first aid cs differentials

Question 0

65 yo F presents with severe, intermittent right temporal headache, fever, blurred vision in her right eye, and pain in her jaw when chewing.

Answer 0

Differential Temporal arteritis (giant cell arteritis) Migraine Cluster headache Tension headache Meningitis Carotid artery dissection Pseudotumor cerebri Trigeminal neuralgia Intracranial neoplasm Workup CBC ESR CRP Temporal artery biopsy Doppler U/S—carotid MRI—brain

Question 1

26 yo M presents with severe right temporal headaches associated with ipsilateral rhinorrhea, eye tearing, and redness. Episodes have occurred at the same time every night for the past week and last for 45 minutes.

Answer 1

Differential Migraine Tension headache Sinusitis Pseudotumor cerebri Trigeminal neuralgia Intracranial neoplasm Workup CBC ESR CT—head MRI—brain LP

Question 2

50 yo F presents with recurrent episodes of bilateral squeezing headaches that occur 3–4 times a week, typically toward the end of her work day. She is experiencing significant stress in her life.

Answer 2

Tension headache Migraine Depression Caffeine or analgesic withdrawal Hypertension Cluster headache Pseudotumor cerebri Intracranial neoplasm CBC Electrolytes ESR CT—head LP

Question 3

25 yo M presents with high fever, severe headache, confusion, photophobia, and nuchal rigidity. Kernig’s and Brudzinski’s signs are positive.

Answer 3

Meningitis Migraine Subarachnoid hemorrhage Sinusitis/encephalitis Intracranial or epidural abscess CBC CT—head MRI—brain LP—CSF analysis (cell count, protein, glucose, Gram stain, PCR for antigens, culture)

Question 4

18 yo obese F presents with a pulsatile headache, vomiting, and blurred vision for the past 2–3 weeks. She is taking OCPs.

Answer 4

Pseudotumor cerebri Tension headache Migraine Cluster headache Meningitis Intracranial venous thrombosis Intracranial neoplasm Urine hCG CBC CT—head LP—opening pressure and CSF analysis

Question 5

30 yo F presents with frontal headache, fever, and nasal discharge. There is pain on palpation of the frontal and maxillary sinuses. She has a history of sinusitis.

Answer 5

Sinusitis Migraine Tension headache Meningitis Intracranial neoplasm CBC XR—sinus CT—sinus LP

Question 6

21 yo F presents with several episodes of throbbing left temporal pain that lasts for 2–3 hours. Prior to its onset, she sees flashes of light in her right visual field and feels weakness and numbness on the right side of her body for a few minutes. Headaches are often associated with nausea and vomiting. She has a family history of migraine.

Answer 6

Migraine (complicated) Tension headache Cluster headache Pseudotumor cerebri Trigeminal neuralgia CNS vasculitis Partial seizure Intracranial neoplasm CBC ESR CT—head MRI—brain LP

Question 7

81 yo M presents with progressive confusion over the past several years together with forgetfulness and clumsiness. He has a history of hypertension, diabetes mellitus, and two strokes with residual left hemiparesis. His mental status has clearly worsened after each stroke (stepwise decline in cognitive function).

Answer 7

Vascular (“multi-infarct”) dementia Alzheimer’s disease Normal pressure hydrocephalus Chronic subdural hematoma Intracranial tumor Depression B12 deficiency Neurosyphilis Hypothyroidism CBC VDRL/RPR Serum B12 TSH MRI—brain CT—head LP—CSF analysis (rare)

Question 8

57 yo M c/o daily pain in the right cheek over the past month. The pain is electric and stabbing in character and occurs while he is shaving. Each episode lasts 2–4 minutes.

Answer 8

Trigeminal neuralgia Tension headache Migraine Cluster headache TMJ dysfunction Intracranial neoplasm CBC ESR MRI—brain

Question 9

72 yo M presents with memory loss, gait disturbance, and urinary incontinence for the past six months.

Answer 9

Normal pressure hydrocephalus Alzheimer’s disease Vascular dementia Chronic subdural hematoma Intracranial neoplasm Depression B12 deficiency Neurosyphilis Hypothyroidism CT—head LP—opening pressure and CSF analysis Serum B12 VDRL/RPR TSH

Question 10

35 yo M presents with sudden severe headache, vomiting, confusion, left hemiplegia, and nuchal rigidity.

Answer 10

Subarachnoid hemorrhage Migraine Meningitis/encephalitis Intracranial hemorrhage Vertebral artery dissection Intracranial venous thrombosis Acute hypertension Intracranial neoplasm CT without contrast—head LP CBC PT/PTT MRI/MRA—brain

Question 11

55 yo M presents with a rapidly progressive change in mental status, inability to concentrate, and memory impairment for the past two months. His symptoms are associated with myoclonus and ataxia.

Answer 11

Creutzfeldt-Jakob disease Vascular dementia Lewy body dementia Wernicke’s encephalopathy Normal pressure hydrocephalus Chronic subdural hematoma Intracranial neoplasm Depression Delirium B12 deficiency Neurosyphilis CBC, electrolytes, calcium Serum B12 VDRL/RPR MRI—brain (preferred) CT—head EEG LP—CSF analysis Brain biopsy

Question 12

70 yo insulin-dependent diabetic M presents with episodes of confusion, dizziness, palpitation, diaphoresis, and weakness.

Answer 12

Hypoglycemia Transient ischemic attack Arrhythmia Delirium Angina Glucose CBC, electrolytes Echocardiography ECG MRI—brain Doppler U/S—carotid

Question 13

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

Answer 13

Subdural hematoma SIADH (causing hyponatremia) Creutzfeldt-Jakob disease Intracranial neoplasm Electrolytes CT—head MRI—brain LP

Question 14

68 yo M presents with a two-month history of crying spells, excessive sleep, poor hygiene, and a 7-kg weight loss, all following his wife’s death. He cannot enjoy time with his grandchildren and reluctantly admits to thinking he has seen his dead wife in line at the supermarket or standing in the kitchen making dinner.

Answer 14

Normal bereavement Adjustment disorder with depressed mood Major depressive disorder with psychotic features Schizoaffective disorder Depressive disorder not otherwise specified (NOS) Physical exam Mental status exam TSH CBC Urine toxicology

Question 15

42 yo F presents with a four-week history of excessive fatigue, insomnia, and anhedonia. She states that she thinks constantly about death. She has suffered five similar episodes in the past, the first in her 20s, and has made two previous suicide attempts. She further admits to increased alcohol use in the past month.

Answer 15

Major depressive disorder Substance-induced mood disorder Dysthymic disorder Physical exam Mental status exam Blood alcohol level TSH CBC Urine toxicology

Question 16

26 yo F presents with a 3-kg weight loss over the past two 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 increased energy, sexual promiscuity, irresponsible spending, and racing thoughts approximately six months before her presentation.

Answer 16

Bipolar I disorder Bipolar II disorder Cyclothymic disorder Major depressive disorder Schizoaffective disorder Physical exam Mental status exam Urine toxicology

Question 17

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. In the same time frame, 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.”

Answer 17

Schizophrenia Schizoid or schizotypal personality disorder Schizophreniform disorder Psychotic disorder due to a general medical condition Substance-induced psychosis Depression with psychotic features Mental status exam Urine toxicology TSH CBC Electrolytes

Question 18

55 yo F c/o dizziness for the past day. She feels faint and has severe diarrhea that started two days ago. She takes furosemide for her hypertension.

Answer 18

Orthostatic hypotension due to dehydration (diarrhea, diuretic use) Vestibular neuronitis Labyrinthitis Benign positional vertigo Vertebrobasilar insufficiency Orthostatic vital signs CBC Electrolytes Stool exam (occult blood, fecal leukocytes)

Question 19

44 yo F c/o dizziness on moving her head to the left. She feels that the room is spinning around her head. Tilt test results in nystagmus and nausea.

Answer 19

Benign positional vertigo Vestibular neuronitis Labyrinthitis Ménière’s disease MRI—brain Audiogram

Question 20

84 yo F brought by her son c/o forgetfulness (e.g., forgets phone numbers, loses her way back home) along with difficulty performing some of her daily activities (e.g., bathing, dressing, managing money, using the phone). The problem has gradually progressed over the past few years.

Answer 20

Alzheimer’s disease Vascular dementia Depression Hypothyroidism Chronic subdural hematoma Normal pressure hydrocephalus Intracranial neoplasm B12 deficiency Neurosyphilis CBC VDRL/RPR Serum B12 TSH MRI—brain (preferred) CT—head LP—CSF analysis (rare)

Question 21

28 yo F c/o seeing bugs crawling on her bed over the past two days and reports hearing loud voices when she is alone in her room. She has never experienced symptoms such as these in the past. She recently ingested an unknown substance.

Answer 21

Substance-induced psychosis Brief psychotic disorder Schizophreniform disorder Schizophrenia Psychotic disorder due to a general medical condition Urine toxicology Mental status exam TSH CBC Electrolytes, BUN/Cr, AST/ ALT

Question 22

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 ER. He has a history of hypertension, diabetes mellitus, and heavy smoking.

Answer 22

Transient ischemic attack (TIA) Hypoglycemia Seizure Stroke Facial nerve palsy CBC Glucose Electrolytes ECG CT—head MRI—brain Doppler U/S—carotid Echocardiography EEG

Question 23

65 yo M presents with postural dizziness and unsteadiness. He has hypertension and was started on hydrochlorothiazide two days ago.

Answer 23

Drug-induced orthostatic hypotension Vestibular neuronitis Labyrinthitis Benign positional vertigo Brain stem or cerebellar tumor Acute renal failure Orthostatic vital signs CBC Electrolytes BUN/Cr MRI—brain

Question 24

48 yo F presents with a one-week history of auditory hallucinations, stating, “I am worthless” and “I should kill myself.” She also reports a two-week history of weight loss, early-morning awakening, decreased motivation, and overwhelming feelings of guilt.

Answer 24

Schizoaffective disorder Mood disorder with psychotic features Schizophrenia Schizophreniform disorder Psychotic disorder due to a general medical condition Mental status exam Beck Depression Inventory TSH CBC Electrolytes

Question 25

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 two days ago and has experienced no hearing loss.

Answer 25

Vestibular neuronitis Labyrinthitis Ménière’s disease Benign positional vertigo Vertigo associated with cervical spine disease/injury Vertebrobasilar insufficiency CBC Electrolytes Electronystagmography MRI/MRA—brain

Question 26

55 yo M c/o falling after feeling dizzy and unsteady. He experienced transient LOC. He has hypertension and is on numerous antihypertensive drugs.

Answer 26

Drug-induced orthostatic hypotension (causing syncope) Cardiac arrhythmia Syncope (vasovagal, other causes) Stroke MI Pulmonary embolism Orthostatic vital signs CBC Electrolytes CT—head ECG V/Q scan CT—chest with IV contrast

Question 27

40 yo F presents with occasional double vision and droopy eyelids at night with normalization by morning.

Answer 27

Myasthenia gravis Horner’s syndrome Multiple sclerosis Intracranial tumor compressing CN III, IV, or VI Amyotrophic lateral sclerosis Tensilon test ACh receptor antibodies (in serum) CXR CT—chest MRI—brain EMG

Question 28

65 yo M presents after falling and losing consciousness for a few seconds. He had no warning prior to passing out but recently had palpitations. His past history includes coronary artery bypass grafting (CABG).

Answer 28

Cardiac arrhythmia (causing syncope) Severe aortic stenosis Syncope (other causes) Seizure Pulmonary embolism ECG Holter monitoring CBC, electrolytes Glucose Echocardiography CT—head

Question 29

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 history of hypertension, diabetes mellitus, and heavy smoking.

Answer 29

Stroke TIA Seizure Intracranial neoplasm Subdural or epidural hematoma CBC, electrolytes PT/PTT CT—head MRI—brain (preferred) Doppler U/S—carotid Echocardiography

Question 30

35 yo F presents with intermittent episodes of vertigo, tinnitus, nausea, and hearing loss over the past week.

Answer 30

Ménière’s disease Vestibular neuronitis Labyrinthitis Benign positional vertigo Acoustic neuroma CBC VDRL/RPR (syphilis is a cause of Ménière’s disease) MRI—brain

Question 31

33 yo F presents with ascending loss of strength in her lower legs over the past two weeks. She had a recent URI.

Answer 31

Guillain-Barré syndrome Multiple sclerosis Polymyositis Myasthenia gravis Peripheral neuropathy Tumor in the vertebral canal CBC, electrolytes CPK LP—CSF analysis MRI—spine EMG/nerve conduction study Tensilon test Serum B12

Question 32

26 yo M presents after falling and losing consciousness at work. He had rhythmic movements of the limbs, bit his tongue, and lost control of his bladder. He was subsequently confused (as witnessed by his colleagues).

Answer 32

Seizure, grand mal (now called complex tonic-clonic seizure) Convulsive syncope Substance abuse/overdose Malingering Hypoglycemia CBC, electrolytes, glucose Urine toxicology EEG MRI—brain CT—head LP—CSF analysis ECG

Question 33

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 vision, and double vision. She reports feeling “electric shocks” down her spine upon flexing her head.

Answer 33

Multiple sclerosis Stroke Conversion disorder Malingering CNS tumor Neurosyphilis Syringomyelia CNS vasculitis CBC, ESR VDRL/RPR MRI—brain LP—CSF analysis Retinal evoked potentials

Question 34

55 yo M presents with tingling and numbness in the hands and feet (glove- and-stocking distribution) over the past two months. He has a history of diabetes mellitus, hypertension, and alcoholism. There is decreased soft touch, vibratory, and position sense in the feet.

Answer 34

Diabetic peripheral neuropathy Alcoholic peripheral neuropathy B12 deficiency Hypocalcemia Hyperventilation Paraproteinemia/myeloma HbA1c ESR Calcium Serum B12 Serum and urine protein electrophoresis

Question 35

40 yo F presents with fatigue, weight gain, sleepiness, cold intolerance, constipation, and dry skin.

Answer 35

Hypothyroidism Depression Diabetes Anemia TSH, FT3, FT4 CBC Glucose, HbA1c

Question 36

40 yo F c/o feeling tired, hopeless, and worthless and of having suicidal thoughts. She recently discovered that her husband is homosexual.

Answer 36

Depression Adjustment disorder Hypothyroidism Anemia CBC TSH HIV/STD testing (given husband’s possible risk factors)

Question 37

55 yo obese M presents with several months of poor sleep and daytime fatigue. His wife reports that he snores loudly.

Answer 37

Obstructive sleep apnea Daytime fatigue in primary hypersomnia Insomnia with circadian rhythm sleep disorder Insomnia related to major depressive disorder CBC TSH Polysomnography ECG

Question 38

25 yo M presents with hemiparesis (after a tonic-clonic seizure) that resolves over a few hours.

Answer 38

Todd’s paralysis TIA Stroke Complicated migraine Malingering CBC, electrolytes EEG MRI—brain Doppler U/S—carotid

Question 39

55 yo M presents with fatigue, weight loss, and constipation. He has a family history of colon cancer.

Answer 39

Colon cancer Hypothyroidism Renal failure Hypercalcemia Depression Rectal exam, stool for occult blood CBC, electrolytes, calcium, BUN/Cr, AST/ALT, TSH Colonoscopy Barium enema

Question 40

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 hypertension.

Answer 40

Obstructive sleep apnea Hypothyroidism Chronic fatigue syndrome Narcolepsy CBC TSH Nocturnal pulse oximetry Polysomnography ECG

Question 41

20 yo M presents with fatigue, thirst, increased appetite, and polyuria.

Answer 41

Diabetes mellitus Atypical depression Primary polydipsia Diabetes insipidus Glucose tolerance test, HbA1c UA CBC, electrolytes, glucose BUN/Cr

Question 42

30 yo M presents with night sweats, cough, and swollen glands of one month’s duration.

Answer 42

Tuberculosis Acute HIV infection Lymphoma Leukemia Hyperthyroidism PPD CBC CXR Sputum Gram stain, acid-fast stain, and culture HIV antibody TSH, FT4

Question 43

25 yo F presents with a three-week history of difficulty falling asleep. She sleeps seven 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.

Answer 43

Stress-induced insomnia Caffeine-induced insomnia Insomnia with circadian rhythm sleep disorder Insomnia related to major depressive disorder Polysomnography Mental status exam Urine toxicology CBC TSH

Question 44

44 yo M presents with fatigue, insomnia, and nightmares about a murder that he witnessed in a mall one year ago. Since then, he has avoided that mall and has not gone out at night.

Answer 44

Post-traumatic stress disorder (PTSD) Depression Generalized anxiety disorder Psychotic or delusional disorder Hypothyroidism CBC TSH Calcium Urine toxicology

Question 45

55 yo M presents with sudden onset of severe chest pain that radiates to the back. He has a history of uncontrolled hypertension.

Answer 45

Aortic dissection MI Pericarditis Esophageal rupture Esophageal spasm GERD Pancreatitis Fat embolism ECG, CPK-MB, troponin CXR CBC, amylase, lipase Transesophageal echocardiography (TEE), MRI/MRA—aorta Aortic angiography Upper endoscopy

Question 46

33 yo F c/o three 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 3.5 kg along with an inability to enjoy the things she once liked to do.

Answer 46

Insomnia related to major depressive disorder Primary hypersomnia Insomnia with circadian rhythm sleep disorder Mental status exam TSH CBC Polysomnography

Question 47

26 yo M presents with sore throat, fever, rash, and weight loss. He has a history of IV drug abuse and sharing needles.

Answer 47

HIV, acute retroviral syndrome Infectious mononucleosis Hepatitis Viral pharyngitis Streptococcal tonsillitis/ scarlet fever Secondary syphilis CBC Peripheral smear HIV antibody and viral load CD4 count Monospot test Throat culture VDRL/RPR AST/ALT/bilirubin/alkaline phosphatase

Question 48

30 yo M presents with shortness of breath, cough, and wheezing that worsen in cold air. He has had several such episodes over the past four months.

Answer 48

Asthma GERD Bronchitis Pneumonitis Foreign body CBC CXR Peak flow measurement PFTs Methacholine challenge test

Question 49

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 two days ago.

Answer 49

Labyrinthitis Vestibular neuronitis Ménière’s disease Acoustic neuroma Vertebrobasilar insufficiency Audiogram Electronystagmography MRI/MRA—brain

Question 50

26 yo F presents with sore throat, fever, severe fatigue, 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.

Answer 50

Infectious mononucleosis Hepatitis Viral or bacterial pharyngitis Acute HIV infection Secondary syphilis CBC, peripheral smear Monospot test Throat culture AST/ALT/bilirubin/alkaline phosphatase HIV antibody and viral load Anti-EBV antibodies VDRL/RPR

Question 51

58 yo M presents with pleuritic chest pain, fever, chills, and cough with purulent yellow sputum. He is a heavy smoker with COPD.

Answer 51

Pneumonia Bronchitis Lung abscess Lung cancer Tuberculosis Pericarditis CBC Sputum Gram stain and culture CXR CT—chest ECG PPD

Question 52

46 yo F presents with fever and sore throat.

Answer 52

Pharyngitis (bacterial or viral) Mycoplasma pneumonia Acute HIV infection Infectious mononucleosis Throat swab for culture and rapid streptococcal antigen Monospot test CBC HIV antibody and viral load

Question 53

56 yo F presents with shortness of breath as well as with a productive cough that has occurred over the past two years for at least three months each year. She is a heavy smoker.

Answer 53

COPD—chronic bronchitis Bronchiectasis Lung cancer Tuberculosis CBC Sputum Gram stain and culture CXR PFTs CT—chest PPD

Question 54

65 yo M presents with worsening cough over the past six months together with hemoptysis, dyspnea, weakness, and weight loss. He is a heavy smoker.

Answer 54

Lung cancer Tuberculosis Lung abscess COPD Vasculitis (i.e., Wegener’s) Interstitial lung disease CHF CBC Sputum Gram stain, culture, and cytology CXR CT—chest PPD Bronchoscopy

Question 55

35 yo M policeman c/o feeling tired and sleepy during the day. He changed to the night shift last week.

Answer 55

Sleep deprivation Sleep apnea Depression Anemia CBC Nocturnal pulse oximetry Polysomnography

Question 56

55 yo M presents with increased dyspnea and sputum production over the past three days. He has COPD and stopped using his inhalers last week. He also stopped smoking two days ago.

Answer 56

COPD exacerbation (bronchitis) Lung cancer Pneumonia URI CHF CBC CXR PFTs Sputum Gram stain and culture CT—chest

Question 57

45 yo F presents with a retrosternal burning sensation that occurs after heavy meals and when lying down. Her symptoms are relieved by antacids.

Answer 57

GERD Esophagitis Peptic ulcer disease Esophageal spasm MI Angina ECG Barium swallow Upper endoscopy Esophageal pH monitoring

Question 58

34 yo F nurse presents with worsening cough of six weeks’ duration together with weight loss, fatigue, night sweats, and fever. She has a history of contact with tuberculosis patients at work.

Answer 58

Tuberculosis Pneumonia Lung abscess Vasculitis Lymphoma Metastatic cancer HIV/AIDS Sarcoidosis CBC PPD Sputum Gram stain, acid-fast stain, and culture CXR CT—chest Bronchoscopy HIV antibody

Question 59

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.

Answer 59

Tuberculosis Pneumonia (including Pneumocystis jiroveci) Bronchitis CHF (cardiomyopathy) Asthma Acute HIV infection CBC PPD Sputum Gram stain, acid-fast stain, silver stain, and culture CXR HIV antibody

Question 60

50 yo M presents with a cough that is exacerbated by lying down at night and improved by propping up on three pillows. He also reports exertional dyspnea.

Answer 60

CHF Cardiac valvular disease GERD Pulmonary fibrosis COPD Postnasal drip CBC CXR ECG Echocardiography PFTs BNP

Question 61

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.

Answer 61

Myocardial infarction (MI) GERD Angina Costochondritis Aortic dissection Pericarditis Pulmonary embolism Pneumothorax ECG CPK-MB, troponin CXR CBC, electrolytes Echocardiography Cardiac catheterization

Question 62

20 yo African-American F presents with acute onset of severe chest pain. She has a history of sickle cell disease and multiple previous hospitalizations for pain and anemia management.

Answer 62

Sickle cell disease—pulmonary infarction Pneumonia Pulmonary embolism MI Pneumothorax Aortic dissection CBC, reticulocyte count, LDH, peripheral smear ABG CXR CPK-MB, troponin ECG CT—chest with IV contrast

Question 63

55 yo M presents with retrosternal squeezing pain that lasts for two minutes and occurs with exercise. It is relieved by rest and is not related to food intake.

Answer 63

Angina Esophageal spasm Esophagitis ECG CPK-MB, troponin CXR CBC, electrolytes Exercise stress test Upper endoscopy/pH monitor Cardiac catheterization

Question 64

25 yo F presents with two weeks of a nonproductive cough. Three weeks ago she had a sore throat and a runny nose.

Answer 64

Atypical pneumonia Reactive airway disease URI-associated (“postinfectious”) Postnasal drip GERD CBC Induced sputum Gram stain and culture CXR IgM detection for Mycoplasma pneumoniae Urine Legionella antigen

Question 65

34 yo F presents with stabbing chest pain that worsens with deep inspiration and is relieved by aspirin. She had a URI one week ago. Chest wall tenderness is noted.

Answer 65

Costochondritis Pneumonia MI Pulmonary embolism Pericarditis Muscle strain ECG CPK-MB, troponin CXR CBC

Question 66

70 yo F presents with acute onset of shortness of breath at rest and pleuritic chest pain. She also presents with tachycardia, hypotension, tachypnea, and mild fever. She is recovering from hip replacement surgery.

Answer 66

Pulmonary embolism Pneumonia Costochondritis MI CHF Aortic dissection ECG CXR ABG CPK-MB, troponin CBC, electrolytes CT—chest with IV contrast Doppler U/S—legs D-dimer

Question 67

34 yo F presents with retrosternal stabbing chest pain that improves when she leans forward and worsens with deep inspiration. She had a URI one week ago.

Answer 67

Pericarditis Aortic dissection MI Costochondritis GERD Esophageal rupture ECG CPK-MB, troponin CXR Echocardiography CBC Upper endoscopy

Question 68

70 yo diabetic M presents with episodes of palpitations and diaphoresis. He is on insulin.

Answer 68

Hypoglycemia Cardiac arrhythmias Angina Hyperthyroidism Hyperventilation episodes Panic attacks Pheochromocytoma Carcinoid Glucose CBC, electrolytes TSH BUN/Cr ECG Holter monitor

Question 69

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 7 kg over the past four months.

Answer 69

Esophageal cancer Achalasia Esophagitis Systemic sclerosis Esophageal stricture Amyotrophic lateral sclerosis CBC CXR Endoscopy with biopsy Barium swallow CT—chest

Question 70

42 yo F presents with a 7-kg weight loss over the past two months. She has a fine tremor, and her pulse is 112.

Answer 70

Hyperthyroidism Cancer HIV infection Dieting/diet drugs Anorexia nervosa Malabsorption TSH, FT4 CBC, electrolytes HIV antibody Urine toxicology

Question 71

45 yo F presents with dysphagia for two weeks together with fatigue and a craving for ice and clay.

Answer 71

Plummer-Vinson syndrome Esophageal cancer Esophagitis Achalasia Systemic sclerosis Mitral valve stenosis CBC Serum iron, ferritin, TIBC Barium swallow Endoscopy

Question 72

48 yo F presents with dysphagia for both solid and liquid foods that has slowly progressed in severity over the past year. It is associated with regurgitation of undigested food, especially at night.

Answer 72

Achalasia Plummer-Vinson syndrome Esophageal cancer Esophagitis Systemic sclerosis Mitral valve stenosis Esophageal stricture Zenker’s diverticulum CXR Endoscopy Barium swallow Esophageal manometry

Question 73

38 yo M presents with dysphagia and pain on swallowing solids more than liquids. Exam reveals oral thrush.

Answer 73

Esophagitis (CMV, HSV, pill- induced) Systemic sclerosis GERD Esophageal stricture Zenker’s diverticulum CBC Endoscopy Barium swallow HIV antibody CD4 count

Question 74

20 yo F presents with nausea, vomiting (especially in the morning), fatigue, and polyuria. Her last menstrual period was six weeks ago, and her breasts are full and tender. She is sexually active with her boyfriend, and they use condoms for contraception.

Answer 74

Pregnancy Gastritis Hypercalcemia Diabetes mellitus UTI Depression Urine hCG Pelvic exam U/S—pelvis CBC, electrolytes, calcium, glucose UA, urine culture Baseline Pap smear, cervical cultures, rubella antibody, HIV antibody, hepatitis B surface antigen, and VDRL/ RPR

Question 75

43 yo obese F presents with RUQ abdominal pain, fever, and jaundice. She was diagnosed with asymptomatic gallstones one year ago.

Answer 75

Ascending cholangitis Acute cholecystitis Hepatitis Choledocholithiasis Sclerosing cholangitis Fitz-Hugh–Curtis syndrome Rectal exam CBC AST/ALT/bilirubin/alkaline phosphatase Viral hepatitis serologies U/S—abdomen MRCP ERCP

Question 76

44 yo F presents with a weight gain of > 11 kg over the past two months. She quit smoking three months ago and is on amitriptyline for depression. She also reports cold intolerance and constipation.

Answer 76

Smoking cessation Drug side effect Hypothyroidism Cushing’s syndrome Polycystic ovary syndrome Diabetes mellitus Atypical depression CBC, electrolytes, glucose TSH 24-hour urine free cortisol Dexamethasone suppression test

Question 77

60 yo M presents with dull epigastric pain that radiates to the back, together with weight loss, dark urine, and clay-colored stool. He is a heavy drinker and smoker.

Answer 77

Pancreatic cancer Acute viral hepatitis Chronic pancreatitis Cholecystitis/choledocholithiasis Abdominal aortic aneurysm Peptic ulcer disease Rectal exam CBC, electrolytes Amylase and lipase AST/ALT/bilirubin/alkaline phosphatase U/S—abdomen CT—abdomen

Question 78

56 yo M presents with severe midepigastric abdominal 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 three days binge drinking.

Answer 78

Acute pancreatitis Peptic ulcer disease Cholecystitis/choledocholithiasis Gastritis Abdominal aortic aneurysm Mesenteric ischemia Alcoholic hepatitis Mallory-Weiss tear Rectal exam CBC, electrolytes, BUN/Cr, amylase, lipase, AST/ALT/ bilirubin/alkaline phosphatase U/S—abdomen CT—abdomen Upper endoscopy ECG

Question 79

35 yo M presents with burning epigastric pain that starts 2–3 hours after meals. The pain is relieved by food and antacids.

Answer 79

Peptic ulcer disease Gastritis GERD Cholecystitis Chronic pancreatitis Mesenteric ischemia Rectal exam Amylase, lipase, lactate AST/ALT/bilirubin/alkaline phosphatase Endoscopy (including H. pylori testing) Upper GI series

Question 80

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 relieved by food and antacids. He also smokes heavily and takes aspirin on a regular basis.

Answer 80

Peptic ulcer perforation Acute pancreatitis Hepatitis Cholecystitis Choledocholithiasis Mesenteric ischemia Rectal exam CBC, electrolytes, amylase, lipase, lactate AST/ALT/bilirubin/alkaline phosphatase AXR Upright CXR Endoscopy (including H. pylori testing)

Question 81

18 yo M boxer presents with severe LUQ abdominal pain that radiates to the left scapula. He had infectious mononucleosis three weeks ago.

Answer 81

Splenic rupture Kidney stone Rib fracture Pneumonia Perforated peptic ulcer Splenic infarct Rectal exam CBC, electrolytes CXR CT—abdomen U/S—abdomen

Question 82

25 yo M presents with RUQ pain, fever, anorexia, nausea, and vomiting. He has dark urine and clay-colored stool.

Answer 82

Acute hepatitis Acute cholecystitis Ascending cholangitis Choledocholithiasis Pancreatitis Acute glomerulonephritis Rectal exam CBC, amylase, lipase AST/ALT/bilirubin/alkaline phosphatase UA Viral hepatitis serologies U/S—abdomen

Question 83

24 yo F presents with bilateral lower abdominal pain that started with the first day of her menstrual period. The pain is associated with fever and a thick, greenish-yellow vaginal discharge. She has had unprotected sex with multiple sexual partners. (8)

Answer 83

PID Endometriosis Dysmenorrhea Vaginitis Cystitis Spontaneous abortion Pyelonephritis

Pelvic exam Rectal exam Urine hCG Cervical cultures CBC/ESR UA, urine culture U/S—pelvis

Question 84

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 received digitalis. Her pain is out of proportion to the exam.

Answer 84

Mesenteric ischemia/infarction Diverticulitis Peptic ulcer disease Gastroenteritis Acute pancreatitis Cholecystitis/choledocholithiasis MI Rectal exam CBC, amylase, lipase, lactate ECG, CPK-MB, troponin AXR CT—abdomen Mesenteric angiography Barium enema

Question 85

45 yo M presents with sudden onset of colicky right-sided flank pain that radiates to the testicles, accompanied by nausea, vomiting, hematuria, and CVA tenderness.

Answer 85

Nephrolithiasis Renal cell carcinoma Pyelonephritis GI etiology (e.g., appendicitis) Rectal exam UA Urine culture and sensitivity BUN/Cr CT—abdomen U/S—renal IVP

Question 86

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 had eaten fatty food. She has had similar but less intense episodes that lasted a few hours. Exam reveals positive Murphy’s sign.

Answer 86

Acute cholecystitis Hepatitis Choledocholithiasis Ascending cholangitis Peptic ulcer disease Fitz-Hugh–Curtis syndrome Rectal exam CBC AST/ALT/bilirubin/alkaline phosphatase U/S—abdomen HIDA scan

Question 87

21 yo F presents with acute onset of severe RLQ pain, nausea, and vomiting. She has no fever, urinary symptoms, or vaginal bleeding and has never taken OCPs. Her last menstrual period was regular, and she has no history of STDs.

Answer 87

Ovarian torsion Appendicitis Nephrolithiasis Ectopic pregnancy Ruptured ovarian cyst PID Bowel infarction or perforation Pelvic exam Rectal exam Urine hCG UA CBC Doppler U/S—pelvis CT—abdomen Laparoscopy

Question 88

68 yo M presents with LLQ abdominal pain, fever, and chills for the past three days. He also reports recent onset of alternating diarrhea and constipation. He consumes a low-fiber, high-fat diet.

Answer 88

Diverticulitis Crohn’s disease Ulcerative colitis Gastroenteritis Abscess Rectal exam CBC, electrolytes CXR AXR CT—abdomen

Question 89

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.

Answer 89

Acute appendicitis Gastroenteritis Diverticulitis Crohn’s disease Nephrolithiasis Volvulus or other intestinal obstruction/perforation Rectal exam CBC, electrolytes AXR CT—abdomen U/S—abdomen

Question 90

40 yo F presents with watery diarrhea and abdominal cramps. Last week she was on antibiotics for a UTI.

Answer 90

Pseudomembranous (Clostridium difficile) colitis Gastroenteritis Cryptosporidiosis Food poisoning Inflammatory bowel disease Rectal exam Stool leukocytes, culture, occult blood C. difficile toxin in stool Electrolytes

Question 91

30 yo F presents with periumbilical pain for six 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.

Answer 91

Irritable bowel syndrome Crohn’s disease Celiac disease Chronic pancreatitis GI parasitic infection (amebiasis, giardiasis) Endometriosis Rectal exam, stool for occult blood Pelvic exam Urine hCG CBC Electrolytes CT—abdomen/pelvis Stool for ova and parasitology, Entamoeba histolytica antigen

Question 92

28 yo M presents with constipation (very hard stool) for the last three weeks. Since his mother died two months ago, he and his father have eaten only junk food.

Answer 92

Low-fiber diet Irritable bowel syndrome Substance abuse (e.g., heroin) Depression Hypothyroidism Rectal exam TSH Electrolytes Urine toxicology

Question 93

67 yo M presents with alternating diarrhea and constipation, decreased stool caliber, and blood in the stool for the past eight months. He also reports unintentional weight loss. He is on a low-fiber diet and has a family history of colon cancer.

Answer 93

Colorectal cancer Irritable bowel syndrome Diverticulosis GI parasitic infection (ascariasis, giardiasis) Inflammatory bowel disease Angiodysplasia Rectal exam CBC AST/ALT/bilirubin/alkaline phosphatase Colonoscopy Barium enema CT—abdomen/pelvis

Question 94

33 yo M presents with watery diarrhea, diffuse abdominal pain, and weight loss over the past three weeks. He has not responded to antibiotics. (8)

Answer 94

Crohn’s disease Gastroenteritis Ulcerative colitis Celiac disease Pseudomembranous colitis Hyperthyroidism Small bowel lymphoma Carcinoid

Rectal exam Stool exam and culture CBC, electrolytes TSH CT—abdomen Colonoscopy Small bowel series Urinary 5-HIAA

Question 95

25 yo M presents with watery diarrhea and abdominal cramps. He was recently in Mexico. (5)

Answer 95

Traveler’s diarrhea Giardiasis Amebiasis Food poisoning Hepatitis A Rectal exam Stool leukocytes, culture, Giardia antigen, Entamoeba histolytica antigen Electrolytes AST/ALT/bilirubin/alkaline phosphatase Viral hepatitis serology

Question 96

35 yo F presents with amenorrhea, galactorrhea, visual field defects, and headaches for the past six months.

Answer 96

Amenorrhea secondary to prolactinoma Pregnancy Thyroid disease Premature ovarian failure Pituitary tumor Pelvic and breast exam Urine hCG Prolactin LH/FSH, TSH MRI—brain

Question 97

30 yo F presents with alternating constipation and diarrhea and abdominal pain that is relieved by defecation. She has no nausea, vomiting, weight loss, or blood in her stool.

Answer 97

Irritable bowel syndrome Inflammatory bowel disease Celiac disease Chronic pancreatitis GI parasitic infection (ascariasis, giardiasis) Lactose intolerance Rectal exam, stool for occult blood CBC Electrolytes Stool for ova and parasitology AXR CT—abdomen/pelvis

Question 98

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.

Answer 98

Infectious diarrhea (gastroenteritis)—bacterial, viral, parasitic, protozoal Food poisoning Inflammatory bowel disease Rectal exam, stool for occult blood Stool leukocytes and culture CBC Electrolytes CT—abdomen/pelvis

Question 99

45 yo F presents with coffee-ground emesis for the last three days. Her stool is dark and tarry. She has a history of intermittent epigastric pain that is relieved by food and antacids.

Answer 99

Bleeding peptic ulcer Gastritis Gastric cancer Esophageal varices Rectal exam CBC, electrolytes AST/ALT/bilirubin/alkaline phosphatase Endoscopy (including H. pylori testing if ulcer is confirmed)

Question 100

40 yo F presents with epigastric pain and coffee-ground emesis. She has a history of rheumatoid arthritis that has been treated with aspirin. She is an alcoholic.

Answer 100

Gastritis Bleeding peptic ulcer Gastric cancer Esophageal varices Mallory-Weiss tear Rectal exam CBC, electrolytes AST/ALT/bilirubin/alkaline phosphatase Barium swallow Endoscopy

Question 101

67 yo M presents with blood in his stool, weight loss, and constipation. He has a family history of colon cancer.

Answer 101

Colorectal cancer Anal fissure Hemorrhoids Diverticulosis Ischemic bowel disease Angiodysplasia Upper GI bleeding Inflammatory bowel disease Rectal exam CBC, PT/PTT AST/ALT/bilirubin/alkaline phosphatase CEA Colonoscopy CT—abdomen/pelvis Barium enema

Question 102

33 yo F presents with rectal bleeding and diarrhea for the past week. She has had lower abdominal pain and tenesmus for several months.

Answer 102

Ulcerative colitis Crohn’s disease Proctitis Anal fissure Hemorrhoids Diverticulosis Dysentery Rectal exam CBC, PT/PTT AXR Colonoscopy CT—abdomen/pelvis Barium enema

Question 103

58 yo M presents with bright red blood per rectum and chronic constipation. He consumes a low-fiber diet.

Answer 103

Diverticulosis Anal fissure Hemorrhoids Angiodysplasia Colorectal cancer Rectal exam CBC, PT/PTT Electrolytes Colonoscopy CT—abdomen/pelvis

Question 104

65 yo M presents with painless hematuria. He is a heavy smoker and works as a painter.

Answer 104

Bladder cancer Renal cell carcinoma Nephrolithiasis Acute glomerulonephritis Prostate cancer Coagulation disorder (i.e., factor VIII antibodies) Polycystic kidney disease Genitourinary exam UA, urine cytology BUN/Cr, PSA, CBC, PT/PTT Cystoscopy U/S—renal/bladder CT—abdomen/pelvis IVP

Question 105

35 yo M presents with painless hematuria. He has a family history of kidney problems.

Answer 105

Polycystic kidney disease Nephrolithiasis Acute glomerulonephritis (e.g., IgA nephropathy) UTI Coagulation disorder Bladder cancer Genitourinary exam UA BUN/Cr, PSA, CBC, PT/PTT U/S—renal CT—abdomen/pelvis IVP

Question 106

55 yo M presents with flank pain and blood in his urine without dysuria. He has experienced weight loss and fever over the past two months.

Answer 106

Renal cell carcinoma Bladder cancer Nephrolithiasis Acute glomerulonephritis Pyelonephritis Prostate cancer Genitourinary, rectal exam UA, urine cytology, BUN/Cr, PSA, CBC, PT/PTT U/S—renal CT—abdomen/pelvis IVP

Question 107

60 yo M presents with nocturia, urgency, weak stream, and terminal dribbling. He denies any weight loss, fatigue, or bone pain. He has had two episodes of urinary retention that required catheterization.

Answer 107

Benign prostatic hyperplasia (BPH) Prostate cancer UTI Bladder stones Rectal exam UA CBC, BUN/Cr, PSA U/S—prostate (transrectal)

Question 108

40 yo M presents with crampy abdominal pain, vomiting, abdominal distention, and inability to pass flatus or stool. He has a history of multiple abdominal surgeries.

Answer 108

Intestinal obstruction Small bowel or colon cancer Volvulus of the bowel Gastroenteritis Food poisoning Ileus Hernia Rectal exam CBC, electrolytes AXR CT—abdomen/pelvis CXR

Question 109

45 yo diabetic F presents with dysuria, urinary frequency, fever, chills, and nausea over the past three days. There is left CVA tenderness on exam.

Answer 109

Acute pyelonephritis Nephrolithiasis Renal cell carcinoma Lower UTI (cystitis, urethritis) UA Urine culture and sensitivity CBC, BUN/Cr U/S—renal CT—abdomen

Question 110

30 yo F presents with watery diarrhea and abdominal cramping and bloating. Her symptoms are aggravated by milk ingestion and are relieved by fasting.

Answer 110

Lactose intolerance Gastroenteritis Inflammatory bowel disease Irritable bowel syndrome Hyperthyroidism Rectal exam Stool exam Hydrogen breath test TSH

Question 111

18 yo M presents with a burning sensation during urination and urethral discharge. He recently had unprotected sex with a new partner.

Answer 111

Urethritis Cystitis Prostatitis Genital ± rectal exam UA Urine culture Gram stain and culture of urethral discharge Chlamydia and gonorrhea PCR

Question 112

47 yo M presents with impotence that started three months ago. He has hypertension and was started on atenolol four months ago. He also has diabetes and is on insulin.

Answer 112

Drug-related ED ED caused by hypertension ED caused by diabetes mellitus Psychogenic ED Peyronie’s disease Genital exam Rectal exam Glucose CBC

Question 113

18 yo F presents with amenorrhea for the past four months. She has lost 95 pounds and has a history of vigorous exercise and cold intolerance.

Answer 113

Anorexia nervosa CBC TSH FT4 ACTH FSH LH

Question 114

71 yo M presents with nocturia, urgency, weak stream, terminal dribbling, hematuria, and lower back pain over the past four months. He has also experienced weight loss and fatigue.

Answer 114

Prostate cancer BPH Renal cell carcinoma UTI Bladder stones Rectal exam UA CBC, BUN/Cr, PSA U/S—prostate (transrectal) CT—pelvis IVP

Question 115

48 yo F presents with amenorrhea for the past six months accompanied by hot flashes, night sweats, emotional lability, and dyspareunia.

Answer 115

Menopause Pregnancy Pituitary tumor Thyroid disease Pelvic exam Urine hCG LH/FSH, TSH, prolactin, testosterone, DHEAS CBC MRI—brain

Question 116

40 yo F presents with amenorrhea, morning nausea and vomiting, fatigue, and polyuria. Her last menstrual period was six weeks ago, and her breasts are full and tender. She uses the rhythm method for contraception.

Answer 116

Pregnancy Anovulatory cycle Hyperprolactinemia UTI Thyroid disease Pelvic exam Urine hCG U/S—pelvis CBC, electrolytes UA, urine culture Prolactin, TSH Baseline Pap smear, cervical cultures, rubella antibody, HIV antibody, hepatitis B surface antigen, and VDRL/ RPR

Question 117

23 yo obese F presents with amenorrhea for six months, facial hair, and infertility for the past three years.

Answer 117

Polycystic ovary syndrome Thyroid disease Hyperprolactinemia Pregnancy Ovarian or adrenal malignancy Premature ovarian failure Pelvic exam Urine hCG U/S—pelvis LH/FSH, TSH, prolactin Testosterone, DHEAS

Question 118

29 yo F presents with amenorrhea for the past six months. She has a history of occasional palpitations and dizziness. She lost her fiancé in a car accident.

Answer 118

Anxiety-induced amenorrhea CBC TSH FT4 ACTH Urine cortisol level Progesterone challenge test FSH/LH/estradiol levels

Question 119

35 yo F presents with amenorrhea, cold intolerance, coarse hair, weight loss, and fatigue. She has a history of abruptio placentae followed by hypovolemic shock and failure of lactation two years ago.

Answer 119

Sheehan’s syndrome Premature ovarian failure Pituitary tumor Thyroid disease Asherman’s syndrome Pelvic exam Urine hCG CBC Thyroid disease LH/FSH, prolactin TSH, FT4 ACTH MRI—brain Hysteroscopy

Question 120

28 yo F who is eight weeks pregnant presents with lower abdominal pain and vaginal bleeding.

Answer 120

Spontaneous abortion Ectopic pregnancy Molar pregnancy Pelvic exam Urine hCG U/S—pelvis CBC, PT/PTT Quantitative serum hCG

Question 121

61 yo obese F presents with profuse vaginal bleeding over the past month. Her last menstrual period was 10 years ago. She has a history of hypertension and diabetes mellitus. She is nulliparous.

Answer 121

Endometrial cancer Cervical cancer Atrophic endometrium Endometrial hyperplasia Endometrial polyps Atrophic vaginitis Pelvic exam Pap smear Endometrial biopsy U/S—pelvis Endometrial curettage Colposcopy Hysteroscopy

Question 122

45 yo G5P5 F presents with postcoital bleeding. She is a cigarette smoker and takes OCPs.

Answer 122

Cervical cancer Cervical polyp Cervicitis Trauma (e.g., cervical laceration) Pelvic exam Pap smear Colposcopy and biopsy

Question 123

28 yo F presents with pain in the metacarpophalangeal joints of both hands. Her left knee is also painful and red. She has morning joint stiffness that lasts for an hour. Her mother had rheumatoid arthritis.

Answer 123

Rheumatoid arthritis SLE Disseminated gonorrhea Arthritis associated with inflammatory bowel disease Osteoarthritis ANA, anti-dsDNA, ESR, RF, CBC XR—hands, left knee Cervical culture Arthrocentesis and synovial fluid analysis

Question 124

35 yo F presents with a malodorous, profuse, frothy, greenish vaginal discharge with intense vaginal itching and discomfort.

Answer 124

Vaginitis—trichomonal Vaginitis—candidal Bacterial vaginosis Cervicitis (chlamydia, gonorrhea) Pelvic exam Wet mount Cervical cultures pH of the vaginal fluid KOH prep (“whiff test”)

Question 125

28 yo F presents with a thin, grayish- white, foul-smelling vaginal discharge.

Answer 125

Bacterial vaginosis Vaginitis—candidal Vaginitis—trichomonal Cervicitis (chlamydia, gonorrhea) Pelvic exam Wet mount Cervical cultures KOH prep (“whiff test”) pH of vaginal fluid

Question 126

30 yo F presents with a thick, white, cottage cheese–like, odorless vaginal discharge and vaginal itching.

Answer 126

Vaginitis—candidal Bacterial vaginosis Vaginitis—trichomonal Pelvic exam KOH prep (“whiff test”) Wet mount Cervical cultures pH of vaginal fluid

Question 127

54 yo F c/o painful intercourse. Her last menstrual period was nine months ago. She has hot flashes.

Answer 127

Atrophic vaginitis Endometriosis Cervicitis Depression Domestic abuse Pelvic exam Wet mount, KOH prep, cervical cultures U/S—pelvis

Question 128

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.

Answer 128

Tennis elbow (lateral epicondylitis) Stress fracture XR—arm Bone scan MRI—elbow

Question 129

30 yo F secretary presents with wrist pain and a sensation 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 shaking of the hand. There is sensory loss in the same fingers. Exam reveals a positive Tinel’s sign.

Answer 129

Carpal tunnel syndrome Median nerve compression in forearm or arm Radiculopathy of nerve roots C6 and C7 in cervical spine Nerve conduction study EMG

Question 130

37 yo F presents with dyspareunia, inability to conceive, and dysmenorrhea.

Answer 130

Endometriosis Cervicitis Vaginismus Vulvodynia PID Depression Domestic violence Pelvic exam Wet mount, KOH prep, cervical cultures U/S—pelvis Laparoscopy

Question 131

28 yo F c/o multiple facial and bodily injuries. She claims that she fell on the stairs. She was hospitalized for some physical injuries seven months ago. She presents with her husband.

Answer 131

Domestic violence Osteogenesis imperfecta Substance abuse Consensual violent sexual behavior XR—skeletal survey CT—maxillofacial Urine toxicology CBC

Question 132

30 yo F presents with multiple facial and physical injuries. She was attacked and raped by two men.

Answer 132

Rape Pelvic exam Urine hCG Wet mount, KOH prep, cervical cultures XR—skeletal survey CBC HIV antibody Viral hepatitis serologies

Question 133

32 yo F presents with sudden onset of left lower abdominal pain that radiates to the scapula and back and is associated with vaginal bleeding. Her last menstrual period was five weeks ago. She has a history of PID and unprotected intercourse.

Answer 133

Ectopic pregnancy Ruptured ovarian cyst Ovarian torsion PID Pelvic exam Urine hCG Cervical cultures U/S—pelvis Quantitative serum hCG

Question 134

17 yo F presents with prolonged, excessive menstrual bleeding occurring irregularly over the past six months.

Answer 134

Dysfunctional uterine bleeding Coagulation disorders (e.g., von Willebrand’s disease, hemophilia) Cervical cancer Molar pregnancy Hypothyroidism Diabetes mellitus Pelvic exam Urine hCG Cervical cultures, Pap smear CBC, ESR, glucose PT/PTT Prolactin, LH/FSH TSH U/S—pelvis

Question 135

28 yo F presents with pain in the interphalangeal joints of her hands together with hair loss and a butterfly rash on her face.

Answer 135

Systemic lupus erythematosus (SLE) Rheumatoid arthritis Psoriatic arthritis Parvovirus B19 infection ANA, anti-dsDNA, ESR, C3, C4, rheumatoid factor (RF), CBC XR—hands UA

Question 136

65 yo F presents with inability to use her left leg and 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 externally rotated, shortened, and adducted, and there is tenderness in her left groin.

Answer 136

Hip fracture Hip dislocation Pelvic fracture XR—hip/pelvis CT or MRI—hip CBC Serum calcium and vitamin D Bone density scan (DEXA)

Question 137

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.

Answer 137

Domestic violence Factitious disorder Substance abuse XR—wrist CT—head Urine toxicology

Question 138

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 noticed swelling and deformity of the joint and is having difficulty walking.

Answer 138

Osteoarthritis Pseudogout Gout Meniscal or ligament damage XR—knee CBC ESR Knee arthrocentesis and synovial fluid analysis (cell count, Gram stain, culture, crystals) MRI—knee

Question 139

45 yo M presents with right knee pain with swelling and redness.

Answer 139

Septic arthritis Gout Pseudogout Lyme arthritis Trauma Reiter’s arthritis CBC Knee arthrocentesis and synovial fluid analysis (see above) Blood, urethral cultures XR—knee Uric acid Lyme antibody

Question 140

65 yo M presents with right foot pain. He has been training for a marathon.

Answer 140

Stress fracture Plantar fasciitis Foot sprain or strain XR—foot Bone scan—foot MRI—foot

Question 141

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 occasionally uses condoms.

Answer 141

Disseminated gonorrhea Rheumatoid arthritis SLE Psoriatic arthritis Reiter’s arthritis Knee arthrocentesis and synovial fluid analysis (cell count, Gram stain, culture) ANA, anti-dsDNA, ESR, RF, CBC Blood, cervical cultures XR—knee

Question 142

45 yo F presents with right calf pain. Her calf is tender, warm, red, and swollen compared to the left side. She was started on OCPs two months ago for dysfunctional uterine bleeding.

Answer 142

DVT Baker’s cyst rupture Myositis Cellulitis Superficial venous thrombosis Doppler U/S—right leg CBC CPK D-dimer PT, aPTT, fibrinogen XR—right leg

Question 143

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.

Answer 143

Plantar fasciitis Heel fracture Splinter/foreign body XR—heel Bone scan

Question 144

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.

Answer 144

Lumbar muscle strain Disk herniation Abdominal aortic aneurysm Vertebral compression fracture XR—L-spine

Question 145

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.

Answer 145

Hip dislocation—traumatic Hip fracture XR—hip CT or MRI—hip CBC PT/PTT Blood type and cross-match Urine toxicology and blood alcohol level

Question 146

60 yo F presents with pain in both legs that is induced by walking and is relieved by rest. She had cardiac bypass surgery six months ago and continues to smoke heavily.

Answer 146

Peripheral vascular disease (intermittent claudication) Leriche’s syndrome (aortoiliac occlusive disease) Lumbar spinal stenosis (pseudoclaudication) Osteoarthritis Ankle-brachial index Doppler U/S—lower extremity Angiography MRI—lumbar spine

Question 147

60 yo F c/o left arm pain that started while she was swimming and was relieved by rest.

Answer 147

Angina/MI Tendonitis Osteoarthritis Shoulder dislocation CPK-MB, troponin, ECG CBC ESR XR—shoulder CXR Echocardiography Stress test

Question 148

50 yo M presents with right shoulder pain after falling onto his outstretched hand while skiing. He noticed deformity of his shoulder and had to hold his right arm.

Answer 148

Shoulder dislocation Fracture of the humerus Rotator cuff injury XR—shoulder XR—arm MRI—shoulder

Question 149

55 yo M presents with crampy bilateral thigh and calf pain, fatigue, and dark urine. He is on simvastatin and clofibrate for hyperlipidemia.

Answer 149

Rhabdomyolysis due to simvastatin or clofibrate Polymyositis Inclusion body myositis Thyroid disease CBC CPK Aldolase UA Urine myoglobin TSH

Question 150

12-month-old M presents with fever for the last two days accompanied by a maculopapular rash on his face and body. He has not yet received the MMR vaccine.

Answer 150

Measles (or other viral exanthem) Rubella Roseola Fifth disease Varicella Scarlet fever Meningitis Physical exam CBC Viral antibodies/titers Throat swab for culture LP

Question 151

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.

Answer 151

Gastroenteritis (viral, bacterial, parasitic) Food poisoning UTI URI Volvulus Intussusception Physical exam Stool exam and culture CBC Electrolytes UA, urine culture AXR

Question 152

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 (e.g., pushing a grocery cart).

Answer 152

Lumbar spinal stenosis Lumbar muscle strain Tumor in the vertebral canal Peripheral vascular disease XR—L-spine MRI—L-spine (preferred) CT—L-spine Ankle-brachial index

Question 153

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.

Answer 153

Neonatal sepsis Meningitis Pneumonia UTI Physical exam CBC, electrolytes UA Urine culture Blood culture CXR LP—CSF analysis

Question 154

3 yo M presents with a two-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.

Answer 154

Acute otitis media URI Meningitis UTI Physical exam (including pneumatic otoscopy) CBC UA

Question 155

15 yo M presents with a one-year history of failing grades, school absenteeism, and legal problems, including 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.

Answer 155

Substance abuse Conduct disorder Oppositional defiant disorder Adjustment disorder Urine toxicology Mental status exam

Question 156

45 yo F presents with low back pain that radiates to the lateral aspect of her left foot. Straight leg raising is positive. The patient is unable to tiptoe

Answer 156

Disk herniation Lumbar muscle strain Tumor in the vertebral canal XR—L-spine MRI—L-spine

Question 157

5 yo M presents with a six-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.

Answer 157

Age-appropriate behavior ADHD Oppositional defiant disorder Physical exam Mental status exam

Question 158

12 yo F presents with a two-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.

Answer 158

Adjustment disorder Substance intoxication/abuse/ dependence Manic episode Oppositional defiant disorder Conduct disorder Physical exam Mental status exam Urine toxicology

Question 159

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.

Answer 159

Psoriatic arthritis Rheumatoid arthritis SLE RF, ANA, ESR CBC XR—hands XR—pelvis/sacroiliac joints Uric acid

Question 160

9 yo M presents with a two-year history of angry outbursts both in school and at home. His mother complains 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.

Answer 160

Attention-deficit hyperactivity disorder (ADHD) Oppositional defiant disorder Manic episode Conduct disorder Physical exam Mental status exam

Question 161

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 injury.

Answer 161

Malingering Lumbar muscle strain Disk herniation Knee or leg fracture Ankylosing spondylitis XR—L-spine/knee MRI—L-spine