DDx & Work-up

Question 1

21 yo f presents with throbbing left temporal pain, flashes of light, weakness, numbness, N/V and photophobia

Answer 1

DDX: 1. Hemiplegic migraine 2. Tension headache 3. Cluster headache Work-up: MRI-brain, CT-head, CBC, ESR

Question 2

26 yo m severe right temporal headache with ipsilateral rhinorrhea, eye tearing and redness; every night and last for 45 min.

Answer 2

DDX: 1. Cluster headache 2. Migraine 3. Trigeminal neuralgia 4. Intracranial neoplasm, 5 .Tension headache Work-up: MRI- brain, CT- head, CBC, ESR

Question 3

65 yo f c/o new onset severe intermittent R temporal headache, fever, blurred vision in R eye, weight loss, and pain in her jaw when chewing. h/o shoulder pain

Answer 3

DDX: Temporal arteritis, 2. Vasculitis, 3. Migraine Work-up: Temporal artery biopsy, ESR, CRP, CBC, Doppler U/S - carotid, MRI-brain

Question 4

30 yo f c/o frontal headache, fever and nasal discharge, the headache worsens when she bends forward. Pain on palpation of frontal and maxillary sinuses.

Answer 4

DDX: 1. Acute sinusitis 2. Migraine 3. Tension headache. Work-up: CBC, XR-sinus, CT- sinus

Question 5

50 yo f c/o recurrent b/l squeezing headache typically towards end of her work-day. Stress in her life. Decreased caffeine intake recently

Answer 5

DDX: 1. Tension headache 2. Migraine 3. Caffeine or analgesic withdrawal 4. Depression Work-up: CBC, electrolytes, ESR, MRI- brain, LP- CSF analysis

Question 6

35 yo m c/o sudden onset severe headache, vomiting, confusion, L hemiplegia, nuchal rigidity.

Answer 6

DDx: 1. Subarachnoid hemorrhage 2. Meningitis/encephalitis 3. Intracranial hemorrhage Work-up: CT-head w/o contrast, LP- opening pressure and CSF analysis, CBC, PT/PTT/INR, Urine toxicology

Question 7

25 yo m army recruit c/o high fever, severe headache, confusion, photophobia, and nuchal rigidity

Answer 7

DDx: 1. Meningitis 2. Subarachnoid hemorrhage 3. Encephalitis 4. Sinusitis Work-up: LP- CSF analysis, Blood culture, CBC, CT- head, MRI- brain, PT/PTT/INR

Question 8

18 yo f c/o daily pulsatile headache, vomiting, and blurred vision. She takes OCPs.

Answer 8

DDx: 1. Pseudotumor cerebri 2. Migraine 3. Tension headache 4. Intracranial venous thrombosis. Work-up: Urine hCG, LP- opening pressure & CSF analysis, Dilated fundoscopy exam, Funduscopic eye exam,

Question 9

75 yo m c/o daily pain in the R cheek. Pain is electric and stabbing and occurs while he is shaving. Each episode lasts for 2 min.

Answer 9

DDx: 1. Trigeminal neuralgia 2. Tension headache 3. Migraine 4. Cluster headaceh 5. TMJ disorder Work-up: MRI- brain, CBC, ESR

Question 10

81 yo m presents with progressive confusion past several years with forgetfulness and clumsiness. h/o HTN, DM, and 2 strokes. Mental status worsened after each stroke.

Answer 10

DDx: 1. Vascular dementia 2. Alzheimer disease 3. Normal pressure hydrocephalus 4. Chronic subdural hematoma work-up: CBC, VDRL/RPR, Sr. B12, TSH, MRI- brain, CT-head, LP- CSF analysis

Question 11

84 yo f brought by her son for forgetfulness (loses way back home, forgets phone numbers). Gradual progression.

Answer 11

DDx: 1. Alzheimer disease 2. Vascular dementia 3. Depression 4. Hypothyroidism Work-up: CBC, VDRL/RPR, TSH, Sr. B12, MRI- brain, CT-head, LP- CSF analysis

Question 12

72 yo m c/o memory loss, gait disturbance and urinary incontinence for past 6 months.

Answer 12

DDx: 1. Normal pressure hydrocephalus 2. Alzheimer disease 3. Vascular dementia 4. Chronic subdural hematoma. Work-up: CT- head, MRI-brain, LP- opening pressure and CSF analysis, Sr. B12, VDRL/RPR, TSH

Question 13

55 yo m c/o rapidly progressive change in mental status, inability to concentrate, and memory impairment x past 2 months. Myclonus, ataxia and a startle response present.

Answer 13

DDx: 1. Crutzfeldt-Jakob disease 2. Vascular dementia 3. Lewy body dementia 4. Wernicke encephalopathy. Work-up: CBC, Electrolytes, calcium, Sr. B12, VDRL/RPR, MRI-brain, CT-head, EEG, LP- CSF analysis

Question 14

70 yo m with insulin-dependent DM c/o episodes of confusion, dizziness, palpitations, diaphoresis, and wweakness.

Answer 14

DDx: 1. Hypoglycemia, 2. TIA 3. Arrhythmia 4. Delirium. Work-up: Glucose, CBC, electrolytes, TSH, CPK-MB, troponin, Echocardography, ECG, MRI-brain, Doppler U/S- carotids, Urine toxicology

Question 15

55 yo f presents with gradual altered mental status and headache. 2 weeks ago she slipped, hit her head on the ground, and lost her consciousness for 2 minutes.

Answer 15

DDx: 1. Subdural hematoma 2. SIADH (causing hyponatremia) 3. Crutzfeldt-Jakob disease 4. Intracranial neoplasm. Work-up: CT-head, CBC, electrolytes, TSH, MRI- brain, LP- CSF analysis

Question 16

73 yo m c/o acute loss of vision in L eye, palpitations, shortness of breath. h/o atrial fibrillation and cataract in his R eye. No eye pain, discharge, redness or photophobia. No headache, weakness or numbness.

Answer 16

DDx: 1.Retinal artery occlusion 2. Retinal vein occlusion 3. Acute angle-closure glaucoma 4. Retinal detachment 5. Temporal arteritis. Work-up: Fluorescein angiogram, Echocardiography, Doppler U/S- carotid, Intraocular tonometry, ESR, CRP, Temporal artery biopsy, CBC

Question 17

68 yo m c/o 2-month h/o crying spells, excessive sleep, poor hygiene, and weight loss, all following his wife’s death.

Answer 17

DDx: 1. Normal bereavement 2. Adjustment disorder with depressed mood 3. Major depressive disorder 4. Schizoaffective diorder. Work-up: TSH, CBC, Urine toxicology, Beck Depression Inventory

Question 18

42 yo f c/o 4-week h/o excessive fatigue, insomnia, and anhedonia. She states that she constantly thinks about death. She has suffered 5 similar episodes in the past, the first in her 20s, and has made 2 previous suicide attempts. She also admits to increased alcohol use in the past month.

Answer 18

DDx: 1. Major depressive disorder 2. Substance-induced mood disorder 3. Persistent depressive disorder (Dysthymia) Work-up: Beck depression invetnory, Blood alcohol levels, TSH, CBC, Urine toxicology

Question 19

26 yo f c/o weight loss in the past 2 months accompanied by early-morning awakening, excessive guilt, and psychomotor retardation. She does not identify a trigger for the depressive episode but reports several weeks of increase energy, sexual promiscuity, irresponsible spending, and racing thoughts approx. 6 months before her presentation.

Answer 19

DDx: 1. Bipolar I disorder 2. Bipolar II disorder 3. Cyclothymic disorder 4. Major depressive disorder 5. Schizoaffective disorder. Work-up: Mood disorder questionnaire, Urine toxicology, TSH, CBC.

Question 20

19 yo m receiving messages from his television set. He reports that he did not have any 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 else noticed. He rarely showered or left his room and recently he has been hearing a voice from his television set telling him to “guard against the evil empire”.

Answer 20

DDx: 1. Schizophrenia 2. Schizoid or Schizotypal personality disorder 3. Schizophreniform disorder 4. Psychotic disorder due to a general medical condition. Work-up: Full mental status exam, Urine toxicology, TSH, CBC, electrolytes

Question 21

28 yo f c/o seeing bug crawling on her bed for the past 2 days and hearing loud voices when she is alone in the reoom. She has never experienced anything similar in the past. She recently ingested an unknown substance.

Answer 21

DDx: 1. Substance-induced psychosis 2. Brief psychotic disorde 3. Schizophreniform disorder 4. Schizophreina 5. Psychotic disorder due to a general medical condition. Work-up: Urine toxicology, Full mental status exam, TSH, CBC, electrolytes, BUN/Cr, AST/ALT

Question 22

48 yo f c/o 1 week h/o auditory hallucinations that state, “ I am worhtless” and “I shall kill myself”. She also reports a 2 week h/o weight loss, early-morning awakening, decreased motivation, and overwhelming feeling of guilt.

Answer 22

DDx: 1. Schizoaffective disorder 2. Mood disorder with psychotic features 3. Schizophrenia 4. Schizophrenifom disorder 5. Psychotic disorder due to a general medical condition. Work-up: Full mental status exam, Beck depression inventory, urine toxicology, TSH, CBC, electrolytes