A 70-year-old woman with a history of a previous myocardial infarction and heart failure presents to the emergency department (ED) with a 2-day history of dyspnea at rest, orthopnea, and paroxysmal nocturnal dyspnea. Physical examination reveals an elevated jugular venous pressure, a third heart sound (ventricular filling gallop), bibasilar rales and wheezing, and bilateral lower extremity edema. The chest radiograph reveals cardiomegaly. An electrocardiogram (ECG) shows atrial fibrillation. Case 2A 65-year-old previously healthy man with a 30 pack-year smoking history presents to the ED with a 3-week history of dyspnea on exertion and at rest, associated with productive cough and sputum. Physical examination reveals bilateral rales and wheezing. The chest radiograph reveals pulmonary venous congestion and a pattern of interstitial edema. An ECG shows lateral STsegment depression. Case 3A 60-year-old man with a history of chronic obstructive pulmonary dis-ease (COPD) and previous myocardial infarction presents to the ED with a 2-week history of worsening dyspnea on exertion and cough. Physical examination reveals an elevated jugular venous pressure, bilateral wheezing, and bilateral lower extremity edema. The chest radiograph shows CME available online at www.jama.com

For identifying cirrhosis, the presence of a variety of clinical findings or abnormalities in a combination of simple laboratory tests that reflect the underlying pathophysiology increase its likelihood. To exclude cirrhosis, combinations of normal laboratory findings are most useful.

Not all feedback conditions seem equally effective. The use of terminal feedback resulted in better learning as demonstrated by superior performance during transfer.

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