Ronald N. Rubin, MD

A 43-year-old fireman comes to your office after a routine blood test revealedthat his serum alanine transferase (ALT) level was elevated to approximatelytwice the normal value. The level was confirmed by repeated testing.

A 22-year-old woman presents with progressive fatigue and dyspnea on exertion that develops after she walks about 30 feet. She also reports orthopnea, lower extremity swelling, weight gain, dry cough, and paroxysmal nocturnal dyspnea.

A palpable nodule on the right lobe of the thyroid gland is detected in a 55-year-old woman. The nodule is firm and nontender and moves freely.

A 68-year-old man with a prosthetic mitral valve presents to the emergency department with acute abdominal pain, nausea, vomiting, and constipation. Surgical evaluation is performed; the results suggest a complete bowel obstruction. Urgent celiotomy is recommended.

A 43-year-old man presents to the emergency department with worsening substernal chest pain that has developed over several hours. He describes the pain as dull and oppressive; it radiates to the left shoulder and jaw and worsens on inspiration and with recumbency. It is not associated with nausea, dizziness, or diaphoresis. He is given nitroglycerin, morphine, hydromorphone, and meperidine parenterally, but none of these relieve the pain.

A 69-year-old woman presents with inflammation near the antecubital fossa of her right elbow that first appeared 4 days earlier. She has a cat but does not recall being scratched or bitten, and she does not recall injuring the area.

A 42-year-old woman presents with severe diarrhea that began 3 days earlier and has become progressively more severe. She is now having 10 or more watery bowel movements per day. She has had moderate nausea but no emesis, hematemesis, or hematochezia.

An 80-year-old man complains of lancinating pain in his right axilla and chest that began 2 days earlier and has kept him awake at night. He has had no fever, cough, sputum production, dyspnea, or symptoms suggestive of congestive heart failure.

A 35-year-old woman who is pregnant for the first time has had elevated blood pressure since she first presented for prenatal care at 28 weeks gestation.