first aid cs differentials Flashcards
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.
Differential
Migraine
Tension headache Sinusitis Pseudotumor cerebri Trigeminal neuralgia Intracranial neoplasm
Workup
CBC
ESR CT—head MRI—brain LP
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.
Migraine (complicated)
Tension headache Cluster headache Pseudotumor cerebri Trigeminal neuralgia CNS vasculitis
Partial seizure Intracranial neoplasm
CBC
ESR CT—head MRI—brain LP
65 yo F presents with severe, intermittent right temporal headache, fever, blurred vision in her right eye, and pain in her jaw when chewing.
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
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.
Sinusitis Migraine Tension headache Meningitis Intracranial neoplasm
CBC
XR—sinus
CT—sinus
LP
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.
Tension headache Migraine Depression Caffeine or analgesic withdrawal Hypertension Cluster headache Pseudotumor cerebri Intracranial neoplasm
CBC Electrolytes ESR CT—head LP
35 yo M presents with sudden severe headache, vomiting, confusion, left hemiplegia, and nuchal rigidity.
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
25 yo M presents with high fever, severe headache, confusion, photophobia, and nuchal rigidity. Kernig’s and Brudzinski’s signs are positive.
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)
18 yo obese F presents with a pulsatile headache, vomiting, and blurred vision for the past 2–3 weeks. She is taking OCPs.
Pseudotumor cerebri Tension headache Migraine Cluster headache Meningitis Intracranial venous thrombosis Intracranial neoplasm
Urine hCG CBC CT—head LP—opening pressure and CSF analysis
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.
Trigeminal neuralgia Tension headache Migraine Cluster headache TMJ dysfunction Intracranial neoplasm
CBC
ESR
MRI—brain
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).
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)
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.
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)
72 yo M presents with memory loss, gait disturbance, and urinary incontinence for the past six months.
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
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.
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
70 yo insulin-dependent diabetic M presents with episodes of confusion, dizziness, palpitation, diaphoresis, and weakness.
Hypoglycemia Transient ischemic attack Arrhythmia Delirium Angina
Glucose CBC, electrolytes Echocardiography ECG MRI—brain Doppler U/S—carotid
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.
Subdural hematoma
SIADH (causing hyponatremia)
Creutzfeldt-Jakob disease
Intracranial neoplasm
Electrolytes
CT—head
MRI—brain
LP
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.
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
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.
Major depressive disorder
Substance-induced mood disorder
Dysthymic disorder
Physical exam Mental status exam Blood alcohol level TSH CBC Urine toxicology
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.
Bipolar I disorder Bipolar II disorder Cyclothymic disorder Major depressive disorder Schizoaffective disorder
Physical exam
Mental status exam
Urine toxicology
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.”
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
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.
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
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.
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
35 yo F presents with intermittent episodes of vertigo, tinnitus, nausea, and hearing loss over the past week.
Ménière’s disease
Vestibular neuronitis Labyrinthitis
Benign positional vertigo Acoustic neuroma
CBC
VDRL/RPR (syphilis is a cause
of Ménière’s disease) MRI—brain
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.
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)
65 yo M presents with postural dizziness and unsteadiness. He has hypertension and was started on hydrochlorothiazide two days ago.
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
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.
Benign positional vertigo
Vestibular neuronitis Labyrinthitis Ménière’s disease
MRI—brain Audiogram
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.
Vestibular neuronitis
Labyrinthitis
Ménière’s disease
Benign positional vertigo Vertigo associated with cervical
spine disease/injury Vertebrobasilar insufficiency
CBC
Electrolytes Electronystagmography MRI/MRA—brain
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.
Labyrinthitis
Vestibular neuronitis Ménière’s disease
Acoustic neuroma Vertebrobasilar insufficiency
Audiogram Electronystagmography MRI/MRA—brain
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).
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
55 yo M c/o falling after feeling dizzy and unsteady. He experienced transient LOC. He has hypertension and is on numerous antihypertensive drugs.
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
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).
Cardiac arrhythmia (causing syncope)
Severe aortic stenosis Syncope (other causes) Seizure
Pulmonary embolism
ECG
Holter monitoring CBC, electrolytes Glucose Echocardiography CT—head
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.
Transient ischemic attack (TIA)
Hypoglycemia Seizure
Stroke
Facial nerve palsy
CBC Glucose Electrolytes ECG CT—head MRI—brain Doppler U/S—carotid Echocardiography 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 history
of hypertension, diabetes mellitus, and heavy smoking.
Stroke TIA Seizure Intracranial neoplasm Subdural or epidural hematoma
CBC, electrolytes PT/PTT
CT—head MRI—brain (preferred) Doppler U/S—carotid Echocardiography
33 yo F presents with ascending loss of strength in her lower legs over the past two weeks. She had a recent URI.
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
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.
Multiple sclerosis Stroke Conversion disorder Malingering CNS tumor Neurosyphilis Syringomyelia CNS vasculitis
CBC, ESR
VDRL/RPR
MRI—brain
LP—CSF analysis Retinal evoked potentials
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.
Diabetic peripheral neuropathy
Alcoholic peripheral neuropathy B12 deficiency
Hypocalcemia
Hyperventilation Paraproteinemia/myeloma
HbA1c ESR Calcium Serum B12 Serum and urine protein electrophoresis
40 yo F presents with occasional double vision and droopy eyelids at night with normalization by morning.
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
25 yo M presents with hemiparesis (after a tonic-clonic seizure) that resolves over a few hours.
Todd’s paralysis
TIA
Stroke
Complicated migraine Malingering
CBC, electrolytes EEG
MRI—brain
Doppler U/S—carotid
40 yo F c/o feeling tired, hopeless, and worthless and of having suicidal thoughts. She recently discovered that her husband is homosexual.
Depression
Adjustment disorder Hypothyroidism Anemia
CBC
TSH
HIV/STD testing (given
husband’s possible risk factors)
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.
Post-traumatic stress disorder (PTSD)
Depression
Generalized anxiety disorder Psychotic or delusional disorder Hypothyroidism
CBC
TSH
Calcium
Urine toxicology
55 yo M presents with fatigue, weight loss, and constipation. He has a family history of colon cancer.
Colon cancer
Hypothyroidism Renal failure Hypercalcemia Depression
Rectal exam, stool for occult blood
CBC, electrolytes, calcium, BUN/Cr, AST/ALT, TSH
Colonoscopy Barium enema
40 yo F presents with fatigue, weight gain, sleepiness, cold intolerance, constipation, and dry skin.
Hypothyroidism
Depression Diabetes Anemia
TSH, FT3, FT4 CBC
Glucose, HbA1c
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.
Obstructive sleep apnea
Hypothyroidism
Chronic fatigue syndrome Narcolepsy
CBC
TSH
Nocturnal pulse oximetry Polysomnography
ECG
20 yo M presents with fatigue, thirst, increased appetite, and polyuria.
Diabetes mellitus
Atypical depression Primary polydipsia Diabetes insipidus
Glucose tolerance test, HbA1c UA
CBC, electrolytes, glucose BUN/Cr
35 yo M policeman c/o feeling tired and sleepy during the day. He changed to the night shift last week.
Sleep deprivation
Sleep apnea Depression Anemia
CBC
Nocturnal pulse oximetry Polysomnography
30 yo M presents with night sweats, cough, and swollen glands of one month’s duration.
Tuberculosis
Acute HIV infection Lymphoma Leukemia Hyperthyroidism
PPD CBC CXR Sputum Gram stain, acid-fast stain, and culture HIV antibody TSH, FT4
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.
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
55 yo obese M presents with several months of poor sleep and daytime fatigue. His wife reports that he snores loudly.
Obstructive sleep apnea
Daytime fatigue in primary hypersomnia
Insomnia with circadian rhythm sleep disorder
Insomnia related to major depressive disorder
CBC
TSH Polysomnography ECG
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.
Insomnia related to major depressive disorder
Primary hypersomnia
Insomnia with circadian rhythm
sleep disorder
Mental status exam TSH
CBC Polysomnography
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.
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
26 yo M presents with sore throat, fever, rash, and weight loss. He has a history of IV drug abuse and sharing needles.
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
46 yo F presents with fever and sore throat.
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
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.
Asthma
GERD Bronchitis Pneumonitis Foreign body
CBC
CXR
Peak flow measurement PFTs
Methacholine challenge test
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.
COPD—chronic bronchitis
Bronchiectasis Lung cancer Tuberculosis
CBC Sputum Gram stain and culture CXR PFTs CT—chest PPD
58 yo M presents with pleuritic chest pain, fever, chills, and cough with purulent yellow sputum. He is a heavy smoker with COPD.
Pneumonia
Bronchitis Lung abscess Lung cancer Tuberculosis Pericarditis
CBC Sputum Gram stain and culture CXR CT—chest ECG PPD
25 yo F presents with two weeks of a nonproductive cough. Three weeks ago she had a sore throat and a runny nose.
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
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.
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
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.
COPD exacerbation (bronchitis)
Lung cancer Pneumonia URI
CHF
CBC
CXR
PFTs
Sputum Gram stain and culture CT—chest
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.
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
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.
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
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.
CHF
Cardiac valvular disease GERD
Pulmonary fibrosis COPD
Postnasal drip
CBC
CXR
ECG Echocardiography PFTs
BNP
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.
Myocardial infarction (MI)
GERD
Angina Costochondritis Aortic dissection Pericarditis Pulmonary embolism Pneumothorax
ECG
CPK-MB, troponin CXR
CBC, electrolytes Echocardiography Cardiac catheterization
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.
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
45 yo F presents with a retrosternal burning sensation that occurs after heavy meals and when lying down. Her symptoms are relieved by antacids.
GERD
Esophagitis
Peptic ulcer disease Esophageal spasm MI
Angina
ECG
Barium swallow
Upper endoscopy Esophageal pH monitoring
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.
Angina
Esophageal spasm Esophagitis
ECG CPK-MB, troponin CXR CBC, electrolytes Exercise stress test Upper endoscopy/pH monitor Cardiac catheterization
