first aid cs differentials Flashcards
0
Q
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.
A
Differential
Migraine
Tension headache Sinusitis Pseudotumor cerebri Trigeminal neuralgia Intracranial neoplasm
Workup
CBC
ESR CT—head MRI—brain LP
1
Q
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.
A
Migraine (complicated)
Tension headache Cluster headache Pseudotumor cerebri Trigeminal neuralgia CNS vasculitis
Partial seizure Intracranial neoplasm
CBC
ESR CT—head MRI—brain LP
2
Q
65 yo F presents with severe, intermittent right temporal headache, fever, blurred vision in her right eye, and pain in her jaw when chewing.
A
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
3
Q
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.
A
Sinusitis Migraine Tension headache Meningitis Intracranial neoplasm
CBC
XR—sinus
CT—sinus
LP
4
Q
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.
A
Tension headache Migraine Depression Caffeine or analgesic withdrawal Hypertension Cluster headache Pseudotumor cerebri Intracranial neoplasm
CBC Electrolytes ESR CT—head LP
5
Q
35 yo M presents with sudden severe headache, vomiting, confusion, left hemiplegia, and nuchal rigidity.
A
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
6
Q
25 yo M presents with high fever, severe headache, confusion, photophobia, and nuchal rigidity. Kernig’s and Brudzinski’s signs are positive.
A
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)
7
Q
18 yo obese F presents with a pulsatile headache, vomiting, and blurred vision for the past 2–3 weeks. She is taking OCPs.
A
Pseudotumor cerebri Tension headache Migraine Cluster headache Meningitis Intracranial venous thrombosis Intracranial neoplasm
Urine hCG CBC CT—head LP—opening pressure and CSF analysis
8
Q
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.
A
Trigeminal neuralgia Tension headache Migraine Cluster headache TMJ dysfunction Intracranial neoplasm
CBC
ESR
MRI—brain
9
Q
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).
A
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)
10
Q
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.
A
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)
11
Q
72 yo M presents with memory loss, gait disturbance, and urinary incontinence for the past six months.
A
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
12
Q
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.
A
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
13
Q
70 yo insulin-dependent diabetic M presents with episodes of confusion, dizziness, palpitation, diaphoresis, and weakness.
A
Hypoglycemia Transient ischemic attack Arrhythmia Delirium Angina
Glucose CBC, electrolytes Echocardiography ECG MRI—brain Doppler U/S—carotid
14
Q
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.
A
Subdural hematoma
SIADH (causing hyponatremia)
Creutzfeldt-Jakob disease
Intracranial neoplasm
Electrolytes
CT—head
MRI—brain
LP
15
Q
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.
A
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
16
Q
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.
A
Major depressive disorder
Substance-induced mood disorder
Dysthymic disorder
Physical exam Mental status exam Blood alcohol level TSH CBC Urine toxicology
17
Q
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.
A
Bipolar I disorder Bipolar II disorder Cyclothymic disorder Major depressive disorder Schizoaffective disorder
Physical exam
Mental status exam
Urine toxicology
18
Q
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.”
A
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
19
Q
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.
A
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
20
Q
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.
A
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
21
Q
35 yo F presents with intermittent episodes of vertigo, tinnitus, nausea, and hearing loss over the past week.
A
Ménière’s disease
Vestibular neuronitis Labyrinthitis
Benign positional vertigo Acoustic neuroma
CBC
VDRL/RPR (syphilis is a cause
of Ménière’s disease) MRI—brain
22
Q
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.
A
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)
23
Q
65 yo M presents with postural dizziness and unsteadiness. He has hypertension and was started on hydrochlorothiazide two days ago.
A
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
24
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
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.
Vestibular neuronitis
Labyrinthitis
Ménière’s disease
Benign positional vertigo Vertigo associated with cervical
spine disease/injury Vertebrobasilar insufficiency
CBC
Electrolytes Electronystagmography MRI/MRA—brain
26
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
27
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
28
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
```
29
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
30
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
```
31
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
32
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
```
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.
```
Multiple sclerosis
Stroke
Conversion disorder Malingering
CNS tumor Neurosyphilis Syringomyelia
CNS vasculitis
```
CBC, ESR
VDRL/RPR
MRI—brain
LP—CSF analysis Retinal evoked potentials
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.
Diabetic peripheral neuropathy
Alcoholic peripheral neuropathy B12 deficiency
Hypocalcemia
Hyperventilation Paraproteinemia/myeloma
```
HbA1c
ESR
Calcium
Serum B12
Serum and urine protein
electrophoresis
```
35
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
36
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
37
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)
38
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
39
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
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
41
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
42
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
43
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
44
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
```
45
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
46
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
47
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
48
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
49
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
```
50
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
51
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
52
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
```
53
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
```
54
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
```
55
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
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.
COPD exacerbation (bronchitis)
Lung cancer Pneumonia URI
CHF
CBC
CXR
PFTs
Sputum Gram stain and culture CT—chest
57
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
```
58
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
```
59
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
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
61
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
```
62
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
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.
Angina
Esophageal spasm Esophagitis
```
ECG
CPK-MB, troponin
CXR
CBC, electrolytes
Exercise stress test
Upper endoscopy/pH monitor Cardiac catheterization
```
64
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.
Pericarditis
Aortic dissection MI Costochondritis GERD
Esophageal rupture
ECG
CPK-MB, troponin CXR Echocardiography CBC
Upper endoscopy
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.
```
Costochondritis
Pneumonia
MI
Pulmonary embolism Pericarditis
Muscle strain
```
ECG
CPK-MB, troponin CXR
CBC
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.
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
```
67
55 yo M presents with sudden onset of severe chest pain that radiates to the back. He has a history of uncontrolled hypertension.
```
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
68
70 yo diabetic M presents with episodes of palpitations and diaphoresis. He is on insulin.
Hypoglycemia
Cardiac arrhythmias Angina Hyperthyroidism Hyperventilation
episodes
Panic attacks Pheochromocytoma Carcinoid
```
Glucose
CBC, electrolytes TSH
BUN/Cr
ECG
Holter monitor
```
69
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.
Hyperthyroidism
Cancer
HIV infection Dieting/diet drugs Anorexia nervosa Malabsorption
TSH, FT4
CBC, electrolytes HIV antibody Urine toxicology
70
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.
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
71
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.
Esophageal cancer
Achalasia
Esophagitis
Systemic sclerosis Esophageal stricture Amyotrophic lateral sclerosis
CBC
CXR
Endoscopy with biopsy Barium swallow CT—chest
72
45 yo F presents with dysphagia for two weeks together with fatigue and a craving for ice and clay.
Plummer-Vinson syndrome
Esophageal cancer Esophagitis Achalasia
Systemic sclerosis Mitral valve stenosis
CBC
Serum iron, ferritin, TIBC Barium swallow Endoscopy
73
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.
Achalasia
Plummer-Vinson syndrome Esophageal cancer Esophagitis
Systemic sclerosis
Mitral valve stenosis Esophageal stricture Zenker’s diverticulum
CXR
Endoscopy
Barium swallow Esophageal manometry
74
38 yo M presents with dysphagia and pain on swallowing solids more than liquids. Exam reveals oral thrush.
Esophagitis (CMV, HSV, pill- induced)
Systemic sclerosis GERD
Esophageal stricture Zenker’s diverticulum
CBC Endoscopy Barium swallow HIV antibody CD4 count
75
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.
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
```
76
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.
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
```
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.
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
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.
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
```
79
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.
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
80
43 yo obese F presents with RUQ abdominal pain, fever, and jaundice. She was diagnosed with asymptomatic gallstones one year ago.
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
```
81
25 yo M presents with RUQ pain, fever, anorexia, nausea, and vomiting. He has dark urine and clay-colored stool.
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
82
35 yo M presents with burning epigastric pain that starts 2–3 hours after meals. The pain is relieved by food and antacids.
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
```
83
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.
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)
```
84
18 yo M boxer presents with severe LUQ abdominal pain that radiates to the left scapula. He had infectious mononucleosis three weeks ago.
Splenic rupture
Kidney stone
Rib fracture Pneumonia
Perforated peptic ulcer Splenic infarct
Rectal exam CBC, electrolytes CXR CT—abdomen U/S—abdomen
85
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.
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
86
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.
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
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.
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
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.
Diverticulitis
Crohn’s disease Ulcerative colitis Gastroenteritis Abscess
Rectal exam CBC, electrolytes CXR
AXR CT—abdomen
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.
```
Acute appendicitis
Gastroenteritis Diverticulitis
Crohn’s disease Nephrolithiasis
Volvulus or other intestinal
obstruction/perforation
```
Rectal exam CBC, electrolytes AXR CT—abdomen U/S—abdomen
90
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.
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
```
91
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.
PID
Endometriosis Dysmenorrhea Vaginitis
Cystitis
Spontaneous abortion Pyelonephritis
Pelvic exam Rectal exam Urine hCG Cervical cultures CBC/ESR
UA, urine culture U/S—pelvis
92
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.
```
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
93
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.
Low-fiber diet
Irritable bowel syndrome Substance abuse (e.g., heroin) Depression
Hypothyroidism
Rectal exam TSH Electrolytes Urine toxicology
94
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.
```
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
```
95
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.
```
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
96
40 yo F presents with watery diarrhea and abdominal cramps. Last week she was on antibiotics for a UTI.
Pseudomembranous (Clostridium difficile) colitis
Gastroenteritis Cryptosporidiosis
Food poisoning Inflammatory bowel disease
Rectal exam
Stool leukocytes, culture, occult
blood
C. difficile toxin in stool Electrolytes
97
25 yo M presents with watery diarrhea and abdominal cramps. He was recently in Mexico.
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
```
98
30 yo F presents with watery diarrhea and abdominal cramping and bloating. Her symptoms are aggravated by milk ingestion and are relieved by fasting.
Lactose intolerance
Gastroenteritis Inflammatory bowel disease Irritable bowel syndrome Hyperthyroidism
Rectal exam
Stool exam Hydrogen breath test TSH
99
33 yo M presents with watery diarrhea, diffuse abdominal pain, and weight loss over the past three weeks. He has not responded to antibiotics.
```
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
```
100
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.
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)
```
101
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.
Gastritis
Bleeding peptic ulcer Gastric cancer Esophageal varices Mallory-Weiss tear
Rectal exam
CBC, electrolytes AST/ALT/bilirubin/alkaline
phosphatase Barium swallow Endoscopy
102
67 yo M presents with blood in his stool, weight loss, and constipation. He has a family history of colon cancer.
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
103
33 yo F presents with rectal bleeding and diarrhea for the past week. She has had lower abdominal pain and tenesmus for several months.
Ulcerative colitis
Crohn’s disease Proctitis
Anal fissure Hemorrhoids Diverticulosis Dysentery
Rectal exam
CBC, PT/PTT
AXR
Colonoscopy CT—abdomen/pelvis Barium enema
104
58 yo M presents with bright red blood per rectum and chronic constipation. He consumes a low-fiber diet.
Diverticulosis
Anal fissure Hemorrhoids Angiodysplasia Colorectal cancer
Rectal exam
CBC, PT/PTT Electrolytes Colonoscopy CT—abdomen/pelvis
105
65 yo M presents with painless hematuria. He is a heavy smoker and works as a painter.
```
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
106
35 yo M presents with painless hematuria. He has a family history of kidney problems.
```
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
107
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.
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
108
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.
Benign prostatic hyperplasia (BPH)
Prostate cancer UTI
Bladder stones
Rectal exam
UA
CBC, BUN/Cr, PSA U/S—prostate (transrectal)
109
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.
Prostate cancer
BPH
Renal cell carcinoma UTI
Bladder stones
Rectal exam
UA
CBC, BUN/Cr, PSA U/S—prostate (transrectal) CT—pelvis
IVP
110
18 yo M presents with a burning sensation during urination and urethral discharge. He recently had unprotected sex with a new partner.
Urethritis
Cystitis Prostatitis
```
Genital ± rectal exam
UA
Urine culture
Gram stain and culture of
urethral discharge Chlamydia and gonorrhea PCR
```
111
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.
Acute pyelonephritis
Nephrolithiasis
Renal cell carcinoma
Lower UTI (cystitis, urethritis)
UA
Urine culture and sensitivity CBC, BUN/Cr
U/S—renal
CT—abdomen
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.
Drug-related ED
ED caused by hypertension ED caused by diabetes mellitus Psychogenic ED
Peyronie’s disease
Genital exam Rectal exam Glucose CBC
113
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.
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
```
114
23 yo obese F presents with amenorrhea for six months, facial hair, and infertility for the past three years.
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
115
35 yo F presents with amenorrhea, galactorrhea, visual field defects, and headaches for the past six months.
Amenorrhea secondary to prolactinoma
Pregnancy
Thyroid disease Premature ovarian failure Pituitary tumor
Pelvic and breast exam Urine hCG
Prolactin
LH/FSH, TSH MRI—brain
116
48 yo F presents with amenorrhea for the past six months accompanied by hot flashes, night sweats, emotional lability, and dyspareunia.
Menopause
Pregnancy Pituitary tumor Thyroid disease
```
Pelvic exam
Urine hCG
LH/FSH, TSH, prolactin,
testosterone, DHEAS CBC
MRI—brain
```
117
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.
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
```
118
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.
Anorexia nervosa
CBC TSH
FT4 ACTH FSH LH
119
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.
Anxiety-induced amenorrhea
```
CBC TSH
FT4
ACTH
Urine cortisol level
Progesterone challenge test
FSH/LH/estradiol levels
```
120
17 yo F presents with prolonged, excessive menstrual bleeding occurring irregularly over the past six months.
```
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
```
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.
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
```
122
45 yo G5P5 F presents with postcoital bleeding. She is a cigarette smoker and takes OCPs.
Cervical cancer
Cervical polyp Cervicitis
Trauma (e.g., cervical
laceration)
Pelvic exam
Pap smear
Colposcopy and biopsy
123
28 yo F who is eight weeks pregnant presents with lower abdominal pain and vaginal bleeding.
Spontaneous abortion
Ectopic pregnancy Molar pregnancy
Pelvic exam
Urine hCG
U/S—pelvis
CBC, PT/PTT Quantitative serum hCG
124
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.
Ectopic pregnancy
Ruptured ovarian cyst Ovarian torsion
PID
Pelvic exam
Urine hCG
Cervical cultures U/S—pelvis Quantitative serum hCG
125
28 yo F presents with a thin, grayish- white, foul-smelling vaginal discharge.
Bacterial vaginosis
Vaginitis—candidal Vaginitis—trichomonal Cervicitis (chlamydia,
gonorrhea)
Pelvic exam
Wet mount
Cervical cultures
KOH prep (“whiff test”) pH of vaginal fluid
126
30 yo F presents with a thick, white, cottage cheese–like, odorless vaginal discharge and vaginal itching.
Vaginitis—candidal
Bacterial vaginosis Vaginitis—trichomonal
Pelvic exam
KOH prep (“whiff test”) Wet mount
Cervical cultures
pH of vaginal fluid
127
35 yo F presents with a malodorous, profuse, frothy, greenish vaginal discharge with intense vaginal itching and discomfort.
Vaginitis—trichomonal
Vaginitis—candidal Bacterial vaginosis Cervicitis (chlamydia,
gonorrhea)
Pelvic exam
Wet mount
Cervical cultures
pH of the vaginal fluid KOH prep (“whiff test”)
128
54 yo F c/o painful intercourse. Her last menstrual period was nine months ago. She has hot flashes.
Atrophic vaginitis
Endometriosis Cervicitis Depression Domestic abuse
Pelvic exam
Wet mount, KOH prep, cervical
cultures U/S—pelvis
129
37 yo F presents with dyspareunia, inability to conceive, and dysmenorrhea.
Endometriosis
Cervicitis Vaginismus Vulvodynia
PID
Depression Domestic violence
Pelvic exam
Wet mount, KOH prep, cervical
cultures U/S—pelvis Laparoscopy
130
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.
Domestic violence
Osteogenesis imperfecta Substance abuse Consensual violent sexual
behavior
XR—skeletal survey CT—maxillofacial Urine toxicology CBC
131
30 yo F presents with multiple facial and physical injuries. She was attacked and raped by two men.
Rape
```
Pelvic exam
Urine hCG
Wet mount, KOH prep, cervical
cultures XR—skeletal survey CBC
HIV antibody
Viral hepatitis serologies
```
132
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.
Domestic violence
Factitious disorder Substance abuse
XR—wrist CT—head Urine toxicology
133
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.
Carpal tunnel syndrome
Median nerve compression in forearm or arm
Radiculopathy of nerve roots C6 and C7 in cervical spine
Nerve conduction study EMG
134
28 yo F presents with pain in the interphalangeal joints of her hands together with hair loss and a butterfly rash on her face.
Systemic lupus erythematosus (SLE)
Rheumatoid arthritis Psoriatic arthritis Parvovirus B19 infection
ANA, anti-dsDNA, ESR, C3, C4, rheumatoid factor (RF), CBC
XR—hands UA
135
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.
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
136
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.
Psoriatic arthritis
Rheumatoid arthritis SLE
RF, ANA, ESR
CBC
XR—hands XR—pelvis/sacroiliac joints Uric acid
137
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.
Hip fracture
Hip dislocation Pelvic fracture
XR—hip/pelvis
CT or MRI—hip
CBC
Serum calcium and vitamin D Bone density scan (DEXA)
138
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.
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
```
139
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.
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
```
140
45 yo M presents with right knee pain with swelling and redness.
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
```
141
65 yo M presents with right foot pain. He has been training for a marathon.
Stress fracture
Plantar fasciitis Foot sprain or strain
XR—foot
Bone scan—foot MRI—foot
142
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.
Plantar fasciitis
Heel fracture Splinter/foreign body
XR—heel Bone scan
143
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.
```
Tennis elbow (lateral epicondylitis)
Stress fracture
```
XR—arm Bone scan MRI—elbow
144
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.
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
145
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.
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
146
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.
```
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
147
60 yo F c/o left arm pain that started while she was swimming and was relieved by rest.
Angina/MI
Tendonitis Osteoarthritis Shoulder dislocation
CPK-MB, troponin, ECG CBC
ESR
XR—shoulder
CXR Echocardiography Stress test
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.
Shoulder dislocation
Fracture of the humerus Rotator cuff injury
XR—shoulder XR—arm MRI—shoulder
149
55 yo M presents with crampy bilateral thigh and calf pain, fatigue, and dark urine. He is on simvastatin and clofibrate for hyperlipidemia.
Rhabdomyolysis due to simvastatin or clofibrate
Polymyositis
Inclusion body myositis Thyroid disease
```
CBC
CPK
Aldolase
UA
Urine myoglobin TSH
```
150
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
Disk herniation
Lumbar muscle strain Tumor in the vertebral canal
XR—L-spine MRI—L-spine
151
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.
Lumbar muscle strain
Disk herniation
Abdominal aortic aneurysm Vertebral compression fracture
XR—L-spine
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).
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
153
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.
Malingering
Lumbar muscle strain Disk herniation
Knee or leg fracture Ankylosing spondylitis
XR—L-spine/knee MRI—L-spine
154
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.
Neonatal sepsis
Meningitis Pneumonia UTI
Physical exam CBC, electrolytes UA
Urine culture Blood culture CXR
LP—CSF analysis
155
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.
Acute otitis media
URI Meningitis UTI
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Physical exam (including pneumatic otoscopy)
CBC UA
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156
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.
Measles (or other viral exanthem)
Rubella Roseola Fifth disease Varicella Scarlet fever Meningitis
Physical exam
CBC
Viral antibodies/titers Throat swab for culture LP
157
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.
Gastroenteritis (viral, bacterial, parasitic)
Food poisoning UTI
URI
Volvulus Intussusception
```
Physical exam
Stool exam and culture CBC
Electrolytes
UA, urine culture
AXR
```
158
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.
Attention-deficit hyperactivity disorder (ADHD)
Oppositional defiant disorder Manic episode
Conduct disorder
Physical exam Mental status exam
159
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.
Adjustment disorder
Substance intoxication/abuse/ dependence
Manic episode
Oppositional defiant disorder Conduct disorder
Physical exam Mental status exam Urine toxicology
160
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.
Substance abuse
Conduct disorder Oppositional defiant disorder Adjustment disorder
Urine toxicology Mental status exam
161
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.
Age-appropriate behavior
ADHD
Oppositional defiant disorder
Physical exam Mental status exam
