Clinical presentations

Question 1

Confusion, fever, agitation, tachycardia, AF

Answer 1

Thyrotoxicosis (fever on top of untreated thyrotoxicosis)

Rehydrate, broad spectrum antibiotic, propranolol and sodium ipodate and neomercrazole

Question 2

Weight loss with normal/increased appetite, heat intolerance, palpitations, tremor and irritability
Can have lid lag, palmer erythema and tachycardia

Answer 2

Thyrotoxicosis- increased T3/T4 and decreased TSH

Question 3

Tiredness, weakness, dry skin, feeling cold, hair loss, difficulty concentrating
Plus: fluffy face/hands/feet, alopecia, bradycardia

Answer 3

Ddx: depression, alzheimers, anaemia

Hypothyroidism- decreased free T3/T4 and increased TSH

Question 4

Heat intolerance, sweating, palpitations, tremor, tachycardia, diffuse goitre, opthalmopathy, pretibial myxoederma

Answer 4

Ddx: thyroiditis, cocain/amphetamine use, cancer, psychological disorder

Hyperthyroidism (Graves)

Question 5

Autoantibodies against thyroglobulin and thyroid peroxidase

Answer 5

Hashimoto’s throiditis

Question 6

Opthalmopathy, hyperfunctional enlargement of thyroid, pretibial myxederma

Answer 6

Grave’s disease

Question 7

Palpitations, pain (headache), profuse perspiration and hypertension

Answer 7

phaeochromocytoma

Question 8

fatigue, anorexia, weight loss, hyperpigmentation, salt craving and antibodies against 21- hyroxylase

Answer 8

Ddx: adrenal suppresion due to drugs, secondary/tertiary adrenal insufficiency, hamochromotosis, hyperthyroidism, anorexia

Addisons

Question 9

glucose intolerance, proximal muscle wasting, moon face, truncal obesity, skin changes, osteopenia, nephrolithias, gonadal dysfunction

Answer 9

DDx: Obesity, Metabolic sndrome

Cushings

Question 10

A 34-year-old woman presents with complaints of weight gain and irregular menses for the last several years. She has gained 20 kg over the past 3 years and feels that most of the weight gain is in her abdomen and face. She notes bruising without significant trauma, difficulty rising from a chair, and proximal muscle wasting. She was diagnosed with type 2 diabetes and hypertension 1 year ago.

Answer 10

Cushings syndrome

Question 11

A 54-year-old man presents for evaluation of an incidentally discovered adrenal nodule. He underwent a CT scan of the abdomen for evaluation of abdominal pain, which was negative except for a 2 cm well-circumscribed, low-density (2 Hounsfield units) nodule in the right adrenal gland. He reports weight gain of 15 kg over the past 4 years. He has difficult-to-control type 2 diabetes and hypertension. He has had 2 episodes of renal colic in the last 5 years.

Answer 11

Cushings syndrome

Question 12

A 48-year-old man has a 4-month history of increasing fatigue and anorexia. He has lost 5.5 kg and noticed increased skin pigmentation. He has been otherwise healthy. His mother has Hashimoto’s thyroiditis and one of his sisters has type 1 diabetes. His BP is 110/85 mmHg (supine) and 92/60 mmHg (sitting). His face shows signs of wasting and his skin has diffuse hyperpigmentation, which is more pronounced in the oral mucosa, palmar creases, and knuckles.

Answer 12

Addison’s

Question 13

A 54-year-old woman with hypothyroidism complains of persistent fatigue, despite adequate thyroxine replacement. She has noticed increasing lack of energy for the past 3 months and additional symptoms of anorexia and dizziness. She also has significant loss of axillary and pubic hair. Her BP is 105/80 mmHg (supine) and 85/70 mmHg (sitting). The only abnormal finding on physical examination is a mild increase in thyroid size, with the thyroid having rubbery consistency.

Answer 13

Addison’s

Question 14

A 33-year-old female presents to her doctor complaining of a several-month history of episodic palpitations and diaphoresis. She states that her husband noticed that she becomes pale during these episodes. She has been experiencing progressive episodic headaches, which are not relieved by paracetamol. In the past, she has been told that she had a high calcium level. She has a history of kidney stones. Her FHx is unremarkable; specifically, there is no history for tumours, endocrinopathies, or HTN. Physical examination reveals a BP of 220/120 mmHg and hypertensive retinal changes.

Answer 14

Phaeochromocytoma

Question 15

A 28-year-old white woman who has smoked 1 pack per day for the last 10 years presents with subacute onset of cloudy vision in 1 eye, with pain on movement of that eye. She also notes difficulty with colour discrimination, particularly of reds. She was treated for a sinus infection 2 weeks ago and on further history recalls that she had a 3-week history of unilateral hemibody paresthesias during exam week in college 6 years ago. She occasionally has some tingling on that side if she is overly tired, stressed, or hot.

Answer 15

Multiple sclerosis

Question 16

A 31-year-old woman with strong family history of autoimmune disease is 6 months postpartum and develops ascending numbness and weakness in both feet, slightly asymmetrically, over a period of 2 weeks. She gradually develops difficulty walking to the point where she presents to an emergency department and is also found to have a urinary tract infection (UTI).

Answer 16

Multiple sclerosis

Question 17

A 53-year-old black woman complains of a sudden, excruciating headache while sitting at work. The headache is diffuse, intense, and accompanied by nausea and vomiting. She describes the headache as the worst headache of her life. She loses consciousness following onset of the headache and is on the floor for less than 1 minute. She is being treated for hypertension and is a smoker. On examination she has a normal mental state, meningismus, bilateral subhyaloid haemorrhages, and right third cranial nerve palsy. There are no sensory deficits or weakness. Brain CT reveals diffuse subarachnoid blood in basal cisterns and sulci.

Answer 17

Subarachnoid haemorrhage

Question 18

A 70-year-old man with a history of chronic HTN and atrial fibrillation is witnessed by a family member to have right-sided weakness as well as difficulty speaking and comprehending language. The symptoms started with only mild slurred speech before progressing over several minutes to severe aphasia and right arm paralysis. The patient is taking warfarin.

Answer 18

Haemorrhagic stroke

Question 19

A 69-year-old man presents with a 1-year history of mild slowness and loss of dexterity. His handwriting has become smaller, and his wife feels his face is less expressive and his voice softer. Over the last few months he has developed a subtle tremor in the right hand, noted while watching television. His symptoms developed insidiously but have mildly progressed. He has no other medical history, but he has noted some mild depression and constipation over the last 2 years. His examination demonstrates hypophonia, masked facies, decreased blink rate, micrographia, and mild right-sided bradykinesia and rigidity. An intermittent right upper extremity resting tremor is noted while he is walking. The rest of his examination and a brain MRI are normal.

Answer 19

Parkinsons

Question 20

A 42-year-old school teacher presents with difficulty managing her classroom. She has become increasingly irritable with students and fails to complete assigned tasks on time. Her sister and husband report that she has become restless, pays less attention to her appearance and social obligations, and at times is anxious and upset. She has stumbled unexpectedly. Her symptoms resemble those of her mother when she was diagnosed with Huntington’s disease. On examination, her speech is somewhat uneven and she is inappropriately flippant. Subtracting serial 7s from 100, while seated with her eyes closed, brings out random ‘piano-playing’ movements of the digits along with other movements of the limbs, torso, and face. Subtraction errors occur with this task. She is unable to keep her tongue fully protruded for 10 seconds. Finger tapping is slower than the examiner’s, and tapping tempo is uneven. Tandem walking is impaired.

Answer 20

Huntingtons

Question 21

A 45-year-old homeless man is found unconscious in the street. He appears stiff, with continuously shaking extremities, foaming at the mouth, and urinary incontinence. On arrival to the emergency department, he has stopped shaking but is still unconscious. Stiffening and shaking resume a few minutes later. Two empty medicine bottles are found in his pocket, labelled phenytoin and valproic acid.

Answer 21

Status Epilepticus

Question 22

A 15-year-old girl wakes up disoriented and confused. She remains still in bed, looking continuously around the room as if daydreaming. When asked about her strange behaviour, she does not appear to understand and replies with unintelligible words. For the last 3 years, she has been having subtle early morning body jerks and has been told by her teachers that she frequently spaces out in class.

Answer 22

Status eplieptics

Question 23

An 18-year-old girl presents with several episodes of confusion over the past several months. Typically, she experiences a warning signal, which she describes as a rising sensation within her abdomen that travels upwards through her chest. She is usually unaware for a few minutes, but others have told her that she smacks her lips, picks at her clothing, and is unable to speak during these episodes. After the event she feels tired, has a headache, and prefers to lie down. She notes that her memory has not been as good as it was in the past, and her school grades have declined. Her past medical history is notable for several febrile seizures as a young child, although she was not treated for seizures at that time. An aunt was diagnosed with seizures many years ago.

Answer 23

Focal seizures

Question 24

A 70-year-old man presents with a generalised tonic-clonic seizure. His wife states that during the past month there have been times when he does not respond, mumbles words that do not make sense, and stares. After several minutes he is usually responsive. His past medical history includes hypertension and hypercholesterolaemia. He had a stroke during the preceding year. Although he recovered significantly, he still walks with a limp on the left side.

Answer 24

Focal seizures

Question 25

A 16-year-old male presents to the emergency department with a first-time seizure event after attending an all-night party and consuming alcohol. Witnesses described the seizure as beginning abruptly with bilateral limb stiffening, followed by jerking movements in all limbs; the patient has no memory of warning symptoms prior to the seizure. The event seemed to last about 1 minute, and the patient was quite somnolent afterwards. Further review of the history reveals that the patient has been experiencing ‘jerks’ in the morning after awakening, usually involving the arms and shoulders and occasionally causing him to drop things. These ‘jerks’ do not seem to present a problem during the rest of the day.

Answer 25

Generalized seizures

Question 26

A 55-year-old woman recently diagnosed with a brain tumour in the left hemisphere has a witnessed seizure event. The seizure is initially recognised when the patient begins staring and is unresponsive to those around her. She seems to be picking at her clothes with her left hand, but the right arm and leg are not moving. After 20 seconds, she displays rapid head-turning and eye deviation to the right, with tonic stiffening of the right arm and flexion of the left arm. This is quickly followed by tonic stiffening of the left arm as well, then clonic jerking occurring in both arms synchronously. This jerking gradually slows and stops after about 30 seconds. The patient then becomes quite somnolent, and she appears to be using her arm and leg less on the right than the left.

Answer 26

Generalized seizure

Question 27

A 32-year-old woman presents with a 13-year history of 1 to 3 attacks per month of disabling pounding pain over one temple, with nausea and sensitivity to light. She says that her headaches can be triggered by lack of sleep and made worse by physical exertion, and are more common during menstrual bleeding. Untreated, they last for 2 days. On 4 occasions, headaches were preceded by the gradual appearance of a shimmering, zigzag line that enlarged, moved to the peripheral visual field, and then faded away over 45 minutes. Examination is normal.

Answer 27

Migraine

Question 28

A 40-year-old man complains of a 1-year history of twice-monthly global headache, worse on the left side in the post-auricular region. It comes on gradually and, at its most severe, the vision in his left eye becomes distorted. He often has to stop watching television as the picture becomes “blurry”. His nose becomes blocked, although sometimes he has a “runny nose”. He takes a non-steroidal anti-inflammatory drug (NSAID) that helps a little, but he feels that his head is about to explode at times. When the headache occurs, he needs to go into a dark quiet room and sleep until it resolves. He reports that the problem is “really getting him down”, and he is having difficulties with his employer due to loss of work time.

Answer 28

Migraine

Question 29

A 37-year-old woman presents with a 12-year history of episodic headaches. She experiences these 4 times a week, typically beginning at the end of a working day. The pain is generalised and described as similar to wearing a tight band around her head. The headaches are bothersome, but not disabling, and she denies any nausea or vomiting. She is slightly sensitive to noise but has no photophobia. Pain during her attacks typically responds to ibuprofen. Examination reveals tenderness of her scalp and both trapezius muscles.

Answer 29

Tension type headache

Question 30

A 56-year-old man presents with a 25-year history of constant headache. The onset was insidious and he is certain that the only time he is headache-free is when he sleeps. He states the headache is generalised and his neck and shoulders are always ‘tight’. He denies any associated autonomic symptoms including eye tearing, nasal congestion, light and sound sensitivity, nausea, or vomiting.

Answer 30

Tension type headache

Question 31

A 45-year-old woman presents with insomnia and irritability lasting for 4 weeks. She recently finalised her divorce from her second husband and now is stuck in a custody dispute over her 2 children. She has a history of gestational diabetes and her mother committed suicide when she was 10 years of age. She is worried that she will soon lose her job due to an inability to meet deadlines. Her examination is notable for poor eye contact and frequent tears. Her TSH and random glucose levels are normal.

Answer 31

Depression

Question 32

A 20-year-old man presents to the hospital emergency department accompanied by his parents, owing to a change in mental status and behaviour, marked by uncharacteristic argumentativeness, eruptions of laughter, excessive talking, and unusual thoughts. He is being treated for depression and insomnia, and has recently been drinking more alcohol. For the past 2 weeks he has missed college classes, while staying up most nights until 4 or 5 a.m., writing feverishly in several notebooks. When asked, he reports that he is writing 2 novels at the same time and also documenting his accomplishments in an autobiography. He denies any illicit substance use while admitting to increasing alcohol consumption “like all the great novelists do”. Efforts by his family to understand his recent change in thinking and behaviour have been met with loud and rambling discourses, and he angrily accuses them of wanting him to stay “subjugated by the tyranny of depression”.

Answer 32

Bipolar

Question 33

A 32-year-old nurse presents to her primary care provider complaining of frequent headaches, irritable bowel, insomnia, and depressed mood. She currently takes no medication and has no history of substance abuse or major medical problems beyond treatment for a single depressive episode in her first year at university. Her physical examination, routine labs, and CT brain are all within normal limits. Her family history is notable for several ancestors who have been affected by psychiatric illness, including depression, bipolar disorder, and schizophrenia. Her paternal grandfather and a maternal aunt committed suicide. She has had 3 prior episodes of several weeks’ duration characterised by insubordinate behaviour at work, irritability, high energy, and decreased need for sleep. She regrets impulsive sexual and financial decisions that she took during these episodes, and has recently filed for personal bankruptcy. For the past month her mood has been persistently low, and she has had reductions in sleep, appetite, energy, and concentration, with some passive thoughts of suicide.

Answer 33

Bipolar

Question 34

A 22-year-old unmarried white man presents to the clinic with his mother. He spends most of his time in the house and refuses to go out at night alone. He used to live independently and worked until a few months ago. The patient states he made an error on his income tax statement and is convinced that the tax authorities have hired detectives to gather information about his whereabouts. He states that, since his mistake, he uncovered an essential flaw in the taxation algorithm, which may expose the underpinning of the taxation system, and is convinced they have hired assassins disguised as bikers. After moving in with his mother, he did not see the bikers, but they are trying to trace his “mental activity”. Also, he hears them outside his house talking about how they will kill him; he reported the problem to the police and is seeking help “to defeat the tax collectors”. He appears suspicious, avoids eye contact, and his answers to questions are delayed, during which he appears internally preoccupied.

Answer 34

Schizophrenia

Question 35

A 12-year-old white girl is brought to the emergency department by her parents due to 12 hours of rapidly worsening nausea, vomiting, abdominal pain, and lethargy. Over the last week she has felt excessively thirsty and has been urinating a lot. Physical examination reveals a lean, dehydrated girl with deep rapid respirations, tachycardia, and no response to verbal commands.

Answer 35

Diabetes (ketoacidosis) type 1

Question 36

An overweight 55-year-old woman presents for preventive care. She notes that her mother died of diabetes, but reports no polyuria, polydipsia, or weight loss. BP is 144/92 mmHg, fasting blood sugar 8.2 mmol/L (148 mg/dL) (on 2 occasions), HbA1c 65 mmol/mol (8.1%), LDL-cholesterol 5.18 mmol/L (200 mg/dL), HDL-cholesterol 0.8 mmol/L (30 mg/dL), and triglycerides 6.53 mmol/L (252 mg/dL).

Answer 36

Diabetes (type 2)

Question 37

A 38-year-old woman, who in the past had tried to lose weight without success, is happy to see that in the last 2 months she has lost about 11 kg (25 pounds). She also has difficulty sleeping at night. Her husband complains that she is keeping the house very cool. She recently consulted her ophthalmologist because of redness and watering of the eyes. Eye drops were not helpful. She consults her doctor for fatigue and anxiety, palpitation, and easy fatigability. On physical examination, her pulse rate is 100 bpm and her thyroid is slightly enlarged. Conjunctivae are red and she has a stare.

Answer 37

Graves

Question 38

A 45-year-old white woman presents with symptoms of fatigue, depression, and mild weight gain. Physical examination demonstrates heart rate of 58 beats per minute, coarse dry skin, and bi-lateral eyelid oedema. Serum TSH is 40 milli-international units/L (normal range 0.35-6.20 milli-international units/L), and free T4 is 6.44 picomol/L (0.5 nanograms/dL) (normal range 9.00-23.12 picomol/L [0.7 to 1.8 nanograms/dL]). Therapy is begun with levothyroxine 100 micrograms daily and the patient’s symptoms improve. Repeat testing 6 weeks later reveals a normal TSH (5 milli-international units/L). The patient is maintained on this dose and repeat TSH testing is planned yearly or if symptoms recur.

Answer 38

Primary hypothyroidism

Question 39

polyuria, polydipsia, renal colic, lethargy, anorexia, nausea
Normal or elevtaed PTH

Answer 39

hypercalcaemia: primary/tertiary hyperparathyroidsim, lithim inudced hpa, familial hypocalciuric hypercalcaimia

Question 40

polyuria, polydipsia, renal colic, lethargy, anorexia, nausea
Low PTH

Answer 40

hypercalcaemia:

malignancy, increased Vit D, thyrotoxicosis

Question 41

Child: carpopedial spasm, stridor and convulsion

Answer 41

hypocalcaemia

Question 42

carpopedial spasm, tingling around hands/feet/mouth and sometimes stidor

Answer 42

hypocalcaemia

Question 43

Scotish female, visual disturbance in one eye

peculiar sensory phenomena (seperated in space and time)

Answer 43

MS

Question 44

Man, Severe pain, always on one side of head, periodically occurs, ptosis, lacrimation

Answer 44

Cluster headache

Question 45

Bilateral tightness of scalp/neck, severity remains constant and may radiate from neck

Answer 45

Tension headache