Clinical Skills Vignettes Flashcards
HEADACHE:
General approach [3]
Physical Exam (4)
General Workup
LIQOPRA, B4, NTC, WAJISS + [FND, aura, nuchal]
Vitals
Inspect/palpate entire head
Complete Neuro Exam
Fundoscopy
CBC, ESR, CT/MRI, LP
21 yoF presenting w/ several episodes of throbbing, left temporal pain lasting 2-3 hrs, associated with aura and right-sided “FND,” as well as n/v. She has a family hx of migraine.
Ddx? Orders?
1) Migraine with Aura (classic)
2) Idiopathic Intracranial HTN (Pseudotumor cerebri)
3) Tension/Cluster
a) CBC
b) ESR
c) CT/MRI
d) LP
26 yoM presenting with severe RT temporal headaches associated w/ ipsilateral rhinorrhea, eye tearing, and redness. Episodes have occurred at the same time every night for the past week and last for 45 minutes.
1) Cluster Headache
2) Migraine/Tension
3) Intracranial Neoplasm/Pseudotumor cerebri
a) CBC
b) ESR
c) CT/MRI
d) LP
65 yo F presenting with severe, intermittent, right temporal headache, fever, blurred vision in right eye, and pain in jaw when chewing
1) Temporal Arteritis (severe, acute, blurred vision unilaterally, jaw pain)
2) Migraine (visual disturbance, unilateral headache, female)
3) Pseudotumor Cerebri (female, blurred vision, headache)
a) ESR/CRP
b) CBC
c) Temporal Artery Biopsy
d) LP
e) CT/MRI
30 yo F, with a history of allergies, presenting with frontal headache, fever, and rhinorrhea. There is pain on palpation of the frontal and maxillary sinuses.
1) acute bacterial rhinosinusitis (frontal/max sinus tenderness, fever, history of allergies)
2) Migraine, meningitis, tension h/a, ICNeoplasm
a) CBC
b) CT of sinuses (only if refractory/chronic!)
50 yo F with recurrent BL squeezing headaches, 3-4x per week, typically towards the end of her work day. Significant stress in her life and recently decreased caffeine intake.
1) Tension Headache (BL, stress)
2) Caffeine/analgesic Withdrawal Headaches (obv)
3) Depression
a) CBC
b) Electrolytes
c) ESR? CT? LP?
35 yo M with sudden headache, vom, confusion, L hemiplegia, and nuchal rigidity
1) SAH (sudden, n/v, meningismus)
2) Meningitis (nuchal, vom/confusion)
3) Epidural Hematoma (sudden, FND)
4) Intracranial Mass (same)
a) CT head (non-contrast, emergent)
b) LP CSF analysis (if CT scan is negative… r/u papilledema first)
c) CBC, PT/INR
25 yo M with high fever, severe headache, confusion, photophobia, nuchal rigidity
1) bacterial meningitis (nuchal, photophobia, fever)
2) SAH (severe ha)
3) migraine
a) LP analysis
b) CBC
c) CT-head
18 yo F, obese, with pulsatile headache, vom, blurred vision for 2-3 weeks. She is taking OCP
1) IIH (obese female, vision, OCP, pulsatile)
2) Common Migraine w/out aura (OCP, vom/vision, female)
3) Cerebral Venous Thrombosis (blurred vision, OCP)
a) LP
b) CT head
c) CBC
57 yo M with daily pain in right cheek for past month. Electric and stabbing in character and occurs while shaving. 2-4 minutes.
1) Trigeminal Neuralgia (location, shaving trigger, electric/stabbing)
2) TMJ
a) MRI to determine V compression
b) CBC
c) ESR
CONFUSION/MEMORY LOSS:
General Approach [5]
Physical Exam
Workup
LIQOPRA; B4, NTC, WAJISS + [incontinence, ataxia, hypothyroid, depression]
Vitals MMSE Complete Neuro Gait General (ENT, heart, lungs, abdominal, extremities)
VDRL, B12, CBC/BMP, MRI, TSH, LP
81 yo M with progressive confusion past several years, accompanied by forgetfulness and clumsiness. He has hx of HTN, DM, and 2 strokes w/ residual L hemiparesis. Mental status has worsened after each stroke.
1) Vascular Dementia (stepwise)
2) Alzheimer’s (insidious, forgetfulness)
3) NPH (wobbly, wacky)
a) MRI brain
b) Serum B12
c) CBC
d) TSH
e) VDRL!
f) electrolytes
84 yo F with forgetfulness (phone numbers, directionality) and difficulty with ADL; progressive
1) Alzheimer (old age, ADL, forgetfulness)
2) Vascular
3) Age-related cognitive decline
a) MRI brain
b) Serum B12
c) CBC
d) TSH
e) VDRL!
f) electrolytes
72 yo M with memory loss, gait disturbance, urinary incontinence, 6 months.
1) NPH (wet, wacky, wobbly)
2) Alzhemier
3) Organophosphate Toxicity (urinary, CNS, muscle)
a) MRI brain
b) Serum B12
c) CBC
d) TSH
e) VDRL!
f) electrolytes
55 yo M with rapidly progressive change in MStatus, inability to concentrate, memory impairment of 2 months’ duration. Myoclonus, ataxia, startle response.
1) CJD (myoclonus, startle response, AMS, young)
2) Vascular Dementia
3) Depression
a) MRI brain + EEG!
b) Serum B12
c) CBC
d) TSH
e) VDRL!
f) electrolytes
70 yo M, hx DM, presenting with confusion, dizziness, palpitations, diaphoresis, and weakness.
1) Acute Hypoglycemia (diaphoresis, palp, weakness, AMS)
2) Global-ischemic cerebrovascular disease 2/2 persistent hypoglycemia
3) TIA (weakness)
4) Delirium (confusion, elderly)
5) MI (diaphoresis, palpitations)
a) Serum Glucose
b) C-peptide
c) CT-head
d) CBC, electrolytes
e) Troponin I, CK-MB, EKG
55 yo F, gradual AMS and h/a, 2 wks s/p fall with trauma to head, LOC for 2 min
1) Subdural Hemorrhage (LOC, trauma, AMS, 2 wks)
2) SIADH
3) Neoplasm
a) CT-head
b) CBC
c) serum electrolytes
73 yo M, hx of a-fib and R eye cataracts, presenting with acute L eye vision loss, palpitations, SOB. No eye pain, discharge, redness, or photophobia. No headache, weakness, numbness.
1) Retinal Artery Occlusion
2) Retinal Vein Occlusion
3) Acute angle-closure glaucoma
4) Retinal Detachment
5) Temporal Arteritis
6) Sickle Cell Disease
a) Fluorescein angiography, Fundoscopy
b) Intraocular Tonometry
c) Carotid Doppler
d) Echo
e) CBC/ESR/temporal artery biopsy
f) Hgb electrophoresis
68 yo M with 2-month hx of crying spells, excessive sleep, poor hygiene, 15 lb weight loss, all following wife’s death. Doesn’t enjoy time w/ his grandchildren and admits to thinking he has seen his dead wife in line at the supermarket or standing in the kitchen making dinner.
1) Normal Bereavement
2) Adjustment disorder w/ depressed mood
3) MDD w/ psychotic features
a) Physical Exam, MSE
b) TSH, CBC, electrolytes
c) Beck’s Depression Inventory
42 yo F presents with 4 week hx of excessive fatigue, insomnia, and anhedonia. She states that she thinks constantly about death. 5 similar episodes in the past, first in her 20s; 2 previous suicidal attempts. Increased alcohol use in the past month.
1) MDD (past hx, suicidal ideation)
2) Substance-induced mood disorder
3) Persistent Depressive Disorder (Double depression)
a) Physical Exam, MSE
b) TSH, CBC, urine toxicology
c) Beck’s Depression Inventory
d) serum EtOH
26 yo F with 6.5 lb weight loss in the past 2 months, early morning awakening, excessive guilt, Psychomotor retardation, no trigger for depressive episodes but reports several weeks of increased energy, sexual promiscuity, irresponsible spending, and racing thoughts approx. 6 months prior.
1) Bipolar I Disorder (manic episode)
2) Bipolar II (hypomanic episode + depressive episode)
3) Cyclothymic Disorder (hasn’t been 2 years)
a) Physical Exam, MSE
b) TSH, CBC, urine toxicology
c) Beck’s Depression Inventory
MOOD DISORDER:
General Approach
Physical Exam
Workup
DISC-E-GAPS
Vitals, MSE, Neuro, Head/Neck
(Appearance, behavior, speech, mood/affect, thought process/content, cognition, insight, judgement)
a) Physical Exam, MSE
b) TSH!, CBC, electrolytes
c) +/-urine toxicology, +/- serum EtOH
d) Beck’s Depression Inventory
e) family interrogation
19 yo M c/o receiving messages from his television set. He reports that he did not have many friends in high school. In college, he started to suspect his roommate of bugging the phone. He stopped going to classes because he felt that his professors were saying horrible things about him that no one else noticed. He rarely showered or left his room and has recently been hearing a voice from his television set telling him to “guard against the evil empire.”
1) Schizophrenia
2) Schizophreniform
3) Schizoid/typal PD
a) Physical/MSE
b) TSH, CBC, Electrolytes
c) Urine Toxicology
28 yo F c/o seeing bugs crawling on her bed for the past 2 days and hearing loud voices when she is alone in her room. She has never experienced any- thing similar in the past. She recently ingested an unknown substance.
1) Substance-induced psychotic episode
2) Brief Psychotic Disorder
a) URINE TOXICOLOGY
b) BUN/Cr, AST/ALT
c) Physical/MSE
d) TSH, CBC, Electrolytes
48 yo F presents with a 4-week history of auditory hallucinations that state, “I am worthless” and “I should kill myself.” She also reports a 2-week history of weight loss, early-morning awakening, decreased motivation, and overwhelming feelings of guilt.
1) Schizoaffective (2 weeks PURE psychosis then psychosis+mood)
2) MDD w/ psychotic features
3) Schizophreniform
a) Beck’s Depression Inventory
b) Physical/MSE
c) TSH, CBC, Electrolytes
d) Urine Toxicology
35 yo F presents with intermittent episodes of vertigo, tinnitus, nausea, and hearing loss within the past week.
1) Meineire’s (intermittent?, hearing loss?)
2) Labyrinthitis (HEARING LOSS) so not vest. neuritis
3) Acoustic Neuroma [vertebrobasilar insufficiency]
a) CBC, Electrolytes
b) electronystagmography
c) MRI/MRA brain
55 yo F c/o dizziness for the past day. She feels faint and has severe diarrhea that started 2 days ago. She takes furosemide for hypertension.
1) dehydrational orthostatic hypotension (diarrhea, diuresis, dehydration)
2) Labyrinthitis/Vest. Neuritis (recent viral infection)
3) Furosemide-induced ototoxicity (furosemide)
a) Orthostatic Vitals/ Repeat
b) Stool leukocytes, rectal
c) CBC, BMP
d) MRI brain
65 yo M presents with postural dizziness and un- steadiness. He has hypertension and was started on hydrochlorothiazide 2 days ago.
1) HCTZ-induced orthostatic hypotension
2) Renal Failure
3) Vertebrobasilar Insufficiency
a) Orthostatic Vitals/Repeat
b) BUN/Cr
c) CBC, BMP
d) MRI brain
44 yo F c/o dizziness on moving her head to the left. She feels that the room is spinning around her head. A tilt test results in nystagmus and nausea.
1) BPPV
2) Meineire’s
3) Labyrinthitis/Vestibular Neuronitis
a) Dix-hallpike maneuver
b) MRI brain
c) audiometry
d) TSH
55 yo F c/o dizziness that started this morning. She is nauseated and has vomited once in the past day. She had a URI 2 days ago and has experienced no hearing loss.
-vs-
55 yo F c/o dizziness that started this morning and of “not hearing well.” She feels nauseated and has vomited once in the past day. She had a URI 2 days ago.
1) Vestibular Neuronitis (2)
2) Labyrinthitis (1)
3) Acoustic Neuroma (hearing loss+dysequillibrium)
a) CBC, electrolytes
b) MRI Brain
c) Audiometry
d) ElectroNystagmography
55 yo M c/o falling after feeling dizzy and unsteady. He experienced transient LOC. PMhx is significant for HTN and DM
1) Drug-induced syncope (orthostatic hypotension)
2) Hypoglycemia
3) TIA, MI, Arrhythmia
a) Redo, Orthostatic Vitals
b) Echo/EKG
c) CBC, BMP, glucose
d) Carotid Ultrasound
e) CT head
65 yo M px s/p falling and LOC for a few seconds. No warning before passing out but recently had palpitations. Hx includes CABG.
1) Syncope (hx of CAGB) [2/2 arrhythmia]
2) Vertebrobasilar Insufficiency (“fall attack”)
3) Carotid Stenosis, Aortic Stenosis
4) Seizure
a) Echo/EKG/holter monitor
b) Carotid doppler
c) CT head
d) CBC, BMP, glucose
68 yo M presents following a 20-minute episode of slurred speech, right facial drooping and numbness, and right hand weakness. His symptoms had totally resolved by the time he got to the emergency de- partment. He has a history of hypertension, diabetes mellitus, and heavy smoking.
1) TIA (HTN, DM, smoke)
2) Lacunar Infarct
3) Hypoglycemia
4) Seizure
5) Facial Nerve Palsy
a) CT head
b) MRI head
c) CBC, BMP, Glucose, Lipid Panel
d) EEG
68 yo M presents with slurred speech, right facial drooping and numbness, and right hand weakness. Babinski’s sign is present on the right. He has a his- tory of hypertension, diabetes mellitus, and heavy smoking.
1) Spinal cord lesion (UMN)
2) Ischemic Stroke
3) Subdural Hematoma
a) CT head
b) MRI brain
c) CBC, BMP, Lipid
d) Carotid Doppler
33 yo F presents with ascending loss of strength in her lower legs over the past 2 weeks. She had a re- cent URI.
1) Guillain Barre Syndrome
2) Polymyositis
3) MG, MS
a) CBC, BMP, CPK!
b) Nerve conduction velocities
30 yo F presents with weakness, loss of sensation, and tingling in her left leg that started this morning. She is also experiencing right eye pain, decreased vi- sion, and double vision. She reports feeling “electric shocks” down her spine upon flexing her head.
2) UMN/stroke
1) Multiple Sclerosis (Lhermmite’s phenomenon, eye pain, diplopia
3) Carotid Stenosis
4) Conversion Disorder
a) CT head/MRI head
b) Carotid Ultrasound
c) Fundoscopy
d) CBC, ESR, VDRL/RPR
55 yo M presents with tingling and numbness in his hands and feet (glove-and-stocking distribution) for the past 2 months. He has a history of diabetes mellitus, hypertension, and alcoholism. There is de- creased soft touch, vibratory, and position sense in the feet.
1) Diabetic Peripheral Neuropathy (stocking glove)
2) B12 deficiency (alcoholism)
3) alcoholic peripheral neuropathy
4) Hypocalcemia
a) HbA1c
b) B12, ESR
c) UA
c) Serum Calcium
40 yo F presents with occasional double vision and droopy eyelids at night with normalization by morn- ing.
1) Myasthenia Gravis (ptosis, diplopia, progressively worse with use)
2) Horner’s
3) ALS
4) EOEM palsy
a) edrophonium challenge
b) Serum ACh receptor Ab
c) MRI/EMG
D) CT CHEST TO R/O THYMOMA!
25 yo M presents with hemiparesis after a tonic- clonic seizure that resolved within a few hours.
1) todd’s paralysis (post-ictal)
2) Malingering
a) MRI-head
b) CBC, BMP
c) Doppler
56 yo obese F c/o tingling and numbness of her thumb, index finger, and middle finger for the past 5 months. Her symptoms are constant, have progressively worsened, and are relieved with rest. She works as a secretary. She has a history of fatigue and a 20-lb (9-kg) weight gain over the same period.
1) Carpal Tunnel Syndrome (median nerve entrapment)
2) Hypothyroidism
3) Cervical Radiculopathy/Brachial Plexopathy
4) Medial Epicondylitis
a) nerve conduction studies
b) TSH, CBC
c) Phalen’s Maneuver/ Tinnel’s Test
44 yo M presents with fatigue, insomnia, and night- mares about a murder that he witnessed in a mall 1 year ago. Since then, he has avoided the mall and has not gone out at night.
1) PTSD (traumatic event)
2) Social Anxiety Disorder (predictable avoidance of public)
3) Generalized Anxiety Disorder (insomnia, fatigue)
a) Physical/MSE
b) Beck’s Depression Inventory
c) polysomnogram
55 yo M presents with fatigue, weight loss, and con- stipation. He has a family history of colon cancer
1) Colonic Adenocarcinoma (family hx, constitutional signs)
2) Inflammatory Bowel Disease (weight loss)
3) Anemia of Chronic Disease (fatigue)
4) Hypothyroidism, Depression, Renal Failure
a) RECTAL EXAM!
b) Colonoscopy with biopsy
c) Barium Enema/CT abdomen for staging (CT colonography)
d) CBC, Electrolytes, TSH, BUN/Cr
e) Stool Sample for occult blood
40 yo F presents with fatigue, weight gain, sleepi- ness, cold intolerance, constipation, and dry skin.
1) Hypothyroidism (fatigue, cold intolerance, const. dry skin, weight gain)
2) Major Depressive Disorder (fatigue, weight gain, sleep)
3) Iron deficiency Anemia
1) TSH, free T3, T4
2) Phys/MSE/Beck’s Depression Inventory
3) CBC, BMP, Glucose
50 yo obese F presents with fatigue and daytime sleepiness. She snores heavily and naps 3–4 times per day but never feels refreshed. She also has hyper- tension.
1) Obstructive Sleep Apnea (obese, snore, fatigue)
2) Hypothyroidism
a) polysomnogram + nocturnal pulse ox
b) CBC, TSH
20 yo M presents with fatigue, thirst, increased ap- petite, and polyuria.
1) DM type 1 (polyuria, polydipsia, fatigue)
2) Diabetes Insipidus (polydipsia)s
3) Primary Polydipsia
4) MDD w/ atypical features (hyperphagia, fatigue)
a) Glucose tolerance test, HbA1C
b) U/A
c) CBC, Electrolytes, BUN/Cr, Glucose serum
35 yo M policeman c/o feeling tired and sleepy during the day. He changed to the night shift last week.
1) Shift Work Circadian Rhythm Disorder
2) Sleep Apnea
3) Depression/Adjustment Disorder w/ depressed mood
a) Phys/MSE/Beck’s Depression Inventory
b) polysomnogram/nocturnal pulse ox
c) CBC
26 yo M presents after falling and losing conscious- ness at work. He had rhythmic movements of the limbs, bit his tongue, and lost control of his bladder. He was subsequently confused after regaining con- sciousness (as witnessed by his colleagues).
1) Generalized Tonic-Clonic Seizure
2) Convulsive Syncope
3) Substance abuse/overdose
4) Malingering
5) Hypoglycemia
a) CBC, BMP, glucose
b) Urine tox
c) EEG
d) MRI brain, CT-head
e) LP
40 yo F c/o feeling tired, hopeless, and worthless and of having suicidal thoughts. She lost her job and has been having fights with her husband about money.
1) MDD (suicidal ideation, stress)
2) Adjustment disorder w/ depressed mood
3) Anemia, Hypothyroidism
a) Beck’s Depression Inventory
b) TSH, CBC
30 yo M presents with night sweats, cough, and swollen glands of 1 month’s duration. He recently emigrated from the African subcontinent.
1) TB
2) Acute HIV
3) Lymphoma
a) CBC, BMP
b) HIV antibody
c) sputum culture/gram stain
d) CXR, quantiferon gold (IFN-gamma), PPD
45 yo F presents with excessive sweating, uninten- tional weight loss, palpitations, diarrhea, and short- ness of breath.
1) Hyperthyroidism
2) Pheochromocytoma
3) Carcinoid Syndrome
4) Tuberculosis
a) TSH, Free T4
b) 24 hour urine metanephrines and catecholamines
c) urine 5-HIAA/serum serotonin
d) CBC, PPD
25 yo F presents with a 3-week history of difficulty falling asleep. She sleeps 7 hours per night without nightmares or snoring. She recently began college and is having trouble with her boyfriend. She drinks 3–4 cups of coffee a day.
1) insomnia secondary to caffeine use
2) insomnia 2/2 acute stress disorder (3 wk, non-life-threatening)
1) Phys/MSE
2) Polysomnogram
3) CBC, urine tox, TSH
33 yo F c/o 3 weeks of fatigue and trouble sleeping. She states that she falls asleep easily but wakes up at 3 A.M. and cannot return to sleep. She also reports an unintentional weight loss of 8 lbs (3.6 kg) and an inability to enjoy the things she once liked to do.
1) MDD (fatigue, sleep/wakenings, weight loss, anhedonia)
2) primary hypersomnia
a) Phys/MSE
b) TSH, CBC
c) Polysomnography
26 yo F presents with sore throat, fever, severe fa- tigue, and loss of appetite for the past week. She also reports epigastric and LUQ discomfort. She has cervical lymphadenopathy and a rash. Her boyfriend recently experienced similar symptoms.
1) Infectious Mononucleosis (fatigue, c-LAD, bf)
2) Streptococcal Pharyngitis (scarlitiniform rash, LAD, fever, sore throat)
3) GERD (pyrosis?), Hepatitis
4) secondary syphilis (rash!, partner)
a) heterophile antibody testing (monostpot)
b) anti-EBV Ab
c) rapid streptococcal antigen test/throat culture
d) esophageal pH monitoring, LFTs (AST/ALT/bili/alk phos)
e) VDRL/RPR
f) CBC w/diff, peripheral smear
26 yo M presents with sore throat, fever, rash, and weight loss. He has a history of IV drug abuse and sharing needles.
1) HIV (IVDU), acute retroviral syndrome
2) strep pharyngitis/tonsillitis, scarlet fever
3) Mono
4) Secondary syphilis
5) hepatitis
a) HIV Ab testing, viral load PCR, CD4 count
b) rapid strep/throat culture
c) LFTs (AST/ALT, Bili, Alk Phos)
d) VDRL/RPR
e) CBC with peripheral smear
46 year old F px with fever and sore throat
1) strep pharyngitis
2) mycoplasma pneumonia, acute HIV, mono
a) RST/Throat culture
b) cold agglutinin for Mycoplasma, HIV Ab/PCR, monospot
c) CBC
30 yo M presents with shortness of breath, cough, and wheezing that worsen in cold air. He has had several such episodes in the past 4 months.
1) Asthma (RAD)
2) Bronchitis
3) GERD
a) Spirometry/Pulmonary Function Tests/Peak Flow
b) Methacholine Challenge/Bronchodilator Response
c) CXR (r/u other causes)
d) Pulse oximetry
e) CBC
56 yo F presents with shortness of breath and a productive cough that has lasted for at least 3 months each year over the past 2 years. She is a heavy smoker.
1) Chronic Bronchitis (productive, smoking hx)
2) COPD (smoking history)
3) Pneumonia (productive cough)
4) Bronchiectasis*
5) TB, Cancer
a) PFTs
b) Sputum Culture w/ gram stain
c) CXR, CT chest
d) Pulse oximetry
e) CBC
58 yo M presents with 1 week of pleuritic chest pain, fever, chills, and cough with purulent yellow spu- tum. He is a heavy smoker with COPD.
1) Pneumonia (pleuritic CP, yellow sputum, fever)
2) COPD exacerbation
3) Chronic Bronchitis
4) Lung abscess
5) Pericarditis*
a) Spirometry/PFTs
b) Sputum Culture
c) CXR, CT chest
d) Pulse oximetry
e) CBC
f) EKG
25 yo F presents with 2 weeks of nonproductive cough. Three weeks ago she had a sore throat and a runny nose.
1) Atypical Pneumonia**
2) Asthma (RAD)
3) Post-infectious cough s/p URI
4) Upper airway cough syndrome (2/2 postnasal drip)
a) Spirometry/PFTs
b) sputum culture
c) Mycoplasma IgM
d) Urine Legionella antigen
e) CXR
65 yo M presents with worsening cough for the past 6 months accompanied by hemoptysis, dyspnea, weakness, and weight loss. He is a heavy smoker.
1) Squamous Cell Carcinoma of the Lung
2) Tuberculosis (weight loss, cough, hemoptysis)
3) Lung Abscess
4) Wegener’s Granulomatosis (granulomatosis with polyangiitis)
a) CXR, low-dose CT chest
b) PPD, quantiferon IFN-g assay, acid fast test
c) CBC, BMP
d) c-ANCA
e) Echo
55 yo M presents with increased dyspnea and spu- tum production for the past 3 days. He has COPD and stopped using his inhalers last week. He stopped smoking 2 days ago.
1) COPD exacerbation
2) Lung Cancer
3) Pneumonia
a) sputum culture w/ gram stain
b) CXR
c) pulse oximetry, PFT
d) CBC, ABG
34 yo F nurse presents with worsening cough of 6 weeks’ duration accompanied by weight loss, fatigue, night sweats, and fever. She has a history of contact with tuberculosis patients at work.
1) TB
2) Pneumonia
3) lymphoma
4) HIV
a) CXR
b) PPD, quantiferon IFN-g assay, acid fast stain
c) HIV Ab testing/PCR for viral load
d) CBC BMP
e) LN biopsy
35 yo M presents with shortness of breath and cough. He has had unprotected sex with multiple sexual partners and was recently exposed to a patient with active tuberculosis.
1) TB
2) Pneumonia (pneumocystis?)
3) HIV
4) CHF/cardiomyopathy?
a) CXR
b) PPD, quantiferon IFN-g assay, acid fast stain
c) HIV Ab testing/PCR for viral load
d) CBC, CMP
50 yo M presents with a cough that is exacerbated by lying down at night and improved by propping up on 3 pillows. He also reports exertional dyspnea.
1) CHF (orthopnea, PND)
2) OSA
3) GERD
4) Upper-airway cough syndrome
a) Echo, ECG
b) Polysomnogram
c) BNP, Troponin I
d) CBC, BMP
e) PFTs
f) CXR, CT chest
60 yo M presents with worsening dyspnea of 6 hours’ duration and a cough that is accompanied by pink, frothy sputum.
1) Pulmonary Edema*
2) CHF exacerbation (frothy sputum)
3) Mitral STENOSIS*
a) TTE/TEE, ECG
b) BNP
c) CBC, BMP
d) Pulse oximetry
60 yo M presents with sudden onset of substernal heavy chest pain that has lasted for 30 minutes and radiates to the left arm. The pain is accompanied by dyspnea, diaphoresis, and nausea. He has a history of hypertension, hyperlipidemia, and smoking.
1) STEMI
2) GERD
3) musculoskeletal strain CC
4) unstable angina
5) PE
a) EKG, troponin I x3 serial, CK-MB
b) CXR
c) CBC, BMP
d) D-dimer, helical CT
e) cardiac cath
20 yo African American F presents with acute onset of severe chest pain for a few hours. She has a history of sickle cell disease and multiple hospitalizations for pain and anemia management.
1) Acute Chest (sickle cell crisis)
2) PE
3) Pnmeumonia
4) Pneumothorax/Aortic Dissection
a) CXR
b) CBC w/ reticulocyte and peripheral smear
c) LDH
d) ABG
45 yo F presents with a retrosternal burning sensa- tion that occurs after heavy meals and when lying down. Her symptoms are relieved by antacids.
1) GERD
2) esophagitis gastritis
3) diffuse esophageal spasm
a) esophageal pH monitoring
b) endoscopy
c) barium swallow
55 yo M presents with retrosternal squeezing pain that lasts for 2 minutes and occurs with exercise. It is relieved by rest and is not related to food intake.
1) Stable Angina
2) DES
3) Esophagitis
a) PFTs, methacholine challenge, bronchodilator response, CXR
b) EKG, stress test, CK-MB, Troponin
34 yo F presents with retrosternal stabbing chest pain that improves when she leans forward and worsens with deep inspiration. She had a URI 1 week ago.
1) PERICARDITIS
2) aortic dissection
a) CXR
b) CBC
33 yo F presents with stabbing chest pain that wors- ens with deep inspiration and is relieved by aspirin. She had a URI 1 week ago. Chest wall tenderness is noted.
1) Costochondritis
2) Pleuritis (pleurisy)
a) CBC
b) CXR
c) Echo/EKG
70 yo F presents with acute onset of shortness of breath at rest and pleuritic chest pain. She also pres- ents with tachycardia, hypotension, tachypnea, and mild fever. She is recovering from hip replacement surgery.
1) Pulmonary Embolism
2) Fat embolus
3) atalectasis
4) pneumonia
a) D-dimer, CTA chest?, LE doppler
b) CXR, pulse oximetry, ABG
c) CBC, BMP
55 yo M presents with sudden onset of severe chest pain that radiates to his back. He has a history of uncontrolled hypertension.
1) aortic dissection
2) AAA
3) Pancreatitis
a) MRA aorta, Echo, CXR
b) abdominal U/S
c) serum amylase/lipase
70 yo diabetic M presents with episodes of palpita- tions and diaphoresis. He is on insulin.
1) Hypoglycemia (2/2 insulin overdose)
2) Factitious /exogenous insulin
3) STEMI
4) Pheochromocytoma
a) CBC, BMP, TSH
b) EKG, Troponin I x3, CK-MB
c) C-peptide, serum insulin
d) 24 hour catecholamine/metanephrine
e) 5-HIAA
35 yo M presents with several episodes of palpita- tions, sweating, and rapid breathing. Episodes occur unexpectedly, and he does not recall any triggers. He has had 4–5 episodes per month for several months. Each episode lasts 2–3 minutes. He does not have any history of psychiatric illness except for separa- tion anxiety as a child.
1) Panic Disorder (attack)
2) GAD, acute stress
3) MVP, asthma, pheochromocytoma
a) phys/MSE
b) CBC, BMP, TSH/T4
c) EKG, echo
d) urine tox
19 yo F presents with episodic palpitations, especially during presentations in front of her class. Episodes include heart pounding, facial blushing, and hand tremor. She also experiences excessive sweating and rapid breathing. She complains of intense worry and trouble sleeping for days or weeks before an upcom- ing social situation. Now she avoids all social events because she is afraid of humiliating herself.
1) Social Anxiety Disorder, performance anxiety subtype
2) GAD
3) vasovagal syncope
a) phys/MSE
b) CBC, BMP, EKG, echo, TSH, T4
34 yo F presents with episodic palpitations accom- panied by lightheadedness and sharp, atypical chest pain.
1) MVP
2) arrythmia
3) pheo
a) EKG, echo
b) 24 hour urine met/cat
42 yo F presents with a 15.5-lb (7-kg) weight loss within the past 2 months. She has a fine tremor, and her pulse is 112.
1) Hyperthyroidism
2) Cancer
3) Anorexia/MDD
a) TSH T4
b) urine tox
c) CBC, BMP
44 yo F presents with a weight gain of > 25 lbs (11.3 kg) within the past 2 months. She quit smoking 3 months ago and is on amitriptyline for depression. She also reports cold intolerance and constipation.
1) SMOKING CESSATION
2) Amitriptyline ADR
3) Hypothyroidism
4) MDD w/ atypical features
5) Cushing’s syndrome
a) TSH
b) Phys/MSE
c) CBC, BMP
d) 24 hr urine cortisol, Dexamethasone suppresion test
30 yo F presents with weight gain over the past 3 months. She also reports tremor, palpitations, anxi- ety, and hunger that is relieved by eating. She exhib- its proximal muscle weakness and easy bruising.
1) Insulinoma
2) Reactive Postprandial Hypoglycemia
3) Cushing’s
a) TSH
b) Glucose, Insulin
c) phys/MSE
d) 24 hr urine cortisol, dexameth supp test
75 yo M presents with dysphagia that started with solids and progressed to liquids. He is an alcoholic and a heavy smoker. He has had an unintentional weight loss of 15 lbs (6.8 kg) within the past 4 months.
1) adenoCA of the esophagus (progressive dysphagia solids->liquids, alc/tob, weight loss) [SSC mc world, adeno USA]
2) Esophageal stricture, Zenker Diverticulum
3) achalasia
a) EGD w/ biopsy
b) Barium Swallow
c) CT for staging
d) CBC
45 yo F presents with dysphagia for 2 weeks accompanied by mouth and throat pain, fatigue, and a craving for ice and clay.
1) Plummer Vinson Syndrome (pica, glossitis, dysphagia)
2) Iron Def.
3) Cancer of the mouth/esophagus
a) EGD
b) esophageal manometry
c) video fluoroscopy, upper endoscpy
d) Fe, Ferritin, TIBC, Transferrin
e) CBC
48 yo F presents with dysphagia for both solids and liquids that has slowly progressed in severity within the past year. It is associated with difficulty belch- ing and regurgitation of undigested food, especially at night. She has lost 5.5 lbs (2.5 kg) in the past 2 months.
1) Achalasia
2) Zenker Diverticulum
3) Esophageal Web, stricture, plummer vinson
a) Barium Swallow
b) Esophageal Manometry ^
c) EGD
38 yo M presents with dysphagia and pain on swal- lowing solids more than liquids. Exam reveals oral thrush.
1) Esophagitis (CMV, HSV, HIV, pill-induced)
2) Scleroderma
a) Manometry
b) barium swallow
c) CD4 count, HIV ab and viral load
d) CBC
39 yo F presents with a single 2-cm mass on the right side of her neck along with night sweats, fever, weight loss, loss of appetite, and early satiety. The mass is painless and movable and has not changed in size. She does not report heat intolerance, tremor, palpitations, hoarseness, cough, difficulty breathing, difficulty swallowing, or abdominal pain. Her hus- band was recently discharged from prison, and her mother has a history of gastric cancer.
1) Lymphoma (painless)
2) Goiter
3) Gastric adenoCA, TB
a) LN biopsy
b) CBC with diff , BMP
c) ESR, CRP
d) U/S thyroid
20 yo F presents with nausea, vomiting (especially in the morning), fatigue, and polyuria. Her last men- strual period was 6 weeks ago, and her breasts are full and tender. She is sexually active with her boy- friend, and they occasionally use condoms for con- traception.
1) pregnancy
2) hypercalcemia
3) DM
4) UTI
a) PELVIC EXAM
b) urine bHCG (qualitative)
c) pelvic u/s
d) CBC, BMP, calcium
e) U/A, urine culture
45 yo M presents with sudden onset of colicky right- sided flank pain that radiates to the testicles, accom- panied by nausea, vomiting, hematuria, and CVA tenderness.
1) Nephrolithiasis
2) urolithiasis
3) pyelonephritis
4) RCC
a) u/a: cytology, culture and sensitivity
b) BMP, CBC
c) renal ultrasound/ CT abdomen
d) KUB, IVP
60 yo M presents with dull epigastric pain that radi- ates to the back, accompanied by weight loss, dark urine, and clay-colored stool. He is a heavy drinker and smoker. He appears jaundiced on exam.
1) Pancreatic Adenocarcinoma
2) Cholangiocarcinoma
3) Acute alcoholic/viral hepatitis
4) gallstone pancreatitis
5) choledocholithiasis
a) U/S gallbladder, CT abdomen
b) CBC, CMP (+AST, ALT, alk phos, bili)
c) amylase/lipase
d) ERCP (dx)
56 yo M presents with severe midepigastric abdomi- nal pain that radiates to the back and improves when he leans forward. He also reports anorexia, nausea, and vomiting. He is an alcoholic and has spent the past 3 days binge drinking.
1) acute pancreatitis
2) PUD
3) Cholecystitis
4) AAA
5) Boerhaave Syndrome
a) amylase/lipase
b) CBC, CMP
c) U/S abdomen
d) CT abdomen
e) upper endoscpy
41 yo obese F presents with RUQ abdominal pain that radiates to the right scapula and is associated with nausea, vomiting, and a fever of 101.5°F. The pain started after she ate fatty food. She has had sim- ilar but less intense episodes that lasted a few hours. Exam reveals a positive Murphy’s sign.
1) acute cholecystitis
2) Biliary colic
3) Hepatitis
a) CBC, CMP
b) U/S gallbladder,abdomen
43 yo obese F presents with RUQ abdominal pain, fever, and jaundice. She was diagnosed with asymp- tomatic gallstones 1 year ago. She is found to be hy- potensive on exam.
1) Acute Suppurative Cholangitis (reynold’s pentad)
2) Acute Ascending Cholangitis (charcot’s triad)
3) Choledocholithiasis
4) Hepatitis/ Fitz-Hugh-Curtis Syndrome (perihepatitis 2/2 PID)
a) CBC, CMP
b) U/S gallbladder
c) MRCP/ERCP/intraoperative cholangiogram/choledocosopy
d) Viral hepatitis serology
25 yo M presents with RUQ pain, fever, anorexia, nausea, and vomiting. He has dark urine and clay- colored stool.
1) acute cholecystitis
2) choledocholithiasis
3) gallstone pancreatitis
4) ACUTE HEPATITIS
a) CBC, CMP
b) U/S gallbladder
c) ERCP/intraoperative cholangiogram/choledocosopy
d) amylase/lipase
E) VIRAL HEP SEROLOGY
35 yo M presents with burning epigastric pain that starts 2–3 hours after meals. The pain is relieved by food and antacids.
1) Duodenal Ulcer (PUD)
2) GERD, Gastritis
a) esophageal pH monitoring
b) upper endoscopy
c) duodenal biopsy/urease breath test/H. Pylori fecal antigen
d) CBC, BMP
E) rectal exam, occult blood in stool
37 yo M presents with severe epigastric pain, nausea, vomiting, and mild fever. He appears toxic. He has a history of intermittent epigastric pain that is re- lieved by food and antacids. He also smokes heavily and takes aspirin on a daily basis.
1) Upper GI bleed 2/2 bleeding duodenal ulcer
2) Perforated duodenal ulcer
3) acute pancreatitis
a) EGD
b) U/s?
c) KUB, CXR
d) CBC, BMP
e) serum amylase/lipase
f) RECTAL EXAM, OCCULT BLOOD
g) LACTATE
18 yo M boxer presents with severe LUQ abdominal pain that radiates to the left scapula. He had infec- tious mononucleosis 3 weeks ago.
1) splenic rupture
2) painful splenomegaly/splenic infarct
3) left rib fracture
a) Lateral CXR
b) CBC, BMP
c) U/S abdomen, CT abdomen
40 yo M presents with crampy abdominal pain, vom- iting, abdominal distention, and inability to pass fla- tus or stool. He has a history of multiple abdominal surgeries.
1) Sm. Bowel Obstruction 2/2 adhesions
2) Malignancy/Hernia
3) Volvulus
a) abdominal U/S
b) KUB
c) CBC, BMP
d) RECTAL
e) colonoscopy
70 yo F presents with acute onset of severe, crampy abdominal pain. She recently vomited and had a massive dark bowel movement. She has a history of CHF and atrial fibrillation, for which she has re- ceived digitalis. Her pain is out of proportion to the exam.
1) acute mesenteric ischemia/bowel necrosis
2) diverticulitis
3) upper GI bleed
a) CT angiography of mesenteric vasculature
b) KUB
c) CBC, BMP
d) PTT, PT
e) EKG, echo
f) RECTAL EXAM
21 yo F presents with acute onset of severe RLQ pain, nausea, and vomiting. She has no fever, uri- nary symptoms, or vaginal bleeding and has never taken OCPs. Her last menstrual period was regular, and she has no history of STDs. She has been told that she had a cyst on her right ovary.
1) OVARIAN TORSION*
2) Ovarian Cyst Rupture
3) Appendicitis
4) PID
5) ectopic pregnancy
a) PELVIC EXAM, RECTAL EXAM
b) transvaginal and abdominal ultrasound
c) CBC, BMP
d) ovarian cyst aspiration
e) bHCG
f) VDRL/RPR, Chlamydia, gonorrhea testing
g) laparoscopy
68 yo M presents with LLQ abdominal pain, fever, and chills for the past 3 days. He also reports recent onset of alternating diarrhea and constipation. He consumes a low-fiber, high-fat diet.
1) Diverticulitis
2) IBD
3) Gastroenteritis
a) CT abdomen
b) CBC, CMP
c) LLQ ultrasound
d) RECTAL EXAM
20 yo M presents with severe RLQ abdominal pain, nausea, and vomiting. His discomfort started yesterday as a vague pain around the umbilicus. As the pain worsened, it became sharp and migrated to the RLQ. McBurney’s and psoas signs are positive.
1) Acute Appendicitis
2) Gastro, Divert, Chole
a) CBC, BMP
b) U/S abdomen
c) CT abdomen
d) RECTAL exam
e) serial abdominal exams
30 yo F presents with periumbilical pain for 6 months. The pain never awakens her from sleep. It is relieved by defecation and worsens when she is upset. She has alternating constipation and diarrhea but no nausea, vomiting, weight loss, or anorexia.
1) IBS
2) Crohn’s, Celiac,
3) GI parasite (Giardiasis, Amebiasis)
4) PID
a) CBC, BMP
b) U/S abdomen, CT abdomen
c) RECTAL, PELVIC, occult blood
d) Stool ova and parasite, entamoeba histolytic Ag
e) colonoscopy
24 yo F presents with bilateral lower abdominal pain that started with the first day of her menstrual pe- riod. The pain is associated with fever and a thick, greenish-yellow vaginal discharge. She has had un- protected sex with multiple sexual partners.
1) PID
2) Endometriosis
3) Vaginitis, Cystitis, Pyelonephritis
4) Dysmenorrhea
a) PELVIC exam, urine BHCG
b) abdominal/transvag U/S (u/s pelvic)
c) CBC, BMP
d) chlamydial PCR test, gonorrhea culture
67 yo M presents with alternating diarrhea and con- stipation, decreased stool caliber, and blood in the stool for the past 8 months. He also reports uninten- tional weight loss. He is on a low-fiber diet and has a family history of colon cancer. His last colonoscopy was 12 years ago.
1) Colonic AdenocA (left sided)
2) Diverticulosis
3) IBD
a) colonoscopy with biopsy
b) CT abdomen, barium enema
c) CBC, BMP
d) RECTAL exam, fecal occult blood
28 yo M presents with constipation (hard stool) for the past 3 weeks. Since his mother died 2 months ago, he and his father have eaten only junk food.
1) LOW FIBER DIET
2) Depression
3) Hypothyroidism
a) RECTAL, FOBT
b) CBC, BMP
c) TSH
30 yo F presents with alternating constipation and diarrhea accompanied by abdominal pain that is re- lieved by defecation. She has no nausea, vomiting, weight loss, or blood in her stool.
1) IBS
2) IBD
3) GI parasite (ascariasis, giardiasis)
4) celiac
a) CBC, BMP
b) RECTAL, FOBT
c) stool o&p
d) fecal lactoferrin
33 yo M presents with watery diarrhea, vomiting, and diffuse abdominal pain that began yesterday. He also reports feeling hot. Several of his coworkers are also ill.
1) gastroenteritis
2) food poisoning
a) Stool ova/parasites
b) CBC, BMP
c) fecal leukocytes/culture
40 yo F presents with watery diarrhea and abdominal cramps. Last week she was on antibiotics for a UTI.
1) Pseudomembranous C. Diff Colitis
2) abx-induced destruction of flora
3) viral syndrome
a) CBC/BMP
b) stool culture/leukocytes
c) c. diff toxin
25 yo M presents with watery diarrhea and abdomi- nal cramps. He was recently in Mexico.
1) Traveler’s diarrhea
2) giardiasis
3) amebiasis
a) CBC/BMP
b) stool culture/leukocytes
c) giardia, entamoeba Ag
30 yo F presents with watery diarrhea, abdominal cramping, and bloating. Her symptoms are aggra- vated by milk ingestion and are relieved by fasting.
1) Lactose intolerance
2) Celiacs disease
3) Hyperthyroidism
a) Lactase hydrogen breath test; lactose absorption test
b) tissue transglutaminase
c) mucosal biopsy to confirm
d) CBC/BMP
e) TSH
33 yo M presents with watery diarrhea, diffuse ab- dominal pain, and weight loss within the past 3 weeks. He has a history of aphthous ulcers. He has not responded to antibiotics.
1) Crohn’s Disease
2) Celiac
3) Hyperthyroidism
a) Lactase breath hydrogen test; lactose absorption test
b) tissue transglutaminase
c) mucosal biopsy to confirm
d) CBC/BMP
e) TSH, 5HIAA
45 yo F presents with coffee-ground emesis for the past 3 days. Her stool is dark and tarry. She has a his- tory of intermittent epigastric pain that is relieved by food and antacids.
40 yo F presents with epigastric pain and coffee- ground emesis. She has a history of rheumatoid ar- thritis that has been treated with NSAIDs. She is an alcoholic.
1) Upper GI bleed
2) PUD hemorrhage (duodenal)
3) Esophageal Varices
a) RECTAL
b) EGD with biopsy, h. pylori testing
c) CBC, BMP, TYPE/CROSS, PT/INR
1) Gastritis
2) PUD hemorrhage (duodenal)
3) Esophageal Varices, Mallory Weiss tear
4) Gastric Adenocarcinoma
a) RECTAL
b) EGD with biopsy
c) CBC, BMP, TYPE/CROSS, PT/INR
67 yo M presents with blood in his stool, weight loss, and constipation. He has a family history of colon cancer.
2) Colon CA^
3) IBD
4) Iron def, hemmorroids, anal fissure, angiodysplasia
a) CBC, CMP, Iron studies (serum Fe, Ferritin, TIBC)
b) Colonoscopy
c) INR, CEA, Colonoscopy/CT
d) RECTAL, FOBT
33 yo F presents with rectal bleeding and diarrhea for the past week. She has had lower abdominal pain and tenesmus for several months.
tenesmus = need to constantly defecate
1) Ulcerative Colitis
2) Crohn
3) Proctitis, Hemorrhoid
a) stool ova¶sites, culture, fecal lactoferrin/leukocytes
b) abdominal u/s, pelvic u/s, KUB
c) barium enema
d) CBC/BMP/ PT-INR
e) RECTAL
58 yo M presents with painless bright red blood per rectum and chronic constipation. He consumes a low-fiber diet.
1) internal hemorrhoid, anal fissure
2) diverticulosis 2/2 low-fiber diet
3) colorectal cancer
a) RECTAL, stool sample, TYPE AND CROSS
b) CBC, BMP, PT-INR
c) colonoscopy/CT
65 yo M presents with painless hematuria. He is a heavy smoker and works as a painter.
1) bladder carcinoma
2) RCC
3) Prostate adenocarcinoma
a) GU exam
b) UA, w/ cytology
c) BUN/CR, PSA
d) CBC, PTT
e) cystoscopy, U/S renal/bladder, CT abdomen/pelvis
 35 yo M presents with painless hematuria. He has a family history of kidney disease.
1) Nephritic Syndrome
2) ADPCKD
3) Bladder Cancer
a) Renal/Bladder u/s, CT abdomen/pelvis, cystoscopy
b) CBC, PTT, BMP,
c) U/A w/ cytology
d) GU EXAM
55 yo M presents with flank pain and blood in his urine without dysuria. He has experienced weight loss and fever over the past 2 months. Exam reveals a flank mass.
1) RCC, bladder CA
2) nephrolithiasis
3) pyelonephritis
a) U/A w/ cytology
b) Renal/Bladder u/s, CT abdomen/pelvis, cystoscopy
c) IVP
d) GU EXAM
e) CBC, BMP
60 yo M presents with nocturia, urgency, weak stream, and terminal dribbling. He denies any weight loss, fatigue, or bone pain. He has had 2 episodes of urinary retention that required catheterization
1) BPH
2) UTI
a) DRE, PSA, prostate u/s transrectal
b) U/A
c) BMP
d) ALK PHOS
18 yo M presents with a burning sensation during urination and urethral discharge. He recently had unprotected sex with a new partner.
1) Urethritis (gonorrhea)
2) Chlamydia
3) Cystitis, prostatitis
a) U/A with culture and cytology , gram stain
b) gonnorrhea gram stain and chlamydial PCR (of discharge)
c) CBC/BMP
d) DRE!
71 yo M presents with nocturia, urgency, a weak stream, terminal dribbling, hematuria, and lower back pain for the past 4 months. He has also experi- enced weight loss and fatigue.
1) Prostatic Adenocarcinoma
2) Metastasis to the lumbar vertebral bodies
3) BPH, RCC, Bladder CA
a) PSA, DRE!; alk phos!
b) Prostate transrectal; U/S, CT abdomen pelvis, MRI spine,
c) Prostate biopsy
d) u/a cytology
e) CBC/BMP
45 yo diabetic F presents with dysuria, urinary frequency, fever, chills, and nausea for the past 3 days. There is left CVA tenderness on exam.
1) Acute Pyelonephritis
2) Nephric abscess
3) Cystitis, Urethritis
a) CBC/BMP
b) IVP
c) Renal U/S, CT abdomen/pelvis
d) UA culture and sensitivity
55 yo F presents with urinary leakage after exercise. She loses a small amount of urine when she coughs, laughs, or sneezes. She also complains of vague low back pain. She has a history of multiple vaginal de- liveries, and her mother had the same problem after the onset of menopause.
1) stress urinary incontinence
2) overflow incontinence
3) UTI
4) mixed incontinence
a) cystourethroscopy, “urodynamic testing”
b) u/a, culture, cytology
c) BMP
d) IVP
33 yo F presents with urinary leakage. She is un- able to suppress the urge to urinate and loses large amounts of urine without warning. She has a history of UTIs and a family history of diabetes mellitus. She drinks 8 cups of coffee per day. She has been under stress since her sister passed away a few months ago.
1) Regression 2/2 stress
2) Caffeine overuse
3) Polyuria 2/2 DM
4) urge incontinence**
a) cystourethroscopy, “urodynamic testing”
b) u/a, culture, cytology
c) CBC, BMP
d) IVP
47 yo M presents with impotence that started 3 months ago. He has hypertension and was started on atenolol 4 months ago. He also has diabetes and is on insulin.
1) medication-induced erectile disorder
2) erectile disorder 2/2 general medical condition (DM/obesity)
3) phychogenic erectile disorder
a) morning erectile tumenscence study
b) PSA, serum testosterone, CBC
c) HgbA1C
d) GU exam, DRE
40 yo F presents with amenorrhea, morning nausea and vomiting, fatigue, and polyuria. Her last men- strual period was 6 weeks ago, and her breasts are full and tender. She uses the rhythm method for contra- ception.
1) pregnancy
2) DM, hypothyroid, hyperprolactinemia
3) anovulatory cycle
a) urine bHCG (qualatative)
b) PELVIC exam, u/s abdomen/pelvis
c) U/A, culture
d) CBC, BMP, fasting glucose
e) TSH, FSH, prolactin?
f) Pap baseline, cervical cultures, rubella Ab, HIV Ab, hep B sAb, VDRL/RPR
23 yo obese F presents with amenorrhea for 6 months, facial hair, and infertility for the past 3 years.
1) PCOS
2) Secondary Amenorrhea
3) thyroid, hyperPL
4) premature ovarian failure
a) Serum FSH, TSH, prolactin
b) Serum LH
c) Testosterone, DHEAS
d) PELVIC
e) BETA HCG!
35 yo F presents with amenorrhea, galactorrhea, visual field defects, and headaches for the past 6 months.
1) Prolactinoma (BTHA)
2) suprasellar mass
3) pituitary adenoma
a) urine b-HCG
b) TSH, prolactin, FSH
c) MRI
d) pelvic/BREAST exam
48 yo F presents with amenorrhea for the past 6 months accompanied by hot flashes, night sweats, emotional lability, and dyspareunia.
1) Menopause
2) thyroid
3) atrophic vaginitis
a) HCG
b) TSH, FSH, LH, prolactin
c) +/- progestin-challenge; estrogen-progestin challenge
d) pelvic exam
e) CBC
35 yo F presents with amenorrhea, cold intolerance, coarse hair, weight loss, and fatigue. She has a his- tory of abruptio placentae followed by hypovolemic shock and failure of lactation 2 years ago.
1) SHEEHAN’S SYNDROME*
2) Premature ovarian failure
3) Pituitary adenoma
4) asherman’s syndrome
5) thyroid
a) HCG
b) TSH, FSH, LH, prolactin
c) +/- progestin-challenge; estrogen-progestin challenge
d) pelvic exam, u/s pelvis, hysteroscopy
e) CBC, ACTH
18 yo F presents with amenorrhea for the past 4 months. She is 5 feet, 6 inches (167.6 cm) and weighs 90 lbs (40.9 kg). She has a history of exercise and heat intolerance.
1) hyperthyroidism
2) anorexia nervosa
3) pregnancy
a) HCG
b) TSH, FSH, LH, prolactin
c) ECG, CBC
29 yo F presents with amenorrhea for the past 6 months. She has a history of occasional palpitations and dizziness. She lost her fiancé in a car accident in which she was a passenger.
1) GAD, PTSD, psychogenic/stress induced-amenorrhea
2) panic attack
3) hyperthyroidism
a) HCG
b) TSH, FSH, LH, prolactin
c) +/- progestin-challenge; estrogen-progestin challenge
d) urine cortisol, CBC
e) phys/MSE
17 yo F presents with prolonged, excessive men- strual bleeding occurring irregularly within the past 6 months.
1) menorrhagia (AUB), COAGULOPATHY (vwD, hemophilia)
2) anovulatory cycle
3) hypothyroidism
4) molar pregnancy
5) cervical CA
a) TSH, FSH, LH, prolactin
b) CBC, Iron studies (serum iron, ferritin, TIBC); PT/INR
c) PELVIC, urine-hcg, pap
d) u/s pelvis
61 yo obese F presents with profuse vaginal bleeding for the past month. Her last menstrual period was 10 years ago. She has a history of hypertension and diabetes mellitus. She is nulliparous.
1) fibroids
2) endometrial CA
3) cervical cancer
4) atrophic vaginitis
a) CBC, BMP
b) PELVIC, PAP, ENDOMETRIAL BIOPSY/CURETTAGE
c) colposcopy, hysteroscopy, u/s pelvis
d)
45 yo G5P5 F presents with postcoital bleeding. She is a cigarette smoker and takes OCPs.
1) Cervical CA/polyp
2) uterine fibroids (leiomyoma)
3) endometrial carcinoma
a) CBC, BMP
b) endometrial biospy
c) transvaginal ultrasound
d) PELVIC, COLP/BIOPSY, PAP
e) HPV test
28 yo F who is 8 weeks pregnant presents with lower abdominal pain and vaginal bleeding.
1) Spont. abortion
2) ectopic pregnancy
3) trophoblastic disease
4) molar pregnancy
a) serum qualitative b-HCG; urine HCG
b) transvaginal ultrasound
c) CBC, BMP, PT/INR
32 yo F presents with sudden onset of left lower ab- dominal pain that radiates to the scapula and back and is associated with vaginal bleeding. Her last menstrual period was 5 weeks ago. She has a history of pelvic inflammatory disease and unprotected in- tercourse.
1) ovarian cyst rupture
2) ectopic pregnancy
3) ovarian torsion
4) PID
a) CBC, BMP, PT/INR
b) liver u/s, pelvic u/s
c) Pelvic Exam
d) serum quant bHCP
28 yo F presents with a thin, grayish-white, foul- smelling vaginal discharge.
1) gardnerella vaginalis (bacterial vaginosis)
2) chlamydia cervicitis
3) gonorrhea cervicitis
a) culture/gram stain the discharge; KOH/wet mount looking for clue cells
b) CBC, BMP
c) pelvic exam, assess for cervical motion tenderness
d) CBC/BMP
e) pH>4.5
30 yo F presents with a thick, white, cottage cheese– like, odorless vaginal discharge and vaginal itching.
1) Candida vulvovaginitis
a) KOH showing pseudohyphae
b) normal pH
c) culture/UA
d) CBC/BMP
e) pelvic exam
35 yo F presents with a malodorous, profuse, frothy, greenish vaginal discharge with intense vaginal itch- ing and discomfort.
1) Trichomonas Vaginalis
2) Cervicitis
a) KOH prep showing trichomonads
b) pH (should be >4.5)
c) culture/UA
d) CBC/BMP
e) pelvic exam
54 yo F c/o painful intercourse. Her last menstrual period was 9 months ago. She has hot flashes.
1) Endometriosis
2) atrophic vaginitis
3) peri-menopausal
a) FSH/LH
b) pelvic exam
c) urinalysis, wet mount, KOH prep
d) cervical cultures
37 yo F presents with dyspareunia, inability to conceive, and dysmenorrhea.
1) stress-induced anovulation
2) vaginismus
3) endometriosis***
4) vulvodynia
a) laparoscopy, PELVIC exam,
b) u/s pelvis, CBC, bHCG,
c) endometrial biopsy
28 yo F c/o multiple facial and bodily injuries. She claims that she fell on the stairs. She was hospital- ized for physical injuries 7 months ago. She presents with her husband.
1) Abuse/Domestic Violence
2) non-accidental trauma
3) consensual violent sexual behavior
a) SKELETAL SURVEY XRAY
b) urine toxicology
c) CBC
30 yo F presents with multiple facial and physical injuries. She states that she was attacked and raped by 2 men.
1) Rape
2) Domestic Violence
a) Forensic exam (sexual assault forensic evidence [SAFE] collection kit)
b) PELVIC
c) urine hCG
d) wet mount KOH, cervical cx, chlamydia/gonorrhea testing
e) skeletal survey
f) HIV Ab, viral hepatitis serology
30 yo F presents with wrist pain and a black eye after tripping, falling, and hitting her head on the edge of a table. She looks anxious and gives an inconsistent story.
1) domestic violence
2) factitious disorder
3) substance abuse
a) skeletal survey, xray wrist
b) urine toxoicology
c) phys/MSE
d) CT-head
30 yo F secretary presents with wrist pain and a sen- sation of numbness and burning in her palm and the first, second, and third fingers of her right hand. The pain worsens at night and is relieved by loose shak- ing of the hand. There is sensory loss in the same fingers. Exam reveals a positive Tinel’s sign.
1) Carpal Tunnel
2) C6/7 radiculopathy
3) median nerve entrapment/palsy
4) dequervain’s tenosynovitis
a) nerve conduction studies/EMG
b) MRI
c) phalen’s test
d) finklestein’s test
28 yo F presents with pain in the interphalangeal joints of her hands accompanied by hair loss and a rash on her face.
1) SLE!!!!!!
2) RA
3) ParvoB19 infection
a) xray hand
b) CBC, u/a
c) ANA, dsDNA, ESR, C3, C4, RF, CCP
d) pB19 Ab titers
28 yo F presents with pain in the metacarpophalan- geal joints of both hands. Her left knee is also pain- ful and red. She has morning joint stiffness that lasts for an hour. Her mother had rheumatoid arthritis.
1) Rheumatoid Arthritis
2) Septic Arthritis (gonococcal)
3) SLE
a) joint aspiration and synovial fluid analysis/culture (arthrocentesis)
b) CBC/BMP
c) CCP, RF, ANA, dsDNA, ESR
d) xray hands, left knee
18 yo M presents with pain in the interphalangeal joints of both hands. He also has scaly, salmon-pink lesions on the extensor surface of his elbows and knees.
1) psoriatic arthritis
2) psoriasis
3) RA, SLE, Gout
a) CBC/CMP
b) xray hands, pelvis, SI joint
c) uric acid level
d) ANA, ESR, RF, CCP
65 yo F presents with inability to use her left leg or bear weight on it after tripping on a carpet. Onset of menopause was 20 years ago, and she did not receive HRT or calcium supplements. Her left leg is exter- nally rotated, shortened, and adducted, and there is tenderness in her left groin.
1) HIP FRACTURE
2) hip dislocation
3) osteoporosis
a) xray hip/pelvis
b) DEXA scan
c) CBC w/ type and cross, BMP
d) serum PTH, calcium, vitamin D
40 yo M presents with pain in the right groin after a motor vehicle accident. His right leg is flexed at the hip, adducted, and internally rotated.
1) posterior hip dislocation
2) hip fracture
3)
a) xray hip/pelvis
b) CBC w/ type and cross
c) urine toxicology, BAC
56 yo obese F presents with right knee stiffness and pain that increases with movement. Her symptoms have gradually worsened over the past 10 years. She has noticed swelling and deformity of the joint and is having difficulty walking.
1) Osteoarthritis, degenerative joint dz
2) PSEUDOGOUT
4) meniscopathy
a) xray knee, MRI knee
b) arthrocentesis with crystal analysis, gram/culture, cytology
c) uric acid, ESR, CBC
d) serum calcium/vitD
45 yo M presents with fevers and right knee pain with swelling and redness.
1) septic arthritis
2) trauma/injury
3) PSEUDOGOUT
4) REITER’S REACTIVE ARTHRITIS
a) xray knee
b) arthrocentesis w/ culture/gram stain and synovial analysis
c) HLA-B27 assay
d) CBC
e) Lyme IgM IgG
65 yo M presents with right foot pain. He has been training for a marathon.
1) foot fracture (stress)
2) plantar fasciitis
3) strain/sprain
a) xray foot
b) MRI foot
65 yo M presents with pain in the heel of the right foot that is most notable with his first few steps and then improves as he continues walking. He has no known trauma.
1) plantar fasciitis
2) foot/heel fracture
3) sprain/strain
a) xray foot
b) MRI foot
55 yo M presents with pain in the elbow when he plays tennis. His grip is impaired as a result of the pain. There is tenderness over the lateral epicondyle as well as pain on resisted wrist dorsiflexion (Cozen’s test) with the elbow in extension.
1) tennis elbow (lateral epicondylitis)
2) stress fracture
a) XRAY elbow
b) MRI elbow
27 yo F presents with painful wrists and elbows, a swollen and hot knee joint that is painful on flexion, a rash on her limbs, and vaginal discharge. She is sexually active with multiple partners and occasion- ally uses condoms.
1) Gonococcal arthritis (superimposed upon cercivitis) [“disseminated gonorrhea”]
2) REACTIVE arthritis
3) SLE
a) arthrocentesis w/ fluid gram, culture, analysis, cytology
b) ANA, dsDNA, ESR
c) xray joint
d) cervical culture/ gram stain (+chlamydial PCR)
e) PELVIC
f) CBC, BMP
60 yo F presents with pain in both legs that is in- duced by walking and is relieved by rest. She had cardiac bypass surgery 6 months ago and continues to smoke heavily.
1) Vascular claudication 2/2 peripheral artery disease
2) Leriche syndrome (aortoiliac occlusive disease)
3) OA
a) ABI
b) doppler LE
c) arteriogram of LE
d) D-dimer/CXR, PT/INR
e) CBC/BMP
45 yo F presents with right calf pain. Her calf is ten- der, warm, red, and swollen compared to the left side. She was started on OCPs 2 months ago for dys- functional uterine bleeding.
1) DVT/PE
2) CELLULITIS!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!
3) Baker/popliteal cyst rupture
4) Myositis
a) LE doppler, D-dimer
b) PT/INR, CBC
c) ABI
60 yo F c/o left arm pain that started while she was swimming and was relieved by rest.
1) rotator cuff tendinitis
2) shoulder impingement
3) muscular strain
4) stable angina
a) MRI shoulder
b) XRAY shoulder
c) stress EKG, CXR
50 yo M presents with right shoulder pain after fall- ing onto his outstretched hand while skiing. He no- ticed deformity of his shoulder and had to hold his right arm.
1) FOOSH (humeral fracture?); shoulder dislocation
2) brachial plexopathy
1) XRAY humerus, shoulder
2) MRI shoulder
3) recheck radial pulses
55 yo M presents with crampy bilateral thigh and calf pain, fatigue, and dark urine. He is on simva- statin and clofibrate for hyperlipidemia.
1) rhabdomyolysis 2/2 to statin use
2) muscular strain
3) polymyositis
a) U/A, urine myoglobin
b) serum haptoglobin?
c) BMP, phosphate, calcium, uric acid
d) doppler LE
e) ESR, CBC, CPK, aldolase
45 yo F presents with low back pain that radiates to the lateral aspect of her left foot. The straight leg raise is positive. The patient is unable to tiptoe.
1) Lumbosacral Radiculopathy
2) LSR 2/2 L5-S1 herniation
3) Vertebral canal malignancy
a) MRI L- spine, XR lumbar spine
b) CT myelogram with contrast if MRI contraindicated
45 yo F presents with low back pain that started after she cleaned her house. The pain does not radiate, and there is no sensory deficit or weakness in her legs. Paraspinal muscle tenderness and spasm are also noted.
1) Lumbosacral muscular strain
2) Lumbar vertebral compression fracture 2/2 osteoporosis
3) Lubar herniated disk
1) XR spine/MRI spine
2) DEXA
3) serum calcium/vitD
45 yo M presents with pain in the lower back and legs during prolonged standing and walking. The pain is relieved by sitting and leaning forward (eg, pushing a grocery cart).
1) Spinal stenosis (lumbar)
2) Neurogenic Claudication
a) MRI spine
b) ABI
17 yo M presents with low back pain that radiates to the left leg and began after he fell on his knee during gym class. He also describes areas of loss of sensation in his left foot. The pain and sensory loss do not match any known distribution. He insists on requesting a week off from school because of his in- jury.
1) Malingering (secondary gain, makes no anatomic sense)
2) Lumbosacral vertebral fracture (unlikely)
3) Ankylosing spondylitis
a) MRI? xray spine/knee
b) MSE
20-day-old M presents with fever, decreased breast- feeding, and lethargy. He was born at 36 weeks as a result of premature rupture of membranes.
1) Neonatal Sepsis
2) GBS meningitis
a) LP
b) physical exam
c) CBC, BMP
d) blood culture
3 yo M presents with a 2-day history of fever and pulling on his right ear. He is otherwise healthy, and his immunizations are up to date. His older sister recently had a cold. The child attends a day care center.
1) acute otitis MEDIA (doesn’t hurt when pulling on ear)
2) URI
3) bacterial sinusitis
a) culture of any purulence (tympanocentesis)
b) otoscopy w/ pneumatic insufflation
c) CBC, physical exam
12-month-old M presents with fever for the past 2 days accompanied by a maculopapular rash on his face and body. He has not yet received the MMR vaccine.
1) measles
2) rubella
3) erythema INFECTIOSUM (fifth dz) ParvoB12
4) roseola (HHV-6)
a) Physical exam, resp, cardiac, abdominal
b) CBC, viral AB
4 yo M presents with diarrhea, vomiting, lethargy, weakness, and fever. The child attends a day care center where several children have had similar symptoms.
1) viral gastroenteritis
2) food poisoning 2/2 lack of hand washing
a) physical exam
b) stool exam and culture
c) CBC, BMP
d) KUB
1-month-old F is brought in because she has been spitting up her milk for the last 10 days. The vom- iting episodes have increased in frequency and forcefulness. Emesis is nonbloody and nonbilious. The episodes usually occur immediately after breast- feeding. She has stopped gaining weight.
1) pyloric stenosis
2) malrotation of the gut (bilious?), duodenal atresia
3) breast milk jaundice/intolerance/allergy
4) galactose intolerance
5) GERD
a) babyram
b) u/s abdomen
c) CBC, CMP, galactose level
d) barium swallow, endoscopy, pH probe
3 yo M presents with constipation. The child has had 1 bowel movement per week since birth despite the use of stool softeners. At birth, he did not pass meconium for 48 hours. He has poor weight gain. There is a family history of this problem.
1) Hirschprung’s Aganglionic Megacolon
2) Anal stenosis
3) Hypothyroidism/Low fiber
a) RECTAL. Stool exam and culture
b) Barium enema
c) Physical exam
d) CBC, BMP, TSH, Serum lead level
e) rectal SUCTION biopsy
8-month-old F presents with sudden-onset colicky abdominal pain with vomiting. The episodes are 20 minutes apart, and the child is completely well be- tween episodes. She had loose stools several hours before the pain, but her stools are now bloody.
1) Inussusseption
2) Volvulus
3) Meckel’s Diverticulum
a) CT abdomen
b) rectal, stool exam
c) CBC,BMP
d) U/S
7 yo M presents with abdominal pain that is general- ized, crampy, worse in the morning, and seemingly less prominent during weekends and holidays. He has missed many school days because of the pain. Growth and development are normal. His parents recently divorced.
1) malingering, somatic symptom disorder
2) adjustment disorder/regression
3) separation anxiety disorder, child abuse
4) IBS
a) phys/MSE
b) abdominal exam
c) CBC, BMP
2-month-old M presents with persistent crying for 2 weeks. The episodes subside after passing flatus or eructation (burp). There is no change in appetite, weight, or growth. There is no vomiting, constipation, or fe- ver.
1) colic
2) food allergy, lactose intolerance, GERD
a) abdominal exam
b) rectal exam
3 yo F presents with a 3-day history of “pink eye.” It began in the right eye but now involves both eyes. She has mucoid discharge, itching, and difficulty opening her eyes in the morning. Her mother had the flu last week. She has a history of asthma and atopic dermatitis.
1) bacterial conjunctivitis (bilateral?, mucoid?)
2) viral conjunctivitis
3) sinusitis/URI/allergies seasonal
4) uveitis/keratitis
a) culture of discharge
b) CBC/BMP
c) fundoscopy/slit lamp exam +/- fluorescein
14 yo M presents with short stature and lack of sex- ual development. His birth weight and length were normal, but he is the shortest child in his class. His father and uncles had the same problem when they were young, but they are now of normal stature.
1) Constitutional growth delay
2) NL development/genetics
3) Hypothyroidism, GH deficiency
1) TSH, GH stimulation test
2) physical exam
3) hand xray ?
4) CBC, BMP
9 yo M presents with a 2-year history of angry out- bursts both in school and at home. His mother com- plains that he runs around “as if driven by a motor.” His teacher reports that he cannot sit still in class, regularly interrupts his classmates, and has trouble making friends.
1) ADHD
2) conduct disorder/opposition defiance
a) Phys/MSE
12 yo F presents with a 2-month history of fighting in school, truancy, and breaking curfew. Her parents recently divorced, and she just started school in a new district. Before her parents divorced, she was an average student with no behavioral problems.
1) adjustment disorder with disturbance of conduct
2) substance use disorder
3) acute stress disorder/conduct disorder
a) Phys/MSE
b) urine tox
c) beck’s depression inventory
15 yo M presents with a 1-year history of failing grades, school absenteeism, and legal problems, in- cluding shoplifting. His parents report that he spends most of his time alone in his room, adding that when he does go out, it is with a new set of friends.
1) substance use
2) conduct disorder
3) schizoid personality disorder
a) physical/MSE
b) urine toxicology
5 yo M presents with a 6-month history of temper tantrums that last 5–10 minutes and immediately follow a disappointment or a discipline. He has no trouble sleeping, has had no change in appetite, and does not display these behaviors when he is at day care.
1) normal development
2) intermittent explosive disorder (or disruptive mood dysregulation disorder?)
3) oppositional defiant/ADHD
a) physical exam
b) reassurance
