Vital signs Normal. Physical examination ● Active abduction is painful between approximately 60° and 120°. ● Passive range of motion is nearly normal. ● Hawkins–Kennedy test is positive. ● There is no deformity or neurological deficit.

Patient profile A 32-year-old woman is brought by her sister because she has slept fewer than two hours per night for six days. She speaks rapidly, says she has discovered a method to become a billionaire and has spent $18,000 during the past week. She reports hearing a voice telling her that she has been selected for a “special global mission.” She becomes irritable when her family questions her plans. Medical history ● Previous depressive episode ● No known neurological disease Medications ● Sertraline, started six weeks ago ● The patient recently doubled the dose without medical advice Vital signs ● Temperature: 37.1°C ● Blood pressure: 148/90 mmHg ● Heart rate: 108/min ● Respiratory rate: 18/min Mental-status examination ● Bright, flamboyant clothing ● Psychomotor agitation ● Pressured speech ● Expansive and irritable mood ● Flight of ideas ● Grandiose delusions ● Auditory hallucinations ● Poor insight and impaired judgment

Patient profile A 61-year-old man presents with dizziness, weakness and two episodes of vomiting dark, coffee-ground material. He reports passing a black, sticky stool earlier that morning. Medical history ● Osteoarthritis ● Hypertension ● Previous dyspepsia Medications ● Ibuprofen, 600 mg three times daily ● Amlodipine Vital signs ● Temperature: 36.7°C ● Blood pressure: 92/58 mmHg while supine ● Heart rate: 118/min ● Respiratory rate: 22/min ● Oxygen saturation: 96% on room air Physical examination The patient appears pale and diaphoretic. His abdomen is mildly tender in the epigastric region without rigidity. Rectal examination reveals black, tarry stool.

Patient profile A 67-year-old woman presents with sudden severe pain in the right eye, blurred vision, headache, nausea and vomiting. The symptoms began while she was watching a movie in a dark theatre. Medical history ● Hyperopia ● Hypertension Medications ● Hydrochlorothiazide ● Recently started an anticholinergic medication for urinary urgency Vital signs ● Temperature: 36.9°C ● Blood pressure: 168/94 mmHg ● Heart rate: 102/min Physical examination The right eye is intensely red. The cornea appears cloudy. The right pupil is moderately dilated, irregular and poorly reactive to light. Visual acuity is reduced.

Patient profile A 43-year-old woman with Graves disease presents with fever, agitation, vomiting, diarrhea and severe palpitations. She stopped taking methimazole three weeks ago because she felt better. She developed cough and dysuria several days ago. Vital signs ● Temperature: 40.1°C ● Blood pressure: 154/72 mmHg ● Heart rate: 164/min, irregularly irregular ● Respiratory rate: 30/min ● Oxygen saturation: 92% on room air Physical examination The patient is restless and confused. Her skin is hot and moist. A diffuse goitre and fine hand tremor are present. Bibasilar crackles and mild lower-extremity edema are noted.

Patient profile A 29-year-old man develops diffuse itching, facial swelling, throat tightness and difficulty breathing several minutes after eating a dessert containing peanuts. Medical history ● Peanut allergy ● Mild asthma Vital signs ● Blood pressure: 78/46 mmHg ● Heart rate: 132/min ● Respiratory rate: 32/min ● Oxygen saturation: 86% on room air Physical examination The patient has diffuse urticaria, swollen lips, inspiratory stridor and bilateral wheezing. He appears frightened and is becoming drowsy.

Patient profile A 2-year-old child is brought to the clinic with a barking cough, hoarse voice and noisy breathing. The illness began with rhinorrhea and low-grade fever one day earlier. Vital signs ● Temperature: 38.0°C ● Heart rate: 148/min ● Respiratory rate: 38/min ● Oxygen saturation: 93% on room air Physical examination The child has inspiratory stridor while resting, suprasternal retractions and decreased air entry. The child is alert but agitated. There is no drooling.

Patient profile A 16-year-old boy develops sudden severe left testicular pain while sleeping. He has nausea and has vomited twice. He denies dysuria, urethral discharge and recent trauma. Vital signs ● Temperature: 37.1°C ● Blood pressure: 126/76 mmHg ● Heart rate: 108/min Physical examination The left testis is swollen, tender and positioned higher than the right. It lies in a horizontal orientation. The left cremasteric reflex is absent.

Patient profile A 74-year-old woman presents with a new right-sided temporal headache, scalp tenderness and fatigue. She reports pain in her jaw while chewing and two brief episodes of blurred vision in the right eye. She has also experienced morning stiffness in both shoulders for several months. Vital signs ● Temperature: 37.5°C ● Blood pressure: 146/82 mmHg ● Heart rate: 88/min Physical examination The right temporal artery is tender, thickened and has reduced pulsation. Shoulder movement is painful but neurological examination is otherwise normal.

Patient profile A 59-year-old man with poorly controlled diabetes presents with severe pain in his left lower leg. He scratched the leg on a metal shelf two days ago. The area has rapidly become swollen and discoloured. He reports fever, vomiting and profound weakness. Vital signs ● Temperature: 39.4°C ● Blood pressure: 86/54 mmHg ● Heart rate: 132/min ● Respiratory rate: 28/min ● Oxygen saturation: 94% Physical examination The lower leg is edematous with rapidly spreading erythema, violaceous discoloration and several hemorrhagic bullae. The pain extends far beyond the visible skin changes. Crepitus is present.

Patient profile A 47-year-old office worker presents with neck pain radiating into the right lateral forearm, thumb and index finger. The symptoms worsen when he rotates and extends his neck toward the affected side. He denies trauma, fever, gait disturbance and bladder dysfunction. Physical examination ● Mild weakness of right elbow flexion and wrist extension ● Reduced right biceps reflex ● Decreased sensation over the thumb ● No lower-extremity hyperreflexia ● Normal gait

Patient profile A 24-year-old soccer player reports twisting the right knee while abruptly changing direction. She heard a “pop,” fell to the ground and developed substantial knee swelling within two hours. She now reports instability and a sensation that the knee will give way. Physical examination ● Moderate knee effusion ● Reduced flexion because of swelling ● Positive Lachman test ● Increased anterior tibial translation with a soft endpoint ● No obvious deformity ● Distal pulses and sensation are intact

Patient profile A 63-year-old man presents with sudden, severe chest pain that began while he was lifting a heavy object. He describes the pain as “tearing” and says it radiates between his shoulder blades. Medical history ● Poorly controlled hypertension ● Tobacco use ● Hyperlipidemia Vital signs ● Temperature: 36.7°C ● Right-arm blood pressure: 198/106 mmHg ● Left-arm blood pressure: 168/92 mmHg ● Heart rate: 112/min ● Respiratory rate: 24/min ● Oxygen saturation: 95% on room air Physical examination The patient is pale and diaphoretic. The right radial pulse is stronger than the left. A new early diastolic murmur is heard along the left sternal border.

Patient profile A 24-year-old woman with type 1 diabetes presents with vomiting, abdominal pain, weakness, and increasing thirst. She has been unwell with influenza-like symptoms and has taken very little insulin during the past two days. Vital signs ● Temperature: 38.1°C ● Blood pressure: 94/60 mmHg ● Heart rate: 124/min ● Respiratory rate: 30/min and deep ● Oxygen saturation: 97% on room air Physical examination She is drowsy but arousable. Her mucous membranes are dry. Her breath has a fruity odor. Diffuse mild abdominal tenderness is present without rigidity.

Patient profile A 46-year-old woman develops a sudden severe headache while exercising. She describes it as “the worst headache of my life.” She vomited and briefly lost consciousness. Medical history ● Hypertension ● Tobacco use ● Sister with a cerebral aneurysm Vital signs ● Temperature: 37.0°C ● Blood pressure: 188/104 mmHg ● Heart rate: 98/min ● Respiratory rate: 20/min Physical examination The patient is photophobic and has neck stiffness. She is alert but appears distressed. No focal neurological deficit is initially detected.

Patient profile A 58-year-old woman presents with cramping abdominal pain, repeated bilious vomiting, abdominal distension, and inability to pass stool or flatus for 24 hours. Medical history ● Previous open abdominal hysterectomy ● Hypertension Vital signs ● Temperature: 37.8°C ● Blood pressure: 104/66 mmHg ● Heart rate: 112/min ● Respiratory rate: 22/min Physical examination The abdomen is distended and tympanitic. High-pitched bowel sounds are heard. There is diffuse tenderness without initial rigidity.

Patient profile A 31-year-old woman presents with sudden severe right-sided pelvic pain accompanied by nausea and vomiting. She has a known 7-cm ovarian cyst. Her last menstrual period was two weeks ago. She denies vaginal bleeding. Vital signs ● Temperature: 37.4°C ● Blood pressure: 118/74 mmHg ● Heart rate: 108/min ● Respiratory rate: 20/min Physical examination There is marked right-lower-quadrant and pelvic tenderness. Guarding is mild. No abdominal rigidity is present.

Patient profile A 10-month-old infant is brought to the clinic for repeated episodes of intense crying. During each episode, the child pulls both knees toward the abdomen and becomes pale. Between episodes, the child initially appears tired but comfortable. The child has vomited twice. Vital signs ● Temperature: 37.6°C ● Heart rate: 142/min ● Respiratory rate: 30/min ● Oxygen saturation: 98% Physical examination The abdomen is mildly distended. A sausage-shaped mass is palpated in the right upper abdomen. The diaper contains stool mixed with blood and mucus.

Patient profile A 48-year-old woman presents with fever, shaking chills, nausea, dysuria, and left-sided flank pain. She became confused shortly before arrival. Medical history ● Type 2 diabetes mellitus ● Recurrent urinary tract infections Vital signs ● Temperature: 39.5°C ● Blood pressure: 84/52 mmHg ● Heart rate: 128/min ● Respiratory rate: 26/min ● Oxygen saturation: 94% Physical examination The patient is lethargic. Left costovertebral-angle tenderness is marked. The lower abdomen is mildly tender.

Patient profile A 52-year-old man presents for assessment of a pigmented lesion on his upper back. His spouse reports that the lesion has enlarged and changed colour during the past six months. Medical history ● Multiple blistering sunburns during childhood ● Frequent outdoor work ● Father previously treated for melanoma Physical examination The lesion is 11 mm in diameter, asymmetrical, and has an irregular border. It contains dark brown, black, red, and pale areas. A small area recently bled without trauma.

Patient profile A 37-year-old woman with myasthenia gravis presents with increasing difficulty swallowing, weak speech, shortness of breath, and inability to hold her head upright. She recently developed pneumonia and was prescribed an antibiotic at an urgent-care clinic. Vital signs ● Temperature: 38.5°C ● Blood pressure: 132/78 mmHg ● Heart rate: 118/min ● Respiratory rate: 30/min ● Oxygen saturation: 91% on room air Physical examination She has bilateral ptosis, fatigable facial weakness, nasal speech, weak cough, and shallow respirations. Sensory examination is normal.

Patient profile A 29-year-old man presents six hours after sustaining a closed tibial fracture during a motor-vehicle collision. His lower leg was immobilized in a circumferential cast. He reports rapidly worsening pain despite opioid medication. Vital signs ● Temperature: 37.2°C ● Blood pressure: 142/86 mmHg ● Heart rate: 116/min ● Respiratory rate: 22/min Physical examination The lower leg is tense and swollen. Passive extension of the toes causes severe pain. Sensation between the first and second toes is reduced. The dorsalis pedis pulse remains palpable.

Patient profile A 49-year-old man presents with progressive shortness of breath, chest pressure, weakness, and lightheadedness. He was diagnosed with metastatic lung cancer three months ago. Vital signs ● Temperature: 37.1°C ● Blood pressure: 84/62 mmHg ● Heart rate: 126/min ● Respiratory rate: 28/min ● Oxygen saturation: 92% on room air Physical examination The patient appears distressed. Neck veins are distended while he is sitting upright. Heart sounds are distant. Lungs are relatively clear. Systolic blood pressure decreases noticeably during inspiration.

Patient profile A 72-year-old woman presents with sudden severe central abdominal pain and nausea. She describes the pain as constant and unbearable. Medical history ● Atrial fibrillation ● Hypertension ● Peripheral arterial disease Medications ● Metoprolol ● She stopped taking her anticoagulant three weeks ago Vital signs ● Temperature: 37.4°C ● Blood pressure: 148/86 mmHg ● Heart rate: 118/min, irregularly irregular ● Respiratory rate: 24/min Physical examination The patient appears distressed. The abdomen is initially soft with only mild diffuse tenderness despite the severity of the reported pain.

Patient profile A 38-year-old woman with primary adrenal insufficiency presents with vomiting, diarrhea, profound weakness, abdominal pain, and dizziness. She developed influenza-like symptoms two days earlier and has been unable to keep her medication down. Medications ● Hydrocortisone ● Fludrocortisone Vital signs ● Temperature: 38.4°C ● Blood pressure: 78/46 mmHg ● Heart rate: 124/min ● Respiratory rate: 24/min ● Oxygen saturation: 97% Physical examination The patient is lethargic and dehydrated. Diffuse abdominal tenderness is present without rigidity. Hyperpigmentation is noted over the palmar creases and buccal mucosa.

Patient profile A 41-year-old man presents with progressive tingling and weakness beginning in both feet and ascending toward the thighs. One week earlier, he recovered from a diarrheal illness. Vital signs ● Temperature: 36.8°C ● Blood pressure: 138/84 mmHg ● Heart rate: 104/min ● Respiratory rate: 20/min ● Oxygen saturation: 97% Physical examination There is symmetric lower-extremity weakness, absent ankle and patellar reflexes, and mild distal paresthesia. Plantar responses are flexor. Cranial nerves are initially intact.

Patient profile A 68-year-old man with atrial fibrillation develops sudden severe pain in the left leg. He reports numbness and difficulty moving the foot. Medications ● Metoprolol ● He stopped anticoagulation because of bruising Vital signs ● Temperature: 36.9°C ● Blood pressure: 146/84 mmHg ● Heart rate: 112/min, irregularly irregular ● Respiratory rate: 20/min Physical examination The left foot is pale, cool, and mottled. The dorsalis pedis and posterior tibial pulses are absent. Capillary refill is markedly delayed. Sensation and motor strength are reduced.

Patient profile A 57-year-old highly myopic man reports sudden flashes of light in the left eye followed by numerous new floaters. He now sees a dark curtain moving across the lateral part of his visual field. He denies eye pain. Vital signs Normal. Physical examination Visual acuity is reduced in the affected eye. The external eye is not red. Pupils are equal, although a relative afferent pupillary defect may be present.

Patient profile A 45-year-old man presents with severe midline back pain, fever, and progressive weakness in both legs. Medical history ● Injection-drug use ● Recent skin abscess ● Type 2 diabetes mellitus Vital signs ● Temperature: 39.1°C ● Blood pressure: 102/66 mmHg ● Heart rate: 116/min ● Respiratory rate: 22/min Physical examination There is marked tenderness over the lower thoracic spine. Hip flexion and knee extension are weak bilaterally. Sensation is reduced below the umbilicus. Reflexes are brisk in the lower extremities.

Patient profile A 32-year-old woman at 35 weeks’ gestation presents with severe headache, blurred vision, right-upper-quadrant pain, and rapidly increasing swelling of her hands and face. Vital signs ● Temperature: 36.8°C ● Blood pressure: 174/112 mmHg ● Heart rate: 96/min ● Respiratory rate: 20/min ● Oxygen saturation: 97% Physical examination She has brisk reflexes with two beats of ankle clonus. Facial and hand edema are present. Right-upper-quadrant tenderness is noted.

Patient profile An 82-year-old woman is brought by her daughter because of sudden confusion, agitation, and visual hallucinations that began yesterday. She was independent and cognitively intact three days ago. Medical history ● Hypertension ● Osteoarthritis ● Mild urinary incontinence Medications ● Amlodipine ● Acetaminophen ● Recently started diphenhydramine for sleep Vital signs ● Temperature: 38.3°C ● Blood pressure: 102/64 mmHg ● Heart rate: 110/min ● Respiratory rate: 24/min ● Oxygen saturation: 93% Physical examination Attention fluctuates during the interview. She cannot recite the months backward. Suprapubic tenderness is present. No focal neurological deficit is detected.

Patient profile A 44-year-old recreational tennis player reports sudden pain in the back of the left ankle while pushing off to reach a ball. He felt as though someone had kicked him and heard a snapping sound. Physical examination There is swelling and tenderness several centimetres above the calcaneus. A palpable tendon gap is present. The patient cannot perform a single-leg heel raise.

Patient profile A 27-year-old man is brought to the clinic after a motorcycle collision. He reports severe right-sided chest pain and rapidly worsening shortness of breath. Vital signs ● Blood pressure: 78/48 mmHg ● Heart rate: 138/min ● Respiratory rate: 34/min ● Oxygen saturation: 82% on room air Physical examination The patient is distressed and cyanotic. The right side of the chest expands less than the left. Breath sounds are absent on the right, and percussion is hyperresonant. Neck veins are distended. The trachea appears displaced toward the left.

Patient profile A 64-year-old woman presents with fever, shaking chills, right-upper-quadrant pain, nausea, and yellowing of her eyes. Medical history ● Gallstones ● Type 2 diabetes mellitus Vital signs ● Temperature: 39.3°C ● Blood pressure: 86/54 mmHg ● Heart rate: 126/min ● Respiratory rate: 26/min ● Oxygen saturation: 95% Physical examination The patient is jaundiced, confused, and diaphoretic. There is right-upper-quadrant tenderness without marked abdominal rigidity.

Patient profile A 56-year-old woman receiving chemotherapy for acute leukemia presents with weakness, chills, and a temperature of 38.2°C. Her last chemotherapy treatment was eight days ago. Vital signs ● Temperature: 38.2°C ● Blood pressure: 90/56 mmHg ● Heart rate: 120/min ● Respiratory rate: 24/min ● Oxygen saturation: 94% Physical examination The patient appears pale and lethargic. Oral ulcers are present. There is no focal lung finding, abdominal rigidity, or obvious skin infection.

Patient profile A 39-year-old man presents with three weeks of fever, fatigue, night sweats, reduced appetite, and unintentional weight loss. Medical history ● Injection-drug use ● Previous skin abscess ● No known congenital heart disease Vital signs ● Temperature: 38.7°C ● Blood pressure: 108/66 mmHg ● Heart rate: 112/min ● Respiratory rate: 20/min Physical examination A new systolic murmur is heard. Several tender red nodules are present on the finger pads. Small linear hemorrhages are visible beneath the fingernails.

Patient profile A 22-year-old woman presents with severe unilateral throat pain, fever, difficulty swallowing, and a muffled voice. She reports that the pain radiates toward the left ear. Vital signs ● Temperature: 39.0°C ● Blood pressure: 118/72 mmHg ● Heart rate: 116/min ● Respiratory rate: 20/min ● Oxygen saturation: 97% Physical examination The patient has difficulty opening her mouth. The left tonsillar region is swollen, and the uvula is displaced toward the right. She is drooling but has no stridor.

Patient profile A 3-year-old boy is brought for assessment of bruising. His caregiver states that the child “fell while walking across the carpet.” Physical examination Bruises are present on the ears, neck, inner thighs, back, and upper arms. Some bruises are yellow-brown, while others are dark blue. A loop-shaped mark is present on the posterior thigh. The child becomes silent and withdrawn when the caregiver enters the room.

Patient profile A 71-year-old man presents with sudden painless loss of vision in the right eye. The loss occurred 45 minutes ago. Medical history ● Atrial fibrillation ● Carotid artery disease ● Hypertension ● Tobacco use Physical examination Visual acuity is markedly reduced in the right eye. A relative afferent pupillary defect is present. The eye is not red or painful. Funduscopic examination suggests a pale retina with a central red fovea.

Patient profile An 81-year-old woman falls from standing height and develops severe left hip and groin pain. She cannot bear weight. Medical history ● Osteoporosis ● Previous vertebral compression fracture ● Long-term corticosteroid use Vital signs ● Temperature: 36.8°C ● Blood pressure: 146/82 mmHg ● Heart rate: 102/min ● Respiratory rate: 18/min Physical examination The left leg appears shortened and externally rotated. Gentle movement of the hip produces severe pain. Distal pulses and sensation are intact.

Patient profile A 35-year-old man presents with agitation, sweating, diarrhea, tremor, and fever. He takes sertraline and began linezolid two days ago for a resistant skin infection. He also uses an over-the-counter product containing dextromethorphan. Vital signs ● Temperature: 39.2°C ● Blood pressure: 168/94 mmHg ● Heart rate: 132/min ● Respiratory rate: 26/min ● Oxygen saturation: 96% Physical examination The patient is restless and confused. Pupils are dilated. Tremor, inducible ankle clonus, ocular clonus, and marked lower-extremity hyperreflexia are present.

Patient profile A 46-year-old woman presents with rapidly progressive enlargement and redness of the left breast over six weeks. She reports heaviness but little pain. Antibiotics prescribed for presumed mastitis produced no improvement. She is not pregnant or breastfeeding. Physical examination The left breast is enlarged, warm, and diffusely erythematous. The skin has a thickened “orange-peel” appearance. The nipple is newly retracted. Firm, enlarged left axillary lymph nodes are present. No discrete breast mass is easily palpated.