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
