Cases

Question 1

Case 27

45-year-old female CC: fatigue

History
Onset of fatigue About three months ago.
Nature of fatigue It’s constant and pervasive.
Weight changes A slight weight gain of about 5 pounds over the last few
Fatigue timing It’s pretty much the same throughout the day.
Sleep pattern changes I often wake up feeling unrested.
Restfulness after sleep I wake up feeling tired.
Recent infections or illnesses No.
Shortness of breath No.
Palpitations or irregular heartbeats No.
Chest pain No.
Lightheadedness or dizziness Occasionally, especially when standing up quickly.
Bowel movement changes No.
Nausea or vomiting No.
Feeling cold Yes, I have been feeling cold more often than usual, even
when others around me are comfortable.
Hair loss or thinning Yes, I’ve noticed some hair thinning, particularly when I brush
my hair or shower.
Skin changes Yes, my skin has been very dry, especially on my hands and
face.
Menstrual period description They are heavy and last 7-8 days with heavy flow for the first 4-
5 days.
Medications or supplements Only occasional ibuprofen for menstrual cramps.
Chronic medical conditions No.
Family history of thyroid disorders or anemia No.
Typical diet Breakfast: cereal and milk; Lunch: sandwich and fruit; Dinner:
chicken, vegetables, and rice.
Caffeine or alcohol consumption I drink 1-2 cups of coffee a day, no alcohol.
Appetite changes No.
Stress or emotional concerns No significant stress or emotional concerns.
Recent travel No.
Physical Exams
General appearance assessment Patient appears tired and pale.
Measurement of vital signs (temperature, pulse,
blood pressure, respiratory rate) Temperature 36.8°C, pulse 88 bpm, blood pressure 110/70
mmHg, respiratory rate 16 breaths per minute.
Inspection of conjunctivae for pallor Pale conjunctivae.
Examination of the skin for dryness and pallor Dry, pale skin.
Thyroid gland examination (inspection and
palpation) No enlargement or nodules.
Cardiac examination (auscultation for heart sounds,
murmurs) Unremarkable.
Lung examination (auscultation for breath sounds) Unremarkable.
Abdominal examination (inspection, palpation for
hepatosplenomegaly) No hepatosplenomegaly.

Neurological examination (assessment of deep
tendon reflexes) Normal reflexes but delayed relaxation.
Assessment for delayed relaxation of deep tendon
reflexes Present.
Inspection of hair for thinning or loss Some diffuse hair thinning.
Examination of extremities for edema No edema.
Assessment of capillary refill time Normal capillary refill time.
Examination of nails for spooning (koilonychia) No spooning.
Orthostatic blood pressure measurement No significant change.

Answer 1

Red Flags:
- Unintentional weight loss → Cancer, chronic infections (TB, HIV)
- Night sweats, fever → TB, lymphoma
- Pallor, easy bruising → Anemia, leukemia
- Polyuria, polydipsia → Diabetes mellitus
- Morning stiffness >1 hour → Autoimmune disease (RA, lupus)
- Post-exertional malaise → Chronic fatigue syndrome

Must-Not-Miss Diagnoses:
Anemia (Iron, B12, Folate deficiency)
Diabetes Mellitus
Thyroid dysfunction (Hypothyroidism, Addison’s disease)
Chronic infections (TB, HIV, EBV, hepatitis)
Depression, Sleep apnea, Fibromyalgia

Tests & Exams:
General Inspection: Cachexia, pallor
Vitals: BP, HR (orthostatic BP for adrenal insufficiency)
HEENT Exam: Look for conjunctival pallor (anemia), goiter (thyroid)
Cardiac/Lung Exam: Rule out heart failure
Abdomen Exam: Hepatosplenomegaly (chronic infection, leukemia)
Neuro Exam: Weakness (neurological disorders, MS)
Blood Tests: CBC, Ferritin, TSH, Fasting glucose, ESR/CRP, Liver/Kidney function, HIV/Hep B/C

The patient’s presentation of fatigue, diffuse hair thinning, and delayed relaxation of deep tendon reflexes is highly suggestive of hypothyroidism. Let’s break it down further with a differential diagnosis and treatment plan.

Differential Diagnoses:
1. Primary Hypothyroidism (most likely):
Rationale:
Fatigue is a common symptom of hypothyroidism.
Delayed relaxation of deep tendon reflexes is a hallmark clinical sign of hypothyroidism.
Diffuse hair thinning can result from decreased thyroid hormone levels affecting hair follicles.
The absence of edema rules out severe hypothyroidism or myxedema.
2. Iron-Deficiency Anemia:
Rationale:
Fatigue is a hallmark of anemia.
However, the absence of spooning of nails (koilonychia) and normal capillary refill time makes this less likely.
3. Vitamin B12 Deficiency:
Rationale:
Fatigue and hair thinning can occur.
However, normal reflexes and no paresthesias argue against significant B12 deficiency.
4. Chronic Fatigue Syndrome (CFS)/Myalgic Encephalomyelitis (ME):
Rationale:
Fatigue is a key symptom.
The presence of delayed reflex relaxation, however, points to a more specific organic cause like hypothyroidism.
5. Depression:
Rationale:
Fatigue can be a symptom of depression.
The presence of delayed reflex relaxation makes a purely psychological cause less likely.
6. Adrenal Insufficiency:
Rationale:
Fatigue is common.
However, normal orthostatic blood pressure and the absence of hyperpigmentation reduce the likelihood.
Diagnostic Workup:
Thyroid Function Tests:

TSH: Elevated in primary hypothyroidism.
Free T4: Low in primary hypothyroidism.
Thyroid Peroxidase (TPO) Antibodies: To confirm autoimmune hypothyroidism (Hashimoto’s thyroiditis).
Complete Blood Count (CBC):

To rule out anemia.
Iron Studies (Ferritin, Iron, TIBC):

To confirm or exclude iron-deficiency anemia.
Vitamin B12 and Folate Levels:

To evaluate for deficiencies.
Electrolytes and Serum Cortisol:

To rule out adrenal insufficiency or other metabolic abnormalities.
Treatment Plan:
1. For Primary Hypothyroidism (most likely diagnosis):
Levothyroxine (synthetic T4):
Starting dose: 1.6 mcg/kg/day (adjusted based on weight and cardiac risk).
Monitor TSH every 6-8 weeks and adjust dosage as needed.
Patient Education:
Explain the importance of medication adherence and lifelong therapy.
Take levothyroxine on an empty stomach, separate from calcium or iron supplements.
2. For Iron-Deficiency Anemia (if diagnosed):
Ferrous sulfate 325 mg orally once daily, with vitamin C to enhance absorption.
Dietary changes: Increase iron-rich foods like red meat, spinach, and legumes.
3. For Vitamin B12 Deficiency (if diagnosed):
Oral or intramuscular B12 supplementation based on severity.
4. Lifestyle Recommendations:
Adequate rest, stress reduction, and a balanced diet.
Referral to a dietitian if nutritional deficiencies are suspected.
5. Follow-Up:
Reassess symptoms and lab results in 6-8 weeks.
Adjust treatment based on thyroid hormone levels or other deficiencies detected.
By addressing the underlying hypothyroidism or alternative diagnoses, the patient’s fatigue and associated symptoms should improve significantly.

Question 2

Case 26:

28-year-old female
CC: sore throat and itchy eyes
History
Onset of symptoms
Symptom timing They started about a week ago
Fever No
Sneezing Yes, I sneeze a few times throughout the day, especially when I’m
outside.
Runny nose Yes, my nose runs a lot, especially when I’m outside.
Throat sensation My throat feels scratchy, like there’s something irritating it.
Eye redness and watering My eyes are red and watery all the time, which makes it hard to
read or use my computer.
Allergen exposure Yes, I spend a lot of time outdoors near a park, which has a lot of
trees and flowers.
Time spent outdoors Yes, I often go for walks in the park near my home in the mornings
and evenings.
New products usage No, I haven’t used any new products like soaps or lotions recently.
Known allergies None
Contact with sick individuals No
Medication changes None
Smoking or secondhand smoke exposure None
Occupation and irritant exposure I’m a teacher, so I work indoors and don’t have exposure to
irritants.
Other symptoms (headaches, body aches) None
Impact on daily activities My symptoms make it hard to concentrate and teach my classes.
Difficulty swallowing or breathing No
Use of over-the-counter medications None
History of chronic illnesses or conditions No
Physical Exams
General appearance Alert & oriented, no acute distress.
Vital signs Within normal Limits
Examination of the head and neck Normocephalic, atraumatic
Inspection of the eyes for redness, tearing,
and discharge Conjunctivae are red and watery; no discharge noted.
Examination of the conjunctivae Red and watery
Examination of the ears, including tympanic
membranes Tympanic membranes are clear bilaterally
Inspection of the nasal passages for swelling
and discharge Nasal mucosa is swollen with clear rhinorrhea
Examination of the oral cavity, including the
pharynx and tonsils Pharynx is erythematous without exudates; no tonsillar hypertrophy
Palpation of the cervical lymph nodes No lymphadenopathy
Auscultation of the lungs Clear to auscultation bilaterally, no wheezes, rales, or rhonchi.
Inspection of the skin for rashes or lesions No rashes or lesions.

Answer 2

Red Flags:
Drooling, difficulty swallowing, muffled voice → Epiglottitis
Stridor, respiratory distress → Anaphylaxis, airway obstruction
Fever + sore throat + lymphadenopathy → Mono (EBV), strep throat
Eye discharge, severe redness, photophobia → Conjunctivitis, uveitis

Must-Not-Miss Diagnoses:
Anaphylaxis, Epiglottitis
Strep throat (GAS) → Rheumatic fever risk
Allergic rhinitis vs. Viral URTI
Mono (EBV)

Tests & Exams:
HEENT Exam: Pharynx redness, exudates, tonsillar swelling, conjunctival injection
Lymph Node Exam: Cervical lymphadenopathy
Monospot test, throat swab (Rapid Strep), CBC (atypical lymphocytes for mono)

This 28-year-old female’s symptoms and findings strongly suggest seasonal allergic rhinitis (hay fever) with associated allergic conjunctivitis. Here’s a detailed breakdown:

Differential Diagnoses:
Seasonal Allergic Rhinitis (Hay Fever) with Allergic Conjunctivitis (most likely):

Rationale:
Symptoms triggered by outdoor exposure near parks with trees and flowers.
Sneezing, runny nose, and itchy, watery, red eyes are hallmark features.
Pharyngeal scratchiness can result from postnasal drip or irritants.
Physical exam findings:
Swollen nasal mucosa with clear rhinorrhea.
Red and watery conjunctivae.
Viral Upper Respiratory Infection (URI):

Rationale:
Symptoms overlap (sore throat, nasal congestion, rhinorrhea).
However, lack of fever, body aches, and lymphadenopathy argues against a viral infection.
Eye redness and watering are not typical of a viral URI.
Irritant Rhinitis:

Rationale:
Caused by exposure to non-allergic irritants (e.g., smoke, perfumes).
The patient reports no new exposures to irritants.
Bacterial Pharyngitis:

Rationale:
Typically presents with fever, purulent exudate, and lymphadenopathy, which are absent here.
The patient’s sore throat is more consistent with postnasal drip.
Non-Allergic Rhinitis with Eosinophilia Syndrome (NARES):

Rationale:
Similar nasal symptoms, but eye involvement and clear allergen exposure favor allergic rhinitis.
Diagnostic Workup:
This diagnosis can often be made clinically. However, if confirmation or differentiation is needed:

Skin Prick Testing or Serum IgE Testing:
To identify specific allergens.
Nasal Smear:
Check for eosinophils to confirm an allergic etiology.
Consider RAST (Radioallergosorbent Test):
If skin testing is not possible.
Complete Blood Count (CBC):
Rule out infection and evaluate for eosinophilia.
Treatment Plan:
1. Lifestyle Modifications:
Limit outdoor exposure, especially during high pollen times (mornings and evenings).
Use a HEPA air purifier at home.
Shower and change clothes after outdoor activities to remove allergens.
2. Medications:
Intranasal Corticosteroids (first-line):
Fluticasone or Mometasone: 1 spray in each nostril daily.
Oral Antihistamines:
Non-sedating options like Loratadine, Cetirizine, or Fexofenadine.
Ophthalmic Antihistamine Drops:
Ketotifen or Olopatadine for itchy, red eyes.
Saline Nasal Irrigation:
Rinse nasal passages to remove allergens and reduce swelling.
Decongestants (if congestion is severe):
Short-term use of pseudoephedrine or oxymetazoline (limit use to 3 days to avoid rebound congestion).
3. Allergen Immunotherapy:
Consider referral to an allergist for subcutaneous or sublingual immunotherapy if symptoms persist despite treatment.
4. Patient Education:
Emphasize adherence to nasal sprays, as they take time to reduce inflammation.
Monitor for worsening symptoms or signs of secondary infection (e.g., sinusitis).
5. Follow-Up:
Reassess symptom control in 4-6 weeks.
Adjust treatment based on response and side effects.
Prognosis:
With appropriate treatment and lifestyle adjustments, her symptoms should improve significantly, allowing her to concentrate better on teaching and daily activities.

Question 3

Case 25

65-year-old male CC: leg pain

Impact on daily activities It’s been limiting how much I can walk and do around the house.
I used to do my own yard work, but now it’s difficult.
Physical Exam
Lower extremity inspection Lower extremities appear pale with thin, shiny skin and diminished hair growth. The patient mentions noticing these
changes over the past year.
Pulses in dorsalis pedis and posterior tibial
arteries Pulses are diminished in both dorsalis pedis and posterior tibial
arteries.
Capillary refill time in toes Capillary refill is delayed, taking more than 3 seconds.
Pallor on elevation Legs show pallor on elevation, which resolves when the legs are
lowered.
Neurological exam (sensation) Reduced sensation to light touch and vibration in the feet, particularly in the toes. The patient says it feels like there’s a bit
of numbness.
Muscle strength (dorsiflexion, plantarflexion) Mild weakness in dorsiflexion of the toes, especially noticeable
when the patient tries to lift their big toe.
Straight-leg raise test Negative.
Spine inspection No tenderness or deformities noted on spine inspection.
Foot examination for ulcers, wounds,
infection No ulcers, wounds, or signs of infection noted.
Temperature of lower extremities Lower extremities feel cool to the touch, especially the feet.
Presence of edema in lower extremities No edema noted.
Bruits over femoral arteries Bruit heard over femoral arteries bilaterally.
Gait observation Gait is normal, but the patient stops frequently due to leg pain.
The patient walks with short, cautious steps.
Romberg test Negative.

Answer 3

Red Flags:
Unilateral swelling, warmth, pain → DVT
Sudden severe pain, cold limb → Arterial occlusion
Fever + swollen joint → Septic arthritis
Pain worse at night, unexplained weight loss → Bone malignancy

Must-Not-Miss Diagnoses:
DVT, PAD (Peripheral artery disease), Compartment syndrome
Fractures, Osteomyelitis, Cancer (Bone metastases)

Tests & Exams:
Inspect for swelling, erythema, ulcers
Palpate pulses (diminished in PAD)
Homan’s sign (DVT, though not reliable)
Doppler ultrasound, D-Dimer (DVT), X-ray (Fracture, arthritis)

This 65-year-old male’s presentation suggests peripheral arterial disease (PAD), a condition characterized by reduced blood flow to the extremities due to atherosclerosis. Here’s an analysis of the case with a focus on conventional and naturopathic approaches to management.

Differential Diagnoses:
Peripheral Arterial Disease (PAD) (most likely):

Rationale:
Pale, shiny skin, diminished hair growth, and delayed capillary refill suggest chronic poor circulation.
Diminished peripheral pulses (dorsalis pedis and posterior tibial).
Pallor on elevation indicates arterial insufficiency.
Pain exacerbated by activity (likely claudication) that resolves with rest is typical of PAD.
Diagnostic Tests:
Ankle-Brachial Index (ABI): Measures blood flow to the legs. ABI < 0.9 confirms PAD.
Doppler Ultrasound: To assess blood flow and locate arterial blockages.
Angiography (CT or MR): If revascularization is considered.
Lipid panel and HbA1c: To assess for contributing factors (e.g., hyperlipidemia, diabetes).
Diabetic Neuropathy:

Rationale:
Reduced sensation and mild motor weakness in the feet are consistent with neuropathy.
However, absence of ulcers and normal gait favor PAD as the primary diagnosis.
Diagnosis: Nerve conduction studies and glucose tolerance test.
Chronic Venous Insufficiency (CVI):

Rationale:
CVI causes leg discomfort but is often associated with edema and hyperpigmentation, which are absent here.
Lumbar Radiculopathy:

Rationale:
Can cause leg pain, but normal spine exam and negative straight-leg raise make this less likely.
Treatment Plan:
Conventional Management:
Lifestyle Modifications:

Smoking cessation (if applicable): Critical to halt disease progression.
Encourage regular exercise, such as a supervised walking program (30-45 minutes, 3-5 times per week), to improve collateral circulation.
Healthy diet: Focus on a Mediterranean-style diet to reduce atherosclerosis risk.
Medications:

Antiplatelet agents:
Aspirin or clopidogrel to reduce thrombotic events.
Statins:
Lower LDL cholesterol and stabilize plaques.
Cilostazol:
Improves walking distance and reduces claudication pain.
Treat comorbidities like hypertension or diabetes if present.
Surgical/Interventional Options (for severe cases):

Angioplasty or stenting: For critical stenosis.
Bypass surgery: If revascularization is necessary.
Naturopathic Modalities:
Nutrition:

Anti-inflammatory diet:
High in fruits, vegetables, whole grains, omega-3 fatty acids (e.g., fatty fish, flaxseeds).
Limit processed foods, sugar, and saturated fats.
Consider garlic (Allium sativum) supplementation: May support vascular health by reducing platelet aggregation.
Cayenne pepper (Capsicum annuum): Contains capsaicin, which may improve circulation.
Herbal Medicine:

Ginkgo biloba:
Improves peripheral circulation and reduces claudication symptoms.
Dose: 120-240 mg/day standardized extract.
Crataegus spp. (Hawthorn):
Supports cardiovascular health and may enhance blood flow.
Vaccinium myrtillus (Bilberry):
Contains anthocyanins that support vascular integrity.
Lifestyle and Exercise:

Daily walking programs:
Encourage graded activity to build collateral circulation.
Contrast hydrotherapy:
Alternating warm and cool foot baths to stimulate circulation.
Mind-Body Approaches:

Address stress with mindfulness or yoga, as chronic stress can exacerbate vascular conditions.
Supplements:

L-arginine:
Precursor to nitric oxide, promotes vasodilation (500-2000 mg/day).
Omega-3 fatty acids:
Anti-inflammatory, supports cardiovascular health (1-3 g/day EPA/DHA).
Vitamin E:
Antioxidant, may improve vascular function (200-400 IU/day).
Acupuncture:

Points such as ST36 (Zusanli) and SP6 (Sanyinjiao) may enhance circulation and reduce claudication.
Follow-Up:
Monitor symptom improvement, walking distance, and vascular status (via ABI).
Adjust treatment based on response and adherence.
Refer for revascularization if conservative measures fail.
Prognosis:
With proper management, symptoms of PAD can be controlled, and progression slowed. Incorporating naturopathic approaches can provide additional benefits and improve overall vascular health.

Question 4

Case 24

28-year-old female CC: low mood

Feeling down, depressed, or hopeless (last 2 weeks) Almost every day. It’s hard to stay positive, and I often feel like
things won’t get better.
Trouble falling or staying asleep, or sleeping too
much (last 2 weeks) Several days. My sleep is very inconsistent, and I often wake up
feeling unrested.
Feeling tired or having little energy (last 2 weeks) Almost every day. Simple tasks feel exhausting, and I often feel like I
need a nap.
Poor appetite or overeating (last 2 weeks) Several days. Sometimes I don’t feel like eating at all, but other
times I snack more than usual.
Feeling bad about yourself or that you are a failure
(last 2 weeks) Several days. I often feel like I’m not good enough or that I’m
disappointing others.
Trouble concentrating (last 2 weeks) Several days. I can’t seem to focus on work or even watch a TV
show without my mind wandering.
Moving or speaking slowly or being fidgety or
restless (last 2 weeks) Not at all. I haven’t noticed any changes in my movement or speech.
Thoughts of being better off dead or self-harm (last 2
weeks) Not at all. I’ve never had thoughts like that.
Physical Exams
General appearance Well-nourished, no acute distress
Vital signs Within normal limits
Mental status examination Alert, oriented, appropriate affect
Thyroid examination No enlargement or nodules
Cardiovascular examination Normal heart sounds, regular rhythm, no murmurs
Respiratory examination Clear breath sounds, normal symmetry
Abdominal examination Normal bowel sounds, no tenderness or masses
Cranial nerves Intact cranial nerves
Motor strength and tone Normal strength and tone
Deep tendon reflexes Normal reflexes
Sensory function Normal sensory function
Coordination and gait Normal coordination and gait

Answer 4

This 28-year-old female’s presentation suggests major depressive disorder (MDD) or another depressive spectrum disorder as the most likely diagnosis, given the emotional and physical symptoms reported. Below is an analysis of the case and a proposed treatment plan incorporating conventional and naturopathic approaches.

Differential Diagnoses:
Major Depressive Disorder (MDD) (most likely):

Rationale:
The patient meets the criteria for depression, with at least 5 of 9 symptoms present over the past two weeks, including:
Depressed mood
Fatigue
Insomnia
Poor appetite
Low self-worth
Difficulty concentrating
Absence of suicidal ideation or psychomotor changes does not rule out MDD.
Diagnostic Tools:
PHQ-9: Patient Health Questionnaire to quantify symptom severity.
Rule out organic causes such as thyroid dysfunction (normal thyroid exam).
Persistent Depressive Disorder (Dysthymia):

Rationale:
If symptoms have been present for over 2 years but are less severe, dysthymia may be considered.
Hypothyroidism:

Rationale:
Can cause low mood, fatigue, and weight changes.
Normal thyroid exam makes this less likely, but confirm with TSH and free T4 labs.
Iron-Deficiency Anemia:

Rationale:
Fatigue and poor concentration may result from anemia.
Lack of pallor and normal physical exam findings make this less likely, but confirm with CBC and ferritin.
Chronic Fatigue Syndrome (CFS):

Rationale:
Overlaps with fatigue and poor concentration, but mood symptoms are less prominent in CFS.
Adjustment Disorder with Depressed Mood:

Rationale:
If symptoms are in response to a specific stressor, this diagnosis may apply.
Treatment Plan:
Conventional Management:
Lifestyle Interventions:

Encourage regular exercise: Aerobic activities such as walking or yoga 30 minutes daily, 5 days per week, have proven antidepressant effects.
Promote good sleep hygiene: Create a consistent bedtime routine, limit screen time before bed, and avoid caffeine in the afternoon.
Psychotherapy:

Cognitive Behavioral Therapy (CBT):
Helps reframe negative thought patterns.
Beneficial for improving self-esteem and coping skills.
Interpersonal Therapy (IPT):
Targets relational issues contributing to depressive symptoms.
Pharmacological Management (if necessary):

Consider starting a Selective Serotonin Reuptake Inhibitor (SSRI) such as sertraline or escitalopram if symptoms are moderate to severe.
Follow up in 4-6 weeks to assess efficacy and side effects.
Address Potential Comorbidities:

Screen for anxiety disorders or substance use.
Evaluate for possible underlying medical contributors (e.g., hypothyroidism, anemia).
Naturopathic Modalities:
Nutritional Support:

Diet:
Anti-inflammatory diet rich in whole foods, vegetables, fruits, lean protein, and healthy fats.
Include omega-3-rich foods (e.g., fatty fish, flaxseeds) for their role in mood regulation.
Supplements:
Omega-3 fatty acids: 1-3 g/day EPA/DHA to support brain health.
Vitamin D: 2,000 IU/day, as deficiencies are associated with depression.
Magnesium glycinate: 200-400 mg/day to support relaxation and improve sleep.
B-complex vitamins: Particularly B6, B9, and B12 to optimize neurotransmitter synthesis.
Botanical Medicine:

Hypericum perforatum (St. John’s Wort):
Evidence supports its use for mild-to-moderate depression.
Dose: 300 mg 3x/day of standardized extract (0.3% hypericin).
Caution: Potential interactions with medications (e.g., SSRIs, contraceptives).
Withania somnifera (Ashwagandha):
Adaptogen that may improve energy levels and reduce stress.
Dose: 300-600 mg/day.
Mind-Body Techniques:

Mindfulness-Based Stress Reduction (MBSR):
Helps regulate mood and decrease ruminative thoughts.
Journaling:
Encourage daily reflection to identify and reframe negative thought patterns.
Acupuncture:

Points such as GV20 (Baihui), HT7 (Shenmen), and SP6 (Sanyinjiao) may help regulate mood and improve energy.
Homeopathy (if appropriate):

Consider constitutional remedies based on the patient’s overall presentation, such as Ignatia or Natrum muriaticum.
Hydrotherapy:

Contrast showers (alternating warm and cool water) to invigorate and reduce fatigue.
Follow-Up:
Schedule follow-up in 2-4 weeks to reassess symptoms, adherence to the plan, and need for further interventions.
Monitor for any emergence of suicidal ideation.
Adjust treatment plan based on the patient’s progress and preferences.
Prognosis:
With a combination of lifestyle changes, psychotherapy, and appropriate interventions, most individuals with mild-to-moderate depression see significant improvement within weeks to months. Integrating naturopathic approaches can enhance overall well-being and resilience.

Question 5

Case 23

45-year-old male CC: cough
History
Duration of cough Two months ago
Description of cough Mostly dry, occasionally productive
Sputum characteristics Clear sputum, sometimes sticky and difficult to cough
up
Time of day when cough worsens Worse at night and early in the morning
Associated symptoms Yes, shortness of breath, especially during physical
activity like climbing stairs or in cold air
Chest pain No
Fever, chills, night sweats No
Recent weight loss No
Known allergies Yes, to pollen and dust mites, causing sneezing and
runny nose during spring and fall
Smoking history Smoked one pack per day for 20 years, quit five years ago. Struggled with quitting but finally managed
Exposure to irritants No
History of asthma, COPD, or other lung diseases No
Family history of asthma or COPD No
Recent travel or contact with ill individuals No
Triggers Physical activity like walking fast, cold air during
winter months
Medications or treatments tried No
Changes in medications or environment No
Impact on daily activities Affecting ability to teach, often needing to pause and
catch breath during lessons
Occupation School teacher, finding it difficult to manage
classroom activities
24-hour diet recall Breakfast: Cereal with milk, coffee. Lunch: Sandwich with turkey, lettuce, tomato. Dinner: Grilled chicken, vegetables, rice. Snacks: Apples, nuts. Fluids: Water,
about 6-8 glasses a day
Physical Exams
General appearance inspection Alert and oriented, in no acute distress
Measurement of vital signs Temperature 37°C, heart rate 88 bpm, respiratory rate 20 breaths per minute, blood pressure 128/82 mmHg
Inspection of the oropharynx Mild erythema of the oropharynx
Palpation of cervical lymph nodes No cervical lymphadenopathy
Auscultation of the lungs Bilateral expiratory wheezes, no crackles
Percussion of the chest Normal percussion
Assessment of chest expansion Symmetrical chest expansion
Auscultation of the heart Normal S1 and S2, no murmurs
Inspection and palpation of the abdomen Soft, non-tender, no organomegaly

Inspection of extremities for edema or cyanosis No edema or cyanosis
Assessment of respiratory effort No increased respiratory effort
Evaluation of nasal passages for discharge or
obstruction No nasal discharge or obstruction

Answer 5

Differential Diagnoses:
COPD (Chronic Obstructive Pulmonary Disease) (most likely):

Rationale:
History of smoking one pack per day for 20 years (significant pack-year history).
Symptoms of chronic cough, shortness of breath, and wheezing.
Exacerbation with physical activity and cold air exposure.
Findings of expiratory wheezes on lung auscultation.
Lack of fever, chest pain, or acute infection makes infectious causes less likely.
Diagnostic Tools:
Spirometry: FEV1/FVC ratio < 0.7 confirms obstruction.
Chest X-ray: To rule out other structural lung conditions.
Alpha-1 antitrypsin levels: To assess for genetic predisposition (in select cases).
Asthma:

Rationale:
Wheezing, night-time worsening of cough, and clear sputum are suggestive.
History of allergies to pollen and dust mites aligns with an atopic profile.
Spirometry may reveal reversible airway obstruction after bronchodilator administration.
Chronic Bronchitis (subset of COPD):

Rationale:
Productive cough lasting >3 months for at least 2 consecutive years would meet criteria.
This case does not yet meet the timeline but remains a possibility given smoking history.
Postnasal Drip Syndrome:

Rationale:
Chronic cough and mild oropharyngeal erythema may suggest this, but absence of significant nasal discharge or obstruction makes it less likely.
Gastroesophageal Reflux Disease (GERD):

Rationale:
Chronic cough can be a symptom, especially if associated with nocturnal worsening, but no heartburn or regurgitation reported.
Interstitial Lung Disease (less likely):

Rationale:
Smoking history raises the risk, but absence of crackles or restrictive findings on exam makes this unlikely.
Management Plan:
Conventional Management:
Lifestyle Modifications:

Encourage smoking cessation maintenance: Offer support groups or follow-up to prevent relapse.
Avoid triggers: Minimize exposure to cold air, physical overexertion, and allergens.
Pharmacological Treatment:

Short-Acting Bronchodilators:
Albuterol (SABA): Use as needed for symptom relief.
Inhaled Corticosteroids (ICS) + Long-Acting Beta-Agonists (LABA):
If asthma or COPD exacerbations are present, combination therapy such as budesonide/formoterol may be considered.
Anticholinergic Bronchodilators:
Tiotropium: For maintenance in COPD.
Mucolytics:
If sputum production becomes problematic, mucolytics like guaifenesin may help.
Diagnostics and Monitoring:

Spirometry: To confirm obstructive airway disease.
Chest X-ray or CT scan: To exclude malignancy or other chronic lung pathology.
Allergy Testing: If asthma is suspected.
Vaccination:

Influenza vaccine annually.
Pneumococcal vaccine if not already administered, to prevent infections that could exacerbate COPD.
Naturopathic Modalities:
Dietary Interventions:

Anti-inflammatory diet:
Emphasize fruits, vegetables, whole grains, and omega-3-rich foods (e.g., salmon, flaxseeds) to reduce inflammation.
Nutritional supplements:
N-acetylcysteine (NAC): 600-1,200 mg/day to support mucus thinning and lung health.
Magnesium: 300-400 mg/day for smooth muscle relaxation in airways.
Vitamin D: 2,000-4,000 IU/day, as deficiency is associated with poor lung function.
Botanical Medicine:

Tussilago farfara (Coltsfoot):
Demulcent and antitussive properties to soothe the airway.
Glycyrrhiza glabra (Licorice):
Anti-inflammatory and mucolytic effects. Avoid in hypertensive patients.
Grindelia robusta:
May help reduce wheezing and spasms.
Mind-Body Techniques:

Breathing exercises:
Diaphragmatic or pursed-lip breathing to improve airflow and reduce dyspnea.
Yoga and meditation:
Can improve stress resilience and respiratory control.
Acupuncture:

Points such as LU7 (Lieque) and ST36 (Zusanli) may support lung health and overall vitality.
Hydrotherapy:

Contrast baths for the chest area to stimulate circulation and reduce inflammation.
Environmental Changes:

Use air purifiers and allergen-proof bedding to reduce indoor triggers.
Humidifiers during winter months to prevent airway irritation from dry air.
Follow-Up:
Reassess in 4-6 weeks to evaluate response to treatment.
Monitor for progression of symptoms, new signs of infection, or respiratory compromise.
Adjust treatment as necessary based on diagnostic findings (e.g., spirometry results).
Prognosis:
With appropriate lifestyle changes, pharmacological intervention, and naturopathic support, the patient’s symptoms and quality of life can improve significantly. Long-term management is critical to prevent disease progression if COPD is diagnosed.

Question 6

Case 22

45-year-old male CC: dizziness

History
Description of dizziness It feels like the room is spinning constantly, and it’s very
unsettling.
Onset of dizziness It started suddenly two days ago while I was at work.
Duration of dizziness episodes The dizziness hasn’t stopped since it started.
Factors affecting dizziness It worsens with any head movements, especially when I turn
my head quickly.
Nausea or vomiting Yes, I’ve been nauseous since it started and vomited twice
yesterday.
Hearing changes None
Ringing in ears Yes, there’s a constant ringing in my right ear that I can’t
ignore.
Ear fullness Yes, my right ear feels full and somewhat pressured.
Recent infections or illnesses None
Recent head trauma No
New medications No
History of similar episodes No, this is the first time I’ve experienced anything like this.
Headaches No
Vision changes No
History of ear problems or surgeries No
Effect on balance or walking Yes, my balance is really off, and I tend to veer to the right
when walking.
Family history of ear or balance disorders None
Use of tobacco, alcohol, or recreational drugs I don’t use tobacco or recreational drugs. I drink alcohol
occasionally, about once a week.
Typical daily diet I usually have cereal with milk for breakfast, a sandwich with some fruit for lunch, and for dinner, I have various meals like
pasta, chicken, or fish with vegetables.
Occupation and exposure to loud noises or head movements I’m an accountant, so I spend most of my time sitting at a
desk without any exposure to loud noises or head movements.
Other medical conditions No, I don’t have any other medical conditions.
Physical Exams
Vital signs Temperature 37.2°C Heart rate 88 bpm
Blood pressure 130/85 mmHg
Respiratory rate 16
Tympanic membranes inspection Normal tympanic membranes
Dix-Hallpike maneuver Negative
Head-thrust test Positive
Spontaneous nystagmus No spontaneous nystagmus
Cranial nerve function Normal
Motor strength in all limbs Normal
Coordination Normal (finger-to-nose test, heel-to-shin test)
Gait and balance Unsteady gait, veers to the right
Signs of ear infection or discharge No signs of ear infection or discharge
Hearing assessment Normal hearing (whisper test, Rinne test, Weber test)
Neck palpation No lymphadenopathy or tenderness
Signs of head trauma No signs of head trauma
Signs of dehydration Normal skin turgor and mucous membranes
Other neurological exams Normal

Answer 6

Red Flags:
Sudden severe vertigo + ataxia + dysarthria → Stroke
Sudden hearing loss, tinnitus → Meniere’s disease
Exertional syncope → Aortic stenosis, cardiac arrhythmia

Must-Not-Miss Diagnoses:
Stroke, Cardiac arrhythmia
Meniere’s disease, BPPV, Vestibular neuritis

Tests & Exams:
Neurological Exam (CNs, Romberg, Dix-Hallpike for BPPV)
Cardiac auscultation (murmurs, arrhythmias)
ECG, Audiometry (Meniere’s), MRI (if stroke suspected)

This 45-year-old male’s presentation is most consistent with vestibular neuritis or Meniere’s disease, with a peripheral vestibular disorder being the most likely cause given the symptoms of vertigo, tinnitus, and ear fullness. The absence of neurological deficits supports a peripheral cause rather than a central one.

Red flags:
Tumor- a

Differential Diagnoses:
Vestibular Neuritis (most likely):

Rationale:
Sudden-onset vertigo lasting for days.
Worsened by head movements.
Positive head-thrust test suggests a peripheral vestibular dysfunction.
No hearing loss, spontaneous nystagmus, or focal neurological findings.
Diagnostic Tools:
Clinical diagnosis based on history and examination (positive head-thrust test).
Audiometry to exclude hearing loss.
MRI if central causes need to be ruled out.
Meniere’s Disease:

Rationale:
Vertigo associated with tinnitus and a feeling of fullness in the ear.
Absence of hearing loss makes this less likely at present but could evolve into Meniere’s disease.
Diagnostic Tools:
Audiometry to assess hearing.
Electrocochleography (if available) to evaluate endolymphatic hydrops.
Benign Paroxysmal Positional Vertigo (BPPV):

Rationale:
Vertigo triggered by head movements, but episodes in BPPV are short-lived and intermittent rather than continuous.
Negative Dix-Hallpike maneuver makes this less likely.
Acoustic Neuroma (Vestibular Schwannoma):

Rationale:
Tinnitus, ear fullness, and balance issues raise suspicion.
Unilateral symptoms align with this diagnosis.
Diagnostic Tools:
MRI with gadolinium to assess for cerebellopontine angle tumors.
Central Vestibular Cause (e.g., stroke, multiple sclerosis):

Rationale:
Less likely due to the absence of focal neurological signs, nystagmus, or cranial nerve deficits.
Diagnostic Tools:
MRI brain to definitively exclude central causes.
Management Plan:
Conventional Management:
Symptomatic Relief:

Antihistamines:
Meclizine (Antivert) or Dimenhydrinate (Dramamine) to reduce vertigo and nausea.
Antiemetics:
Ondansetron (Zofran) or Metoclopramide to manage nausea and vomiting.
Vestibular suppressants:
Benzodiazepines (e.g., diazepam) for severe episodes, used short-term.
Corticosteroids:

Consider a short course of prednisone (60 mg/day for 5 days, then taper) if vestibular neuritis is diagnosed early.
Vestibular Rehabilitation:

Referral to a physical therapist for vestibular exercises aimed at improving balance and reducing dizziness.
Diagnostics and Follow-Up:

Audiometry to assess for hearing loss.
MRI if symptoms persist or worsen, to exclude central causes like acoustic neuroma.
Patient Education:

Reassurance that most cases of vestibular neuritis resolve within weeks to months.
Avoid driving or operating heavy machinery until symptoms improve.
Naturopathic Modalities:
Botanical Medicine:

Ginkgo biloba:
Improves microcirculation in the inner ear and may support recovery.
Dosage: 120-240 mg/day (standardized extract).
Zingiber officinale (Ginger):
Reduces nausea and supports vestibular function.
Dosage: 1-2 grams/day as a tea or capsule.
Matricaria chamomilla (Chamomile):
Calming effect for vertigo-related anxiety.
Acupuncture:

Focus on points like PC6 (Neiguan) and GB20 (Fengchi) for vertigo and nausea relief.
Nutritional Support:

Magnesium:
Helps stabilize vestibular nerve function. Dosage: 300-400 mg/day.
Vitamin B6:
May help with nausea and support neurological function. Dosage: 50-100 mg/day.
Mind-Body Techniques:

Breathing exercises:
To manage anxiety and reduce hyperventilation, which can exacerbate dizziness.
Lifestyle Recommendations:

Avoid sudden head movements and minimize stress.
Rest initially but gradually incorporate balance exercises as tolerated.
Hydrotherapy:

Contrast neck compresses: Alternating warm and cool compresses on the neck to support circulation.
Follow-Up:
Reassess in 1-2 weeks to monitor symptom resolution.
If symptoms persist beyond 4-6 weeks or worsen, consider advanced imaging (e.g., MRI) to evaluate for central or structural causes.
Long-term vestibular rehabilitation may be needed if balance issues persist.
Prognosis:
With appropriate treatment, vestibular neuritis usually resolves within weeks, though some patients may have residual imbalance for months. Early intervention with corticosteroids and rehabilitation can improve recovery outcomes.

Question 7

Case 21

45-year-old woman CC: fatigue

History
Onset of fatigue I first noticed the fatigue about six months ago.
Progression of fatigue It has been gradually getting worse over the past few months.
Feeling rested after sleep No, I still feel tired even after a full night’s sleep.
Changes in sleep patterns Not really, I still sleep about the same amount, but I don’t feel
rested.
Other symptoms Yes, I have occasional headaches and sometimes feel dizzy,
especially when I stand up quickly.
Feeling unusually cold Yes, I feel cold more often than I used to, even when others
are comfortable.
Changes in appetite My appetite has decreased, and I don’t feel as hungry as I used
to.
Recent weight changes Yes, I have lost some weight.
Amount of weight lost About 5 kilograms in the last three months.
Irritability or mood changes Yes, I feel more irritable lately, especially with my family.
Difficulty concentrating Yes, it’s been harder to concentrate at work, and I find myself
making more mistakes than usual.
Changes in bowel habits None
History of thyroid problems None
Family history of thyroid disease No, not that I know of.
Current medications or supplements None
History of anemia or blood disorders None
Hair loss or changes in skin texture Yes, my skin feels drier, and I’ve noticed some hair loss,
especially when I brush my hair.
Muscle weakness or joint pain No
Swelling in neck No
Known allergies None
Daily diet For breakfast, I usually have a bowl of oatmeal with a banana and a cup of coffee. For lunch, I might have a small salad with mixed greens, cherry tomatoes, and a light vinaigrette. For dinner, I often have grilled chicken with steamed vegetables and a small portion of brown rice. I sometimes have an apple or a handful of almonds as a snack.
Physical activity I don’t engage in much physical activity.
Smoking or alcohol consumption None
Unusual stress No, there hasn’t been any unusual stress recently.
Physical Exams
General appearance assessment Patient appears pale.
Vital signs measurement Temperature: 36.5°C, HR: 88 bpm, BP: 110/70 mmHg, RR: 16
breaths/min
Inspection of the conjunctiva for pallor Mild pallor noted in the conjunctiva.
Inspection of the nail beds for pallor Mild pallor noted in the nail beds.
Examination of the thyroid gland Thyroid gland slightly enlarged but non-tender.
Cardiac examination Normal heart sounds, no murmurs.
Lung examination Clear lung sounds.
Abdominal examination No hepatosplenomegaly.
Inspection for peripheral edema No peripheral edema.
Skin examination for texture and dryness Skin appears dry.
Examination for hair loss Normal
Assessment of deep tendon reflexes Reflexes within normal limits.
Assessment of muscle strength Normal muscle strength.
Evaluation of mental status Patient is alert and oriented

Answer 7

Red Flags:
Unintentional weight loss → Cancer, chronic infections (TB, HIV)
Night sweats, fever → TB, lymphoma
Pallor, easy bruising → Anemia, leukemia
Polyuria, polydipsia → Diabetes mellitus
Morning stiffness >1 hour → Autoimmune disease (RA, lupus)
Post-exertional malaise → Chronic fatigue syndrome

Must-Not-Miss Diagnoses:
Anemia (Iron, B12, Folate deficiency)
Diabetes Mellitus
Thyroid dysfunction (Hypothyroidism, Addison’s disease)
Chronic infections (TB, HIV, EBV, hepatitis)
Depression, Sleep apnea, Fibromyalgia

Tests & Exams:
General Inspection: Cachexia, pallor
Vitals: BP, HR (orthostatic BP for adrenal insufficiency)
HEENT Exam: Look for conjunctival pallor (anemia), goiter (thyroid)
Cardiac/Lung Exam: Rule out heart failure
Abdomen Exam: Hepatosplenomegaly (chronic infection, leukemia)
Neuro Exam: Weakness (neurological disorders, MS)
Blood Tests: CBC, Ferritin, TSH, Fasting glucose, ESR/CRP, Liver/Kidney function, HIV/Hep B/C

Differential Diagnoses:
1. Hypothyroidism (Most Likely)
Rationale:
Fatigue, cold intolerance, dry skin, hair loss, and weight loss are classic symptoms.
Mild thyroid enlargement on exam.
Decreased appetite but weight loss (suggestive of metabolic slowing or mixed pathology).
Diagnostic Tools:
Thyroid-stimulating hormone (TSH) and free thyroxine (fT4) levels.
Thyroid antibodies (anti-TPO and anti-thyroglobulin antibodies) to assess for autoimmune thyroiditis (Hashimoto’s disease).
2. Iron Deficiency Anemia
Rationale:
Fatigue, pallor of conjunctiva and nail beds, and occasional dizziness are typical.
Possible dietary insufficiency or mild chronic blood loss.
Diagnostic Tools:
Complete blood count (CBC): hemoglobin, hematocrit, mean corpuscular volume (MCV).
Iron studies: serum ferritin, iron, total iron-binding capacity (TIBC).
3. Chronic Illness-Related Anemia
Rationale:
Fatigue and pallor could result from anemia of inflammation or chronic disease.
Consider in the context of an undiagnosed chronic condition.
Diagnostic Tools:
CBC with differential and inflammatory markers (CRP, ESR).
4. Vitamin B12 Deficiency
Rationale:
Fatigue, irritability, and difficulty concentrating are consistent with this deficiency.
Dietary history suggests limited intake of vitamin B12-rich foods (no mention of eggs, dairy, or fortified cereals).
Diagnostic Tools:
Serum vitamin B12 and methylmalonic acid levels.
5. Hyperthyroidism or Subacute Thyroiditis
Rationale:
Enlarged thyroid raises the possibility of thyroid dysfunction.
Weight loss without hyperphagia and mild irritability could suggest thyroiditis, although classic symptoms (e.g., tachycardia, tremors) are absent.
Diagnostic Tools:
Thyroid panel and thyroid ultrasound.
Initial Workup:
Laboratory Tests:

TSH, fT4, and thyroid antibodies.
CBC with differential.
Serum ferritin, serum iron, and TIBC.
Serum vitamin B12 and folate levels.
Basic metabolic panel (BMP) to evaluate electrolytes and renal function.
Imaging:

Thyroid ultrasound if thyroid nodules or significant enlargement are suspected.
Management Plan:
Conventional Approach:
Hypothyroidism:

Initiate levothyroxine therapy if hypothyroidism is confirmed (dose adjusted to TSH levels and body weight).
Monitor TSH levels every 6-8 weeks after initiation or dosage adjustment.
Iron Deficiency Anemia:

Oral iron supplementation (e.g., ferrous sulfate 325 mg once daily with vitamin C to enhance absorption).
Dietary counseling to include iron-rich foods (e.g., lean meats, spinach, lentils).
Vitamin B12 Deficiency:

Oral or intramuscular B12 supplementation based on severity.
Symptom Management:

Adequate hydration and nutrient-dense foods to support energy levels.
Gentle physical activity to prevent deconditioning.
Naturopathic Approach:
Botanical Medicine:

Ashwagandha (Withania somnifera): Adaptogen for fatigue and irritability.
Nettle leaf (Urtica dioica): Supports iron levels and overall vitality.
Nutritional Support:

Emphasize a balanced diet with thyroid and energy-supportive nutrients:
Iodine (seaweed, iodized salt).
Selenium (Brazil nuts, fish).
B12 (eggs, fortified plant-based options).
Mind-Body Practices:

Yoga or mindfulness meditation to improve mood and energy levels.
Lifestyle Changes:

Gradual increase in physical activity tailored to energy levels.
Optimize sleep hygiene.
Follow-Up:
Reassess fatigue and associated symptoms in 4-6 weeks.
Adjust treatment based on lab results and clinical improvement.
Consider referral to an endocrinologist or hematologist if symptoms persist or diagnosis remains unclear.
Prognosis:
With appropriate diagnosis and intervention, symptoms like fatigue, cold intolerance, and irritability are likely to improve significantly within weeks to months.

Question 8

Case 20
History
Description of abdominal pain The pain is crampy and located in the lower abdomen. It’s like a
squeezing sensation.
Onset of pain The pain started about 6 months ago, around the time my
workload increased.
Frequency of pain I experience the pain intermittently, usually a few times a week.
Nature of pain The pain is intermittent and can vary in intensity.
Timing of pain The pain often occurs after meals, particularly heavy meals.
Relieving factors The pain is relieved by defecation, and sometimes by lying down.
Aggravating factors Eating meals, especially fatty or spicy foods, seems to worsen the
pain.
Changes in bowel movements Yes, I have noticed changes in my bowel movements.
Type of bowel movement changes I experience both diarrhea and constipation. It alternates every
few days.
Presence of mucus or blood in stool I sometimes see mucus in my stool, but no blood.
Sensation of bloating or incomplete evacuation Yes, I often feel bloated and have a sensation of incomplete
evacuation. It’s like I can never fully empty my bowels.
Recent weight loss or appetite changes I have lost about 5 kilograms recently without trying. My appetite
is a bit decreased.
Fatigue or lack of energy Yes, I feel fatigued, especially in the afternoons.
Fevers or night sweats I occasionally have low-grade fevers, particularly during episodes
of diarrhea.
Nausea or vomiting No, I haven’t had any nausea or vomiting.
Other symptoms (joint pain, skin rashes) No, I don’t have any joint pain or skin rashes.
Symptom patterns or triggers Stress seems to trigger my symptoms. Whenever I have a stressful
week at work, my symptoms get worse.
Family history of gastrointestinal diseases No, there is no family history of gastrointestinal diseases.
Medications or supplements No, I am not taking any medications or supplements.
Significant recent stress Yes, I have been under significant stress at work lately, with tight
deadlines and long hours.
Typical day’s diet I usually have cereal for breakfast, a sandwich for lunch, and pasta for dinner. I also snack on fruits and drink coffee and water throughout the day. On weekends, I might have a more varied diet
with takeout or restaurant food.
Food allergies or intolerances No, I don’t have any known food allergies or intolerances.
Smoking or alcohol use I occasionally drink alcohol, usually wine on weekends, but do not
smoke.
Other medical conditions No, I don’t have any other medical conditions.
Physical Exams
General appearance and vital signs Temperature: 37.5°C, Pulse: 80 bpm, Blood pressure: 120/80
mmHg, Respiratory rate: 16 breaths/min
Abdominal inspection No visible abnormalities
Abdominal auscultation Normal bowel sounds
Abdominal palpation Mild tenderness in the lower quadrants
Abdominal percussion No abnormalities detected
Rectal examination No abnormalities detected
Assessment for rebound tenderness Negative for rebound tenderness

Assessment for guarding Negative for guarding
Assessment for abdominal masses No palpable masses
Assessment for organomegaly No organomegaly detected
Skin examination No rashes, skin appears normal
Oral examination No ulcers or signs of malnutrition
Assessment for signs of dehydration No signs of dehydration, normal skin turgor and mucous
membranes

Answer 8

This case presents a 34-year-old female with intermittent lower abdominal pain and associated symptoms suggestive of irritable bowel syndrome (IBS). Here’s a breakdown of the key features and possible diagnosis:

Key Symptoms:
Crampy, squeezing lower abdominal pain: Often occurs after meals, especially heavy meals, and is relieved by defecation or lying down.
Alternating diarrhea and constipation: Suggests IBS with mixed bowel habits (IBS-M).
Mucus in stool: Common in IBS, though not specific to it.
Bloating and sensation of incomplete evacuation: Classic symptoms of IBS.
Fatigue: Often associated with IBS, especially if stress is a trigger.
Weight loss and decreased appetite: May warrant further investigation, though it can be due to the chronic nature of the symptoms or stress.
Low-grade fevers during diarrhea episodes: Possible, though it could also point to another underlying gastrointestinal issue.
Potential Differential Diagnosis:
Irritable Bowel Syndrome (IBS): The most likely diagnosis given the pattern of symptoms—intermittent abdominal pain, changes in bowel habits (diarrhea and constipation), bloating, mucus in stool, and a relationship with stress.

IBS-M (mixed type) fits well with the alternating diarrhea and constipation, especially with symptoms worsening with stress and diet.
IBS is a functional gastrointestinal disorder, and the patient’s symptoms do not suggest any red flags (e.g., significant weight loss, blood in stool, etc.).
Inflammatory Bowel Disease (IBD) (Crohn’s disease or ulcerative colitis):

While the patient has some concerning features (weight loss, fatigue, low-grade fevers), the lack of blood in the stool and absence of other inflammatory markers makes IBD less likely. The negative rectal examination and absence of other systemic symptoms further reduce this likelihood.
Celiac Disease:

Celiac could present with similar gastrointestinal symptoms, but the absence of other hallmark signs like malabsorption or specific dietary triggers (e.g., gluten-containing foods) makes it less likely.
Gastroenteritis or Infection:

A recent episode of diarrhea could suggest gastroenteritis, but the chronicity of symptoms (6 months) and the lack of systemic infection signs make this diagnosis less probable.
Gastritis or Peptic Ulcer Disease:

While these conditions can cause pain after meals, the absence of nausea, vomiting, or significant upper abdominal discomfort makes this diagnosis less likely. Additionally, the lack of epigastric tenderness is inconsistent with these conditions.
Stress-related functional gastrointestinal disorder:

The patient’s symptoms are triggered by stress, which is a well-known factor in IBS and other functional disorders. The correlation between stress and symptom flare-ups is significant and could be contributing to the patient’s overall clinical picture.
Diagnostic Approach:
Stool tests: To rule out infections or parasites.
Complete blood count (CBC): To assess for anemia or signs of infection.
Inflammatory markers (CRP, ESR): To help rule out inflammatory conditions like IBD.
Thyroid function tests: To check for hypothyroidism, as fatigue and weight changes could also indicate thyroid dysfunction.
Abdominal imaging: While not immediately necessary, an ultrasound or CT scan might be useful if symptoms worsen or other concerns arise.
Management and Next Steps:
Dietary management: Consider a low FODMAP diet to help control symptoms of IBS.
Stress management: Techniques like mindfulness, yoga, or cognitive-behavioral therapy (CBT) may help manage stress and reduce symptom exacerbation.
Probiotics: Some evidence suggests that probiotics may help balance gut microbiota in IBS.
Symptom relief: Antispasmodics (like hyoscine or peppermint oil) can relieve cramping, and fiber supplements (such as psyllium) can help regulate bowel movements.
Further evaluation: If symptoms persist or worsen, referral to a gastroenterologist may be necessary for further evaluation and possible diagnostic testing (e.g., colonoscopy) to rule out IBD or other conditions.
Conclusion:
This patient most likely has irritable bowel syndrome (IBS), particularly the mixed type (IBS-M), based on her symptom profile. The patient’s stress levels appear to play a significant role in symptom exacerbation. Management should focus on stress reduction, dietary adjustments, and symptom management. Further testing might be needed to rule out other conditions if symptoms persist or new red flags emerge

Question 9

Case 19
45-year-old female CC: fatigue

Question
Onset of fatigue About six months ago. It started gradually and has been
getting worse.
Impact on daily activities It makes it difficult to perform at work and engage in social activities. I often feel too tired to cook or clean, and I’ve
had to take more sick days.
Sleep quality Yes, but I still feel tired. I usually sleep around 8 hours a
night, but it doesn’t seem to help.
Weight changes Yes, I have gained some weight. I’ve put on about 10
pounds over the last few months.
Concentration difficulties Yes, it’s hard to focus on tasks. I find myself rereading things
multiple times and making mistakes at work.
Feeling unusually cold Yes, I feel cold even in warm weather. I often wear extra
layers or blankets.
Mood changes Yes, I’ve been feeling more sad and hopeless. It’s like a
cloud I can’t shake off.
Feeling sad or hopeless Yes, frequently. It’s there most days, and sometimes it feels
overwhelming.
Loss of interest in activities Yes, things like gardening and spending time with friends. I used to love those activities, but now they feel like a chore.
Frequency of crying More often than I used to. Sometimes I cry for no apparent
reason.
Difficulty making decisions Yes, even simple decisions are difficult. Choosing what to
eat or what to wear feels overwhelming.
Appetite changes Yes, some days I don’t feel like eating, and other days I
overeat. It’s very inconsistent.
Eating more or less than usual Both, it varies. I can go a day without eating much and then
binge on snacks the next day.
Changes in skin or hair Yes, my skin is dry and my hair is thinning. I’ve noticed more
hair on my brush and my skin feels rough.
Swelling around eyes Yes, a little bit. My eyes often look puffy, especially in the
mornings.
Other health changes No, nothing else significant.
Past medical conditions No.
Current medications No.
Family history of thyroid disease or mental health
issues No.
Typical diet It’s pretty normal, but varies some days. Breakfast is usually cereal or toast, lunch is a sandwich or salad, and dinner is something like pasta or chicken. I snack on fruits or nuts.
Exercise frequency Not much recently. I used to walk daily, but now I barely
have the energy to do that.
Smoking or drinking alcohol No.
Work and home life Work is stressful, and I feel disconnected at home. My workload has increased, and I don’t have the energy to
spend quality time with my family.
Recent stressors Yes, work has been particularly stressful. There have been a
lot of deadlines and I feel like I’m falling behind.
PHQ-9: Feeling down, depressed, or hopeless Nearly every day. It feels like a weight on my shoulders.
PHQ-9: Little interest or pleasure in doing things Nearly every day. Even activities I used to enjoy feel
unappealing.
PHQ-9: Trouble falling or staying asleep, or sleeping
too much Nearly every day. I sleep a lot but it’s never restful.
PHQ-9: Feeling tired or having little energy Nearly every day. I wake up tired and it lasts all day.
PHQ-9: Poor appetite or overeating Nearly every day. My eating habits are all over the place.
PHQ-9: Feeling bad about yourself or that you are a
failure Nearly every day. I feel like I’m letting everyone down.
PHQ-9: Trouble concentrating on things Nearly every day. I can’t seem to focus on anything for long.
PHQ-9: Moving or speaking slowly or being fidgety
and restless Nearly every day. Sometimes I feel sluggish, other times I
can’t sit still.
PHQ-9: Thoughts of being better off dead or
hurting yourself Not at all.
Physical Exam
Heart rate and blood pressure measurement Heart Rate: 68 bpm, Blood Pressure: 130/85 mmHg.
Respiratory rate assessment Respiratory Rate: 14 breaths per minute.
BMI 27, slightly overweight.
Skin inspection Skin is dry.
Hair inspection Hair is thinning.
Periorbital puffiness check Mild periorbital puffiness present.
Reflexes assessment Reflexes are slightly delayed.
Thyroid palpation No thyroid enlargement or nodules detected.
Cardiovascular examination Normal cardiovascular exam.
Respiratory examination Normal respiratory exam.
Mental status assessment Patient appears sad and has difficulty concentrating.
Mood and affect evaluation Mood is depressed, affect is flat.
Signs of depression or anxiety Tearfulness noted.
Muscle strength and tone assessment Normal muscle strength and tone.
Joint swelling or tenderness check No joint swelling or tenderness.
Abdominal examination No organomegaly or masses detected.
Neurological examination Normal neurological exam.
Nail inspection Nails are brittle.

Answer 9

This case presents a 45-year-old female with chronic fatigue, depressive symptoms, and physical signs such as dry skin, thinning hair, and periorbital puffiness. Based on the information provided, here’s an analysis of potential diagnoses and next steps:

Key Symptoms:
Fatigue: Persistent and worsening over the last six months, not relieved by sleep.
Mood changes: Feelings of sadness, hopelessness, and lack of interest in previously enjoyable activities (anhedonia).
Concentration difficulties: Impaired focus and decision-making, with an increase in mistakes at work.
Appetite changes: Inconsistent eating habits, with both overeating and not eating at times.
Physical symptoms: Dry skin, thinning hair, and mild periorbital puffiness suggest a potential endocrine issue.
Swelling around eyes: Could be indicative of hypothyroidism.
PHQ-9 results: High score on the depression screening, indicating significant depressive symptoms that impact daily functioning.
Potential Differential Diagnoses:
Hypothyroidism:

The patient has several signs and symptoms that align with hypothyroidism, including fatigue, weight gain, cold intolerance, dry skin, hair thinning, constipation, and depression. While the thyroid exam did not show enlargement or nodules, subclinical hypothyroidism or early stages of hypothyroidism could still be contributing to the symptoms.
The delayed reflexes and periorbital puffiness further support the possibility of hypothyroidism.
Major Depressive Disorder (MDD):

The PHQ-9 suggests significant depressive symptoms, including low mood, anhedonia, sleep disturbances, poor concentration, and feelings of worthlessness. This pattern of symptoms could point to a diagnosis of major depressive disorder.
Depression can also present with physical symptoms like fatigue, appetite changes, and cognitive difficulties, which overlap with hypothyroidism.
Chronic Fatigue Syndrome (CFS):

Chronic fatigue, unrefreshing sleep, and impaired concentration could also fit with CFS. However, the presence of other physical signs such as dry skin, hair thinning, and cold intolerance make hypothyroidism a more likely primary diagnosis. CFS is typically diagnosed after ruling out other medical conditions.
Perimenopause:

The patient is in the perimenopausal age range, and hormonal fluctuations during this time could contribute to symptoms of fatigue, mood changes, and cognitive difficulties. However, the physical symptoms like cold intolerance and dry skin are more suggestive of a thyroid-related issue.
Anemia:

The patient reports fatigue and weight changes, though without specific symptoms like pallor, dizziness, or significant shortness of breath. Anemia is unlikely given the lack of red flags, but it could still be a consideration.
Vitamin D Deficiency:

Fatigue, mood changes, and physical symptoms like hair thinning can sometimes be linked to vitamin D deficiency, especially in patients who are not exposed to sufficient sunlight. However, it’s less likely to explain the combination of symptoms seen in this case.
Diagnostic Approach:
Thyroid Function Tests:

Given the suspicion of hypothyroidism, checking TSH, free T4, and free T3 levels would be essential. In the case of subclinical hypothyroidism, the TSH could be elevated while T3 and T4 remain normal.
Complete Blood Count (CBC):

To rule out anemia or other blood disorders that could be contributing to fatigue.
Vitamin D Levels:

A deficiency in vitamin D can present with fatigue, mood disturbances, and other nonspecific symptoms.
Mental Health Assessment:

While the patient’s depressive symptoms are significant, it’s important to evaluate whether the depression is secondary to an underlying physical issue (e.g., hypothyroidism) or if it is primary. If necessary, consider referral to a mental health professional for therapy or further assessment.
Additional Lab Tests:

If thyroid function tests are inconclusive, consider further workup for autoimmune thyroid disorders (e.g., anti-TPO antibodies to assess for Hashimoto’s thyroiditis).
Management and Next Steps:
If Hypothyroidism is Confirmed:

Levothyroxine (synthetic thyroid hormone) would likely be prescribed to normalize thyroid hormone levels. Regular follow-up is necessary to monitor progress and adjust the dosage as needed.
Once thyroid function is normalized, improvements in fatigue, mood, and physical symptoms (like hair thinning) are expected.
Depression Management:

If depression is confirmed, cognitive behavioral therapy (CBT) and/or antidepressant medication (e.g., SSRIs or SNRIs) could be considered. It’s important to address both the psychological and physical aspects of the patient’s symptoms.
Lifestyle Modifications:

Encourage regular exercise as tolerated, which can improve both mood and energy levels.
Sleep hygiene: Although the patient reports poor sleep despite adequate duration, addressing sleep hygiene and considering CBT for insomnia could be helpful.
Dietary adjustments: A balanced diet with adequate protein, healthy fats, and micronutrients (including B-vitamins and iron) might help with energy levels.
Monitoring:

Regular follow-up to assess progress with any treatment plan, including thyroid hormone replacement or depression therapy, will be necessary. Additionally, keep track of the patient’s mood and energy levels.
Conclusion:
The most likely diagnosis for this patient is hypothyroidism, given the combination of fatigue, weight gain, cold intolerance, dry skin, hair thinning, and mood changes. However, major depressive disorder is a close second, as the depressive symptoms are significant and could be secondary to the thyroid dysfunction or represent a co-occurring condition. Further thyroid testing and possibly mental health evaluation are critical for determining the appropriate treatment plan.

Question 10

Case 18
45-year-old male CC: low back pain

Question
Onset Two weeks ago
Pain description The pain is sharp and severe, sometimes making it hard to
move or get comfortable.
Radiation The pain shoots down the left leg to the knee, feeling like a
sharp, electric shock.
Activity at onset I was lifting a heavy box at work when I felt a sudden sharp
pain in my back.
Recent injuries or accidents No recent injuries or accidents.
Aggravating factors Sitting for long periods, bending over, and lifting anything
heavy make the pain worse.
Relieving factors Lying flat on my back provides some relief from the pain.
Medications taken for pain Yes, I’ve been taking ibuprofen and acetaminophen.
Relief from medications The medications only provide minimal relief, not enough to
make a big difference.
Numbness or tingling I occasionally feel tingling in my left leg, which comes and goes.
Weakness in legs No weakness in my legs.
Bowel or bladder control issues No problems with bowel or bladder control.
Previous episodes of back pain This is the first time I’ve had back pain like this.
Previous healthcare providers seen No, I haven’t seen any healthcare providers for this problem
before today.
Other medical conditions I don’t have any other medical conditions.
Current medications I’m not taking any other medications.
Medication allergies I don’t have any medication allergies.
Family history of back problems No one in my family has a history of back problems.
Occupation I work as a warehouse worker, which involves a lot of heavy
lifting and physical activity.
Physical activities or sports I don’t participate in any physical activities or sports.
Diet I usually skip breakfast, have a sandwich for lunch, and eat pasta or meat with vegetables for dinner. I snack on chips
throughout the day.
Tobacco use I don’t smoke or use any tobacco products.
Alcohol use I drink alcohol occasionally, about 1-2 drinks on weekends.
Recreational drug use I don’t use any recreational drugs.
Physical Exam
Lumbar spine inspection The alignment of the lumbar spine appears normal.
Lumbar spine and paraspinal muscles
palpation There is tenderness over the lower lumbar paraspinal muscles.
Lumbar spine range of motion The range of motion in the lumbar spine is decreased due to
pain.
Straight leg raise test The test is positive on the left side at 40 degrees, causing pain
to radiate down the leg.

Answer 10

This case describes a 45-year-old male with acute low back pain radiating to the left leg, likely caused by a work-related lifting incident. The findings suggest involvement of the lumbar spine nerve roots, with the most likely diagnosis being lumbar radiculopathy, possibly due to a herniated lumbar disc.

Key Findings:
Pain characteristics:
Sharp, severe pain radiating down the left leg to the knee, described as an “electric shock.”
Aggravated by sitting, bending, and lifting; relieved by lying flat.
Neurological symptoms:
Positive straight leg raise (SLR) test on the left at 40 degrees, indicating nerve root irritation or compression.
No motor weakness or sensory deficits in the lower extremities, suggesting no severe nerve compromise.
Mechanism of injury:
Acute onset after lifting a heavy box, a common mechanism for lumbar disc herniation.
No red flags:
No bowel/bladder dysfunction, no leg weakness, and no family history of back problems, ruling out more serious conditions like cauda equina syndrome or systemic disease.
Differential Diagnoses:
Herniated Lumbar Disc:

Most likely given the acute onset, radiation of pain, and positive SLR test. The sharp, radiating pain is typical of radicular pain due to nerve root compression, commonly affecting L5 or S1 roots.
Likely level: L4-L5 or L5-S1, as these are the most common sites of herniation.
Lumbar Muscle Strain:

While muscle strain could explain localized back pain and tenderness, it does not typically cause radiating leg pain or a positive SLR test. This is less likely the primary cause.
Lumbar Spinal Stenosis:

Unlikely in this case, as stenosis typically presents as chronic, progressive back pain with leg symptoms during walking (neurogenic claudication), not acute radiculopathy.
Piriformis Syndrome:

May mimic radicular pain but is less likely here due to the positive SLR test and the history of heavy lifting, which is more consistent with a disc herniation.
Sacroiliac Joint Dysfunction:

SI joint issues typically present with localized pain over the joint, not radiating pain or positive SLR findings.
Red Flags to Rule Out:
Cauda Equina Syndrome:
Symptoms like urinary retention, saddle anesthesia, or bilateral leg weakness are absent.
Fracture or Malignancy:
No trauma history (besides lifting), no night pain, and no systemic symptoms (e.g., fever, weight loss).
Diagnostic Approach:
Imaging:

MRI of the lumbar spine: The gold standard to confirm disc herniation and assess nerve root involvement. Recommended if symptoms persist or worsen after conservative management.
X-ray: Consider only to rule out other conditions like fractures or spondylolisthesis.
Neurological Assessment:

Continued monitoring for any progression of neurological deficits (e.g., weakness, numbness, or bowel/bladder symptoms).
Management:
Conservative Treatment (First Line):
Pain Relief:

NSAIDs (e.g., ibuprofen or naproxen): To reduce inflammation and provide pain relief.
Consider a short course of muscle relaxants or acetaminophen if NSAIDs are insufficient.
Activity Modifications:

Encourage light activities as tolerated. Avoid heavy lifting and prolonged sitting.
Prolonged bed rest is not recommended; instead, maintain gentle mobility to prevent deconditioning.
Physical Therapy:

Stretching and strengthening exercises for the back and core.
Gradual return to normal activities under guidance.
Heat or Ice Therapy:

To reduce muscle spasm and improve comfort.
Referral/Follow-Up:
If symptoms worsen or do not improve in 4-6 weeks, refer for imaging or specialist evaluation.
Referral to a physiatrist or orthopedic surgeon if conservative measures fail.
Consider Corticosteroid Injections:
Epidural steroid injections may be considered for severe or persistent radicular pain if conservative treatment does not provide relief.
Education and Prevention:
Ergonomics:
Teach proper lifting techniques to reduce the risk of future injuries.
Strengthening Exercises:
Long-term core and lumbar muscle strengthening to prevent recurrence.
Weight Management:
Encourage weight loss if BMI is elevated, as excess weight can increase strain on the lumbar spine.
Conclusion:
The most likely diagnosis is lumbar radiculopathy secondary to a herniated lumbar disc, likely involving the L5 or S1 nerve root. Conservative management, including NSAIDs, activity modifications, and physical therapy, is the first-line approach. Monitor for any red flag symptoms or progression of neurological deficits, and consider MRI if symptoms persist.

Naturopathic Approach:
Lifestyle Recommendations:
Activity modification:
Avoid heavy lifting, prolonged sitting, and bending forward.
Incorporate light stretching and walking as tolerated.
Ergonomics:
Educate on proper lifting techniques and workplace ergonomics.
Nutrition:
Anti-inflammatory diet:
Include omega-3-rich foods like fatty fish, walnuts, and flaxseeds.
Minimize processed foods, sugar, and refined grains.
Magnesium-rich foods:
Include spinach, almonds, and bananas to relax muscles.
Herbal Medicine:
Nervine relaxants:
Valerian root (Valeriana officinalis) for muscle relaxation.
Dose: 200–400 mg extract before bed.
Anti-inflammatory herbs:
Turmeric (Curcuma longa):
Dose: 500–1,000 mg curcumin/day with black pepper.
Physical Modalities:
Hydrotherapy:
Alternate hot and cold compresses on the lower back to reduce inflammation and relax muscles.
Acupuncture:
Points: BL23, BL40, BL60, and GV3 for pain relief and radicular symptoms.
Manual Therapy:
Gentle spinal mobilization or referral to a chiropractor.
Supplements:
Magnesium glycinate:
Dose: 200–400 mg/day for muscle relaxation.
B-complex:
Dose: 50 mg/day for nerve health.
Follow-Up:
Reassess in 1–2 weeks. If symptoms worsen or bowel/bladder issues arise, refer immediately for imaging.

Question 11

Case 17

58-year-old female CC: Knee pain
History
Description of knee pain A deep, aching sensation that is worse with activity like
walking, especially on stairs.
Onset of pain Gradually over the past year.
Activities worsening the pain Going up and down stairs, gardening, walking for more
than 30 minutes.
Pain improvement with rest Yes, the pain improves with rest, usually after sitting or
lying down.
Knee stiffness Yes, especially in the mornings when I wake up or after
sitting for more than an hour.
Knee swelling Yes, occasional swelling that seems to get worse
towards the end of the day.
Knee catching or locking Yes, a catching sensation that sometimes makes me stop
mid-step.
Knee giving way Yes, sometimes it feels like it might give way, particularly when I’m carrying something heavy like groceries.
Recent knee injuries or trauma Twisted knee awkwardly a few months ago while
gardening; I stepped into a hole.
Knee clicking or popping sounds Yes, a clicking sound, especially when I bend my knee or
go up stairs.
Daily physical activity Light gardening and occasional walking around the
neighborhood.
Difficulty performing daily activities Yes, difficulty with stairs, gardening, and sometimes
even walking for longer periods.
Treatments tried for knee pain Over-the-counter pain medication, like ibuprofen, which
helps a little, and using ice packs after activity.
Other joint pain or stiffness No, only the knee.
Family history of arthritis or joint conditions Yes, my mother had arthritis, and she struggled with it in
her later years.
Current medications Over-the-counter pain medication, like ibuprofen, and antihypertensive medication for my blood pressure.
Other medical conditions Hypertension, which I’ve had for about 10 years.
Occupation and physical activity Retired school teacher, no current occupational physical
activity.
Smoking or alcohol consumption No smoking, I quit 20 years ago, and I have an occasional
glass of wine with dinner.
24-hour diet recall Breakfast: oatmeal with fruit and nuts, Lunch: a mixed green salad with chicken, Dinner: grilled chicken with steamed vegetables, Snacks: an apple or a handful of nuts, Drinks: water, green tea, and sometimes a glass of
wine with dinner.
Physical Exams
Inspection of the knee Mild swelling, no erythema or deformity.
Palpation of the knee Tenderness over the medial joint line, no warmth.
Range of motion assessment Reduced range of motion with pain on both flexion and
extension.
McMurray’s test Clicking sound with pain on the medial side of the knee.
Thessaly test Pain and instability at 20-degree knee flexion.
Apley’s compression test Pain with compression and rotation.
Crepitus check Crepitus noted during movement.
Ligamentous stability tests No ligamentous instability noted.
Gait assessment Antalgic gait observed.
Varus and valgus stress tests No abnormal findings.
Other joint inspection No signs of arthritis in other joints.

Answer 11

Red Flags:
Swelling, erythema, fever → Septic arthritis
Locking, giving way → Meniscus/ligament tear
Severe pain post-trauma → Fracture

Must-Not-Miss Diagnoses:
Septic arthritis, DVT
Meniscus tear, Ligament tear (ACL, MCL, PCL)

Tests & Exams:
Lachman’s test, McMurray’s test, Joint aspiration (if infection suspected), X-ray, MRI

This case describes a 58-year-old female with chronic right knee pain that is exacerbated by activity and associated with occasional catching and giving way. The history, physical exam findings, and risk factors point to medial knee osteoarthritis with a possible meniscal tear.

Key Findings:
Symptoms:

Chronic, gradual onset of deep, aching knee pain, worsened by activity (stairs, walking, gardening), and improved by rest.
Morning stiffness and stiffness after prolonged sitting suggest degenerative joint disease.
Intermittent swelling, crepitus, catching, and occasional giving way further support mechanical derangement, such as meniscal involvement.
Risk Factors:

Age (58 years), history of joint overuse (gardening, stairs), and family history of arthritis.
Previous twisting injury to the knee.
Physical Exam:

Tenderness over the medial joint line and positive McMurray’s test suggest a medial meniscus tear.
Crepitus, reduced range of motion, and an antalgic gait are consistent with knee osteoarthritis (OA).
Negative ligament tests rule out ligament instability.
Differential Diagnoses:
Primary Osteoarthritis (OA):

The most likely diagnosis given the gradual onset, activity-related pain, stiffness, and occasional swelling.
Mechanical symptoms like catching and crepitus further suggest OA, which may involve the medial compartment.
Medial Meniscus Tear:

A likely concurrent diagnosis given the twisting injury history, medial joint line tenderness, and positive McMurray’s test.
OA and meniscal tears often coexist in middle-aged and older adults.
Patellofemoral Pain Syndrome (PFPS):

Less likely as primary cause since the pain is localized to the medial joint and not predominantly anterior.
Rheumatoid Arthritis (RA):

Unlikely in the absence of systemic symptoms, other joint involvement, or synovitis.
Gout/Pseudogout:

Less likely as there is no erythema or acute, intense flare-ups.
Diagnostic Approach:
Imaging:

X-ray of the knee: First-line to confirm osteoarthritis and assess joint space narrowing, osteophytes, or subchondral sclerosis.
MRI of the knee: Consider if meniscal tear needs confirmation or if mechanical symptoms (e.g., locking) are severe.
Laboratory Tests (if needed to rule out other causes):

Rheumatoid factor and anti-CCP to rule out RA if clinical suspicion arises.
Serum uric acid or joint aspiration if gout/pseudogout is suspected.
Management:
Non-Pharmacological:
Weight Management:
If BMI is elevated, weight loss can reduce knee joint stress and alleviate symptoms.
Physical Therapy:
Focus on strengthening the quadriceps and improving joint mobility.
Low-impact activities like swimming or cycling.
Assistive Devices:
Knee braces or walking aids (e.g., a cane) to offload the affected compartment.
Activity Modifications:
Avoid deep knee bends, prolonged standing, and heavy lifting.
Pharmacological:
Pain Relief:
Acetaminophen: First-line for mild to moderate pain.
NSAIDs (e.g., ibuprofen or naproxen): For moderate to severe pain, but use cautiously due to potential cardiovascular and gastrointestinal risks (given her hypertension history).
Topical NSAIDs: Effective for localized pain with fewer systemic side effects.
Intra-articular Injections:
Corticosteroid injections: For flare-ups with significant pain and swelling.
Viscosupplementation (hyaluronic acid): May help with lubrication and symptom relief in OA.
Surgical:
Arthroscopy:
Considered for persistent mechanical symptoms (e.g., catching/locking) with confirmed meniscal tear.
Knee Replacement (Partial or Total):
Indicated for severe OA refractory to conservative management.
Education and Prevention:
Joint Care:
Importance of gentle, regular exercise to maintain joint function.
Lifestyle Modifications:
Maintaining a balanced diet to support joint health and manage hypertension.
Conclusion:
The most likely diagnoses are medial knee osteoarthritis with a possible medial meniscus tear. Treatment should focus on conservative management, including weight management, physical therapy, and NSAIDs or topical pain relief. Referral to an orthopedic specialist for imaging or further intervention may be necessary if symptoms persist or mechanical symptoms worsen.

Naturopathic Approach:
Lifestyle Recommendations:
Weight management:
If appropriate, suggest strategies for weight loss to reduce joint load.
Gentle exercise:
Low-impact activities like swimming or cycling to maintain joint mobility.
Nutrition:
Joint-supportive nutrients:
Collagen peptides: Support cartilage repair (10 g/day).
Vitamin C: Citrus fruits, bell peppers (500–1,000 mg/day).
Anti-inflammatory diet:
Focus on Mediterranean-style eating: olive oil, fish, and vegetables.
Herbal Medicine:
Anti-inflammatory herbs:
Boswellia serrata (Frankincense):
Dose: 300–500 mg boswellic acids/day.
Turmeric (Curcuma longa):
Dose: 500 mg curcumin 2–3 times/day.
Lymphatic support:
Calendula (Calendula officinalis) for swelling and lymphatic drainage.
Physical Modalities:
Hydrotherapy:
Epsom salt baths (2–3 times/week) for pain relief and relaxation.
Manual Therapy:
Joint mobilization or massage for stiffness and swelling.
Acupuncture:
Points: ST35, SP9, and SP6 for knee pain and swelling.
Supplements:
Glucosamine and chondroitin:
Dose: 1,500 mg/day for cartilage health.
Omega-3 fatty acids:
Dose: 1,000–2,000 mg EPA/DHA daily to reduce inflammation.
Follow-Up:
Monitor pain and function in 4–6 weeks. Consider imaging if symptoms do not improve.

Question 12

Case 16
17 year old
CC: Sort throat

History
Duration of sore throat One week
Severity of sore throat Progressively worsened, with difficulty swallowing
Difficulty swallowing Yes, especially when trying to eat solid foods
Cough No
Fever Yes, up to 38.5°C
Chills or night sweats Yes to both, the night sweats disrupt sleep
Headaches Yes, mostly in the afternoon
Fatigue Yes, extremely fatigued, needing to take naps during
the day
Body aches Yes, especially in the muscles of the back and legs
Swelling in neck Yes, noticeable on both sides
Abdominal pain No
Swelling or pain in abdomen No
Nausea or vomiting No
Loss of appetite No
Weight loss No
Skin rashes No
Recent close contact with sick individuals No
Allergies No
Current medications No
Other medical conditions No
Tobacco use No
Alcohol use No
Recreational drug use No
24-hour diet recall Breakfast: Cereal with milk and a banana. Lunch: Sandwich with turkey and cheese, an apple. Snack: Granola bar. Fluid intake: 2-3 glasses of water, one
glass of juice, and a soda.
Family history of similar symptoms No
Recent travel No
Physical Exam
Temperature 38.3°C
Oropharynx inspection Erythematous and swollen tonsils with white
exudates
Cervical lymph nodes palpation Notable cervical lymphadenopathy
Anterior cervical lymphadenopathy Present
Posterior cervical lymphadenopathy Present
Axillary lymphadenopathy None
Inguinal lymphadenopathy None
Heart sounds Normal
Lung sounds Normal
Abdominal tenderness Mild tenderness

Hepatomegaly (percussion) Liver span estimated at 16 cm
Hepatomegaly (palpation) Mild hepatomegaly
Splenomegaly (percussion) Mild splenomegaly
Splenomegaly (palpation) Mild splenomegaly
Skin inspection No rashes
Signs of dehydration No signs of dehydration
Tonsillar size and symmetry Tonsils are swollen but symmetrical

Answer 12

This case describes a 17-year-old with a sore throat, fatigue, fever, lymphadenopathy, and hepatosplenomegaly. These findings strongly suggest infectious mononucleosis (IM) caused by the Epstein-Barr Virus (EBV) as the primary diagnosis.

Key Findings:
History:

One-week duration of progressively worsening sore throat.
Difficulty swallowing with swollen tonsils and white exudates.
Fever, chills, night sweats, fatigue, body aches, and significant cervical lymphadenopathy (anterior and posterior).
Mild hepatosplenomegaly, a hallmark of systemic infection, particularly EBV.
Physical Exam:

Tonsillopharyngitis: Swollen tonsils with white exudates.
Generalized lymphadenopathy: Both anterior and posterior cervical lymph nodes are enlarged.
Mild hepatosplenomegaly: Detected by percussion and palpation.
Normal heart and lung sounds.
Absence of Symptoms:

No cough, abdominal pain, or rash rules out other infectious and non-infectious causes.
Differential Diagnoses:
Infectious Mononucleosis (EBV):

Most likely based on fever, sore throat, fatigue, lymphadenopathy (posterior involvement is characteristic), and hepatosplenomegaly.
Night sweats and systemic symptoms also align with EBV infection.
Streptococcal Pharyngitis (Strep Throat):

Could explain fever, sore throat, and anterior cervical lymphadenopathy.
However, hepatosplenomegaly and posterior lymphadenopathy are atypical for strep throat.
Cytomegalovirus (CMV) Infection:

Similar presentation to EBV but less common in adolescents and typically associated with milder pharyngitis.
Toxoplasmosis:

Can cause lymphadenopathy and mild hepatosplenomegaly, but sore throat and exudative tonsillitis are uncommon.
Acute HIV Infection:

Possible in sexually active individuals but less likely here due to the lack of high-risk behaviors and absence of rash.
Diagnostic Workup:
Laboratory Tests:

Monospot Test (Heterophile Antibody Test): First-line for infectious mononucleosis.
EBV Serology: If Monospot is negative, assess for anti-VCA IgM and IgG to confirm EBV.
Rapid Strep Test or Throat Culture: Rule out bacterial pharyngitis.
Complete Blood Count (CBC):
Look for atypical lymphocytosis (characteristic of EBV).
Elevated white blood cell count.
Liver Function Tests (LFTs):
Mild transaminitis (elevated AST/ALT) is common in EBV infection.
Imaging:

Ultrasound of Abdomen (if hepatosplenomegaly worsens): Assess spleen size for risk of rupture.
Management:
General Measures:
Supportive Care:

Hydration and adequate rest.
Analgesics/Antipyretics: Acetaminophen or ibuprofen for fever and throat pain.
Dietary Adjustments:

Encourage soft foods and increased fluid intake to manage difficulty swallowing.
Activity Restrictions:

Avoid contact sports for at least 4 weeks to reduce the risk of splenic rupture due to splenomegaly.
Medications:
Antibiotics:

Not indicated unless bacterial co-infection is confirmed (e.g., strep throat).
Avoid amoxicillin or ampicillin, as they can cause a rash in patients with EBV.
Corticosteroids:

Reserved for severe tonsillar swelling or airway obstruction.
Education and Monitoring:
Course of Disease:
Symptoms typically resolve within 2-4 weeks, though fatigue may persist longer.
Follow-Up:
Monitor for complications, such as splenic rupture, secondary bacterial infections, or prolonged symptoms.
When to Seek Help:
Worsening abdominal pain (indicating splenic rupture), difficulty breathing, or worsening fever.
Conclusion:
The clinical picture strongly suggests infectious mononucleosis. Immediate focus should be on confirming the diagnosis with Monospot or EBV serology, providing supportive care, and advising activity modifications to avoid complications. Further evaluation for bacterial pharyngitis is prudent to rule out co-infection.

1. Lifestyle Recommendations:
   Rest and Recovery:
   Emphasize adequate rest to support the immune system.
   Limit strenuous activities and avoid contact sports due to splenomegaly.
   Hydration:
   Encourage drinking plenty of fluids (water, herbal teas, broths) to prevent dehydration and soothe the throat.
   Sleep Hygiene:
   Establish a consistent sleep schedule to improve fatigue and recovery.
2. Nutrition and Dietary Support:
   Immune-Boosting Diet:
   Anti-inflammatory foods: Incorporate berries, leafy greens, turmeric, ginger, and fatty fish.
   Immune-supportive nutrients:
   Vitamin C: Oranges, bell peppers, kiwi, or a supplement (e.g., 500–1,000 mg/day).
   Zinc: Pumpkin seeds, chickpeas, or a supplement (15–30 mg/day).
   Vitamin D: Fatty fish, fortified foods, or a supplement (2,000–4,000 IU/day).
   Protein-rich foods: Support tissue repair with lean meats, eggs, legumes, and tofu.
   Soothing Foods:
   Warm broths, soups, or soft foods (mashed sweet potatoes, applesauce) to ease swallowing discomfort.
   Avoid:
   Sugary or processed foods that can suppress immune function.
3. Herbal Medicine:
   Immune-Modulating and Antiviral Herbs:
   Elderberry (Sambucus nigra):
   Supports immune response and may reduce viral replication.
   Dose: 1 teaspoon of elderberry syrup 2–3 times/day.
   Astragalus (Astragalus membranaceus):
   Strengthens the immune system (avoid in autoimmune conditions if relevant).
   Dose: 1–2 grams of dried root daily as tea or tincture (30–60 drops/day).
   Licorice Root (Glycyrrhiza glabra):
   Antiviral and anti-inflammatory properties, soothing for the throat.
   Dose: 1 cup of tea 2–3 times/day or 400 mg of extract (avoid in hypertension).
   Lymphatic Herbs:
   Cleavers (Galium aparine):
   Supports lymphatic drainage and reduces swelling.
   Dose: 1–2 mL tincture 2–3 times/day.
   Calendula (Calendula officinalis):
   Anti-inflammatory and supports lymphatic system.
   Dose: 2–4 mL tincture 3 times/day or as tea.
   Adaptogenic Herbs for Fatigue:
   Ashwagandha (Withania somnifera):
   Supports recovery from fatigue and stress.
   Dose: 300–600 mg standardized extract/day.
4. Nutritional Supplements:
   Immune Support:
   Probiotics:
   Enhance immune function and gut health.
   Dose: 10–20 billion CFU/day from a multi-strain product.
   N-acetylcysteine (NAC):
   Antioxidant, supports liver function, and reduces inflammation.
   Dose: 600–1,200 mg/day.
   Antioxidants:
   Quercetin:
   Reduces inflammation and supports the immune system.
   Dose: 500 mg 2–3 times/day.
   Fatigue Management:
   B-complex vitamins:
   Support energy metabolism and reduce fatigue.
   Dose: As directed, with at least 25–50 mg of B6.
5. Hydrotherapy:
   Warming Compress for Lymph Nodes:
   Use a warm, moist cloth over swollen lymph nodes for 10–15 minutes to reduce swelling and discomfort.
   Contrast Showers:
   Alternate hot (3 minutes) and cold (30 seconds) water to boost circulation and immune response.
6. Physical Modalities:
   Manual Lymphatic Drainage (MLD):
   Gentle massage technique to promote lymphatic circulation and reduce swelling.
   Acupuncture:
   Helps boost immune function, reduce fatigue, and relieve sore throat or pain.
   Focus on points like LI4, ST36, and CV22.
7. Homeopathy:
   Belladonna 30C:
   For fever with red, swollen tonsils.
   Dose: 2–3 pellets every 2–4 hours during acute symptoms.
   Phytolacca 30C:
   For throat pain radiating to the ears and swollen lymph nodes.
   Dose: 2–3 pellets every 4–6 hours.
8. Patient Education:
   Recovery Timeline:
   Educate that full recovery may take several weeks, with fatigue possibly lingering.
   Splenic Safety:
   Warn against heavy lifting or contact sports for at least 4–6 weeks to prevent splenic rupture.
   Symptom Monitoring:
   Advise seeking immediate care for severe abdominal pain (splenic rupture), difficulty breathing, or worsening symptoms.
9. Follow-Up:
   Monitor fatigue, lymphadenopathy, and splenomegaly.
   If symptoms persist beyond 4–6 weeks or worsen, reassess for complications like secondary bacterial infections or post-viral fatigue.
   This integrative approach ensures a comprehensive plan addressing both immediate symptoms and long-term recovery.

Question 13

Case 15

56 year old female
CC: Knee Pain
History
Onset of the pain 3 months ago
Location of the pain The right knee
Duration of the pain For the last couple of weeks
Quality of the pain It’s a deep ache in the joint with some stiffness
Aggravating factors Heavy use always makes the pain worse, like going up and down
stairs or dancing
Alleviating factors Rest after heavy use. Also gentle movement helps to reduce stiffness
after prolonged sitting
Radiation of the pain None
Timing: Frequency of pain All the time
Severity of the pain 3-4 out of 10
Change of the pain over time It’s getting worse
Stiffness Yes, it comes on after being in the same position for a long time, like
when I’m sitting at the office desk or lying down
Trauma to the joint No
Fever No
Grinding, clicking, locking, popping, or giving way No
Swelling No
History of repetitive joint overuse No
Other joints affected No
Rash No
Exercise I used to dance but, not in the last two and a half months
Dancing frequency before the pain started About once a week for an hour
Treated for these symptoms before No
Diagnosed with rheumatoid arthritis No
Numbness or tingling No
Occupation I’m an assistant branch manager at a bank
Ability to perform activities of daily living Yes, but I’m worried if I will be able to if the pain continues to get
worse
Recent dietary changes No, I follows the Canada Food Guide, and I drink water when I’m
thirsty
Sexually active Yes
New partners No
Dysuria No
Weight I’m about 155 pounds, probably about 30 pounds overweight
Height 5’5”
Medications About 1 regular strength Tylenol tablet 2 times per day for the past 2 weeks. Before that, I only took occassional Tylenol
Supplements None
Similar previous events No
Sexually transmitted infections None
Previous hospitalizatons or surgeries None
Past illnesses Nothing serious
Family History Mom had painfully swollen finger joints near the ends of her fingers.
She died of pneumonia at age 85
Alcohol 2 drinks per week
Illicit drugs None
Tobacco use None
Physical Exams
Blood pressure Normal
Pulse rate Normal
Respiration rate Normal
Temperature Normal
Knee inspection No swelling, erythema, or deformity
Right knee palpation Tenderness at the joint line
Left knee palpation No tenderness
Patellar ballotment test Normal
Milking suprapatellar pouch to elicit effusion
(petellar tap) Normal
Patellar bulge Normal
Active range of motion (AROM) Right knee AROM is restricted at the end range;
Left knee has full AROM
Passive range of motion (PROM) Tenderness at the end range with PROM of the right knee
Resisted range of motion Normal
All tests of the anterior collateral ligament (ACL) Normal
All tests of the posterior collateral ligament (PCL) Normal
All tests of the medial collateral ligament (MCL) Normal
All tests of the lateral collateral ligament (LCL) Normal
Knee crepitus Grating is felt throughout the movement in the right knee
McMurray test Normal
Leg length Equal
Feet alignment and foot position Normal
Weight bearing ability Normal
Gait assessment Normal
All hip assessments Normal
All ankle assessments Normal
All hand assessments Normal

Answer 13

Differential Diagnoses
1. Osteoarthritis (Most Likely):

Key Features:
Gradual onset of knee pain over months.
Deep ache, stiffness after inactivity, and crepitus (grating during knee movement).
Aggravation with activity and improvement with rest.
Absence of systemic symptoms (no fever, no rash, no other joint involvement).
Family History: Suggestive of osteoarthritis (mother with finger joint issues, potentially Heberden’s nodes).

2. Patellofemoral Pain Syndrome (PFPS):
   Key Features:
   Anterior knee pain worsened by activities like stair climbing.
   No trauma or specific injury but possible overuse due to prior dancing.
   No swelling or locking, but tenderness on palpation.
   Distinguishing Factor: PFPS usually involves pain behind or around the kneecap; crepitus suggests deeper joint pathology.

3.Meniscal Degeneration:
Key Features:
Chronic knee pain with tenderness along the joint line.
Crepitus and restricted motion.
Distinguishing Factor: No locking or clicking, which reduces the likelihood of a meniscal tear.

4. Rheumatoid Arthritis (Less Likely):
   Key Features:
   Symmetrical joint involvement, systemic symptoms, or signs of inflammation (e.g., swelling or warmth), all of which are absent.

Diagnostic Workup
1. Imaging Studies:

X-ray of the right knee: To assess for joint space narrowing, osteophytes, or subchondral sclerosis (hallmarks of osteoarthritis).
MRI (if needed): To evaluate cartilage health and rule out meniscal or ligament damage.

2. Blood Work (to rule out inflammatory or autoimmune causes):
   ESR/CRP: To check for inflammation.
   Rheumatoid factor (RF) and Anti-CCP antibodies: To rule out rheumatoid arthritis.
   Serum Calcium, Vitamin D, and Bone Mineral Density: To assess bone health if osteoporosis is a concern.
   Treatment Plan

Naturopathic Modalities
1. Lifestyle Modifications:
Weight Loss:
Aim to reduce weight through a balanced diet and exercise to decrease pressure on the knee joint.
Recommend gentle, low-impact exercises (e.g., swimming, cycling, or yoga).
Activity Adjustment:
Avoid repetitive knee stressors like stairs or dancing for now.
Incorporate frequent breaks during prolonged sitting.

2. Dietary Recommendations:
   Anti-inflammatory Diet:
   Emphasize omega-3-rich foods (fatty fish, flaxseeds, walnuts).
   Add anti-inflammatory herbs/spices like turmeric (curcumin) and ginger.
   Bone and Joint Health:
   Include calcium (leafy greens, almonds) and vitamin D (sun exposure, fortified foods) for joint and bone support.
   Consider collagen-rich bone broth or supplements.
3. Physical Therapies:
   Hydrotherapy:
   Alternate warm and cold compresses on the knee to reduce stiffness and improve circulation.
   Physiotherapy Referral:
   Strengthening exercises targeting the quadriceps and hamstrings.
   Manual therapy to improve joint mobility.
   Acupuncture:
   To reduce pain and promote healing by improving local circulation around the knee.
   Herbal and Supplement Support:

Glucosamine and Chondroitin Sulfate:
To support cartilage repair and reduce joint pain.
Boswellia Serrata (Indian Frankincense):
Anti-inflammatory herb to alleviate joint pain.
Turmeric (Curcumin):
Potent anti-inflammatory; suggest a bioavailable supplement (e.g., with black pepper for absorption).
Devil’s Claw (Harpagophytum procumbens):
To alleviate pain and inflammation in osteoarthritis.
Pain Management:

Topical Arnica Gel or Capsaicin Cream:
Apply to the affected knee to reduce pain and inflammation.
Homeopathic Remedies:
Rhus Toxicodendron: For stiffness and joint pain that improves with movement.
Arnica: For general joint pain.
Mind-Body Interventions:

Stress Reduction Techniques:
Incorporate mindfulness or meditation to address chronic pain perception.
Conventional Recommendations
Continue Tylenol as needed for mild pain relief.
Consider non-steroidal anti-inflammatory drugs (NSAIDs) if pain worsens (only short-term use to minimize side effects).
Follow-Up
Short-Term (2-4 weeks): Reassess pain levels, range of motion, and stiffness after lifestyle and dietary adjustments.
Long-Term (3-6 months): Monitor progression with imaging and ensure adherence to physical therapy and dietary interventions. Adjust treatment if symptoms worsen.

Question 14

Case 14

48 year old female
CC: Weight Gain

History
Initiation of weight gain It started two years ago
Rate of weight gain Gradual over time; I’ve gained about 25 pounds
Current weight and height 155lb (increased 25lb in 2 years), Height: 5’5”
Attempts to lose weight A low carbohydrate diet had helped me in the past, but not this time
Weight distribution I notice it most around my waist, hips, fingers and thighs
Energy changes I’ve been feeling heavy, tired and sleepy with difficulty concentrating
at work.
Appetite changes Decreased. I’ve recently changed to a low-carbohydrate diet to try to
lose weight. I don’t think I’ve been eating more than usual
Sleep changes No major changes. Maybe I’m not getting enough deep sleep. I wakes up earlier than my alarm clock. I have no trouble falling asleep. Ideally,
I’d sleep 9-10 hours, but I currently get 7-8 hours
Exercise changes I used to get exercise in the form of line dancing or yoga but I haven’t
had the stamina to do this in the past year
Bowel habits Constipated. I have small stools with 1 bowel movement every 3 days
or so
Perspiration changes No
Cold intolerance Yes
Hair loss Hair loss when I brush after showers
Skin changes Drier skin than before. I use lotion
Nail changes No
Mood changes None
Menstrual history 28 day cycle regular cycle but it’s been a heavier flow lately (6 maxi
pads per day for 3 to 5 days).
Dyspnea on exertion No
Ankle swelling No
Orthopnea No
Increased urination No
Increased thirst No
24-hour diet recall Breakfast: Whole grain blueberry muffin; Lunch: Cream of mushroom soup, garden salad, turkey breast; Dinner: Halibut steak, potatoes, carrots, chocolate cake. Beverages: water (2 cups), coffee (2 cups)
Smoking No
Recreational drugs No
Alcohol intake 1-2 drinks red wine/week
Medications Occasional advil (for the occasional headache)
Supplements I take ginkgo, fish oil, and calcium supplements
Past medical history I had my wisdom teeth out in my 20s. I had frequent sore throat as
teenager, chronic ear infections as child, and I’ve had a urinary tract infection
Family medical history My father passed away from lung cancer at 62 years of age. My mother is 76 year-old. She’s diabetic
My sister is 38-year-old and suffers with depression.
Psychosocial history Separated from husband 2 years ago
Work environment I’m an office manager. It’s stressful.
Physical Exam
Heart rate 56 bpm
Thyroid Inspection Thyroid appears slightly enlarged
Abdomen Inspection Adipose tissue is primarily over the abdomen and hips
Eye inspection No periorbital edema, no eyebrow thinning
Skin Inspection Skin is dry
Thyroid Palpation Thyroid is enlarged
Edema No edema
Heart Auscultation No murmurs, no S3
Lung Auscultation No crackles/rales
Ascites No shifting dullness or fluid wave

Answer 14

Differential Diagnoses
Hypothyroidism (Most Likely):

Key Features:
Gradual weight gain over 2 years, particularly around the abdomen, hips, and thighs.
Fatigue, cold intolerance, dry skin, hair loss, constipation, and difficulty concentrating (“brain fog”).
Slightly enlarged thyroid on inspection and palpation.
Bradycardia (heart rate of 56 bpm).
Polycystic Ovary Syndrome (PCOS):

Key Features:
Weight gain around the abdomen.
Menstrual changes (heavier flow).
Distinguishing Factors: Absence of other PCOS signs such as hirsutism, acne, and irregular periods.
Cushing’s Syndrome:

Key Features:
Weight gain with central distribution (abdomen and hips).
Distinguishing Factors: No evidence of a “buffalo hump,” purple striae, or muscle weakness, making this less likely.
Depression or Chronic Stress:

Key Features:
Weight gain, fatigue, and stress from her work environment and separation from her husband.
Distinguishing Factors: Lack of other depressive symptoms such as anhedonia or low mood.
Perimenopause:

Key Features:
Age and heavier menstrual flow could indicate perimenopausal hormonal changes.
Distinguishing Factors: Fatigue and systemic symptoms are better explained by hypothyroidism.
Diagnostic Workup
Laboratory Testing:

Thyroid Function Tests: TSH, Free T4, and Free T3 to confirm hypothyroidism.
Thyroid Antibodies: Anti-TPO and Anti-thyroglobulin to assess for Hashimoto’s thyroiditis.
Lipid Panel: To evaluate for hypothyroidism-related dyslipidemia.
CBC and Ferritin: To rule out anemia contributing to fatigue.
Fasting Glucose and HbA1c: Given family history of diabetes.
Imaging:

Thyroid Ultrasound: If thyroid enlargement or nodules are noted during the physical exam.
Treatment Plan
Naturopathic Modalities
Lifestyle and Diet:

Hypothyroid-Supportive Diet:
Focus on whole, nutrient-dense foods, particularly selenium (Brazil nuts, sunflower seeds) and iodine (seaweed, iodized salt) to support thyroid function.
Increase fiber intake to address constipation (e.g., vegetables, flaxseeds, psyllium husk).
Reduce simple carbohydrates and refined sugar intake to support weight management and energy levels.
Meal Timing:
Emphasize smaller, balanced meals throughout the day to stabilize blood sugar.
Exercise:
Start with low-impact exercises like walking or yoga, gradually increasing as energy improves.
Herbal and Supplement Support:

Ashwagandha (Withania somnifera): Adaptogen to support stress response and improve thyroid function.
Bladderwrack (Fucus vesiculosus): Rich in iodine, supports thyroid function (ensure no iodine hypersensitivity or contraindications).
Selenium Supplementation: 200 mcg/day to support thyroid health.
Probiotics: To improve gut health and aid in regular bowel movements.
Physical Therapies:

Hydrotherapy: Alternating warm and cool compresses on the neck to improve thyroid circulation and reduce inflammation.
Mind-Body Techniques:

Stress Management:
Practice mindfulness or meditation to address work stress and emotional fatigue.
Counseling Referral: To process emotional stress related to her separation and work environment.
Additional Recommendations:

Sleep Hygiene:
Encourage consistent sleep and wake times, and address potential sleep disturbances with relaxation practices before bed.
Dry Skin Care:
Use hypoallergenic moisturizers with natural emollients like shea butter or coconut oil.
Conventional Management Integration
Consider initiating levothyroxine treatment if hypothyroidism is confirmed.
Collaborate with an endocrinologist for long-term thyroid management if needed.
Follow-Up
Short-Term (2-4 Weeks):
Reassess energy levels, bowel habits, and weight changes after dietary and lifestyle interventions.
Review thyroid function test results to confirm diagnosis.
Long-Term (3-6 Months):
Monitor thyroid levels and adjust treatment accordingly.
Evaluate adherence to lifestyle changes and reassess weight and fatigue.

Question 15

Case 13
43 year old male
CC: Cough
History
Onset of cough Six months ago
Progression over time Gradually getting more frequent over last three weeks
Frequency of coughing episodes Currently 3 – 4 episodes of coughing per day. Used to cough less
frequently.
Productive or non-productive Mostly dry occasionally a little wet
Amount of sputum Small amounts (2 tbsp per day)
Description of sputum Thin, with white or clear colour
Sputum odor No
Blood in sputum No
Alleviating factors Nothing seems to help
Associated symptoms (chect pain or tightness) Noticeable tightness in chest with cough.
Aggravating factors or triggers Worse at night. It’s often triggered by the smell of air freshener my
wife sprays when she cleans. Recently, sometimes with exercise.
Shortness of breath Sometimes with activity. It’s more noticeable lately.
Worse with physical activity Yes. I have always been a jogger, but for the last 3-4 weeks. I have
stopped jogging because it brings on coughing.
History of cardiovascular disease None
Wheeze Yes (noisy chest mostly at night)
History of lung conditions I don’t know. No one’s ever told me.
Fever About 6 weeks ago I had a fever for 3 days when I had flu symptoms. I
had a cough, fever, chills, muscle pain and a headache
Leg swelling No
Heart palpitations No
Chest pain No
Affecting sleep Sometimes. Two to three times per month the cough will keep me
from sleeping
Frequency of respiratory illnesses Usually one or two colds per year
Sore throat No
Nasal congestion No
Headache No
Exposure to tuberculosis I don’t know. I don’t think so.
International travel No
Weight loss No
Night sweats No
Similar symptoms in the past No
Heartburn No
Sour regurgitation No
Loss of smell No
Allergies None
Medications No current medication. My family physician prescribed antibiotics
about six weeks ago because of my flu symptoms but it didn’t help and I am still coughing. I tried Robitussin occasionally at night – a few teaspoons at a time but it doesn’t help. Nothing else seems to help.
Natural health products No. My friend gave me a herbal cough medicine that helped him during
the flu but I tried it a few times and it doesn’t help my cough

Occupational exposure I work on the floor of a factory that makes paper products for the last
15 years. We use solvents and there’s a fair amount of dust.
Smoking history Smoking - I used to smoke socially and infrequently in my early 20’s.
Now I occasionally have a cigar socially 2-3 times a year.
Stress level Low
Family life Happily married with two children, my daughter, age 8, and my son,
age 12
Alcohol 1 glass wine each night with dinner. Several beers on the weekends.
Recreational drugs None
Smoke exposure My wife occasionally smokes at home with friends after dinner.
Home heating system It’s an oil burning furnace
Carpeting at home Upstairs in the bedrooms.
Type and age of your home It’s a 25-year-old brick home.
Mould exposure None
Dust at home Minimal
Pets A year-old Labrador retriever.
Family history Younger brother has seasonal allergies and eczema. Mother side: Mother has hypothyroidism. Maternal grandmother had breast cancer but died of old age. Maternal grandfather died of old age and had digestive problems. Father side: Father has hypertension. Paternal grandmother died of old age. Paternal grandfather died of a heart attack age 60.
Physical Exams
Respiratory rate Normal
Blood pressure Normal
Temperature Normal
Heart rate Normal
Cyanosis None apparent on the skin or lips
Nail clubbing None
Pharynx No visible post nasal discharge, mucosal edema, cobblestone
appearance of the oropharyngeal mucosa or tonsillar enlargement
Nasoscopy No polyps, mucosal swelling, discharge or obstruction
Observe respiration No use of accessory muscles, intercostals muscle retractions or nasal
flaring
Shape of rib cage Normal
Peripheral edema None
Sinus palpation Non-tender
Observe the position of the trachea Midline position
Neck inspection No masses
Cervical lymph nodes No lymphadenopathy
Lung Percussion Normal
Lung Auscultation Generalized end-expiratory wheeze, expiration phase is longer than
inspiration phase, no crackles
PMI palpation Normal
Heart auscultation Normal
Jugular venous distension None
Otoscopy Normal

Tactile fremitis, egophony, bronchophony,
whispered pectoriliquy Normal
Diaphragmatic expansion Normal
Diaphragmatic excursion Normal

Answer 15

Differential Diagnoses
Asthma (Most Likely):

Key Features:
Chronic cough worsened by exercise and specific triggers (e.g., air fresheners).
Nocturnal symptoms (wheezing and coughing at night).
End-expiratory wheeze and prolonged expiration on auscultation.
History of factory work with potential irritant exposure (dust and solvents).
Lack of response to antibiotics, ruling out bacterial infection.
Occupational Asthma:

Key Features:
Long history of exposure to factory dust and solvents.
Symptoms triggered by occupational exposure (workplace-related irritants).
Chronic Obstructive Pulmonary Disease (COPD):

Key Features:
Chronic cough with sputum production.
History of smoking (though limited, this might contribute).
Exacerbation with environmental irritants (dust, air freshener).
Distinguishing Factors: Lack of significant smoking history and absence of airflow limitation findings reduce the likelihood of COPD.
Gastroesophageal Reflux Disease (GERD):

Key Features:
Chronic cough with no apparent infection.
Distinguishing Factors: No symptoms of heartburn, regurgitation, or other GERD indicators.
Post-Infectious Cough:

Key Features:
Persistent cough following a viral illness six weeks ago.
Distinguishing Factors: The cough has persisted for over six months and worsened over the last few weeks, making this less likely.
Hypersensitivity Pneumonitis:

Key Features:
Possible exposure to organic antigens (e.g., pet dander, dust from work).
Distinguishing Factors: No systemic symptoms (e.g., fever, fatigue) or crackles on auscultation, making this less likely.
Diagnostic Workup
Spirometry with Bronchodilator Testing:

To confirm asthma and assess for reversible airflow obstruction.
Peak Expiratory Flow Rate (PEFR):

Home monitoring over several weeks to identify diurnal variation.
Methacholine or Exercise Challenge Test:

If spirometry results are inconclusive but asthma is still suspected.
Chest X-Ray:

To rule out other causes of chronic cough, such as infection or structural abnormalities.
Allergy Testing:

Evaluate potential allergic triggers (e.g., pet dander, dust mites).
Exhaled Nitric Oxide (FeNO):

To assess airway inflammation, often elevated in asthma.
Treatment Plan
Conventional Management:
Short-Term Symptom Relief:

Prescribe a short-acting beta-agonist (SABA) (e.g., albuterol) as a rescue inhaler for immediate relief.
Long-Term Management:

Inhaled corticosteroids (ICS): To control airway inflammation.
Consider a long-acting beta-agonist (LABA) if symptoms persist despite ICS.
Addressing Triggers:

Minimize exposure to workplace dust and solvents; consider workplace adjustments.
Encourage reducing air freshener use at home.
Education:

Provide asthma education, including proper inhaler use and trigger management.
Naturopathic Modalities:
Lifestyle and Environmental Modifications:

Dust Control: Regular dusting with damp cloths, using air purifiers, and ensuring proper ventilation at work and home.
Pet Management: Reduce direct contact with the Labrador retriever if allergies are confirmed.
Dietary Support:

Incorporate anti-inflammatory foods (e.g., turmeric, omega-3-rich fish).
Encourage hydration to thin mucus.
Herbal Support:

Thyme (Thymus vulgaris): Antispasmodic and expectorant properties.
Lobelia (Lobelia inflata): Bronchodilator, if appropriate, in low doses.
Licorice root (Glycyrrhiza glabra): Soothing to inflamed airways; avoid in hypertensive patients.
Mind-Body Techniques:

Breathing Exercises: Teach diaphragmatic breathing to improve lung capacity and relaxation.
Physical Medicine:

Hydrotherapy: Alternating hot and cold compresses to the chest for symptom relief.
Follow-Up Plan
Short-Term (1-2 Weeks):

Reassess symptom response to short-term medication (e.g., SABA).
Medium-Term (1-3 Months):

Monitor asthma control with spirometry or PEFR.
Adjust treatment plan based on symptom progression.
Long-Term:

Reevaluate occupational exposure risks and provide recommendations for long-term asthma management.

Question 16

Case 12
52-year-old male CC: chest discomfort
History
Timing of onset Last week or two
Change over time Getting worse
Character of the pain Feels like burning or gnawing
Location of the pain Behind my breastbone
Pain radiation None
Frequency of the pain Wakes me up almost every night of the week
Intensity of the pain 5 – 6 out of 10 (10 = worst)
Duration of pain episodes It lasts 1 to 2 hours
Associations or aggravating factors Worse after drinking alcohol, after a large meal, eating
spicy foods, and chocolate
Relieving factors Nothing really relieves it, walking around helps
Sour taste in the mouth Yes, sometimes
Pain change with position change Symptoms are made worse by bending over or lying
down
Symptoms worse with exercise No
Relieved by rest No
Shortness of breath No
Blood or black color in stool No
Recent history of vomiting No
Difficulty swallowing No
Hoarseness No
Persistent non-productive cough No
Weight loss No
Smoking No
Alcohol use Social drinker - drinks to relieve stress – will have 2-3
drinks when socializing 3 times per week
Recreational drugs No
Diet – standard North American diet Standard North American diet
Medications or natural health products No
Have you been treated for these symptoms in the past? No
Heart problem, diabetes, hypertension No
Stomach problem, gallbladder No
Back problem No
Family History Mother has diabetes
Father had high BP and died at the age of 75 from a stroke
Social History Marriage is fine;
Work is stressful - level 7/10
Physical Exams
HR - normal Normal
RR - normal Normal
Blood pressure – Normal Normal
Temperature - no fever Normal
Inspection - Chest Normal
Inspection - Abdomen Normal
Auscultation – Heart Normal
Auscultation – Abdomen Normal
Percussion – Abdomen Normal
Light Palpation - Abdomen Normal
Deep Palpation – Abdomen Tender epigastric area
Organomegaly tests No splenomegaly or hepatomegaly
Murphy’s sign Negative
Palpation of the chest No pain
Pitting edema None

Answer 16

Differential Diagnoses
Gastroesophageal Reflux Disease (GERD) - Most Likely:

Key Features:
Burning, gnawing chest pain behind the breastbone (classic for GERD).
Pain worsened by eating large meals, spicy foods, alcohol, and chocolate.
Symptoms worsen when lying down or bending over.
Associated with sour taste in the mouth (acid regurgitation).
No weight loss, dysphagia, or alarming signs (e.g., bleeding).
Peptic Ulcer Disease (PUD):

Key Features:
Burning, gnawing epigastric pain that wakes him up at night (nocturnal symptoms).
Tenderness in the epigastric area on palpation.
Symptoms aggravated by stress and diet.
Distinguishing Factor: GERD is more likely given the positional exacerbation and absence of melena or hematemesis.
Esophageal Spasm:

Key Features:
Retrosternal chest pain that can mimic GERD.
Distinguishing Factor: Typically associated with dysphagia or difficulty swallowing, which this patient does not report.
Non-Cardiac Chest Pain:

Key Features:
Chest discomfort not related to exertion, relieved by movement.
Distinguishing Factor: GERD-related symptoms fit better with this patient’s history.
Cardiac Ischemia (Unstable Angina):

Key Features:
Retrosternal chest discomfort that can sometimes mimic GERD.
Distinguishing Factor: Symptoms are not exertion-related, and cardiac examination is normal. While less likely, this diagnosis should be ruled out if symptoms worsen or if there are additional risk factors.
Diagnostic Workup
Esophagogastroduodenoscopy (EGD):

To evaluate for GERD, peptic ulcers, or esophagitis.
Ambulatory pH Monitoring:

To confirm acid reflux if the diagnosis is unclear after initial treatment.
H. pylori Testing:

Stool antigen test or urea breath test to rule out infection contributing to symptoms.
Electrocardiogram (ECG):

To exclude cardiac causes of chest discomfort given his age and family history.
Complete Blood Count (CBC):

To assess for anemia, which could suggest a bleeding peptic ulcer or other GI pathology.
Treatment Plan
Conventional Management
Lifestyle Modifications:

Avoid known triggers (large meals, spicy foods, chocolate, alcohol).
Eat smaller, more frequent meals.
Avoid lying down within 2-3 hours of eating.
Elevate the head of the bed to reduce nighttime symptoms.
Pharmacological Therapy:

Proton Pump Inhibitor (PPI): Omeprazole 20-40 mg daily for 4-8 weeks.
Reduces gastric acid production and promotes healing.
Antacids: As needed for immediate symptom relief (e.g., calcium carbonate).
Stress Management:

Encourage stress-reduction techniques (e.g., mindfulness, yoga, counseling).
Naturopathic Approaches
Dietary Support:

Eliminate trigger foods (alcohol, chocolate, spicy foods).
Incorporate soothing foods (e.g., oatmeal, bananas, ginger tea).
Herbal Medicine:

DGL (Deglycyrrhizinated Licorice): Supports mucosal healing and soothes the stomach.
Slippery Elm (Ulmus rubra): Forms a protective coating for the esophagus and stomach.
Probiotics:

To support gut health, especially if an H. pylori infection is suspected or treated.
Acupuncture:

May help with stress reduction and support digestive function.
Hydrotherapy:

Warm compresses to the epigastric area to relax and improve blood flow.
Follow-Up Plan
Short-Term (1-2 Weeks):

Assess response to PPI and lifestyle modifications.
Medium-Term (1-2 Months):

Evaluate for symptom resolution.
Consider further testing if symptoms persist or worsen.
Long-Term:

Reassess lifestyle habits and stress management strategies to prevent recurrence.

Question 17

Case 11

38 year old male
CC: Diarrhea
History
Onset of the diarrhea Started 2 years ago
Change over time Periods of diarrhea are getting more frequent. Last 3 months diarrhea
does not go away completely.
Description of stools Soft, watery stools with a light brown colour. There’s a lot of it too,
and when when I have to go, I have to go right away
Color of stools Light brown in color
Frequency of bowel movements 3-4 times per day on most days
Change from previous bowel movement (BM) Prior to 2 years: BM used to be well formed, 1 BM per day, dark brown
Associated symptoms (pain, gas, incomplete
emptying) Pain in lower abdomen; can be sharp “turning“ (like a spasm) and dull
at other times. Lots of gas with bowel movement. Bloating (feels heavy and distended). Feels like not getting it all out.
Intensity of pain 5-6/10 (10 = worst)
Alleviating factors Sometimes passing gas or having a bowel movement
Aggravating or precipitating factors Definitely aggravated by stress; and by some foods (uncertain about
which ones).
Weight loss 10 lbs over last 2 years, unintended
Current weight is 160
Fever No
Blood in stool Sometimes, very little, dark red, in streaks
Mucous in stool Sometimes
Greasy or oily stools No
Undigested food Yes, most of the time
Nocturnal diarrhea No
Nausea or vomiting No
Energy level 5/10
Change in urination No
24hr diet recall Breakfast: Corn Flakes with soy milk, large coffee with cream
Lunch (at work): Deli Sandwich (different kinds) and soup of the day (like beef barley) with a coffee
Dinner (wife cooks): lots of vegetables, chicken or fish Snacks: trail mix (1 cup), granola bar, some almonds
Diet changes No significant change
Smoking Smokes cigarettes (1/2 pack per day for 16 years)
Alcohol Alcohol: rarely (1-2 drinks every other weekend)
Medications Tried over-the-counter options like Imodium and Pepto Bismol with
mixed results (sometime it works, but often does not); does not use any medications currently
Supplements None
Past medical history Age 10 – broke arm while playing hockey - had to get a cast and bone
needed to be reset because of comminuted fracture
Recent travel No
Social Attorney, Lots of stress at work
Home life Monogamous, married, 3 kids

Anyone else in the family with similar
symptoms No
Physical Exam
Abdomen Inspection Normal
Abdominal Auscultation Bowel sounds present; high pitched throughout.
Abdomen Percussion Some discomfort felt in lower quadrants of abdomen.
Light Palpation No tenderness noted
Deep Palpation Tenderness experienced by patient in lower quadrants of abdomen at
a moderate level of pain.
Lymph nodes Normal
Temperature 36.5C
Blood pressure 126/80 mmHg
Pulse 76 bpm
Tissue turgor/mobility Normal
Inspect mouth, tongue Normal
Inspect skin for color and rashes Normal
Inspect conjunctiva Normal
Palpate liver Normal
Percuss liver Normal
Palpate thyroid Normal

Answer 17

This case presents a 38-year-old male with chronic diarrhea of two years’ duration, associated symptoms such as abdominal pain, gas, and weight loss, and some concerning signs such as occasional blood and mucus in the stool, undigested food, and worsening symptoms over time. Below is an analysis and possible differential diagnoses.

Key Points from History and Physical Exam:
Chronic Nature (2 years): Symptoms are persistent, with recent worsening in frequency.
Stool Characteristics:
Watery, light brown stools, undigested food: Suggests malabsorption or functional gut issue.
Blood (dark red, streaks) and mucus: Suggests possible inflammation or mucosal damage.
Associated Symptoms:
Abdominal pain: Lower abdominal location, sharp and dull, suggests potential colonic involvement.
Gas, bloating, and urgency: May be related to irritable bowel syndrome (IBS), inflammatory bowel disease (IBD), or malabsorption.
Weight Loss (10 lbs in 2 years): Raises concern for malabsorption or a chronic inflammatory condition.
Triggers: Symptoms are stress-related and possibly food-related.
Social History: High stress level, smoking, no significant dietary changes.
Physical Exam:
High-pitched bowel sounds: Indicates increased bowel activity, common in diarrhea and malabsorption.
Lower abdominal tenderness: Suggests involvement of the distal small intestine or colon.
Possible Differential Diagnoses:
Irritable Bowel Syndrome (IBS-D):

Symptoms overlap with IBS-D (diarrhea-predominant IBS), including urgency, bloating, and stress association.
However, the presence of blood, weight loss, and undigested food makes IBS less likely.
Inflammatory Bowel Disease (IBD):

Crohn’s Disease: Chronic diarrhea with abdominal pain, weight loss, blood in stool, and malabsorption could indicate Crohn’s.
Ulcerative Colitis: The absence of nocturnal diarrhea and the location of tenderness (lower quadrants) make UC less likely.
Celiac Disease:

Chronic diarrhea with undigested food and malabsorption (weight loss) is consistent.
However, the patient has no typical associations like gluten intolerance or iron deficiency anemia.
Small Intestinal Bacterial Overgrowth (SIBO):

Symptoms of bloating, gas, and malabsorption are consistent with SIBO.
The high-pitched bowel sounds are a potential clue.
Chronic Smoking-Associated Enteropathy:

Smoking can alter gut function and inflammation, contributing to diarrhea and malabsorption.
Microscopic Colitis:

Associated with watery diarrhea and can be triggered by smoking or stress. The absence of other systemic symptoms makes this a possibility.
Investigations:
Blood Tests:

CBC: Look for anemia or infection.
CRP/ESR: Assess for inflammation (IBD or other).
Electrolytes: Check for dehydration or malabsorption effects.
Celiac Serology: Tissue transglutaminase antibodies (tTG-IgA).
Stool Studies:

Fecal calprotectin: Evaluate for inflammation (IBD vs IBS).
Fecal occult blood test (FOBT) or fecal immunochemical test (FIT): Assess for blood in stool.
Stool culture and ova/parasites: Rule out infection.
Fecal elastase: Assess pancreatic function.
Imaging:

Abdominal ultrasound or CT: Assess for structural abnormalities or inflammation.
Consider small bowel imaging (e.g., MR enterography) for Crohn’s.
Endoscopy:

Colonoscopy with biopsies: Gold standard to assess for IBD or microscopic colitis.
Breath Test:

To rule out SIBO.
Management Plan:
Dietary modifications: Trial of low-FODMAP diet or elimination of suspected triggers (e.g., dairy or gluten).
Smoking cessation: Smoking can worsen IBD and other gut disorders.
Stress management: Psychological support or stress-reduction techniques could benefit.
Referral: If IBD or other serious pathology is suspected, refer to a gastroenterologist.
Would you like to explore further on diagnostics or a specific differential?

Question 18

Case 10
34-year-old female CC: headache

History
Onset of headaches 5 years ago
Timing: Progression Seems to be getting worse. It is more frequent in the last 3
months
Timing: Frequency of headaches They’re happening 3 times a week for the past 3 months. For
5 years before that, they happened about once a week
Timing: Duration of the headaches Takes a day to go away completely
Character/Quality of the headaches Throbbing, especially with exertion
Location of headaches At my temple. It’s more noticeable on right side
Intensity of the pain 6/10 (10 worst) with the same intensity over the past 3
months. Impairs concentration, performance at work and relationship with friends. It’s frustrating
Associated symptoms (photophobia or
phonophobia) I get sensitivity to bright light
Aggravating factors 2 days premenstrual, first days of menses
Alleviating factors I take Advil (or Excedrin) up to 4 tablets/day, which helps a
little. Closing my eyes, or stay in dark room and napping
Precipitating factors Stress of presentations to board members, sweets
Systemic symptoms (myalgia, fever, weight loss) No
Headache worse on coughing/sneezing/changing
position No
Visual disturbance (blurry, flashes, double vision,
dark spots) No
Neurological changes: weakness, numbness,
tingling, speech difficulties, dizziness No
Recent/ current pregnancy No
Change in mental status (loss of consciousness, confusion, forgetfulness or disorientation) No
Recent head trauma No
Vomiting No
Nausea Yes
Pain in the ears/dental concerns No
Pain in sinuses No
Phonophobia Yes
Medications Advil/Excedrin up to 4 tablets per day
Past medical history Only these headaches over the last 5 years
Recent change in diet/lifestyle Recent promotion at work, more responsibility, less time for meals, skips meals, compensates by eating sweets. Drinks
about 5 glasses of water/day
Social history/stress level Executive in a high-pressured office position (computer programmer, testing team leader). Married, no children, stable relationship for 4 years. Feels stressed-out due to new
authority at work

Substance use No alcohol, smoking, or illicit drug use, 1 cup of coffee per day
Physical Exams
Pulse Normal
Temperature Normal
Blood pressure Normal
Respiration rate Normal
Opthalmoscopy Normal
Meningeal signs No nuchal rigidity, Brudzinski’s sign or Kernig’s sign
Palpate frontal and maxillary sinuses No pain
Dermatomes Normal
Myotomes Normal
Inspect Nose Normal
Inspect Mouth Normal
Otoscopy Normal
Palpate TMJ Normal
Cranial nerves All normal
Cervical AROM/PROM/RROM All normal
Palpate head and neck Normal

Answer 18

Thunderclap headache (sudden, severe onset) → Subarachnoid hemorrhage
New onset in someone >50 years old → Giant cell arteritis, tumor, stroke
Progressive worsening despite treatment → Tumor, increased intracranial pressure (ICP)
Focal neurological symptoms (weakness, vision loss, ataxia, speech issues, seizures) → Stroke, tumor, multiple sclerosis
Headache that worsens with coughing, sneezing, or positional changes → Increased ICP, Chiari malformation
Papilledema on fundoscopy → Raised ICP (tumor, idiopathic intracranial hypertension)
Signs of meningitis (fever, stiff neck, altered mental status) → Infection
History of cancer, HIV, or immunosuppression → Metastatic disease or CNS infection
Worsening headache in pregnancy/postpartum → Cerebral venous sinus thrombosis (CVST), preeclampsia

Differential Diagnoses
Most Likely
Migraine without aura

Throbbing pain, worsens with exertion
Unilateral (right temple)
Associated with photophobia, phonophobia, and nausea
Triggered by stress, hormonal changes, diet (sweets, skipped meals)
Partial relief with Advil/Excedrin
Tension-Type Headache (TTH)

Can be associated with stress and prolonged screen time
Less likely due to its typically bilateral nature and lack of nausea
Usually not worsened by exertion
Less Likely but Consider
Medication Overuse Headache (Rebound Headache)

Regular use of Excedrin (contains caffeine) and Advil
Worsening pattern over time
Headaches occurring ≥3 times per week
Menstrual Migraine

Clear pattern of worsening headaches pre-menstrual and during menstruation
Likely an exacerbating factor rather than the sole cause
Cervicogenic Headache

Could mimic migraine but usually associated with neck pain or stiffness
Normal cervical exam makes this less likely
Cluster Headache

Severe, unilateral pain, often orbital or temporal
More common in men and associated with autonomic symptoms (eye watering, nasal congestion)
Not consistent with this presentation
Idiopathic Intracranial Hypertension (IIH)

More common in obese women of childbearing age
Papilledema would be expected on exam

Treatment Plan
Lifestyle & Preventative Measures
Dietary Adjustments:

Eat regular meals to prevent hypoglycemia-induced headaches
Reduce sugar intake (possible trigger)
Increase hydration (≥8 glasses/day)
Stress Management:

Cognitive Behavioral Therapy (CBT), relaxation techniques
Regular exercise (but avoid over-exertion)

Sleep Hygiene:
Regular sleep schedule (migraines often linked to irregular sleep)
Acute Treatment (During Headache)

First-line:
NSAIDs (ibuprofen 400-600 mg) or acetaminophen
Triptans (sumatriptan, rizatriptan) if NSAIDs are ineffective

Adjuncts:
Dark, quiet room during attacks
Cold compress to temples
Preventative Treatment (If Frequent or Severe)
If headaches continue ≥4 times per month or significantly impact daily life, consider:

Beta-blockers (e.g., propranolol)
Amitriptyline (if tension-type headache overlap)
Topiramate (esp. if associated with weight concerns)
Magnesium, riboflavin, CoQ10 supplementation (evidence suggests migraine prevention)
Conclusion
Most likely: Migraine without aura, possibly exacerbated by stress and diet
Next steps: Lifestyle changes, headache diary, trial of triptans if needed
Monitor for red flags, consider MRI if worsening persists

Question 19

Case 9 34-year-old female
CC: difficulty conceiving
History
Duration of trying to conceive My husband and I have been trying for about 18 months now. We’ve
been really hoping to start a family.
Previous pregnancies None
Menstrual cycle regularity My cycles are somewhat irregular. They don’t always come at the same
time every month.
Interval between periods It usually ranges from 30 to 40 days. Sometimes it comes a little earlier,
sometimes later.
Duration of period My periods typically last around 5 to 7 days.
Pain during period Yes, I have a lot of pain during my period. It usually starts a day or two
before my period and lasts through it.
Severity of menstrual pain The pain is usually moderate to severe. I sometimes have to take time
off work because of it.
Pain outside menstrual period Yes, I sometimes have a dull ache in my pelvis even when I’m not on my
period. It can get sharp, especially during ovulation.
Pain during or after intercourse Yes, sometimes after intercourse, I feel a sharp pain that can last for a
Change in menstrual flow Yes, my periods have gotten heavier over the last year. I used to be able to manage with regular pads, but now I need the heavy-duty ones.
Pain during bowel movements Yes, especially during my period, it can hurt when I have a bowel
movement. It’s a sharp pain that makes it really uncomfortable.
Bloating or pelvic discomfort Yes, I feel bloated and have discomfort in my pelvis, especially around
my period and during ovulation.
Recent weight changes Yes, it’s been harder to lose weight lately. I’ve been trying to eat healthy
and exercise, but the weight isn’t coming off like it used to.
Difficulty losing or gaining weight Yes, I’ve always had to watch my weight, but it’s been more difficult to
lose weight over the past couple of years.
Skin changes Yes, I’ve noticed more acne, especially around my jawline, and I’ve had some hair growth on my chin and upper lip that I find really
embarrassing.
Unusual hair growth Yes, I’ve noticed some coarse hairs on my chin and upper lip that
weren’t there before. I have to pluck them regularly.
Previous reproductive health diagnoses None
Medical conditions or surgeries None
Medications or supplements I take a multivitamin daily to stay healthy, but that’s it.
Smoking, alcohol, or drug use I don’t smoke or use drugs. I do drink socially, like a glass of wine on the
weekends with friends.
Family history of reproductive health issues Nothing I’m aware of.
24-hour diet recall I try to eat balanced meals. For breakfast, I usually have oatmeal with some fruit. Lunch is often a salad or a sandwich, and for dinner, I have a home-cooked meal with vegetables and some protein like chicken or fish. I also drink plenty of water throughout the day.
Physical activity I try to stay active. I usually exercise at least three times a week, mostly
walking in the neighborhood or doing yoga at home.
Frequency of sexual intercourse We have sex a few times a week, especially when I think I’m ovulating.
Fertility testing or treatments None

Physical Exams
General appearance assessment Well-nourished, in no acute distress.
Vital signs BP: 120/80 mmHg, HR: 76 bpm, RR: 16/min, Temp: 36.7°C
Height, weight, BMI height: 5’4” (163 cm), weight: 160 lbs (73 kg), (BMI: 27.5 kg/m²)
Abdominal palpation Mild tenderness in lower abdomen, particularly on left side
Pelvic examination Slightly enlarged, retroverted uterus with tenderness on movement
Speculum examination Cervix normal
Bimanual examination Uterus slightly enlarged, retroverted, tender on palpation
Adnexa palpation No masses, generalized tenderness bilaterally
Skin examination for hirsutism Mild hirsutism on chin and upper lip
Skin examination for acne Mild acne on face
Breast examination Normal, no masses or discharge
Thyroid examination No enlargement or nodules
External genitalia inspection Normal
Hair distribution examination Coarse hairs on chin and upper lip, normal chest and back hair
distribution
Secondary sexual characteristics Normal breast development and pubic hair distribution

Answer 19

Red Flags to Check For
Since the patient is experiencing difficulty conceiving for 18 months with irregular cycles, menstrual pain, weight gain, and signs of hyperandrogenism (hirsutism, acne),

Red Flags for Ovarian Pathology:
Sudden, severe, unilateral pelvic pain → Ovarian torsion, ruptured cyst
Abdominal distension, bloating, unexplained weight loss → Adnexal tumor
Amenorrhea + pelvic pain + vaginal bleeding → Ectopic pregnancy
Fevers, chills → Possible infection/abscess

consider:

Immediate Concerns (Requiring Urgent Evaluation)
Severe, sudden pelvic pain → Consider ovarian torsion, ruptured cyst, or ectopic pregnancy
Rapid unexplained weight gain, fatigue, or mood changes → Consider thyroid dysfunction, Cushing’s syndrome
Abnormal uterine bleeding (postcoital, intermenstrual, postmenopausal, prolonged or very heavy periods) → Consider endometrial hyperplasia, fibroids, or malignancy
No urgent red flags are present, but further investigation is needed given infertility, cycle irregularity, and signs of hyperandrogenism.

Differential Diagnoses
Most Likely
Polycystic Ovary Syndrome (PCOS)

Irregular cycles (30-40 days)
Hirsutism (chin, upper lip hair), acne
Weight gain, difficulty losing weight
Possible anovulation leading to infertility
Enlarged, retroverted uterus (could be incidental or linked to PCOS/metabolic changes)
Bilateral adnexal tenderness (may suggest ovarian cysts)
Endometriosis

Severe dysmenorrhea and chronic pelvic pain
Dyspareunia (pain after intercourse)
Painful bowel movements during periods
Infertility risk due to adhesions and inflammation
Retroverted uterus, tenderness on bimanual exam
Other Considerations
Hypothyroidism

Irregular cycles, weight gain, difficulty losing weight
Could affect ovulation and fertility
Needs thyroid function testing (TSH, free T4)
Hyperprolactinemia

Can cause anovulation, irregular cycles, infertility
Check prolactin levels (especially if galactorrhea is present)
Cushing’s Syndrome

Hirsutism, weight gain, acne, irregular cycles
Needs further testing (24-hour urinary cortisol, dexamethasone suppression test)
Congenital Adrenal Hyperplasia (Non-Classical CAH)

Mild hirsutism, acne, irregular cycles
Consider if 17-hydroxyprogesterone levels are elevated
Next Steps (Diagnostic Workup)
1. Bloodwork
✅ Hormonal Testing:

FSH, LH (PCOS: ↑ LH:FSH ratio)
Total & free testosterone (hyperandrogenism)
DHEA-S (adrenal source of androgens)
Prolactin (rule out hyperprolactinemia)
TSH, Free T4 (rule out hypothyroidism)
17-hydroxyprogesterone (rule out non-classical CAH)
✅ Metabolic Panel (If PCOS suspected):

Fasting glucose & insulin (check for insulin resistance)
HbA1c (assess prediabetes/diabetes risk)
Lipid panel (PCOS often linked to dyslipidemia)
2. Pelvic Ultrasound (Key for PCOS & Endometriosis)
PCOS: Multiple small follicles (≥12 per ovary), “string of pearls” appearance
Endometriosis: Ovarian cysts (endometriomas), thickened endometrium, signs of adhesions
3. Ovulation Tracking
Serum progesterone (day 21 of cycle, or 7 days before expected period)
Basal body temperature tracking (to confirm ovulation)
Treatment Plan
Lifestyle Modifications
✅ For PCOS (if confirmed):

Weight management: Even 5-10% weight loss can restore ovulation
Diet: Low glycemic index (GI) foods, high fiber, anti-inflammatory diet
Exercise: Regular moderate exercise to improve insulin sensitivity
✅ For Endometriosis (if confirmed):

Anti-inflammatory diet (omega-3, turmeric, avoiding processed foods)
Stress reduction (yoga, acupuncture, mindfulness)
Pharmacologic Treatment (Depends on Diagnosis)
✅ For PCOS-Induced Anovulation:

First-Line for Ovulation Induction:

Letrozole (preferred over clomiphene)
Metformin (if insulin resistance is present)
Regulate Cycles (If Not Trying to Conceive Immediately):

Oral contraceptives (to lower androgens, regulate cycles, reduce acne/hirsutism)
Spironolactone (for hirsutism/acne if contraception is used)
✅ For Endometriosis:

NSAIDs (for pain relief)
Hormonal therapy (OCPs, GnRH analogs like leuprolide, or progestins)
Surgical management (if severe adhesions or infertility present)
Fertility Considerations
If ovulation induction (letrozole) fails → Refer to a fertility specialist
Consider intrauterine insemination (IUI) or in-vitro fertilization (IVF) if needed
Conclusion
Most likely diagnosis: PCOS vs. Endometriosis (or both)
Next steps: Hormonal testing, pelvic ultrasound, ovulation tracking
Treatment: Lifestyle modifications, ovulation induction if PCOS, hormonal suppression if endometriosis

Question 20

Case 6

65-year-old male
CC: shortness of breath
History
Duration of shortness of breath Six months. It started slowly and has been getting
progressively worse.
Distance walked before breathless A few blocks. I used to walk a mile without any issues.
Timing of shortness of breath On exertion, such as walking up stairs or carrying groceries.
Wheezing Yes, occasionally, especially at night or when I lie down.
Chest tightness No
Cough Yes, it’s persistent.
Duration of cough I’ve had it for years, but it’s been more noticeable in the past
six months.
Sputum appearance White, mostly in the mornings.
Previous lung conditions No
Chest pain No
Heart racing No
Heart skipping beats No
Fainting No
Feeling like fainting No
Swelling in legs Yes, by the end of the day, especially if I’ve been on my feet a
lot.
Swelling in ankles Yes, it gets worse in the evenings.
Nocturnal shortness of breath No
Number of pillows used at night I sleep with one pillow.
Sitting up to breathe at night No
Known heart conditions No
Recent weight loss No
Smoking history Yes, I smoked a pack a day for 40 years.
Amount smoked 1 pack per day
Duration of smoking Since I was 20, quit five years ago.
Family history of lung disease No
Family history of heart disease No
Current medications None
Allergies No
Occupation Retired, previously worked as a factory worker.
Exposure to dust, chemicals, fumes No, not anymore. I was exposed to dust and fumes in the
factory.
Regular exercise No, I get out of breath too easily.
Typical day’s meals and snacks Breakfast: cereal with milk, Lunch: ham and cheese sandwich, Dinner: grilled chicken with vegetables, Snacks: apples or bananas, Fluid intake: mostly water and a couple of cups of
coffee.
Alcohol consumption Yes, socially.
Amount of alcohol A couple of beers on weekends with friends.
Frequency of alcohol consumption Weekly
Use of recreational drugs No

Recent travel No, I haven’t traveled recently.
Exposure to respiratory infections No, not that I’m aware of.
Physical Exams
Blood pressure 135/85 mmHg
Heart rate 88 bpm
Respiratory rate 22 breaths/min
Temperature 37.0°C
Jugular venous distension No JVD
Pitting edema Mild bilateral pitting edema in lower extremities
Chest anteroposterior diameter Increased
Breath sounds Diminished bilaterally
Lung wheezes Scattered wheezes
Lung crackles No crackles
Heart sounds Normal heart sounds
Heart murmurs No murmurs
Abdominal tenderness Non-tender
Hepatosplenomegaly No hepatosplenomegaly
Clubbing No clubbing
Cyanosis No cyanosis
Muscle wasting No significant muscle wasting

Answer 20

True Red Flags (Require Urgent/Emergency Action)
🚨 Severe Progressive Shortness of Breath – Could indicate acute respiratory failure, pulmonary embolism (PE), or heart failure exacerbation.
🚨 Sudden-Onset Severe Wheezing & Cough – Could indicate status asthmaticus (A prolonged and severe asthma attack that does not respond to standard treatment.), anaphylaxis, or acute bronchospasm.
🚨 Severe Bilateral Lower Extremity Edema + SOB – Could indicate acute decompensated heart failure (ADHF), pulmonary hypertension, or massive DVT.
🚨 Respiratory Rate >30/min or Signs of Respiratory Distress – Suggests impending respiratory failure.

Differential Diagnosis:
Chronic Obstructive Pulmonary Disease (COPD) (Most Likely) – Due to smoking history, progressive SOB, wheezing, chronic cough, and increased chest diameter.
Chronic Bronchitis (Subtype of COPD) – Daily cough with white sputum.
Emphysema (Subtype of COPD) – Air trapping with increased AP diameter, diminished breath sounds.
Cor Pulmonale (Right-Sided Heart Failure due to Lung Disease) – Bilateral pitting edema without JVD.
Asthma (Less Likely) – Chronic but progressive worsening is more typical of COPD.
Congestive Heart Failure (CHF) (Less Likely without JVD or crackles) – Mild edema but no orthopnea, PND, or significant heart signs.
Lung Cancer (Needs Ruling Out) – Smoking history + chronic cough.
Next Steps (Investigations & Referrals)
Pulmonary Function Tests (PFTs): To confirm COPD (FEV1/FVC < 70% post-bronchodilator).
Chest X-ray: To assess lung hyperinflation (COPD) or rule out lung masses.
CT Chest (if suspicious of cancer): Especially if cough worsens or hemoptysis occurs.
Spirometry: To assess obstructive vs. restrictive patterns.
Echocardiogram: If suspecting cor pulmonale or heart failure.
BNP & NT-proBNP (if heart failure suspected).
Pulse Oximetry & ABG (if hypoxia suspected).
6-Minute Walk Test (Assess functional lung impairment).
Naturopathic Treatment Plan:
🔹 Lifestyle & Respiratory Support:

Smoking Cessation Support: Although he quit 5 years ago, reinforce avoiding secondhand smoke.
Pulmonary Rehabilitation: Breathing exercises, pursed-lip breathing, and incentive spirometry.
Exercise (as tolerated): Gentle walking with rest periods to improve lung function.
🔹 Diet & Supplements:

Anti-inflammatory Diet: Increase omega-3s (flaxseeds, walnuts, fish), turmeric, and ginger to reduce airway inflammation.
Magnesium (300-400 mg/day): Supports bronchodilation.
N-Acetylcysteine (NAC) (600-1200 mg/day): Mucolytic to help clear sputum.
Vitamin D (2000-5000 IU/day): Low vitamin D is linked to COPD exacerbations.
🔹 Herbal Medicine:

Mullein (Verbascum thapsus): Lung tonic, expectorant.
Lobelia (Lobelia inflata) (low dose): Bronchodilator.
Licorice root (Glycyrrhiza glabra) (short-term): Anti-inflammatory, supports lung health. Avoid if hypertensive.
🔹 Hydrotherapy:

Steam inhalation with eucalyptus oil or peppermint to open airways.
🔹 Acupuncture:

Points like LU9 (lung qi deficiency), ST36 (energy), and BL13 (lung shu) may help.
Follow-Up:
Monitor for worsening SOB, increased sputum, or weight loss (concern for lung cancer).
If diagnosed with COPD, focus on preventing exacerbations, improving lung function, and optimizing quality of life.

Question 21

Case 8

34-year-old woman CC: low mood
History
Onset of low mood I started feeling low about six months ago.
Events or situations worsening mood I feel much worse when I’m at home, especially after a fight with my partner. I
try to avoid being around him when he’s angry.
Loss of interest in activities Yes, I used to love painting, but I haven’t touched a brush in months. Nothing
seems enjoyable anymore.
Relationship with partner It’s been really stressful.
Challenges in relationship Yes, he has a short temper and sometimes yells at me for small things. I’m
always on edge, worried about what might set him off.
Safety at home No, I don’t feel safe. I’m always worried something might happen.
Physical harm by partner He’s pushed me a couple of times, usually during arguments. I tried to brush it
off, but it scared me.
Threats from partner He’s threatened to leave me and take our child with him. I’m afraid to stand up
to him because of that.
Support system No, I’ve been avoiding everyone. I don’t want them to see how bad things
have gotten, and I’m embarrassed to talk about it.
Physical symptoms - headaches Yes, I get headaches almost every day. They usually start in the afternoon and
get worse by evening, especially after stressful days.
Physical symptoms - stomachaches Yes, I often feel nauseous, especially when I’m anxious or when I’m about to
see my partner. Sometimes, I skip meals because of it.
Recent major life changes None
Recent major stressors Just the stress at home with my partner. Every day feels like I’m walking on
eggshells.
Effect on work I’ve been missing deadlines and making mistakes. My boss has noticed, and I’m
worried I might lose my job if this keeps up.
Effect on daily functioning It’s hard to do anything; I feel tired all the time. Even getting out of bed feels
like a chore. I barely have the energy to take care of my child.
Alcohol use I drink occasionally, maybe a glass of wine with dinner once a week. I’ve been
tempted to drink more to cope with the stress, but I haven’t.
Recreational drug use No
Medications No
Supplements None
Little interest or pleasure in doing things Nearly every day, I find it hard to enjoy anything. Even things I used to love,
like painting, feel pointless now.
Feeling down, depressed, or hopeless Nearly every day, I wake up with this heavy feeling that today will be just as
bad as yesterday, and I don’t see it getting better.
Trouble falling or staying asleep Several days, I struggle to fall asleep because my mind is racing, and when I do
sleep, I often wake up in the middle of the night, worried.
Sleeping too much Several days, I’ve slept in late or gone back to bed after getting my child ready,
just to escape the day.
Feeling tired or having little energy Nearly every day, I’m exhausted. Even simple tasks like making breakfast feel
like they take all my energy.
Poor appetite Not at all. My appetite hasn’t changed, but I sometimes skip meals because of
nausea.
Overeating Not at all. If anything, I’ve been eating less because of the nausea.
Feeling bad about yourself Nearly every day, I feel like a failure, especially when I think about how I’ve let
my work slip and how I’m not being the best mom I could be.
Thoughts of failure or letting family down Several days, I think about how I’m not living up to what my family needs. I
worry that my partner is right about me being worthless.

Trouble concentrating Nearly every day, I find it hard to focus on anything, whether it’s at work or
just watching TV. My mind feels foggy.
Moving or speaking slowly Not at all. I don’t think I’ve noticed anything like that.
Fidgety or restless Several days, I’ve found myself pacing around the house, unable to sit still
because of the stress.
Thoughts of self-harm A few times, I’ve thought it might be better if I weren’t here, but I wouldn’t act
on those thoughts. I couldn’t do that to my child.
Physical Exams
General appearance The patient appears tired and slightly disheveled, with dark circles under her
eyes.
Skin inspection No signs of trauma, although there are faint bruises on her upper arms
(if asked, she attributes these to bumping into things)
Palpation of painful/tender areas None
Neurological exam Cranial nerves II-XII intact. Patient’s reflexes are normal and symmetrical.
Mental status exam The patient is oriented to person, place, and time. Her affect is flat, and she
avoids eye contact. She speaks in a slow, monotone voice.
Eye inspection No signs of anemia or jaundice. Pupils are equal, round, and reactive to light.
Thyroid palpation Thyroid is non-enlarged, no nodules palpated.
Cardiovascular exam Heart rate and rhythm are regular, blood pressure is 118/76 mmHg. No
murmurs, gallops, or rubs heard.
Respiratory exam Breath sounds are clear bilaterally. No wheezing or crackles detected.
Abdominal exam Abdomen is soft, non-tender, no organomegaly. Bowel sounds are normal.
Musculoskeletal exam Normal range of motion, muscle strength 5/5 in all major muscle groups. No
joint swelling or deformities.
Head and neck exam No tenderness or deformities noted.
Reflexes evaluation Reflexes are 2+ and symmetric in all extremities. Babinski reflex is negative.
Nails and hair inspection Nails are well-groomed, and hair appears healthy, although slightly unkempt.
Gait and coordination Gait is normal, coordination is intact. Patient walks slowly, with a slight
hesitation.

Answer 21

Red Flags to Check For
Safety concerns (Domestic violence & abuse)
Suicidal ideation, self-harm thoughts → Psychiatric emergency
Weight loss, sleep changes → Depression, malignancy
Memory loss, cognitive impairment → Dementia, hypothyroidism

Must-Not-Miss Diagnoses:
Major Depression, Bipolar Disorder
Hypothyroidism, Chronic illness (Cancer, Diabetes)
Substance abuse, B12 deficiency

Tests & Exams:
Mental Status Exam (MSE): Affect, cognition, insight
Thyroid Panel (TSH, Free T4)
CBC (Anemia), B12, Fasting glucose

The patient does not feel safe at home and has been physically pushed by her partner.
Bruises on her arms that she dismisses as “bumping into things.”
Threats from her partner (taking her child away).
Next step: Immediate screening for intimate partner violence (IPV) and referral to support services.
Suicidal ideation

Has had thoughts of self-harm but states she wouldn’t act on them.
Next step: Assess for suicide risk using direct questioning (e.g., “Do you have a plan?”), safety planning, and referral for crisis intervention if needed.
Severe depression

Low mood nearly every day for 6 months
Anhedonia (loss of interest in activities)
Sleep disturbances, fatigue, guilt, difficulty concentrating
Flat affect, monotone voice, avoiding eye contact
Next step: Consider Major Depressive Disorder (MDD) and assess for severity.
Effects on daily functioning

Declining work performance, fear of job loss.
Struggling to care for child due to low energy.
Next step: Evaluate ability to function independently and provide support.
Differential Diagnosis
Primary Considerations:
Major Depressive Disorder (MDD)

Meets ≥5 criteria of SIGECAPS (Sleep, Interest, Guilt, Energy, Concentration, Appetite, Psychomotor, Suicidal thoughts).
Key findings: Persistent low mood, anhedonia, guilt, fatigue, poor concentration, appetite disturbance, suicidal thoughts.
Post-Traumatic Stress Disorder (PTSD) (if IPV is ongoing)

Key findings: Hypervigilance, fear at home, avoidance, anxiety.
Generalized Anxiety Disorder (GAD)

Key findings: Constant worry, difficulty relaxing, restlessness, somatic symptoms (headaches, nausea).
Adjustment Disorder with Depressed Mood

Key findings: Depressive symptoms triggered by stressful life events (partner issues).
Hypothyroidism (rule out medical causes of depression)

Key findings: Fatigue, low mood, weight gain (though not reported), hair thinning.
Next Steps
Immediate Steps (Today)
✅ Ensure safety

Ask directly about abuse and document findings carefully.
If she’s in immediate danger, provide resources for domestic violence shelters, crisis lines, and legal aid.
✅ Screen for suicide risk

Ask if she has a plan or intent.
Develop a safety plan if needed.
✅ Provide emotional support & validate concerns

Let her know she’s not alone and there are ways to get help.
✅ Physical exam & lab tests to rule out medical causes:

CBC (anemia)
TSH, Free T4 (hypothyroidism)
CMP (electrolytes, kidney/liver function)
Naturopathic Treatment Plan
1️⃣ Emotional & Psychological Support
✅ Refer for therapy (Cognitive Behavioral Therapy (CBT), trauma-informed care).
✅ Mindfulness techniques to manage stress.
✅ Journaling & creative expression to process emotions.

2️⃣ Lifestyle & Nutrition
✅ Mediterannean diet (anti-inflammatory)

Whole foods, omega-3s (flaxseeds, walnuts, fish).
✅ Stable blood sugar levels
Protein at every meal, complex carbs (quinoa, oats).
✅ Gentle movement
Yoga, walking to improve mood.
✅ Sleep hygiene
Magnesium, chamomile tea, no screens before bed.
3️⃣ Botanical & Nutritional Support
✅ Adaptogens for stress:

Ashwagandha (supports adrenal function, reduces anxiety).
✅ Mood support:
St. John’s Wort (if not on medications).
Rhodiola (helps with fatigue and mood).
✅ Omega-3s (EPA/DHA)
Supports brain health, reduces depression risk.
✅ Vitamin D & B-complex
Essential for mood and energy.
Referral & Follow-Up
Psychologist or counselor for therapy.
Community resources for domestic violence support.
Follow-up in 1-2 weeks to reassess mood & safety.

Question 22

Case 7
65-year-old male
CC: Cough
History
Cough duration It started about four months ago.
Nature of cough It was just a dry cough at first, but now it’s started bringing up some
phlegm. Sometimes there’s a bit of blood in it.
Change in cough over time Yes, from dry to productive, especially in the mornings.
Sputum production Yes, especially in the mornings. Sometimes there’s a streak of blood
in it.
Presence of blood in sputum Yes, just streaks here and there.
Shortness of breath Yes, I get winded easily now.
Activities causing shortness of breath Walking up stairs or doing anything physical makes me feel short of
breath.
Chest pain Yes, a dull ache, worse with deep breaths.
Weight loss Yes, 10 pounds in two months.
Fatigue Yes, more than usual.
Fever or chills No.
Night sweats No.
Recent upper respiratory infections or colds No.
Recent travel No.
Exposure to tuberculosis No.
Smoking history Yes, 40-pack-year history.
Smoking cessation I quit five years ago.
Lung conditions (bronchitis, asthma) Chronic bronchitis.
COPD diagnosis No.
Occupational exposure to pollutants/chemicals I’m not sure, worked in construction for over 30 years.
Occupation Retired, formerly in construction.
Voice changes No.
Other medical conditions No.
Medications None.
Allergies No.
Recent chest X-ray or CT scan No.
Physical Exam
General appearance Thin, with noticeable fatigue.
Vital signs BP 130/85 mmHg, HR 90 bpm, RR 22/min, Temp 36.8°C
Chest inspection Increased anteroposterior diameter.
Chest palpation for tenderness No tenderness.
Chest palpation for tactile fremitus Decreased over right upper lung field.
Lung field percussion Dullness over right upper lung field.
Lung auscultation Decreased breath sounds, coarse crackles in right upper lung, mild
wheezing bilaterally.
Cardiovascular auscultation Regular rate and rhythm, no murmurs, rubs, or gallops.
Abdominal inspection Normal appearance.
Abdominal palpation Non-tender.
Abdominal percussion No organomegaly.
Abdominal auscultation Bowel sounds normal.
Extremity inspection No clubbing, cyanosis, or edema.

Answer 22

🚨 Red Flags to Check For:
Hemoptysis (blood in sputum) – Can indicate lung cancer, tuberculosis, or another serious lung condition.
Unintentional weight loss (10 lbs in 2 months) – Suggests a systemic illness like malignancy.
Progressive shortness of breath – Could indicate worsening lung disease, pleural effusion, or malignancy.
Dullness to percussion + decreased breath sounds – Suggestive of lung consolidation, mass, or pleural effusion.
40-pack-year smoking history + construction work – High risk for lung cancer, COPD, and occupational lung disease.
Fatigue + chronic cough + constitutional symptoms – Possible serious underlying disease like cancer or chronic infection.

🩺 Differential Diagnoses:
Lung Cancer (Primary or Metastatic) – Given smoking history, weight loss, hemoptysis, and focal lung findings.
Chronic Obstructive Pulmonary Disease (COPD) with Exacerbation – Smoking history, chronic cough, wheezing, and dyspnea.
Tuberculosis (TB) – Less likely without travel/exposure, but chronic cough, hemoptysis, weight loss raise concern.
Pneumonia (Bacterial or Atypical) – Focal lung findings (crackles, dullness), productive cough.
Bronchiectasis – Chronic productive cough, recurrent infections, possible hemoptysis.
Interstitial Lung Disease (ILD) – Occupational exposure raises suspicion.
Pulmonary Embolism (PE) – Less likely given chronicity, but should be ruled out if symptoms worsen suddenly.
Fungal Lung Infection (Histoplasmosis, Coccidioidomycosis) – Depends on geographical risk.

🔬 Next Steps:
Diagnostic Workup
Imaging:

Urgent Chest X-ray → Look for mass, consolidation, fibrosis, effusion.
CT Chest (with contrast if safe) → Evaluate for malignancy, nodules, or fibrosis.
Lab Tests:

CBC + Differential → Check for anemia, infection.
ESR/CRP → Inflammation markers.
Sputum Culture & Cytology → Rule out TB, lung cancer.
TB Testing (PPD or IGRA) → If TB still a concern.
Lung Function Tests (Spirometry) → Check for COPD/ILD.
Referral:

Pulmonologist → For further workup, bronchoscopy if needed.
Oncology → If imaging suggests malignancy.
🌿 Naturopathic Supportive Treatments:
🛑 (These are supportive only, not a replacement for urgent medical care.)

Lifestyle & Dietary Support
Anti-inflammatory diet → Rich in antioxidants (berries, leafy greens, turmeric).
Hydration → Warm fluids like ginger tea, herbal expectorants (thyme, licorice root).
Avoid irritants → No smoking, limit air pollutants.
Lung-Supportive Botanicals
Mullein (Verbascum thapsus) – Soothes respiratory tract, supports expectoration.
Lobelia (Lobelia inflata) (low dose!) – Can help with bronchial dilation.
Astragalus (Astragalus membranaceus) – Immune-modulating (avoid if active infection).
Cordyceps (Cordyceps sinensis) – Supports lung function and endurance.
Stress & Immune Support
Adaptogens (Ashwagandha, Rhodiola) – Support stress response.
Vitamin D, C, Zinc – Immune-supportive, especially if infection is a concern.
⚠ When to Seek Emergency Care?
Rapidly worsening shortness of breath.
Coughing up large amounts of blood (>1 tsp per episode).
Severe chest pain.
New onset confusion, dizziness, or syncope.
This case needs urgent imaging and pulmonology referral due to high suspicion of lung cancer or another serious lung pathology. 🚑

what is the most common type of cancer i think it is non small cell lung cancer but correct me if I am wrong also why is it the most common
ChatGPT said:
You’re close! Non-small cell lung cancer (NSCLC) is indeed the most common type of lung cancer, but the most common type of cancer overall depends on whether you’re looking at global or regional data.

Most Common Cancers Worldwide (2024 Estimates)
Breast cancer – Most common globally (~12.5% of all new cancer cases)
Lung cancer (including NSCLC & small cell lung cancer) – Second most common (~12.4%)
Colorectal cancer – Third (~10%)
Prostate cancer – Fourth (~7.3%)
Why is NSCLC the Most Common Lung Cancer?
~85% of all lung cancers are NSCLC, making it the most common lung cancer type.
It includes subtypes like adenocarcinoma, squamous cell carcinoma, and large cell carcinoma.
Smoking, air pollution, and radon exposure are major risk factors.
So, while NSCLC is the most common lung cancer, breast cancer is actually the most common cancer overall. However, lung cancer remains the leading cause of cancer-related death worldwide due to its late diagnosis and aggressive nature.

Question 23

Case 5

45-year-old male CC: rash
History
Onset I first noticed the rash about five days ago. It was just a small red spot on
my left thigh back then.
Changes in rash Yes, it has gradually gotten bigger
Initial appearance It was a small red spot at first.
Other rashes No, there’s only the one on my left thigh.
Pain or tenderness Yes, there’s mild pain and tenderness in the area.
Itching or burning No
Fever or chills No
Night sweats No
Fatigue Yes, I’ve been feeling more tired than usual lately.
Headaches Yes, I’ve had mild headaches for the past week.
Muscle or joint pain No
Insect bites Not that I recall
Swelling or drainage No
Injuries or trauma No
Recent travel No
Outdoor activities Yes, I spend a lot of time outdoors.
Hiking, camping, gardening Yes, I’ve been hiking and gardening recently.
Pets Yes, I have a dog that goes outdoors.
Contact with animals Yes, my dog and some wildlife around my home.
Tick bites No, I don’t recall any tick bites or finding ticks on my body.
Allergies None
Medications and supplements None
Chronic conditions None
Occupation I’m a teacher.
Diet For breakfast, I usually have cereal or toast. For lunch, I eat a sandwich or
salad. For dinner, I often have chicken or fish with vegetables. I snack on fruit or yogurt.
Smoking No
Alcohol Occasionally, I have a glass of wine with dinner on weekends.
Past similar rashes No, I’ve never had a similar rash or skin problem before.
Family history No history of skin conditions or autoimmune diseases in my family.
Physical Exams
General appearance Appears well but slightly tired.
Vital signs Temperature: 37.2°C, BP: 120/80 mmHg, Pulse: 72 bpm, RR: 16 breaths per
minute.
Inspection of the rash Erythematous, slightly raised, clear center with advancing border,
approximately 15 cm in diameter.
Palpation of the rash Mild tenderness, no fluctuance or drainage.
Fluctuance or drainage None
Additional skin lesions None
Lymphadenopathy None
Cardiovascular exam Normal heart sounds, no murmurs, peripheral pulses intact.
Respiratory exam Clear lung sounds, no wheezes or crackles.

Answer 23

Red Flags to Check For:
Expanding rash with central clearing → Possible erythema migrans (Lyme disease)
Fatigue, headaches → Possible systemic infection (e.g., Lyme, early sepsis)
Outdoor exposure, gardening, hiking, animal contact → Vector-borne or zoonotic disease risk
Rash >5 cm in diameter → Concern for Lyme disease
Fever, chills, night sweats (absent here but should monitor) → Systemic infection warning signs
Signs of cellulitis (red, warm, swollen, tender, fever, drainage, spreading erythema, fluctuance)
Neurological symptoms (numbness, weakness, facial droop, meningitis signs)
Differential Diagnosis:
Lyme Disease (Erythema Migrans) → Most Likely

Expanding rash with central clearing
History of outdoor activity, pet exposure
Fatigue, headaches (possible early systemic symptoms)
Cellulitis (less likely but possible)

Usually warmer, more tender, may have drainage
Fever/chills typically present (not reported here)
Tinea Corporis (Ringworm)

Annular rash with central clearing
No systemic symptoms (fatigue + headache make this less likely)
Erythema Multiforme

More common with recent infection or medication reaction
Multiple targetoid lesions, not a single expanding rash
Spider Bite / Localized Skin Infection

Typically painful, may have necrotic center
No clear exposure or bite history

Next Steps:
Confirm Diagnosis:

Order Lyme disease testing:
ELISA for Borrelia burgdorferi
Western Blot for confirmation
Consider CBC, ESR, CRP to check for systemic infection
If cellulitis is suspected: Blood cultures if febrile
Treatment Plan:

If Lyme disease is suspected (even without lab confirmation, given the classic rash):
Doxycycline 100 mg BID x 10–14 days (First-line)
Amoxicillin or Cefuroxime (if pregnant or allergic to doxycycline)
If cellulitis is suspected:
Cephalexin or Clindamycin (if bacterial cause suspected)
Monitor for Progression:

Watch for neurological symptoms (facial droop, weakness) → Could indicate Lyme neuroborreliosis
If rash worsens, becomes painful, or systemic symptoms develop → Re-evaluate for different infection
Naturopathic Treatments (Adjunct to Medical Care):
Support Immune Function:
Andrographis, Cat’s Claw, Japanese Knotweed (herbs used in Lyme protocols)
Vitamin C, Zinc, Probiotics to support immune response
Anti-inflammatory Support:
Curcumin, Omega-3s for inflammation
Garlic, Oregano oil for antimicrobial support
Lymphatic Drainage Support:
Dry brushing, lymphatic massage
Herbal Support for Detox Pathways:
Milk Thistle, Dandelion Root to support liver function
Follow-Up:
Re-evaluate in 2 weeks (rash should resolve with appropriate treatment)
If symptoms worsen or persist:
Check for chronic Lyme symptoms
Consider further infectious disease testing

Question 24

Case 4

42 year old female
CC: Fatigue

History
Onset of fatigue Six months ago
Nature of fatigue Persistent and severe, not relieved by rest
Severity of fatigue 8/10 (10 worst)
Feeling rested after sleep No
Hours of sleep per night 8-9 hours
Difficulty falling or staying asleep No
Changes in sleep patterns No
Effect of physical or mental activity on fatigue Yes, makes fatigue worse
Fatigue relieved by rest No
Recent infections or illnesses No
Muscle or joint pain Yes
Nature and location of pain Dull ache affecting neck, shoulders, back, and hips
Severity of pain 6/10 (10 worst)
Treatments tried for pain Over-the-counter pain medications and supplements with little relief
Headaches Yes, occasionally
Difficulty concentrating or memory problems Yes, finds it hard to focus at work and often forgets small details like
appointments or grocery lists
Foggy feeling in mind Yes, feels like she is in a haze, especially in the afternoons
Significant weight changes No
Night sweats No
Appetite Normal
Gastrointestinal symptoms No
Swelling, redness, or warmth in joints No
Numbness or tingling in extremities No
Other medical conditions Anxiety and irritable bowel syndrome
Medications or supplements Vitamin D and a multivitamin
Family medical history Mother with hypothyroidism, father with hypertension
Occupation Accountant
Effect of condition on work Finds it increasingly difficult to keep up with work demands, often has
to take breaks due to fatigue
Impact on daily life and activities Significantly, has trouble performing daily tasks such as cooking and
cleaning, relies more on family members for help
Symptoms of anxiety or depression Yes, feels anxious about her health and sometimes feels overwhelmed
and sad
Changes to diet or lifestyle Tried various supplements, no significant changes
Physical Exam
General appearance Tired but in no acute distress
Temperature 36.8°C
Blood pressure 120/80 mmHg
Heart rate 78 beats per minute
Respiratory rate 16 breaths per minute
Skin inspection for rashes No rashes
Skin inspection for lesions No lesions
Tender points in the trapezius Tender
Tender points in the elbows Tender

Answer 24

Red Flags to Check For:
Fatigue Unrelieved by Rest → Suggests systemic or chronic illness.
Worsening Fatigue with Activity → May indicate chronic fatigue syndrome/Myalgic Encephalitis (CFS/ME), fibromyalgia, or autoimmune disease.
Cognitive Impairment (“Brain Fog”) → Concerning for thyroid dysfunction, CFS/ME, or nutrient deficiencies.
Muscle/Joint Pain Without Swelling → Suggests fibromyalgia but consider polymyalgia rheumatica, autoimmune disease, or chronic infections.
Family History of Hypothyroidism → Consider Hashimoto’s thyroiditis or hypothyroidism.
Anxiety & IBS History → Possible gut dysbiosis, HPA-axis dysfunction (stress-related fatigue), or post-viral syndrome.
Differential Diagnoses:
Common Causes:
Fibromyalgia – Chronic pain + fatigue + tender points.
Chronic Fatigue Syndrome (ME/CFS) – Persistent, unexplained fatigue worsened by activity.
Hypothyroidism – Fatigue, brain fog, weight issues, family history.
Iron Deficiency (With or Without Anemia) – Fatigue, brain fog.
Adrenal Fatigue (HPA-Axis Dysfunction) – Stress-related burnout.
Sleep Apnea (if undiagnosed) – Persistent fatigue despite 8-9 hours of sleep.
Less Common, But Consider:
Autoimmune Disease (e.g., Lupus, RA, Polymyalgia Rheumatica) – Unexplained fatigue, aches.
Chronic Infections (e.g., EBV reactivation, Lyme disease, post-viral syndrome) – If fatigue followed an infection.
Nutrient Deficiencies (B12, Vitamin D, Magnesium, Omega-3s) – Common with IBS.
Depression/Anxiety-Related Fatigue – If emotional burden is significant.
Next Steps:
1. Lab Testing:
CBC, Ferritin (Check for anemia/iron deficiency)
TSH, Free T3, Free T4, Anti-TPO (Thyroid function & Hashimoto’s)
Vitamin B12, Vitamin D, Magnesium (Deficiencies common with fatigue)
Cortisol (Saliva or AM blood test) (Adrenal function)
CRP, ESR (Inflammatory markers for autoimmune conditions)
ANA, Rheumatoid Factor (If autoimmune disease suspected)
2. Lifestyle & Dietary History:
Meal patterns & Blood Sugar Regulation (Skipping meals, sugar crashes)
Sleep Quality & Possible Apnea Screening
Stress Management & Mental Health Assessment
Gut Health (since IBS is present) – Could impact nutrient absorption.
Naturopathic Treatments:
1. Lifestyle Adjustments
Sleep hygiene: Consistent bedtime, limit screens before sleep.
Gentle movement: Walking, yoga (avoid overexertion with fatigue).
Stress reduction: Mindfulness, meditation, deep breathing.
Sunlight exposure for circadian rhythm & Vitamin D.
2. Nutritional Support
Protein-rich breakfast to support cortisol balance.
Anti-inflammatory diet: Reduce processed foods, refined sugars.
Omega-3s (Fish oil or flaxseed oil) – Brain function & inflammation.
Magnesium (glycinate or malate) – Helps muscle pain, sleep, stress.
B-complex vitamins – Supports energy metabolism.
3. Herbal & Supplement Support
Adaptogens for stress & adrenal support (Ashwagandha, Rhodiola).
Curcumin & Boswellia (For pain & inflammation if fibromyalgia suspected).
CoQ10 & L-Carnitine (Mitochondrial energy support).
Iron + Vitamin C (If deficiency present).
Probiotics & Digestive Support (If gut dysbiosis suspected due to IBS).
4. Additional Therapies
Acupuncture (for chronic fatigue, stress, & pain relief).
Contrast hydrotherapy (alternating hot & cold showers to improve circulation & energy levels).
Follow-Up:
Monitor symptom changes with dietary/lifestyle modifications.
Repeat lab testing in 3-6 months if treatment is initiated.
If no improvement, referral to specialist (endocrinology, rheumatology, or functional medicine provider) for further evaluation.

Question 25

Case 3 28-year-old male CC: anxiety History Onset of anxiety symptoms I first noticed my anxiety symptoms about six months ago. Frequency of anxiety I feel anxious every day. Description of inability to relax I always feel tense and on edge, like I can't calm down. Impact on work It's making it hard to concentrate and get things done at work. Impact on social life I avoid social situations because I feel too anxious. Changes in sleep patterns Yes, I have trouble falling asleep and staying asleep. Difficulty concentrating Yes, I have a lot of trouble concentrating. Muscle tension location Yes, especially in my shoulders and neck. Alcohol consumption I consume 4-5 drinks every evening. Marijuana usage frequency I smoke marijuana 3-4 times a week. Increase in substance use Yes, I've noticed an increase in my substance use over the past year. Substance use helps with anxiety Yes, but I know it's not a good solution. Attempts to cut down or stop Yes, but I haven't been successful. Annoyed when others criticize alcohol use No Guilty about alcohol use Sometimes Ever needed an eye-opener No Withdrawal symptoms No History of panic attacks No History of depressive episodes No Psychiatric conditions diagnosis None Prescription medications None Drug allergies None Family history My mother has anxiety, and my father had alcohol dependence. Occupation I work in marketing. Hobbies Not really, I haven't been doing much because of my anxiety. Typical daily diet It's pretty normal, I guess. I eat three meals a day, nothing special. Exercise frequency No, I don't exercise regularly. Tobacco use None Other recreational drugs None Physical Exams General appearance The patient appears anxious and fidgety. Blood pressure measurement 125/80 mmHg Heart rate measurement 78 bpm Respiratory rate measurement 16 breaths per minute Temperature measurement 36.8°C Inspection for signs of alcohol withdrawal: tremors No tremors Inspection for signs of alcohol withdrawal: sweating No sweating Neurological exam: Cranial nerves examination Normal Neurological exam: Motor strength assessment Normal Neurological exam: Sensory function assessment Normal Neurological exam: Deep tendon reflexes Normal Mental status examination: Appearance and behavior Anxious and fidgety Mental status examination: Speech and language Normal Mental status examination: Mood and affect Anxious mood, appropriate affect Mental status examination: Thought process and content Logical thought process, no delusions or hallucinations Mental status examination: Cognitive function (attention, memory, orientation) Normal Heart auscultation Normal Lung auscultation Normal Abdominal exam: Inspection Normal Abdominal exam: Palpation Normal Abdominal exam: Auscultation Normal Musculoskeletal exam: Inspection of muscles (particularly shoulders and neck) Normal Musculoskeletal exam: Palpation of muscles (particularly shoulders and neck) Tension in shoulders and neck Musculoskeletal exam: Range of motion assessment Normal Skin exam: Inspection for signs of substance use (track marks) No track marks Skin exam: Inspection for signs of substance use (skin lesions) No skin lesions

Answer 25

**Red Flags to Check for** Physical signs of substance dependence: Despite the patient's admission of increased substance use (alcohol and marijuana), there are no signs of withdrawal (e.g., tremors, sweating). Co-occurring psychiatric conditions: Even though the patient does not have a history of panic attacks or depressive episodes, it’s essential to remain vigilant for potential comorbid mental health disorders. Alcohol misuse: The patient drinks 4-5 drinks every evening, which is a concern for alcohol use disorder, especially since there is a family history of alcohol dependence. Substance-induced anxiety: The patient’s use of alcohol and marijuana may be exacerbating or even causing the anxiety symptoms. Suicidality or self-harm: While no indications are given here, it’s crucial to assess the risk of self-harm or suicidal thoughts due to the anxiety and alcohol use. Physical health changes: Though the physical exam is normal, consistent muscle tension in the shoulders and neck could point to somatic symptoms, often linked with chronic anxiety. Differential Diagnosis Generalized Anxiety Disorder (GAD): The patient reports chronic, pervasive anxiety that is present every day and affects work and social life, which is consistent with GAD. Substance-Induced Anxiety Disorder: Alcohol and marijuana use, especially if they are self-medicating, may exacerbate or contribute to anxiety symptoms. Adjustment Disorder with Anxiety: The onset of anxiety symptoms occurring in the past six months may coincide with a stressful life event or change, although this is not specifically detailed in the history. Panic Disorder: Although the patient denies panic attacks, it is still important to rule out panic disorder since the anxiety could be related to undiagnosed panic symptoms. Alcohol Use Disorder: The patient's daily alcohol consumption may be masking or worsening anxiety symptoms, making it difficult to distinguish whether the anxiety is a primary condition or a consequence of substance use. Depressive Disorders (e.g., Major Depressive Disorder): Anxiety can be a prominent symptom in depression, though the absence of other depressive symptoms (e.g., low mood, anhedonia) makes this less likely. Next Steps Screen for Substance Use Disorder: Given the history of increased alcohol and marijuana use, a formal screening for alcohol use disorder (e.g., AUDIT-C) should be conducted. Assess Anxiety Severity: Use standardized anxiety assessment tools, such as the Generalized Anxiety Disorder 7 (GAD-7) scale, to better quantify the severity of the anxiety and evaluate any impact on daily functioning. Screen for Depressive Symptoms: Even though depressive episodes are not reported, further exploration with tools like the Patient Health Questionnaire-9 (PHQ-9) might be useful to rule out depression. Mental Health Referral: Considering the patient's chronic anxiety, lack of coping mechanisms (e.g., avoiding social situations), and substance use, referral to a mental health professional (e.g., therapist or psychiatrist) is crucial for further assessment and intervention. Substance Use Counseling: Addressing alcohol and marijuana use through counseling, as well as considering options like cognitive behavioral therapy (CBT) or motivational interviewing, could be beneficial. Stress Management and Relaxation Techniques: Introducing stress-reduction strategies (e.g., mindfulness, progressive muscle relaxation) and encouraging regular exercise may help alleviate physical symptoms like muscle tension. Consider Pharmacotherapy: Depending on the severity of the anxiety and after a mental health assessment, medications like SSRIs (e.g., sertraline, fluoxetine) or benzodiazepines (for short-term use) may be considered. Treatment Cognitive Behavioral Therapy (CBT): This is the gold standard for treating generalized anxiety disorder and can be helpful in addressing the underlying cognitive distortions that contribute to the anxiety. Substance Use Treatment: A substance use program or counseling, including harm reduction strategies, may help the patient reduce reliance on alcohol and marijuana for anxiety management. Relaxation Techniques: Progressive muscle relaxation, meditation, and yoga can help address the somatic symptoms of anxiety, including muscle tension in the shoulders and neck. Lifestyle Modifications: Encouraging regular exercise and a consistent sleep routine would be beneficial in managing anxiety symptoms. Pharmacologic Intervention: If symptoms persist, SSRIs (like sertraline) or SNRIs (like venlafaxine) could be prescribed for long-term management of generalized anxiety disorder. Short-term use of benzodiazepines may be considered, but this should be done with caution due to the risk of dependency, especially given the patient’s alcohol use.

Question 26

Case 2 28-year-old female CC: dysmenorrhea History Onset of pain The pain started about a year ago. Pain description The pain is sharp and cramping, located in the lower abdomen and pelvis. Pain radiation Yes, it sometimes radiates to my lower back and thighs, especially during my periods. Pain duration It starts a few days before my period and lasts until it ends, usually about a week in total. Pain outside menstruation Yes, sometimes during intercourse and bowel movements, which makes these activities very uncomfortable. Changes in menstrual cycle No Regular periods Yes, every 28 days. Duration of menstrual period About 5 days. Medications tried Yes, over-the-counter pain medications. Effectiveness of treatments They provide minimal relief, sometimes I have to take more than the recommended dose to get any relief. Pain during intercourse Yes, it is painful, especially deep penetration, which has affected my relationship. Pain during bowel movements Occasionally, yes, particularly during my period, making it quite distressing. Episodes of fever or malaise Occasionally, especially around my periods, I feel feverish and generally unwell. Abnormal vaginal discharge No History of urinary tract infections Yes, I've had recurrent urinary tract infections, about 3-4 times in the past year. Number of sexual partners I have had multiple partners in the past, about five. Current relationship status Yes, for the past two years, I have been in a monogamous relationship. Consistent condom use No, not consistently, sometimes we rely on other forms of contraception. Other medical conditions No other medical conditions. Regular medications No, not regularly. Allergies No known allergies. Family medical history My mother has diabetes, and my father is healthy. My maternal grandmother had some gynecological issues, but I'm not sure of the details. Occupation I work as a marketing manager, which involves long hours and a fair amount of stress. Tobacco use No Alcohol or drug use I occasionally drink alcohol, but no recreational drugs. Typical day's diet I usually have a balanced diet with fruits, vegetables, and lean proteins, though I sometimes skip meals due to work. Children or pregnancy history No children and I've never been pregnant. Physical Exam Blood pressure 120/80 mmHg Heart rate 76 bpm

Answer 26

**Red Flags to Check for** Physical signs of substance dependence: Despite the patient's admission of increased substance use (alcohol and marijuana), there are no signs of withdrawal (e.g., tremors, sweating). Co-occurring psychiatric conditions: Even though the patient does not have a history of panic attacks or depressive episodes, it’s essential to remain vigilant for potential comorbid mental health disorders. Alcohol misuse: The patient drinks 4-5 drinks every evening, which is a concern for alcohol use disorder, especially since there is a family history of alcohol dependence. Substance-induced anxiety: The patient’s use of alcohol and marijuana may be exacerbating or even causing the anxiety symptoms. Suicidality or self-harm: While no indications are given here, it’s crucial to assess the risk of self-harm or suicidal thoughts due to the anxiety and alcohol use. Physical health changes: Though the physical exam is normal, consistent muscle tension in the shoulders and neck could point to somatic symptoms, often linked with chronic anxiety. Differential Diagnosis Generalized Anxiety Disorder (GAD): The patient reports chronic, pervasive anxiety that is present every day and affects work and social life, which is consistent with GAD. Substance-Induced Anxiety Disorder: Alcohol and marijuana use, especially if they are self-medicating, may exacerbate or contribute to anxiety symptoms. Adjustment Disorder with Anxiety: The onset of anxiety symptoms occurring in the past six months may coincide with a stressful life event or change, although this is not specifically detailed in the history. Panic Disorder: Although the patient denies panic attacks, it is still important to rule out panic disorder since the anxiety could be related to undiagnosed panic symptoms. Alcohol Use Disorder: The patient's daily alcohol consumption may be masking or worsening anxiety symptoms, making it difficult to distinguish whether the anxiety is a primary condition or a consequence of substance use. Depressive Disorders (e.g., Major Depressive Disorder): Anxiety can be a prominent symptom in depression, though the absence of other depressive symptoms (e.g., low mood, anhedonia) makes this less likely. Next Steps Screen for Substance Use Disorder: Given the history of increased alcohol and marijuana use, a formal screening for alcohol use disorder (e.g., AUDIT-C) should be conducted. Assess Anxiety Severity: Use standardized anxiety assessment tools, such as the Generalized Anxiety Disorder 7 (GAD-7) scale, to better quantify the severity of the anxiety and evaluate any impact on daily functioning. Screen for Depressive Symptoms: Even though depressive episodes are not reported, further exploration with tools like the Patient Health Questionnaire-9 (PHQ-9) might be useful to rule out depression. Mental Health Referral: Considering the patient's chronic anxiety, lack of coping mechanisms (e.g., avoiding social situations), and substance use, referral to a mental health professional (e.g., therapist or psychiatrist) is crucial for further assessment and intervention. Substance Use Counseling: Addressing alcohol and marijuana use through counseling, as well as considering options like cognitive behavioral therapy (CBT) or motivational interviewing, could be beneficial. Stress Management and Relaxation Techniques: Introducing stress-reduction strategies (e.g., mindfulness, progressive muscle relaxation) and encouraging regular exercise may help alleviate physical symptoms like muscle tension. Consider Pharmacotherapy: Depending on the severity of the anxiety and after a mental health assessment, medications like SSRIs (e.g., sertraline, fluoxetine) or benzodiazepines (for short-term use) may be considered. Treatment Cognitive Behavioral Therapy (CBT): This is the gold standard for treating generalized anxiety disorder and can be helpful in addressing the underlying cognitive distortions that contribute to the anxiety. Substance Use Treatment: A substance use program or counseling, including harm reduction strategies, may help the patient reduce reliance on alcohol and marijuana for anxiety management. Relaxation Techniques: Progressive muscle relaxation, meditation, and yoga can help address the somatic symptoms of anxiety, including muscle tension in the shoulders and neck. Lifestyle Modifications: Encouraging regular exercise and a consistent sleep routine would be beneficial in managing anxiety symptoms. Pharmacologic Intervention: If symptoms persist, SSRIs (like sertraline) or SNRIs (like venlafaxine) could be prescribed for long-term management of generalized anxiety disorder. Short-term use of benzodiazepines may be considered, but this should be done with caution due to the risk of dependency, especially given the patient’s alcohol use. Would you like further details on treatment options or the next steps for follow-up? You said: what are the red flags to check for, what are the differential diagnosis, what are the next steps and any treatments: 28-year-old female CC: dysmenorrhea History Onset of pain The pain started about a year ago. Pain description The pain is sharp and cramping, located in the lower abdomen and pelvis. Pain radiation Yes, it sometimes radiates to my lower back and thighs, especially during my periods. Pain duration It starts a few days before my period and lasts until it ends, usually about a week in total. Pain outside menstruation Yes, sometimes during intercourse and bowel movements, which makes these activities very uncomfortable. Changes in menstrual cycle No Regular periods Yes, every 28 days. Duration of menstrual period About 5 days. Medications tried Yes, over-the-counter pain medications. Effectiveness of treatments They provide minimal relief, sometimes I have to take more than the recommended dose to get any relief. Pain during intercourse Yes, it is painful, especially deep penetration, which has affected my relationship. Pain during bowel movements Occasionally, yes, particularly during my period, making it quite distressing. Episodes of fever or malaise Occasionally, especially around my periods, I feel feverish and generally unwell. Abnormal vaginal discharge No History of urinary tract infections Yes, I've had recurrent urinary tract infections, about 3-4 times in the past year. Number of sexual partners I have had multiple partners in the past, about five. Current relationship status Yes, for the past two years, I have been in a monogamous relationship. Consistent condom use No, not consistently, sometimes we rely on other forms of contraception. Other medical conditions No other medical conditions. Regular medications No, not regularly. Allergies No known allergies. Family medical history My mother has diabetes, and my father is healthy. My maternal grandmother had some gynecological issues, but I'm not sure of the details. Occupation I work as a marketing manager, which involves long hours and a fair amount of stress. Tobacco use No Alcohol or drug use I occasionally drink alcohol, but no recreational drugs. Typical day's diet I usually have a balanced diet with fruits, vegetables, and lean proteins, though I sometimes skip meals due to work. Children or pregnancy history No children and I've never been pregnant. Physical Exam Blood pressure 120/80 mmHg Heart rate 76 bpm ChatGPT said: Red Flags to Check For Pain outside menstruation (dyspareunia and bowel pain): The pain during intercourse and bowel movements could indicate a more serious underlying issue, such as endometriosis or pelvic inflammatory disease (PID). Episodes of fever or malaise around periods: This could suggest an infection (e.g., PID) or a more systemic condition like endometriosis or adenomyosis. Recurrent UTIs: The history of frequent urinary tract infections could be related to interstitial cystitis, which sometimes co-occurs with endometriosis. Pain radiating to back and thighs: This could indicate pelvic floor dysfunction or endometriosis that affects surrounding organs, or it could be associated with other gynecological pathologies like fibroids or adenomyosis. Minimal relief from over-the-counter medications: This may indicate a more severe underlying pathology (e.g., endometriosis or fibroids) that requires a more targeted treatment plan. Differential Diagnosis Endometriosis: The most likely diagnosis given the sharp, cramping pain, especially during menstruation, intercourse, and bowel movements. Endometriosis commonly presents with these symptoms and could explain the pain radiation and episodes of fever or malaise. Adenomyosis: This occurs when the endometrial tissue grows into the muscle wall of the uterus. It causes heavy, painful periods, as well as pelvic pain and discomfort during intercourse. Pelvic Inflammatory Disease (PID): This condition results from infection of the female reproductive organs and can cause pain during intercourse, bowel movements, fever, and malaise. The recurrent UTIs may also be linked to this. Fibroids: Uterine fibroids can cause pelvic pain, abnormal menstrual bleeding, and sometimes pain during intercourse. However, they are less likely to explain the pain radiating to the back and thighs. Interstitial Cystitis (IC): Given the recurrent UTIs and pelvic pain, IC could be considered, as it causes chronic pelvic pain and discomfort, especially during bladder filling and emptying, but may also be associated with other gynecological conditions. Ovarian cysts: While less likely in this case, an ovarian cyst could cause pelvic pain, especially if it ruptures or twists. Sexually Transmitted Infections (STIs): Although the patient denies abnormal discharge, the patient’s history of multiple sexual partners and inconsistent condom use warrants screening for chlamydia or gonorrhea which can cause pelvic pain and contribute to PID. Next Steps Detailed Gynecological Examination: A thorough pelvic exam should be performed to check for tenderness, masses, or abnormal findings. Bimanual examination will also help assess for adenomyosis, fibroids, or other abnormalities. Transvaginal Ultrasound: This is the next step in imaging to assess for fibroids, ovarian cysts, or signs of adenomyosis. Laparoscopy: If endometriosis is suspected but not visible on ultrasound, a laparoscopy would be the gold standard for diagnosis. This procedure allows direct visualization of endometrial tissue outside the uterus. Pelvic MRI: An MRI may be helpful in diagnosing adenomyosis or deep infiltrating endometriosis. STI Screening: Given the patient's history of multiple sexual partners and inconsistent condom use, a full STI screening (including chlamydia and gonorrhea) should be performed. Urine Culture or Cystoscopy: To investigate the recurrent UTIs, a urine culture should be performed to confirm the presence of any bacterial infections. If recurrent UTIs persist despite treatment, cystoscopy may be considered to rule out interstitial cystitis. Complete Blood Count (CBC): To check for signs of infection, such as an elevated white blood cell count, which could indicate PID. Treatment Endometriosis: Medical Management: NSAIDs for pain relief (if not effective, stronger analgesics or hormonal therapy such as oral contraceptives, progestins, or GnRH agonists like leuprolide can be used to reduce endometrial growth). Surgical Management: Laparoscopic excision of endometriosis can be considered if medical treatment is ineffective. Adenomyosis: Medical Management: NSAIDs for pain management. Hormonal therapies such as the intrauterine device (IUD) with levonorgestrel or oral contraceptives may help reduce symptoms. Surgical Management: Hysterectomy is considered if symptoms are severe and other treatments fail. Pelvic Inflammatory Disease (PID): Antibiotic Treatment: Broad-spectrum antibiotics like doxycycline combined with ceftriaxone for gonorrhea or chlamydia coverage. Hospitalization: May be required for severe PID with fever or signs of systemic infection. Fibroids: Medical Management: NSAIDs for pain, hormonal treatments (e.g., IUD, GnRH agonists). Surgical Management: Myomectomy or hysterectomy if fibroids are causing significant symptoms. Interstitial Cystitis (IC): Medications: Antihistamines (e.g., hydroxyzine), pentosan polysulfate sodium, or bladder instillations may help reduce symptoms. Bladder training: Behavioral therapy and pelvic floor physical therapy may be helpful. Ovarian Cysts: Watchful Waiting: If the cyst is small and asymptomatic, monitoring is appropriate. Surgical Intervention: If the cyst is large, persistent, or causes significant pain, surgical removal may be necessary. STI Treatment: If the screening returns positive for an STI, appropriate antibiotic therapy should be prescribed. Both partners should be treated to prevent reinfection. Follow-up: Regular follow-up: After initial management (especially if conservative treatment like pain relief or hormonal therapy is used), follow-up is necessary to assess the effectiveness and make further adjustments. Referral to a specialist: If conditions like endometriosis or PID are diagnosed, referral to a gynecologist may be required for further management, including surgical options or long-term treatment strategies.

Question 27

Case 1 67-year-old male CC: reduced exercise tolerance History Onset of reduced exercise tolerance Three months ago. Progression of exercise tolerance It has progressively worsened. Shortness of breath at rest No. Shortness of breath with activity Yes. Walking distance before shortness of breath A short distance, less than a block. Nighttime shortness of breath No. Swelling in legs Yes. Swelling in ankles Yes, especially by the end of the day. Recent weight change No significant changes. History of heart problems Yes, I have hypertension. History of high blood pressure Yes, I have hypertension. History of lung diseases No. History of asthma No. Recent respiratory infections No. Recent colds No. Current smoking status I quit six months ago. Past smoking history Yes, I smoked one pack per day for 40 years. Smoking quantity One pack per day. Medications for breathing Yes, I use an albuterol inhaler occasionally. Inhalers for breathing Yes, I use an albuterol inhaler occasionally. Relief from inhaler Some relief. Presence of cough Yes. Duration of cough Several years. Productive cough Yes. Sputum appearance White sputum. Presence of wheezing Yes. Chest pain No. Discomfort No. Palpitations No. Irregular heartbeats No. Recent fevers No. Recent night sweats No. Changes in appetite No. Known allergies No. Current medications Just the albuterol inhaler. Family history of heart diseases No significant family history. Family history of lung diseases No significant family history. Occupation Retired factory worker. Daily diet I eat three meals a day, mostly home-cooked. 24-hour diet recall Breakfast: Two scrambled eggs, whole wheat toast with butter, a banana, and black coffee. Mid-morning: An apple. Lunch: Grilled chicken sandwich with lettuce and tomato, a small salad with Italian dressing, and water. Afternoon: A handful of almonds. Dinner: Baked salmon, steamed broccoli, brown rice, and a glass of water. Evening: A bowl of mixed berries and a cup of herbal tea. Alcohol consumption per week I drink socially, maybe a few drinks on the weekends. Recreational drug use No. Physical Exams General appearance assessment Mildly distressed due to dyspnea. Measurement of blood pressure 145/90 mmHg. Measurement of heart rate 92 bpm. Measurement of respiratory rate 20 breaths per minute. Measurement of oxygen saturation 94% on room air. Inspection for jugular venous distention Present. Auscultation of the lungs for crackles Bilateral crackles at the bases. Auscultation of the lungs for wheezes Expiratory wheezes. Auscultation of the lungs for other abnormal sounds None. Auscultation of the heart for gallops S3 gallop present. Auscultation of the heart for murmurs None. Auscultation of the heart for other abnormal sounds None. Inspection for peripheral edema Present. Palpation for peripheral edema Pitting edema in both ankles. Palpation of the chest wall for tenderness No tenderness. Palpation of the chest wall for abnormalities No abnormalities. Inspection of the extremities for cyanosis None. Inspection of the extremities for clubbing None. Abdominal palpation for hepatomegaly None. Abdominal palpation for ascites None. Assessment of capillary refill time Normal. Palpation of radial pulse Normal. Palpation of femoral pulse Normal. Palpation of dorsalis pedis pulse Normal. Palpation of posterior tibial pulse Normal. Examination of the oral cavity for signs of infection None. Examination of the oral cavity for signs of cyanosis None. Evaluation of the patient’s gait Mildly impaired due to dyspnea. Evaluation of the patient’s exercise tolerance Reduced. Observation of respiratory effort Increased effort noted. Observation of use of accessory muscles Mild use of accessory muscles. Assessment of skin turgor Normal. Assessment of skin temperature Normal. Inspection of the nail beds for signs of hypoxia None.

Answer 27

**Red Flags to Check For** Swelling in legs and ankles, especially by the end of the day: This could indicate heart failure or pulmonary hypertension. Worsening exercise tolerance: Progressive exercise intolerance can be a sign of heart or lung disease, particularly heart failure, chronic obstructive pulmonary disease (COPD), or cor pulmonale. Bilateral crackles at the lung bases: Suggests pulmonary edema, which can occur in heart failure or chronic respiratory diseases. S3 gallop heart sound: This is suggestive of heart failure, particularly in the setting of dyspnea, peripheral edema, and crackles. Wheezing: The presence of wheezing along with a chronic cough and occasional use of albuterol inhaler suggests chronic obstructive pulmonary disease (COPD), especially considering the patient’s smoking history. Pitting edema: The presence of edema, particularly in the lower extremities, could indicate right heart failure, congestive heart failure, or pulmonary hypertension. Differential Diagnosis Congestive Heart Failure (CHF): The combination of progressive dyspnea, peripheral edema, crackles on lung auscultation, and an S3 gallop suggests possible left-sided heart failure leading to pulmonary congestion. Chronic Obstructive Pulmonary Disease (COPD): The patient’s long smoking history, wheezing, and productive cough raise the concern for COPD, which may also contribute to exercise intolerance and peripheral edema if the right side of the heart is affected (cor pulmonale). Cor Pulmonale: Right-sided heart failure due to chronic lung disease (e.g., COPD) can lead to swelling in the legs, dyspnea, and wheezing. Pulmonary Embolism (PE): Although less likely given the patient’s symptoms, a PE can cause sudden dyspnea and discomfort. If suspected, PE should be ruled out. Atrial Fibrillation (AF): Although no irregular heartbeats are reported, AF is common in heart failure and could contribute to symptoms of dyspnea and exercise intolerance. Chronic Bronchitis or Emphysema: Both are common components of COPD and could explain the patient's chronic cough, wheezing, and smoking history. Emphysema would lead to more severe respiratory limitations, while chronic bronchitis would contribute to productive cough and wheezing. Next Steps Chest X-ray: To check for signs of pulmonary edema, enlarged heart, or any other lung abnormalities (e.g., COPD or emphysema). Electrocardiogram (ECG): To assess for any arrhythmias, including atrial fibrillation or signs of left ventricular hypertrophy that may accompany heart failure. Echocardiogram: This is crucial to assess left ventricular function and look for any evidence of heart failure or valvular abnormalities that could explain the symptoms (e.g., diastolic dysfunction, reduced ejection fraction, or valvular insufficiency). B-type natriuretic peptide (BNP): This biomarker can help diagnose heart failure. Elevated levels of BNP are indicative of heart failure. Pulmonary Function Tests (PFTs): To assess for COPD, specifically to evaluate the FEV1/FVC ratio, which would be reduced in obstructive diseases like COPD. Arterial Blood Gas (ABG): If there is concern for respiratory failure, an ABG can assess the patient’s oxygenation status. D-dimer or CT Pulmonary Angiogram (CTPA): If pulmonary embolism is suspected, these tests can help rule it out. Complete Blood Count (CBC): To check for signs of infection or anemia that may exacerbate heart failure symptoms. Treatment For Heart Failure (if diagnosed): Diuretics (e.g., furosemide): To manage fluid retention and edema. ACE inhibitors (e.g., enalapril) or ARBs (e.g., losartan): To reduce blood pressure and improve heart function. Beta-blockers (e.g., metoprolol): To manage heart rate and reduce the workload on the heart. Aldosterone antagonists (e.g., spironolactone): If there is evidence of volume overload or diuretic resistance. For COPD (if diagnosed): Inhaled bronchodilators (e.g., albuterol, ipratropium): To relieve wheezing and shortness of breath. Inhaled corticosteroids (e.g., fluticasone): To reduce inflammation and control symptoms of chronic bronchitis. Oxygen therapy: If the oxygen saturation falls below 88-90%, supplemental oxygen may be required. Pulmonary rehabilitation: To help improve exercise tolerance and breathing techniques. For Smoking Cessation: Since the patient quit smoking six months ago, ongoing support and possible counseling or pharmacotherapy (e.g., nicotine replacement therapy or varenicline) may be beneficial to ensure they do not relapse. For Pitting Edema: Elevation of legs, compression stockings, and possible diuretic therapy (if related to heart failure or COPD) can help. For Cough and Wheezing: If related to COPD or bronchitis, optimizing inhaler use, ensuring adherence to prescribed treatments, and smoking cessation support are key. Follow-Up: Regular follow-up: To assess for changes in symptoms and ensure medications are effective. Referral to cardiology or pulmonology: If heart failure or COPD is confirmed, specialist referral for further management and testing is recommended.