Mini-Cases Flashcards
Differentials & Diagnostics
21 yo F presents with several episodes of throbbing left temporal pain that last for 2 to 3 hours. Before 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. Her headaches are often associated with nausea and vomiting and she feels bothered by light. She has a family history of migraine.
Differentials:
- Hemiplegic Migraine (migraine with motor aura)
- Tension Headache
- Cluster Headache
- TIA
- Partial Seizure
- Pseudotumor Cerebri
- CNS Vasculitis
- Focal Seizure (occipito-parietal)
- Intracranial Neoplasm
Diagnostics:
- MRI-brain
- CT-head
- CBC
- ESR
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.
Differentials:
- Cluster Headache
- Migraine
- Trigeminal Neuralgia
- Intracranial Neoplasm
- Tension Headache
Diagnostics:
- MRI-brain
- CT-head
- CBC
- ESR
65 yo F presents with a new-onset severe, intermittent right temporal headache, fever, blurred vision in her right eye, weight loss, and pain in her jaw when chewing. She has a history of shoulder stiffuess. On examination she has right temporal tenderness to palpation and reduced right eye visual acuity.
Differentials:
- Temporal Arteritis (Giant Cell Arteritis)
- Vasculitis
- Migraine
- Cerebral Abscess
- Cluster Headache
- Tension Headache
- Meningitis
- Carotid Artery Dissection
- Pseudotumor Cerebri
- Trigeminal Neuralgia
- Intracranial Neoplasm
- Temporomandibular Joint (TMJ) Disorder
Diagnostics:
- Temporal Artery Biopsy
- ESR
- CRP
- CBC
- Doppler U/S-carotid
- MRI-brain
30 yo F presents with 1 week of frontal headache, fever, and nasal discharge, the headache worsens when she bends forward. There is pain on palpation of the frontal and maxillary sinuses. She has a history of allergies.
Differentials:
- Acute Sinusitis
- Migraine
- Tension Headache
- Cerebral Abscess
- Meningitis
- Intracranial Neoplasm
Diagnostics:
- CBC
- XR-sinus
- CT-sinus
50 yo F presents with recurrent episodes of bilateral squeezing headaches that occur 3 to 4 times a week, typically toward the end of her workday. She is experiencing significant stress in her life and recently decreased her intake of caffeine. Neurological examination is normal.
Differentials:
- Tension Headache
- Migraine
- Caffeine or Analgesic Withdrawal
- Depression
- Intracranial Neoplasm
- Cluster Headache
- Pseudotumor Cerebri
Diagnostics:
- CBC
- Electrolytes
- ESR
- MRI-brain
- LP-CSF analysis
- MRI-brain
35 yo M presents with sudden severe headache, vomiting, confusion, left hemiplegia, and nuchal rigidity.
Differentials:
- Subarachnoid Hemorrhage
- Meningitis/Encephalitis
- Intracranial Hemorrhage
- Vertebral Artery Dissection
- Intracranial Venous Thrombosis
- Migraine
- Hypertensive Encephalopathy
- Intracranial Neoplasm
Diagnostics:
- CT-head without contrast
- LP-opening pressure and CSF analysis
- CBC
- PT/PTT/INR
- Urine Toxicology
- Digital Subtraction Angiography (DSA)
- MRI-brain
- CT-angiography
25 yo M army recruit presents with high fever, severe headache, confusion, photophobia, and nuchal rigidity.
Differentials:
- Meningitis
- Subarachnoid Hemorrhage
- Encephalitis
- Sinusitis
- Migraine
- Intracranial or Epidural Abscess
Diagnostics:
- LP-CSF analysis (cell count, protein, glucose, Gram stain, PCR for specific pathogens, culture)
- Blood Culture
- CBC
- CT-head
- MRI-brain
- PT/PTT/INR
18 yo obese F presents with a daily pulsatile headache, vomiting, and blurred vision for the past 2 to 3 weeks. She is taking OCPs.
Differentials:
- Pseudotumor Cerebri
- Migraine
- Tension Headache
- Intracranial Venous Thrombosis
- Intracranial Neoplasm
- Cluster Headache
- Meningitis
Diagnostics:
- Urine hCG
- LP-opening pressure and CSF analysis
- Dilated Fundoscopy Examination
- Funduscopic Eye Exam
- MRI-brain
- Visual Field Testing
57 yo M c/o daily pain in the right cheek for the past month. The pain is electric and stabbing in character and occurs while he is shaving. Each episode lasts 1 to 2 minutes.
Differentials:
- Trigeminal Neuralgia
- Tension Headache
- Migraine
- Cluster Headache
- TMJ Disorder
- Temporal Arteritis
- Intracranial Neoplasm
Diagnostics:
- MRI-brain
- CBC
- ESR
81 yo M presents with progressive confusion for the past several years accompanied by forgetfulness and clumsiness. He has a history of hypertension, diabetes mellitus, and two strokes with residual left hemiparesis. His mental status has worsened after each stroke (stepwise decline in cognitive function).
Differentials:
- Vascular (“multi-infarct”) Dementia
- Alzheimer Disease
- Normal Pressure Hydrocephalus
- Chronic Subdural Hematoma
- Intracranial Neoplasm
- Depression
- B12 Deficiency
- Neurosyphilis
- Hypothyroidism
Diagnostics:
- CBC
- VDRL/RPR
- Serum B12
- TSH
- MRI-brain
- CT-head
- LP-CSF analysis
84 yo F brought by her son c/o forgetfulness (forgets phone numbers, loses her way back home) and difficulty performing some of her daily activities (bath· ing, dressing, managing money, using the phone). The problem has progressed gradually over the past few years.
Differentials:
- Alzheimer Disease
- Vascular Dementia
- Depression
- Hypothyroidism
- Chronic Subdural Hematoma
- Normal Pressure Hydrocephalus
- Intracranial Neoplasm
- B12 Deficiency
- Neurosyphilis
Diagnostics:
- CBC
- VDRL/RPR
- Serum B12
- TSH
- MRI-brain
- CT-head
- LP-CSF analysis
72 yo M presents with memory loss, gait disturbance, and urinary incontinence for the past 6 months.
Differentials:
- Normal Pressure Hydrocephalus
- Alzheimer Disease
- Vascular Dementia
- Chronic Subdural Hematoma
- Intracranial Neoplasm
- Depression
- B12 Deficiency
- Neurosyphilis
- Hypothyroidism
Diagnostics:
- CT-head
- MRI-brain
- 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 2 months. His symptoms are associated with myoclonus, ataxia, and a startle response.
Differentials:
- Creutzfeldt·Jakob Disease
- Vascular Dementia
- Lewy Body Dementia
- Wernicke Encephalopathy
- Normal Pressure Hydrocephalus
- Chronic Subdural Hematoma
- Intracranial Neoplasm
- Depression
- Delirium
- B12 Deficiency
- Neurosyphilis
Diagnostics:
- 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, palpitations, diaphoresis, and weakness.
Differentials:
- Hypoglycemia
- Transient Ischemic Attack
- Arrhythmia
- Delirium
- Angina
- Medication·Induced
Diagnostics:
- Glucose
- CBC
- Electrolytes
- TSH
- CPK·MB, Troponin
- Echocardiography
- ECG
- MRI-brain
- Doppler U/S-carotid
- Urine Toxicology
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 2 minutes.
Differentials:
- Subdural Hematoma
- SIADH (causing hyponatremia)
- Creutzfeldt-Jakob Disease
- Intracranial Neoplasm
- CNS Infection (eg. encephalitis)
Diagnostics:
- CT-head
- CBC
- Electrolytes
- TSH
- MRI-brain
- LP-CSF analysis
73 yo M presents with acute loss of vision in his left eye, palpitations, and shortness of breath. He has a history of atrial fibrillation and cataracts in his right eye. He has no eye pain, discharge, redness, or photophobia. He has not experienced headache, weakness, or numbness.
Differentials:
- Retinal Artery Occlusion
- Retinal Vein Occlusion
- Acute Angle-Closure Glaucoma
- Retinal Detachment
- Temporal Arteritis (Giant Cell Arteritis)
Diagnostics:
- Fluorescein Angiogram
- Echocardiography
- Doppler U/S-carotid
- Intraocular Tonometry
- ESR, CRP
- Temporal Artery Biopsy
- CBC
68 yo M presents with a 2-month history of crying spells, excessive sleep, poor hygiene, and a 15 lb (6.8 kg) weight loss, all following his wife’s death. He cannot enjoy time with his grandchildren and admits to thinking he has seen his dead wife in line at the supermarket or standing in the kitchen making dinner.
Differentials:
- Normal Bereavement
- Adjustment Disorder with Depressed Mood
- Major Depressive Disorder
- Schizoaffective Disorder
- Depressive Disorder (not otherwise specified)
Diagnostics:
- TSH
- CBC
- Urine Toxicology
- Beck Depression Inventory
- PHQ-9
- QIDS-SR16
42 yo F presents with a 4-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.
Differentials:
- Major Depressive Disorder
- Substance-Induced Mood Disorder
- Persistent Depressive Disorder (Dysthymia)
Diagnostics:
- Beck Depression Inventory
- PHQ-9
- QIDS-SR16
- Blood Alcohol Level
- TSH
- CBC
- Urine Toxicology
26 yo F presents with a 6.5 lb (2.9 kg) weight loss in the past 2 months, accompanied by early morning awakening, excessive guilt, and psychomotor retardation. She does not identify a trigger for the depressive episode but reports several weeks of increased energy, sexual promiscuity, irresponsible spending, and racing thoughts approximately 6 months before her presentation.
Differentials:
- Bipolar I Disorder
- Bipolar II Disorder
- Cyclothymic Disorder
- Major Depressive Disorder
- Schizoaffective Disorder
Diagnostics:
- Mood Disorder Questionnaire
- Urine Toxicology
- TSH
- CBC
19 yo M c/o receiving messages from his television set. He reports that he did not have many friends in high school. In college, he started to suspect his roommate of bugging the phone. He stopped going to classes because he felt that his professors were saying horrible things about him that no one else noticed. He rarely showered or left his room and has recently been hearing a voice from his television set telling him to “guard against the evil empire.”
Differentials:
- Schizophrenia
- Schizoid or Schizotypal Personality Disorder
- Schizophreniform Disorder
- Psychotic Disorder due to a General Medical Condition
- Substance-Induced Psychosis
- Depression with Psychotic Features
Diagnostics:
- Mental Status Exam
- Urine Toxicology
- TSH
- CBC
- Electrolytes
28 yo F c/o seeing bugs crawling on her bed for the past 2 days and hearing loud voices when she is alone in her room. She has never experienced anything similar in the past. She recently ingested an unknown substance.
Differentials:
- Substance-Induced Psychosis
- Brief Psychotic Disorder
- Schizophreniforn Disorder
- Schizophrenia
- Psychotic Disorder due to a General Medical Condition
Diagnostics:
- Urine Toxicology
- Mental Status Exam
- TSH
- CBC
- Electrolytes, BUN/Cr
- AST/ALT
48 yo F presents with a 1 -week history of auditory hallucinations that state, “I am worthless” and “I should kill myself.” She also reports a 2-week history of weight loss, early-morning awakening, decreased motivation, and overwhelming feelings of guilt.
Differentials:
- Schizoaffective Disorder
- Mood Disorder with Psychotic Features
- Schizophrenia
- Schizophreniform Disorder
- Psychotic Disorder due to a General Medical Condition
Diagnostics:
- Mental Status Exam
- Beck Depression Inventory
- Urine Toxicology
- TSH
- CBC
- Electrolytes
35 yo F presents with intermittent episodes of vertigo, tinnitus, nausea, and hearing loss within the past week. Examination is normal.
Differentials:
- Meniere Disease
- Benign Positional Vertigo
- Labyrinthitis
- Vestibular Neuronitis
- Acoustic Neuroma
Diagnostics:
- Dix-Hallpike Maneuver
- Audiometry
- Electronystagmography
- CBC
- VDRL/RPR (syphilis is a cause of Meniere disease)
- MRI-brain
55 yo F c/o dizziness for the past day upon standing. She feels faint and has severe diarrhea that started 2 days ago. She takes furosemide for hypertension. On examination, she feels dizzy upon standing.
Differentials:
- Orthostatic Hypotension due to Dehydration (diarrhea, diuretic use)
- Vertebrobasilar Insufficiency
- Cardiac Arrhythmias
- Vestibular Neuronitis
- Labyrinthitis
- Benign Positional Vertigo
Diagnostics:
- Orthostatic VS
- Rectal Examination
- CBC
- Urea, Electrolytes
- ECG
- Stool for Occult Blood
- Stool Leukocytes
65 yo M presents with postural dizziness and unsteadiness. He has hypertension and was started on furosemide 2 days ago.
Differentials:
- Drug-Induced Orthostatic Hypotension
- Furosemide Ototoxicity
- Vertebrobasilar Insufficiency
- Vestibular Neuronitis
- Labyrinthitis
- Benign Positional Vertigo
- Brain Stem or Cerebellar Tumor
Diagnostics:
- Orthostatic VS
- CBC
- Urea, Electrolytes
- ECG
- Echocardiography
- MRI-brain
44 yo F c/o episodes of dizziness on moving her head to the left. She feels that the room is spinning around her head. Dix-Hallpike maneuver reproduces the symptoms and elicits nystagmus.
Differentials:
- Benign Positional Vertigo
- Meniere Disease
- Vestibular Neuronitis
- Labyrinthitis
- Acoustic Neuroma
Diagnostics:
- Audiometry
- Electronystagmograph
- MRI-brain
55 yo F c/o dizziness that started this morning. She is nauseated and has vomited once in the past day. She had a URI 2 days ago and has experienced no hearing loss or tinnitus.
Differentials:
- Vestibular Neuronitis
- Labyrinthitis
- Benign Positional Vertigo
- Meniere Disease
- Vertebrobasilar Stroke/TIA
Diagnostics:
- Audiogram
- Electronystagmography
- CT-head
- 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 2 days ago.
Differentials:
- Labyrinthitis
- Vestibular Neuronitis
- Meniere Disease
- Acoustic Neuroma
- Vertebrobasilar Stroke/TIA
Diagnostics:
- Audiogram
- Electronystagmography
- CT-head
- 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 after regaining consciousness (as witnessed by his colleagues).
Differentials:
- Generalized Tonic-Clonic Seizure
- Convulsive Syncope
- Substance Abuse/Overdose
- Malingering
- Hypoglycemia
Diagnostics:
- 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 loss of consciousness. His past medical history is significant for hypertension and diabetes mellitus.
Differentials:
- Drug-Induced Orthostatic Hypotension (causing syncope)
- Hypoglycemia
- Cardiac Arrhythmia
- Syncope (vasovagal, other causes)
- Stroke
- MI
- Pulmonary Embolism
Diagnostics:
- Orthostatic VS
- CBC
- Electrolytes, Glucose
- Echocardiography
- CT-head
- ECG
- V/Q Scan
- CTA-chest with IV contrast
- D-dimer
65 yo M presents after falling and losing consciousness for a few seconds. He had no warning before passing out, but recently had palpitations. His history includes a coronary artery bypass graft.
Differentials:
- Cardiac Arrhythmia (causing syncope)
- Severe Aortic Stenosis
- Syncope (other causes)
- Seizure
- Pulmonary Embolism
Diagnostics:
- ECG
- Holter Monitoring
- CBC
- Electrolytes, Glucose
- Echocardiography
- CT-head
53 yo M presents following a 20·minute episode of right-sided arm and face numbness. His symptoms had totally resolved by the time he got to the emergency department. He has a history of hypertension, migraine, diabetes mellitus, and heavy smoking. Physical examination is within normal limits.
Differentials:
- Transient Ischemic Attack (TIA)
- Stroke Migraine with Sensory Aura
- Hypoglycemia
- Seizure with Todd Paresis
Diagnostics:
- CT-head
- CBC
- Electrolytes, Glucose
- Fasting Lipid Panel
- ECG
- MRI-brain, with DWI
- Doppler U/S-carotid
- Echocardiography
- EEG
68 yo M presents with slurred speech, right facial drooping and numbness, and right hand weakness. Babinski sign is present on the right, he has weakness of the right side of his body. and his deep tendon reflexes are brisk. He has a history of hypertension, diabetes mellitus, and heavy smoking.
Differentials:
- Stroke
- TIA
- Seizure with Todd Paresis
- Intracranial Neoplasm
- Subdural or Epidural Hematoma
- Hypoglycemia
Diagnostics:
- CT-head
- CBC
- Electrolytes, Glucose
- PT/PTT/INR
- Fasting Lipid Panel
- MRI-brain, with DWI
- MRA
- Doppler U/S-carotid
- Echocardiography
- ECG
33 yo F presents with ascending loss of strength and numbness in her lower legs over the past 2 weeks. She had a recent URI. Examination shows weakness of her lower limbs with reduced reflexes.
Differrentials:
- Guillain-Barre Syndrome
- Multiple Sclerosis
- Transverse Myelitis
- Spinal Cord Compression
- Peripheral Neuropathy
Diagnostics:
- CBC
- Electrolytes
- MRI-spine
- CPK
- Electromyography
- Nerve Conduction Studies
- LP-CSF analysis
- PFTs
- Serum B12
30 yo F presents with weakness, loss of sensation, and tingling in her left leg that started this morning. She also experienced right eye pain with reduced vision that resolved transiently 3 months ago. She reports feding “electric shocks” down her spine upon flexing her head. Examination reveals left lower limb weakness and ataxia.
Differentials:
- Multiple Sclerosis
- Stroke
- CNS Vasculitis
- Conversion Disorder
- Malingering
- CNS Tumor
- Vitamin B12 Deficiency
- Neurosyphilis
Diagnostics:
- CBC
- ESR
- ANA, ANCA
- VDRL/RPR
- Serum B12
- MRI-brain, spine
- LP-CSF analysis
- Visual Evoked Potentials
55 yo M presents with tingling and numbness in his hands and feet (glove-and-stocking distribution) for the past 2 months. He has a history of diabetes mellitus, hypertension, and alcoholism. There is decreased soft touch, vibratory, and position sense in the feet, reflexes are absent.
Differentials:
- Diabetic Peripheral Neuropathy
- Alcoholic Peripheral Neuropathy
- B12 deficiency
- Uremic Nephropathy
- Hypocalcemia
- Hyperventilation
- Paraproteinemia/Myeloma
Diagnostics:
- HbA1C, Glucose
- ESR
- Calcium
- Serum B12
- UA
- TFTs
- Urea, Electrolytes
- Serum and Urine Protein Electrophoresis
- Electromyography
- Nerve Conduction Studies
40 yo F presents with occasional double vision and droopy eyelids at night with normalization by morning. Her past medical history is significant for hypothyroidism.
Differentials:
- Myasthenia Gravis
- Multiple Sclerosis
- Intracranial Neoplasm compressing CN III, IV, or VI
- Horner Syndrome
- Botulism
Diagnostics:
- Ice Pack Test
- Tensilon (Edrophonium) Test
- Anti-ACh Receptor Antibodies
- Electromyography
- Nerve Conduction Studies
- CXR
- CT-chest
- MRI-brain
25 yo M presents with hemiparesis after a tonic-clonic seizure that resolved within a few hours.
Differentials:
- Todd Paralysis
- TIA
- Stroke
- Intracranial Neoplasm
- Hemiplegic Migraine
- Head Injury
- Hypoglycemia
- Malingering
Diagnostics:
- CBC
- Glucose, Electrolytes
- Toxin Levels
- EEG
- CT-brain
- MRI-brain
- Doppler U/S-carotid
56 yo obese F c/o tingling and numbness of her thumb, index finger, and middle finger for the past 5 months. Her symptoms are constant, have progressively worsened, and are relieved with rest. She works as a secretary. She has a history of fatigue and a 20 lb (9 kg) weight gain over the same period.
Differentials:
- Carpal Tunnel Syndrome secondary to overuse
- Overuse Injury of Median Nerve
- Cervical Disc Disease
- Medial Epicondylitis
Diagnostics:
- TSH
- CBC
- Electromyography
- Nerve Conduction Study
40 yo F c/o feeling tired, hopeless, and worthless and of having suicidal thoughts. She lost her job and has been having fights with her husband about money.
Differentials:
- Depression
- Adjustment Disorder
- Hypothyroidism
- Anemia
Daignostics:
- PHQ-9
- Beck Depression Inventory
- TSH
- CBC
44 yo M presents with fatigue, insomnia, and nightmares about a murder that he witnessed in a mall 1 year ago. Since then, he has avoided the mall and has not gone out at night.
Differentials:
- Posttraumatic Stress Disorder
- Depression
- Generalized Anxiety Disorder
- Psychotic or Delusional Disorder
- Hypothyroidism
Diagnostics:
- PHQ-9
- Beck Depression Inventory
- CBC
- TSH
- Urine Toxicology
55 yo M presents with fatigue, weight loss, and constipation. He has a family history of colon cancer.
Differentials:
- Colon Cancer
- Hypothyroidism
- Renal Failure
- Hypercalcemia
- Depression
Diagnostics:
- Rectal Exam with Stool Guaiac Test
- CBC
- CMP
- TSH
- Colonoscopy
- Barium Enema
- CT-abdomen/pelvis
40 yo F presents with fatigue, weight gain, sleepiness, cold intolerance, constipation, and dry skin.
Differentials:
- Hypothyroidism
- Depression
- Diabetes
- Anemia
Diagnostics:
- TSH, FT3, FT4
- CBC
- Fasting Glucose
- HbA1C
50 yo obese F presents with fatigue and daytime sleepiness. She snores heavily and naps 3 to 4 times per day but never feels refreshed. She also has hypertension.
Differentials:
- Obstructive Sleep Apnea
- Hypothyroidism
- Chronic Fatigue Syndrome
- Narcolepsy
Diagnostics:
- CBC
- TSH
- Nocturnal Pulse Oximetry
- Polysomnography
- ECG
20 yo M presents with fatigue, thirst, increased appetite, and polyuria.
Differentials:
- Diabetes Mellitus
- Atypical Depression
- Primary Polydipsia
- Diabetes Insipidus
Diagnostics:
- HbA1C
- Glucose Tolerance Test
- UA
- CBC
- Electrolytes, BUN/Cr, Fasting Glucose
35 yo M policeman c/o feeling tired and sleepy during the day. He changed to the night shift last week.
Differentials:
- Shift Work Sleep Disorder
- Sleep Apnea
- Depression
- Anemia
Diagnostics:
- CBC
- Nocturnal Pulse Oximetry
- Polysomnography
30 yo M presents with night sweats, cough, and swollen glands of 1 month’s duration. He recently emigrated from the African subcontinent.
Differentials:
- Tuberculosis
- Acute HIV Infection
- Lymphoma
- Leukemia
- Hyperthyroidism
Diagnostics:
- PPD/QuantiFERON-TB Gold
- CBC
- CXR
- Sputum Gram Stain, Acid-Fast Stain, and Culture
- HIV Antibody/RNA Levels
- TSH, FT4
- CT-chest
45 yo F presents with excessive sweating. unintentional weight loss, palpitations, diarrhea, and shortness of breath.
Differentials:
- Hyperthyroidism
- Pheochromocytoma
- Carcinoid Syndrome
- Tuberculosis
Diagnostics:
- TSH, FT4
- 24-hour Urinary Catecholamine
- 5-HIAA
- CBC
- PPD
25 yo F presents with a 3-week history of difficulty falling asleep. She sleeps 7 hours per night without nightmares or snoring. She recently began college and is having trouble with her boyfriend. She drinks three to four cups of coffee a day.
Differentials:
- Stress·Induced Insomnia
- Caffeine-Induced Insomnia
- Insomnia with Circadian Rhythm Sleep Disorder
- Insomnia related to Major Depressive Disorder
Diagnostics:
- Polysomnography
- Urine Toxicology
- CBC
- TSH
55 yo obese M presents with several months of poor sleep, daytime fatigue, and morning headaches. His wife reports that he snores loudly.
Differentials:
- Obstructive Sleep Apnea
- Daytime Fatigue in Primary Hypersomnia
- Insomnia with Circadian Rhythm Sleep Disorder
- Insomnia related to Major Depressive Disorder
Diagnostics:
- Polysomnography
- ECG
- CBC
- TSH
33 yo F presents with 3 weeks of fatigue and trouble sleeping. She states that she falls asleep easily but wakes up at 3 AM and cannot return to sleep. She also reports an unintentional weight loss of 8 lbs (3.6 kg) and an inability to enjoy the things she once liked to do.
Differentials:
- Insomnia related to Major Depressive Disorder
- Primary Hypersomnia
- Insomnia with Circadian Rhythm Sleep Disorder
Diagnostics:
- 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 recendy experienced similar symptoms.
Differentials:
- Infectious Mononucleosis
- Hepatitis
- Viral or Bacterial Pharyngitis
- Acute HIV Infection
- Secondary Syphilis
Diagnostics:
- CBC with differentials and 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.
Differentials:
- HIV, Acute Retroviral Syndrome
- Infectious Mononucleosis
- Hepatitis
- Viral Pharyngitis
- Streptococcal Tonsillitis/Scarlet Fever
- Secondary Syphilis
Diagnostics:
- CBC with differentials and peripheral smear
- Throat Culture
- HIV Antibody and Viral Load
- CD4 count
- Monospot Test
- LFTs
- VDRL/RPR
46 yo F presents with fever and sore throat.
Differentials:
- Pharyngitis (Bacterial or Viral)
- Mycoplasma Pneumonia
- Acute HIV Infection
- Infectious Mononucleosis
Diagnostics:
- Centor Criteria
- Throat Swab for Culture and Rapid Streptococcal Antigen
- Monospot Test
- CBC
- Serologic Test (Cold Agglutinin Titer) for Mycoplasma
- HIV Antibody and Viral Load
30 yo M presents with shortness of breath, cough, and wheezing that worsen in cold air. He has had multiple, similar episodes in the past 4 months.
Differentials:
- Asthma
- GERD
- Bronchitis
- Pneumonitis
Diagnostics:
- CBC
- CXR
- Peak Flow Measurement
- PFTs
56 yo F presents with shortness of breath and a productive cough that has lasted for at least 3 months each year over the past 2 years. She is a heavy smoker.
Differentials:
- COPD-Chronic Bronchitis
- COPD-Emphysema
- Bronchiectasis
- Lung cancer
- Tuberculosis
Diagnostics:
- CBC
- Sputum Gram Stain and Culture
- CXR
- PFTs
- CT-chest
- QuantiFERON-TB Gold
58 yo M presents with 1 week of pleuritic chest pain, fever, chills, and cough with purulent yellow sputum. He is a heavy smoker with preexisting COPD.
Differentials:
- Pneumonia
- COPD Exacerbation (Bronchitis)
- Lung Abscess
- Lung Cancer
- Tuberculosis
- Pericarditis
Diagnostics:
- CBC
- Sputum Gram Stain and Culture
- CXR
- CT-chest
- ECG
- QuantiFERON-TB Gold
25 yo F presents with 2 weeks of nonproductive cough. Three weeks ago, she had a sore throat and a runny nose.
Differentials:
- Atypical Pneumonia
- Asthma
- URI-Associated Cough (“postinfectious”)
- Postnasal Drip
- GERD
Diagnostics:
- CBC
- Induced Sputum Gram Stain and Culture
- CXR
- IgM-Mycoplasma pneumoniae
- Urine Legionella Antigen
65 yo M presents with 6 months of worsening cough accompanied by hemoptysis, dyspnea, weakness, and weight loss. He is a heavy smoker.
Differentials:
- Lung Cancer
- Tuberculosis
- Lung Abscess
- COPD
- Vasculitis (eg. granulomatosis with polyangiitis)
- Interstitial Lung Disease
- CHF
Diagnostics:
- CBC
- Sputum Gram Stain, Culture, and Cytology
- CXR
- CT-chest
- QuantiFERON-TB Gold
- ANCA
- Bronchoscopy
- Echocardiography
55 yo M presents with increased dyspnea and sputum production for the past 3 days. He has COPD and stopped using his inhalers last week. He stopped smoking 2 days ago.
Differentials:
- COPD Exacerbation (Bronchitis)
- Lung Cancer
- Pneumonia
- URI
- CHF
Diagnostics:
- CBC
- CXR
- ABG
- PFTs
- Sputum Gram Stain and Culture
- CT-chest
- Echocardiography
34 yo F nurse presents with worsening cough of 6 weeks’ duration accompanied by weight loss, fatigue, night sweats, and fever. She has a history of contact with tuberculosis patients at work.
Differentials:
- Tuberculosis
- Pneumonia
- Lung Abscess
- Vasculitis
- Lymphoma
- Metastatic Cancer
- HIV/AIDS
- Sarcoidosis
Diagnostics:
- CBC
- PPD/QuantiFERON-TB Gold
- Sputum Gram Stain, Acid-Fast Stain, and Culture
- CXR
- CT-chest
- Bronchoscopy
- HIV Antibody
- Lymph Node Biopsy
35 yo M presents with shortness of breath and cough. He has had unprotected sex with multiple sexual partners and was recently exposed to a patient with active tuberculosis.
Differentials:
- Tuberculosis
- Pneumonia (including Pneumocystis jirovecii)
- Bronchitis
- Asthma
- Acute HIV Infection
- CHF (cardiomyopathy)
Diagnostics:
- CBC
- PPD/QuantiFERON-TB Gold
- Sputum Gram Stain, Acid-Fast Stain, Silver Stain, and Culture
- CXR
- HIV Antibody
- Echocardiography
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.
Differentials:
- CHF
- Cardiac Valvular Disease
- GERD
- Pulmonary Fibrosis
- COPD
- Postnasal Drip
Diagnostics:
- CBC
- CXR
- ECG
- Echocardiography
- PFTs
- BNP
- CT-chest
60 yo M presents with worsening dyspnea of 6 hours’ duration and a cough that is accompanied by pink, frothy sputum.
Differentials:
- Pulmonary Edema
- Pneumonia
- CHF
- Mitral Valve Stenosis
- Arrhythmia
- Asthma
Diagnostics:
- CXR
- ECG
- CBC
- ABG
- 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.
Differentials:
- Myocardial Infarction (MI)
- GERD
- Angina
- Costochondritis
- Aortic Dissection
- Pericarditis
- Pulmonary Embolism
- Pneumothorax
Diagnostics:
- ECG
- CPK-MB, Troponin x 3
- CXR
- CBC
- Electrolytes
- Helical CT
- Echocardiography
- Cardiac Catheterization
- D-dimer
20 yo African American F presents with acute onset of severe chest pain for a few hours. She has a history of sickle cell disease and multiple hospitalizations for pain and anemia management.
Differentials:
- Sickle Cell Disease-Acute Chest Syndrome
- Pulmonary Embolism
- Pneumonia
- MI
- Pneumothorax
- Aortic Dissection
Diagnostics:
- CBC with reticulocyte count and peripheral smear
- LDH
- ABG
- D-dimer
- CXR
- CPK-MB, Troponin
- ECG
- CTA-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.
Differentials:
- GERD
- Esophagitis
- Peptic Ulcer Disease
- Esophageal Spasm
- MI
- Angina
Diagnostics:
- ECG
- Barium Swallow
- Upper Endoscopy
- Esophageal pH Monitoring
- H. pylori Stool Antigen
55 yo M presents with retrosternal squeezing pain that lasts for 2 minutes and occurs with exercise. It is relieved by rest and is not related to food intake.
Differentials:
- Stable Angina
- Esophageal Spasm
- Esophagitis
Diagnostics:
- ECG
- CPK-MB, Troponin
- CXR
- CBC
- Electrolytes
- Exercise Stress Test
- Upper Endoscopy/pH Monitor
- Cardiac Catheterization
34 yo F presents with retrosternal stabbing chest pain that improves when she leans forward and worsens with deep inspiration. She had a URI 1 week ago.
Differentials:
- Pericarditis
- Aortic Dissection
- MI
- Costochondritis
- GERD
- Esophageal Rupture
Diagnostics:
- ECG
- CPK-MB, Troponin
- CXR
- Echocardiography
- CBC
- Upper Endoscopy
- ESR
33 yo F presents with stabbing chest pain that worsens with deep inspiration and is relieved by aspirin. She had a URI 1 week ago. Chest wall tenderness is noted.
Differentials:
- Costochondritis
- Pneumonia
- MI
- Pulmonary Embolism
- Pericarditis
- Pleurisy
- Muscle Strain
Diagnostics:
- ECG
- CXR
- CPK-MB, Troponin
- CBC
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.
Differentials:
- Pulmonary Embolism
- Pneumonia
- Costochondritis
- MI
- CHF
- Aortic Dissection
Diagnostics:
- D-dimer
- CTA-chest with IV contras
- CXR
- ECG
- ABG
- CPK-MB, Troponin
- CBC
- Electrolytes, BUN/Cr, Glucose
- Doppler U/S-legs
55 yo M presents with sudden onset of severe chest pain that radiates to his back. He has a history of uncontrolled hypertension.
Differentials:
- Aortic Dissection
- MI
- Pericarditis
- Esophageal Rupture
- Esophageal Spasm
- GERD
- Pancreatitis
- Fat Embolism
Diagnostics:
- TTE
- ECG
- CPK-MB, Troponin
- CXR
- CBC
- Amylase, Lipase
- CTA-chest with IV contrast
- MRI/MRA-aorta
- Aortic Angiography
- Upper Endoscopy