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
70 yo diabetic M presents with episodes of palpitations and diaphoresis. He is on insulin.
Differentials:
- Hypoglycemia
- Cardiac Arrhythmia
- Angina
- Hyperthyroidism
- Hyperventilation Episodes
- Panic Attack
- Pheochromocytoma
- Carcinoid Syndrome
Diagnostics:
- Glucose
- CBC
- Electrolytes
- TSH
- ECG
- 24-hour Urinary Catecholamines
- 5-HIAA
35 yo M presents with several episodes of palpitations, sweating, and rapid breathing. Episodes occur unexpectedly, and he does not recall any triggers. He has had four to five episodes per month for several months. Each episode lasts 2 to 3 minutes. He does not have any history of psychiatric illness except for separation anxiety as a child.
Differentials:
- Panic Attack
- Generalized Anxiety Disorder
- Specific Phobia
- Acute Stress Disorder
- Hyperthyroidism
- Substance Abuse/Dependence
- Pheochromocytoma
Diagnostics:
- CBC
- Electrolytes
- TSH, FT4
- ECG
- Echocardiography
- Urine Toxicology
- 24-hour Urinary Catecholamines
19 yo F presents with episodic palpitations, especially during presentations in front of her class. Episodes include heart pounding, facial blushing, and hand tremor. She also experiences excessive swearing and rapid breathing. She complains of intense worry and trouble sleeping for days or weeks before an upcoming social situation. Now she avoids all social events because she is afraid of humiliating herself.
Differentials:
- Social Phobia
- Avoidant Personality Disorder
- Agoraphobia/Specific Phobia
- Panic Attack
- Generalized Anxiety Disorder
- Substance Abuse/Dependence
- Hyperthyroidism
Diagnostics:
- CBC
- Electrolytes
- ECG
- TSH, FT4
34 yo F presents with episodic palpitations accompanied by lightheadedness and sharp, atypical chest pain.
Differentials:
- Mitral Valve Prolapse
- Cardiac Arrhythmia
- Panic Attack
- Pheochromocytoma
Diagnostics:
- ECG
- TEE
- Event Monitor
- Holter Monitor
- 24-hour Urinary Catecholamine
42 yo F presents with a 15.5 lb (7 kg) weight loss within the past 2 months. She has a fine tremor, and her pulse is 112.
Differentials:
- Hyperthyroidism
- Cancer
- HIV Infection
- Dieting/Diet Drugs
- Anorexia Nervosa
- Malabsorption
Diagnostics:
- TSH, FT4
- CBC
- BMP
- HIV Antibody
- Urine Toxicology
- Age-Appropriate Cancer Screenings
44 yo F presents with a weight gain of >25 lbs (11.3 kg) within the past 2 months. She quit smoking 3 months ago and is on amitriptyline for depression. She also reports cold intolerance and constipation.
Differentials:
- Smoking Cessation
- Drug Side Effect (Amitriptyline)
- Hypothyroidism
- Cushing Syndrome
- Polycystic Ovary Syndrome
- Diabetes Mellitu
- Atypical Depression
Diagnostics:
- CBC
- BMP, Glucose
- TSH
- 24-hour Urine Free Cortisol
- Dexamethasone Suppression Test
30 yo F presents with weight gain over the past 3 months. She also reports tremor, palpitations, anxiety, and hunger that are relieved by eating. She exhibits proximal muscle weakness and easy bruising.
Differentials:
- Insulinoma
- Reactive Postprandial Hypoglycemia
- Cushing Syndrome
- Pregnancy
Diagnostics:
- Blood Glucose
- Plasma Insulin after Induced Hypoglycemia
- Glucose Tolerance Test
- 24-hour Urine Free Cortisol
- Urine β-hCG
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 15 lbs (6.8 kg) within the past 4 months.
Differentials:
- Esophageal Cancer
- Achalasia
- Esophagitis
- Systemic Sclerosis
- Esophageal Stricture
Diagnostics:
- CBC
- CXR
- Upper Endoscopy with Biopsy
- Barium Swallow
- CT-chest
45 yo F presents with dysphagia for 2 weeks accompanied by mouth and throat pain, fatigue, and a craving for ice and day.
Differenials:
- Plummer·Vinson Syndrome
- Esophageal Cancer
- Diffuse Esophageal Spasm
- Esophagitis
- Achalasia
- Systemic Sclerosis
Diagnostics:
- CBC
- Serum Iron, Ferritin, TIBC
- Barium Swallow
- Upper Endoscopy
- Esophageal Manometry
48 yo F presents with dysphagia for both solids and liquids that has slowly progressed in severity within the past year. It is associated with difficulty burping and regurgitation of undigested food, especially at night. She has lost 5.5 lbs (2.5 kg) in the past 2 months.
Differentials:
- Achalasia
- Plummer-Vinson Syndrome
- Esophageal Cancer
- Esophagitis
- Systemic Sclerosis
- Esophageal Stricture
- Zenker Diverticulum
Diagnostics:
- CXR
- Upper Endoscopy
- Barium Swallow
- Esophageal Manometry
38 yo M presents with dysphagia and pain on swallowing solids more than liquids. Exam reveals oral thrush.
Differentials:
- Esophagitis (CMV, HSV, HIV, pill-induced)
- Systemic Sclerosis
- GERD
- Esophageal Stricture
Diagnostics:
- CBC
- Upper Endoscopy
- Barium Swallow
- HIV Antibody and Viral Load
- CD4 count
39 yo F presents with a single 2 cm mass on the right side of her neck along with night sweats, fever, weight loss, loss of appetite, and early satiety. The mass is painless and movable and has not changed in size. She does not report heat intolerance, tremor, palpi, tarions, hoarseness, cough, difliculty breathing, dif, ficulty swallowing, or abdominal pain. Her husband was recently discharged from prison, and her mother has a history of gastric cancer.
Differentials:
- Hodgkin/Non-Hodgkin Lymphoma
- Tuberculosis
- HIV
- Thyroid Nodule
- Metastatic GI or Head and Neck Malignancy
Diagnostics:
- CBC with differentials
- BMP
- ESR, CRP
- Lymph Node Biopsy
- PPD/QuanriFERQN-TB Gold
- CXR
- TSH
- HIV Antibody/RNA
- U/S-neck
- Upper Endoscopy
- Fine Needle Aspiration
20 yo F presents with nausea, vomiting (especially in the morning), fatigue, and polyuria. Her last menstrual period was 6 weeks ago. She is sexually active with her boyfriend, and they use condoms for contraception.
Differentials:
- Pregnancy
- Hypercalcemia
- Diabetes Mellitus
- Gastritis/GERD
- UTI
- Depression/Eating Disorder
- Substance Use (eg. alcohol)
Diagnostics:
- Urine hCG
- Pelvic Exam
- U/S-transvaginal
- CBC
- Electrolytes, Calcium, Glucose, Liver Function Tests
- UA, Urine Culture
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.
Differentials:
- Nephrolithiasis
- Renal Cell Carcinoma
- Pyelonephritis
- GI Etiology (eg. appendicitis)
Diagnostics:
- UA, Urine Culture and Sensitivity, Urine Cytology
- BUN/Cr
- CT-abdomen
- U/S-renal
- KUB
- IVP
- Blood Culture
60 yo M presents with dull epigastric pain that radiates to the back, accompanied by weight loss, dark urine, and clay-colored stool. He is a heavy drinker and smoker. He appears jaundiced on exam.
Differentials:
- Pancreatic Cancer
- Cholangiocarcinoma
- Primary Sclerosing Cholangitis
- Chronic Pancreatitis
- Cholecystitis/Choledocholithiasis
- Acute Viral Hepatitis
- Acute Alcoholic Hepatitis
- Abdominal Aortic Aneurysm
- Peptic Ulcer Disease
Diagnostics:
- CT-abdomen
- CBC
- Electrolytes
- Amylase, Lipase
- AST/ALT/Bilirubin/Alkaline Phosphatase
- U/S-abdomen
56 yo M presents with severe mid-epigastric 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 3 days binge drinking.
Differentials:
- Acute Pancreatitis
- Peptic Ulcer Disease
- Cholecystitis/Choledocholithiasis
- Gastritis
- Abdominal Aortic Aneurysm
- Mesenteric Ischemia
- Alcoholic Hepatitis
- Boerhaave Syndrome
Diagnostics:
- CBC
- Electrolytes, BUN/Cr
- Amylase, Lipase
- AST/ALT/Bilirubin/Alkaline Phosphatase
- U/S-abdomen
- CT-abdomen
- Upper Endoscopy
- ECG
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 ate fatty food. She has had similar but less intense episodes that lasted a few hours. Exam reveals a positive Murphy sign.
Differentials:
- Acute Cholecystitis
- Choledocholithiasis
- Hepatitis
- Ascending Cholangitis
- Peptic Ulcer Disease
- Firz-Hugh-Curtis Syndrome
- Acute Subhepatic Appendicitis
Diagnostics:
- CBC
- AST/ALT/Bilirubin/Alkaline Phosphatase
- U/S-abdomen
- CT-abdomen Blood Culture
43 yo obese F presents with RUQ abdominal pain, fever, and jaundice. She was diagnosed with asymptomatic gallstones 1 year ago. She is found to be hypotensive on exam.
Differentials:
- Ascending Cholangitis
- Acute Gallstone Cholangitis
- Acute Cholecystitis
- Hepatitis
- Primary Sclerosing Cholangitis
- Firz-Hugh-Curtis Syndrome
Diagnostics:
- CBC
- AST/ALT/Bilirubin/Alkaline Phosphatase
- Blood Culture
- Viral Hepatitis Serologies
- U/S-abdomen
- MRCP
- ERCP
25 yo M presents with RUQ pain, fever, anorexia, nausea, and vomiting. He has dark urine and clay-colored stool.
Differentials:
- Acute Hepatitis
- Acute Cholecystitis
- Ascending Cholangitis
- Choledocholithiasis
- Pancreatitis
- Primary Sclerosing Cholangitis
- Primary Biliary Cirrhosis
- Acute Glomerulonephritis
Diagnostics:
- CBC
- Amylase, Lipase
- AST/ALT/Bilirubin/Alkaline Phosphatase
- Viral Hepatitis Serologies
- UA
- U/S-abdomen
- ERCP
- MRCP
35 yo M presents with burning epigastric pain that starts 2 to 3 hours after meals. The pain is relieved by food and antacids.
Differentials:
- Peptic Ulcer Disease
- Gastritis
- GERD
- Cholecystitis
- Chronic Pancreatitis
- Mesenteric Ischemia
Diagnostics:
- Rectal Exam, Stool for Occult Blood
- Amylase, Lipase, Lactate
- AST/ALT/Bilirubin/Alkaline Phosphatase
- Upper Endoscopy (including H. pylori testing)
- Upper GI Series
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 daily basis.
Differentials:
- Perforated Peptic Ulcer
- Acute Pancreatitis
- Hepatitis
- Cholecystitis
- Gallstone Cholangitis
- Mesenteric Ischemia
Diagnostics:
- Rectal Exam
- CBC
- Electrolytes
- Amylase, Lipase, Lactate
- AST/ALT/Bilirubin/Alkaline Phosphatase
- CXR
- KU
- CT-abdomen
- Upper Endoscopy (including H. pylori testing)
- Blood Culture
18 yo M boxer presents with severe LUQ abdominal pain that radiates to the left scapula. He had infectious mononucleosis 3 weeks ago.
Differentials:
- Splenic Rupture
- Kidney Stone
- Rib Fracture
- Pneumonia
- Perforated Peptic Ulcer
- Splenic Infarct
Diagnostics:
- CBC
- Electrolytes
- CXR
- CT-abdomen
- U/S-abdomen (if hemodynamically unstable)
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.
Differentials:
- Intestinal Obstruction
- Small Bowel or Colon Cancer
- Volvulus
- Gastroenteritis
- Food Poisoning
- Ileus
- Hernia
Diagnostics:
- Rectal Exam
- CBC
- Electrolytes
- AXR
- CT-abdomen/pelvis with contrast
- Colonoscopy
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.
Differentials:
- Mesenteric Ischemia/Infarction
- Diverticulitis
- Peptic Ulcer Disease
- Gastroenteritis
- Acute Pancreatitis
- Cholecystitis
Diagnostics:
- Rectal Exam
- CBC
- Amylase, Lipase, Lactate
- ECG
- AXR
- CT-abdomen
- Mesenteric Angiography
- Barium Enema
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. She has been told that she had a cyst on her right ovary.
Differentials:
- Ovarian Torsion
- Appendicitis
- Nephrolithiasis
- Ectopic Pregnancy
- Ruptured Ovarian Cyst
- Pelvic Inflammatory Disease
- Bowel Infarction or Perforation
Diagnostics:
- Pelvic Exam
- Urine hCG
- Doppler U/S-pelvis/transvaginal
- Rectal Exam
- UA
- CBC
- CT-abdomen
- Laparoscopy
- Chlamydia and Gonorrhea Testing, VDRL/RPR
68 yo M presents with LLQ abdominal pain, fever, and chills for the past 3 days. He also reports recent onset of alternating diarrhea and constipation. He consumes a low-fiber, high-fat diet.
Differentials:
- Diverticulitis
- Crohn Disease
- Ulcerative Colitis
- Gastroenteritis
- Abscess
Diagnostics:
- Rectal Exam
- CBC
- Electrolytes
- CXR
- AXR
- CT-abdomen
- Blood Culture
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 and psoas signs are positive.
Differentials:
- Acute Appendicitis
- Gastroenteritis
- Diverticulitis
- Crohn Disease
- Nephrolithiasis
- Volvulus or other intestinal obstruction
- Perforation
- Acute Cholecystitis
Diagnostics:
- CBC
- Electrolytes
- CT-abdomen
- AXR
- U/S-abdomen
- Blood Culture
30 yo F presents with periumbilical pain for 6 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.
Differentials:
- Irritable Bowel Syndrome
- Crohn Disease
- Celiac Disease
- Chronic Pancreatitis
- GI Parasitic Infection (Amebiasis, Giardiasis)
- Endometriosis
Diagnostics:
- Rectal Exam, Stool for Occult Blood
- Pelvic Exam
- Urine hCG
- CBC
- Electrolytes
- Colonoscopy
- CT-abdomen/pelvis
- Stool for Ova and Parasitology, Entamoeba histolytica Antigen
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.
Differentials:
- Pelvic Inflammatory Disease
- Endometriosis
- Dysmenorrhea
- Vaginitis
- Cystitis
- Spontaneous Abortion
- Pyelonephritis
Diagnostics:
- Pelvic Exam
- Urine hCG
- Cervical Cultures
- CBC
- ESR
- UA, Urine Culture
- U/S-pelvis
67 yo M presents with alternating diarrhea and constipation, decreased stool caliber, and blood in the stool for the past 8 months. He also reports unintentional weight loss. He is on a low-fiber diet and has a family history of colon cancer. His last colonoscopy was 12 years ago.
Differentials:
- Colorectal Ccancer
- Irritable Bowel Syndrome
- Diverticulosis
- GI Parasitic Infection (Ascariasis, Giardiasis)
- Inflammatory Bowel Disease
Diagnostics:
- Rectal Exam, Stool for Occult Blood
- CBC with differentials
- CMP
- Colonoscopy
- Barium Enema
- CT-abdomen/pelvis
- Stool for Ova and Parasitology
28 yo M presents with constipation for the past 3 weeks. Since his mother died 2 months ago, he and his father have eaten only junk food.
Differentials:
- Constipation due to low-fiber diet
- Depression
- Substance Abuse (eg. heroin)
- Irritable Bowel Syndrome
- Hypothyroidism
Diagnostics:
- Rectal Exam
- TSH, FT4
- BMP
- Urine Toxicology
30 yo F presents with alternating constipation and diarrhea accompanied by abdominal pain that is relieved by defecation. She has no nausea, vomiting, weight loss, or blood in her stool.
Differentials:
- Irritable Bowel Syndrome
- Inflammatory Bowel Disease
- Celiac Disease
- Chronic Pancreatitis
- GI Parasitic Infection (Ascariasis, Giardiasis)
- Lactose Intolerance
Diagnostics:
- Rectal Exam, Stool for Occult Blood
- CBC with differentials
- CMP
- Colonoscopy
- tTG Antibody Test
- Stool for Ova and Parasitology
- CT-abdomen/pelvis
- Hydrogen Breath Test
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.
Differentials:
- Infectious Ddiarrhea (Gastroenteritis) - bacterial, viral, parasitic, protozoal
- Food Poisoning
Diagnostics:
- Rectal Exam, Stool for Occult Blood
- Stool Leukocytes and Culture
- CBC
- BMP
- CT-abdomen/pelvis
40 yo F presents with watery diarrhea and abdominal cramps. Last week she was on antibiotics for a UTI.
Differentials:
- Pseudomembranous (Clostridium difficile) Colitis
- Gastroenteritis
- Cryptosporidiosis
- Food Poisoning
- Inflammatory Bowel Disease
Diagnostics:
- Stool for C. difficile Toxin
- Rectal Exam, Stool for Occult Blood
- Stool Leukocytes and Culture
- CBC
- CMP
25 yo M presents with watery diarrhea and abdominal cramps. He was recently in Mexico.
Differentials:
- Traveler’s Diarrhea
- Giardiasis
- Amebiasis
- Food Poisoning
- Hepatitis A
Diagnostics:
- Rectal Exam
- Stool Leukocytes, Culture, Giardia Antigen, Entamoeba histolytica Antigen
- CBC
- CMP
- Viral Hepatitis Serologies
30 yo F presents with watery diarrhea, abdominal cramping, and bloating. Her symptoms are aggravated by milk ingestion and are relieved by fasting.
Differentials:
- Lactose Intolerance
- Gastroenteritis
- Inflammatory Bowel Disease
- Irritable Bowel Syndrome
- Hyperthyroidism
Diagnostics:
- Rectal Exam
- Stool Leukocytes and Culture
- Hydrogen Breath Test
- TSH
33 yo M presents with watery diarrhea, diffuse abdominal pain, and weight loss within the past 3 weeks. He has a history of aphthous ulcers. He has not responded to antibiotics.
Differentials:
- Crohn Disease
- Gastroenteritis
- Ulcerative Colitis
- Celiac Disease
- Pseudomembranous Colitis
- Hyperthyroidism
- Small Bowel Lymphoma
- Carcinoid Syndrome
Diagnostics:
- Rectal Exam, Stool for Occult Blood
- Stool Leukocytes and Culture
- CBC
- Electrolytes
- Colonoscopy with Biopsy
- CT-abdomen
- TSH
- AXR
45 yo F presents with colfee-ground emesis for the past 3 days. Her stool is dark and tarry. She has a history of intermittent epigastric pain that is relieved by food and antacids.
Differentials:
- Bleeding Peptic Ulcer
- Gastritis
- Gastric Cancer
- Esophageal Varices
Diagnostics:
- Upper Endoscopy (including H. pylori testing if ulcer is confirmed)
- CBC, type and crossmatching
- CMP
- AST/ALT/Bilirubin/Alkaline Phosphatase
- INR
- Rectal Exam, Stool Guaiac Testing
40 yo F presents with epigastric pain and coffee-ground emesis. She has a history of rheumatoid arthritis that has been treated with NSAIDs. She is an alcoholic.
Differentials:
- Gastritis
- Bleeding Peptic Ulcer
- Mallory-Weiss Tear
- Esophageal Varices
- Gastric Cancer
Diagnostics:
- Upper Endoscopy (including H. pylori testing if ulcer is confirmed)
- CBC, type and crossmatching
- CMP
- AST/ALT/Bilirubin/Alkaline Phosphatase
- INR
- Stool Guaiac Testing
67 yo M presents with blood in his stool, weight loss, and constipation. He has a family history of colon cancer.
Differentials:
- Colorectal Cancer
- Diverticulosis
- Hemorrhoids
- Anal Fissure
- Angiodysplasia
- Upper GI Bleeding
- Inflammatory Bowel Disease
- Ischemic Bowel Disease
Diagnostics:
- Colonoscopy
- Rectal Exam with Stool Guaiac Testing
- CT-abdomen/pelvis
- CBC
- CMP
- AST/ALT/Bilirubin/Alkaline Phosphatase
- PT/PTT
- CEA
33 yo F presents with rectal bleeding and diarrhea for the past week. She has had lower abdominal pain and tenesmus for several months.
Differentials:
- Ulcerative Colitis
- Crohn Disease
- Hemorrhoids
- Anal Fissure
- Proctitis
- Diverticulosis
- Dysentery
Diagnostics:
- Colonoscopy
- Rectal Exam with Stool Guaiac Testing
- CT-abdomen/pelvis
- CBC
- CMP
- PT/PTT
58 yo M presents with painless bright red blood per rectum and chronic constipation. He consumes a low-fiber diet.
Differentials:
- Diverticulosis
- Hemorrhoids
- Anal Fissure
- Colorectal Cancer
- Angiodysplasia
Diagnostics:
- CT-abdomen/pelvis
- Colonoscopy
- Rectal Exam with Stool Guaiac Testing
- CBC
- CMP
- PT/PTT
- Tagged RBC Scan
65 yo M presents with painless hematuria. He is a heavy smoker and works as a painter.
Differentials:
- Bladder Cancer
- Renal Cell Carcinoma
- Nephrolithiasis
- Prostate Cancer
- Acute Glomerulonephritis
- Coagulation Disorder (ie. factor VIII antibodies)
Diagnostics:
Cystoscopy
- U/S-renal/bladder
- CT-abdomen/pelvis
- UA, Urine Cytology
- Prostate Biopsy
- CBC
- CMP
- PT/PTT
- PSA
35 yo M presents with painless hematuria. He has a family history of kidney disease.
Differentials:
- Polycystic Kidney Disease
- Nephrolithiasis
- UTI
- Acute Glomerulonephritis (eg. IgA Nephropathy)
- Coagulation Disorder
- Bladder Cancer
Diagnostics:
- U/S-renal
- CT-abdomen/pelvis
- UA, Urine Cytology
- CBC
- CMP
- PT/PTT
55 yo M presents with flank pain and blood in his urine without dysuria. He has experienced weight loss and fever over the past 2 months. Exam reveals a flank mass.
Differentials:
- Renal Cell Carcinoma
- Pyelonephritis
- Acute Glomerulonephritis
- Bladder Cancer
- Nephrolithiasis
Diagnostics:
- U/S-renal
- CT-abdomen/pelvis
- Cystoscopy
- UA, Urine Cytology
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.
Differentials:
- Benign Prostatic Hypertrophy (BPH)
- Prostate Cancer
- Urolithiasis
- UTI
Diagnostics:
- U/S-prostate (transrectal)
- PSA
- UA
- CBC
- CMP
71 yo M presents with nocturia, urgency, weak stream, terminal dribbling, hematuria, and lower back pain for the past 4 months. He has also experienced weight loss and fatigue.
Differentials:
- Prostate Cancer
- BPH
- Renal Cell Carcinoma
- UTI
- Urolithiasis
Diagnostics:
- U/S-prostate (transrectal)
- CT-pelvis
- MRI-spine
- Prostate Biopsy
- PSA
- UA
- CBC
- CMP
18 yo M presents with a burning sensation during urination and urethral discharge. He recently had unprotected sex with a new partner.
Differentials:
- Urethritis
- Cystitis
- Prostatitis
Diagnostics:
- NAAT Urine for Chlamydia and Gonorrhea Screening
- RPR
- HIV Test
- UA, Urine Culture
- Gram Stain and Culture of Urethral Discharge
45 yo diabetic F presents with dysuria, urinary frequency, fever, chills, and nausea for the past 3 days. There is left CVA tenderness on exam.
Differentials:
- Acute Pyelonephritis
- Lower UTI (Cystitis, Urethritis)
- Nephrolithiasis
- Renal Cell Carcinoma
Diagnostics:
- UA, Urine Culture and Sensitivity
- Blood Cultures
- U/S-renal
- CT-abdomen
- CBC
- CMP
55 yo F presents with urinary leakage after exercise. She loses a small amount of urine when she coughs, laughs, or sneezes. She also complains of vague low back pain. She has a history of multiple vaginal deliveries, and her mother had the same problem after the onset of menopause.
Differentials:
- Stress Incontinence
- Mixed Incontinence
- Overflow Incontinence
- Urge Incontinence
- Functional Incontinence
- UTI
Diagnostics:
- Postvoid Residual
- Bladder Stress Test
- UA, Urine Culture
- CMP
- Cystourethroscopy
- Urodynamic Testing
33 yo F presents with urinary leakage. She is unable to suppress the urge to urinate and loses large amounts of urine without warning. She has a history of UTis and a family history of diabetes mellitus. She drinks 8 cups of coffee per day. She has been under stress since her sister passed away a few months ago.
Differentials:
- Urge Incontinence
- Mixed Incontinence
- Overflow Incontinence
- Stress Incontinence
- Functional Incontinence
- UTI
Diagnostics:
- Postvoid Residual
- Bladder Stress Test
- UA, Urine Culture
- CBC
- CMP
- Cystourethroscopy
- Urodynamic Testing
47 yo M presents with impotence that started 3 months ago. He has hypertension and was started on atenolol 4 months ago. He also has diabetes and is on insulin.
Differentials:
- Drug-Related Erectile Dysfunction (ED)
- ED caused by Hypertension
- ED caused by Diabetes Mellitus
- Psychogenic ED
- Peyronie Disease
Diagnostics:
- CMP
- CBC
- Fasting Glucose Level
- Testosterone Level
- TSH
40 yo F presents with amenorrhea, morning nausea and vomiting, fatigue, and polyuria. Her last menstrual period was 6 weeks ago. Her breasts are full and tender. She uses the rhythm method for contraception.
Differentials:
- Pregnancy
- Anovulatory Cycle
- Hyperprolacrinemia
- UTI
- Hypothyroidism
Diagnostics:
- Urine hCG
- Pelvic Exam
- U/S-transvaginal
- CBC
- UA, Urine Culture
- Prolactin, TSH
- Baseline Pap Smear, Cervical Cultures
- Rubella Antibody, HIV Antibody, Hepatitis B Surface Antigen, VDRL/RPR
23 yo obese F presents with amenorrhea for 6 months, facial hair, and infertility for the past 3 years.
Differentials:
- Polycystic Ovary Syndrome
- Thyroid Disease
- Hyperprolactinemia
- Pregnancy
- Ovarian or Adrenal Malignancy
- Premature Ovarian Failure
Diagnostics:
- Pelvic Exam
- Urine hCG
- Transabdominal and Transvaginal Ultrasound
- LH/FSH, TSH, Prolactin
- Testosterone, DHEAS
35 yo F presents with amenorrhea, galactorrhea, visual field defects, and headaches for the past 6 months.
Differentials:
- Amenorrhea secondary to Prolactinoma
- Pregnancy
- Thyroid Disease
- Premature Ovarian Failure
- Pituitary Tumor
Diagnostics:
- Pelvic and Breast Exams
- Urine hCG
- LH/FSH, TSH, Prolactin
- MRI-brain
48 yo F presents with amenorrhea for the past 6 months accompanied by hot flashes, night sweats, emotional lability. and dyspareunia.
Differentials:
- Menopause
- Pregnancy
- Pituitary Tumor
- Thyroid Disease
Diagnostics:
- Pelvic Exam
- Urine hCG
- LH/FSH, TSH, Prolactin
- Testosterone, DHEAS
- CBC
- MRI-brain
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 2 years ago.
Differentials:
- Pituitary Infarction (Sheehan Syndrome)
- Premature Ovarian Failure
- Pituitary Tumor
- Thyroid Disease
- Asherman Syndrome
Diagnostics:
- ACTH
- Pelvic Exam
- Urine hCG
- LH/FSH, Prolactin
- CBC
- TSH, FT4
- MRI-brain
- Hysteroscopy
18 yo F presents with amenorrhea for the past 4 months. BMI is 14.5 kg/m2. She attends vigorous exercise classes frequendy and has a history of heat intolerance.
Differentials:
- Anorexia Nervosa
- Pregnancy
- Hyperthyroidism
Diagnostics:
- Urine hCG
- CBC
- Electrolytes
- TSH, FT4
- LH/FSH
29 yo F presents with amenorrhea for the past 6 months. She has a history of occasional palpitations and dizziness. She lost her fiance in a car accident in which she was a passenger.
Differentials:
- Anxiety-Induced Amenorrhea
- Pregnancy
- Posttraumatic Stress Disorder
- Depression
- Hyperthyroidism
Diagnostics:
- Urine hCG
- CBC
- TSH, FT4
- Urine Cortisol Level
- Progesterone Challenge Test
- LH/FSH, Estradiol Levels
17 yo F presents with prolonged, excessive menstrual bleeding occurring irregularly for the past 6 months.
Differentials:
- Dysfunctional Uterine Bleeding
- Coagulation Disorder (eg. von Willebrand disease, hemophilia)
- Cervical Cancer
- Molar Pregnancy
- Hypothyroidism
Diagnostics:
- Pelvic Exam
- Pap Smear
- CBC
- PT/PTT
- Urine hCG
- Cervical Culture
- ESR
- LH/FSH, TSH, Prolactin
- U/S-pelvis
61 yo obese F presents with profuse vaginal bleeding for the past month. Her last menstrual period was 10 years ago. She has a history of hypertension and diabetes mellitus. She is nulliparous.
Differentials:
- Endometrial Cancer
- Cervical Cancer
- Atrophic Endometrium
- Endometrial Hyperplasia
- Endometrial Polyps
- Atrophic Vaginitis
Diagnostics:
- Pelvic Exam
- Pap Smear
- Endometrial Biopsy
- Endometrial Curettage
- U/S-pelvis
- Colposcopy
- Hydro-ultrasonography
45 yo G5P5 F presents with postcoital bleeding. She is a cigarette smoker and does not use contraceptive protection.
Differentials:
- Cervical Cancer
- Endometrial Cancer
- Cervical Polyp
- Cervicitis
- Trauma (eg. cervical laceration)
Diagnostics:
- Pelvic Exam
- Pap Smear
- Colposcopy and Biopsy
- HPV Testing
- Endometrial Biopsy
28 yo F who is 8 weeks pregnant presents with lower abdominal pain and vaginal bleeding.
Differentials:
- Spontaneous Abortion
- Ectopic Pregnancy
- Molar Pregnancy
Diagnostics:
- Urine hCG
- Pelvic Exam
- Quantitative Serum hCG
- U/S-abdomen/pelvis
- CBC
- PT/PTT
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 5 weeks ago. She has a history of pelvic inflammatory disease and unprotected intercourse.
Differentials:
- Ectopic Pregnancy
- Ruptured Ovarian Cyst
- Ovarian Torsion
- Pelvic Inflammatory Disease
Diagnostics:
- Urine hCG
- Pelvic Exam
- Quantitative Serum hCG
- U/S-abdomen/pelvis
- Cervical Cultures
28 yo F presents with a thin, grayish-white, foul-smelling vaginal discharge.
Differentials:
- Bacterial Vaginosis
- Vaginitis-Candidal
- Vaginitis-Trichomonal
- Cervicitis (Chlamydia, Gonorrhea)
Diagnostics:
- Pelvic Exam
- Wet Mount, KOH Prep, “whiff test”
- pH of Vaginal Fluid
- Cervical Cultures
30 yo F presents with a thick, white, cottage cheese-like, odorless vaginal discharge and vaginal itching.
Differentials:
- Vaginitis-Candidal
- Bacterial Vaginosis
- Vaginitis-Trichomonal
Diagnostics:
- Pelvic Exam
- Wet Mount, KOH Prep, “whiff test”
- pH of Vaginal Fluid
- Cervical Cultures
35 yo F presents with a malodorous, profuse, frothy, greenish vaginal discharge with intense vaginal itching and discomfort.
Differentials:
- Vaginitis-Trichomonal
- Vaginitis-Candidal
- Bacterial Vaginosis
- Cervicitis (Chlamydia, Gonorrhea)
Diagnostics:
- Pelvic Exam
- Wet Mount, KOH Prep, “whiff test”
- pH of Vaginal Fluid
- Cervical Cultures
54 yo F reports painful intercourse for the past year. Her last menstrual period was 2 years ago. She has hot flashes.
Differentials:
- Atrophic Vaginitis
- Endometriosis
- Cervicitis
- Domestic Violence
Diagnostics:
- Pelvic Exam
- LH/FSH
- Wet Mount, KOH Prep
- Cervical Cultures
37 yo F presents with dyspareunia, dysmenorrhea, and infertility for the past 2 years.
Differentials:
- Endometriosis
- Cervicitis
- Vaginismus
- Vulvodynia
- Pelvic Inflammatory Disease
- Depression
Diagnostics:
- Pelvic Exam
- Wet Mount, KOH Prep
- Cervical Cultures
- U/S-pelvis
- Laparoscopy
- Endometrial Biopsy
28 yo F c/o multiple facial and bodily injuries. She claims that she fell on the stairs. She was hospitalized for physical injuries 7 months ago. She presents with her husband.
Differentials:
- Domestic Violence
- Osteogenesis Imperfecta
- Substance Abuse
Diagnostics:
- XR-skeletal survey
- CT-maxillofacial
- Urine Toxicology
30 yo F presents with multiple facial and physical injuries. She states that she was attacked and raped by two men.
Differentials:
- Rape
- Domestic Violence
Diagnostics:
- Forensic Exam (sexual assault forensic evidence [SAFE] collection kit)
- Pelvic Exam
- Urine β-hCG
- Wet Mount, KOH Prep
- Cervical Cultures
- Chlamydia and Gonorrhea Testing
- XR-skeletal survey
- CBC
- HIV Antibody
- Viral Hepatitis Serologies
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.
Differentials:
- Domestic Violence
- Factitious Disorder
- Substance Abuse
Diagnostics:
- XR-wrist
- CT-head
- Urine Toxicology
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 sign.
Differentials:
- Carpal Tunnel Syndrome
- Median Nerve Compression in the forearm or arm
- Radiculopathy of nerve roots C6 and C7 in the cervical spine
- De Quervain Tenosynovitis
Diagnostics:
- Nerve Conduction Studies
- EMG
- U/S-wrist
- MRI-spine
28 yo F presents with pain in the interphalangeal joints of her hands accompanied by hair loss and a rash on her face.
Differentials:
- Systemic Lupus Erythematosus (SLE)
- Rheumatoid Arthritis
- Psoriatic Arthritis
- Parvovirus B19 Infection
Diagnostics:
- ANA, Anti-dsDNA, Anti-Sm, ESR, C3, C4, Antiphospholipid Antibodies
- RF, Anti-CCP
- ESR,CRP
- CBC
- XR-hands
- UA, Urine Sediment
- Antibody Titers for Parvovirus B19
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.
Differentials:
- Rheumatoid Arthritis
- SLE
- Disseminated Gonorrhea
- Arthritis associated with Inflammatory Bowel Disease
Diagnostics:
- XR-hands, left knee
- ANA, Anti-dsDNA, ESR, RF, Anti-CCP
- CBC
- Cervical Culture
- Arthrocentesis and Synovial Fluid Analysis
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.
Differentials:
- Psoriatic Arthritis
- Rheumatoid Arthritis
- SLE
- Gout
Diagnostics:
- ESR, CRP, RF, Anti-CCP, ANA
- CBC
- XR-hands
- XR-pelvis/sacroiliac joints
- Uric Acid
65 yo F presents with inability to use her left leg or 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.
Differentials:
- Hip Fracture
- Hip Dislocation
- Pelvic Fracture
Diagnostics:
- XR-hip/pelvis
- CT or MRI-hip
- CBC, type and crossmatching
- Serum Calcium and Vitamin D
- Bone Density Scan (DEXA)
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.
Differentials:
- Hip Dislocation-Traumatic
- Median Nerve Compression in the forearm or arm
- Hip Fracture
Diagnostics:
- XR-hip
- CT or MRI-hip
- CBC, type and crossmatching
- PT/PTT
- Urine Toxicology
- Blood Alcohol Level
- U/S-abdomen (FAST Exam)
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 has noticed swelling and deformity of the joint and is having difficulty walking.
Differentials:
- Osteoarthritis
- Pseudogout
- Gout
- Meniscal or Ligament Damage
Diagnostics:
- XR-knee
- CBC
- ESR
- Knee Arthrocentesis and Synovial Fluid Analysis (cell count, Gram stain, culture, crystals)
- Uric Acid
- MRI-knee
45 yo M presents with fevers and right knee pain with swelling and redness.
Differentials:
- Septic Arthritis
- Gout
- Pseudogout
- Lyme Arthritis
- Trauma
- Reiter Syndrome (Reactive Arthritis)
Diagnostics:
- CBC
- Knee Arthrocentesis and Synovial fluid analysis (cell count, Gram stain, culture, crystals)
- Blood, Urethral Cultures
- XR-knee
- Uric Acid
- Lyme Titers-IgG and IgM
65 yo M presents with right foot pain. He has been training for a marathon.
Differentials:
- Stress Fracture
- Plantar Fasciitis
- Foot Sprain or Strain
Diagnostics:
- XR-foot
- Bone Scan-foot
- MRI-foot
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.
Differentials:
- Plantar Fasciitis
- Heeld Fracture
- Splinter/Foreign Body
Diagnostics:
- XR-heel
- Bone Scan-foot
55 yo M presents with crampy bilateral thigh and calf pain, fatigue, and dark urine. He is on simvastatin and clofibrate for hyperlipidemia.
Differentials:
- Rhabdomyolysis due to Statins
- Polymyositis
- Inclusion Body Myositis
Diagnostics:
- CPK
- CBC
- CMP, Calcium, Phosphate, Uric Acid
- Aldolase
- UA
- Urine Myoglobin
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 test) with the elbow in extension.
Differentials:
- Tennis Elbow (Lateral Epicondylitis)
- Stress Fracture
Diagnostics:
- XR-arm
- Bone Scan
- MRI-elbow
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.
Differentials:
- Disseminated Gonorrhea
- Rheumatoid Arthritis
- SLE
- Reiter Syndrome (Reactive Arthritis)
Diagnostics:
- Knee Arthrocentesis and Synovial Fluid Analysis (cell count, Gram stain, culture)
- Blood, Cervical Cultures
- RF, Anti-CCP, ESR
- ANA, Anti-dsDNA, CBC
- XR-knee
60 yo F presents with pain in both legs that is induced by walking and is relieved by rest. She had cardiac bypass surgery 6 months ago and continues to smoke heavily.
Differentials:
- Peripheral Vascular Disease (Intermittent Claudication)
- Leriche Syndrome (Aortoiliac Occlusive Disease)
- Lumbar Spinal Stenosis (Pseudodaudication)
- Osteoarthritis
Diagnostics:
- Ankle-Brachial Index
- Doppler U/S-lower extremity
- Angiography
- MRI-L-spine
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 2 months ago for dysfunctional uterine bleeding.
Differentials:
- DVT
- Baker Cyst Rupture
- Myositis
- Cellulitis
- Superficial Venous Thrombosis
Diagnostics:
- Doppler U/S-right leg
- CBC
- CPK
- D-dimer
60 yo F c/o left arm pain that started while she was swimming and was relieved by rest.
Differentials:
- Angina/MI
- Tendinitis
- Osteoarthritis
Diagnostics:
- ECG, Troponin, CK-MB
- CBC
- XR-shoulder
- CXR
- Echocardiography
- Stress Test
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.
Differentials:
- Shoulder Dislocation
- Fracture of the Humerus
- Rotator Cuff Injury
Diagnostics:
- XR-shoulder
- XR-arm
- MRI-shoulder
45 yo F presents with low back pain that radiates to the lateral aspect of her left foot. The straight leg raise is positive. The patient is unable to tiptoe.
Differentials:
- Disk Herniation
- Lumbar Muscle Strain
- Tumor in the Vertebral Canal
Diagnostics:
- XR-L-spine
- MRI-L-spine
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.
Differentials:
- Lumbar Muscle Strain
- Disk Herniation
- Vertebral Compression Fracture
Diagnostics:
- XR-L-spine
- MRI-L-spine
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 (eg. pushing a grocery cart).
Differentials:
- Lumbar Spinal Stenosis
- Lumbar Muscle Strain
- Tumor in the Vertebral Canal
- Peripheral Vascular Disease
Diagnostics:
- MRI-L-spine (preferred)
- XR-L-spine
- CT-L-spine
- Ankle-Brachial Index
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.
Differentials:
- Malingering
- Lumbar Muscle Strain
- Disk Herniation
- Knee or Leg Fracture
- Ankylosing Spondylitis
Diagnostics:
- XR-L-spine/knee
- MRI-L-spine
- ESR, CRP
20-day-old M presents with fever, decreased breastfeeding, and lethargy. He was born at 36 weeks as a result of premature rupture of membranes.
Differentials:
- Neonatal Sepsis
- Meningitis
- Pneumonia
- Pyelonephritis
Diagnostics:
- CBC
- Electrolytes
- Blood Culture
- LP-CSF analysis
- CXR
- UA, Urine Culture
3 yo M presents with a 2-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.
Differentials:
- Acute Otitis Media
- URI
- Meningitis
- Pyelonephritis
Diagnostics:
- CBC, Blood Culture
- LP-CSF analysis
- UA, Urine Culture
12 mo M presents with fever for the past 2 days accompanied by a maculopapular rash on his face and body. He has not yet received the MMR vaccine.
Differentials:
- Measles (or other Viral Exanthem)
- Rubella
- Roseola
- Fifth Disease
- Varicella
- Scarlet Fever
- Meningitis
Diagnostics:
- CBC
- Viral Antibodies/Titers
- Throat Swab for Culture
- LP-cerebrospinal fluid analysis
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.
Differentials:
- Gastroenteritis (viral, bacterial, parasitic)
- Food Poisoning
- UTI
- URI
- Intussusception
- Volvulus
Diagnostics:
- Stool Exam and Culture
- CBC
- Electrolytes
- UA, Urine Culture
- Abdominal X-ray
1 mo infant is brought in because she has been spitting up her milk for the past 10 days. The vomiting episodes have increased in frequency and forcefulness. Emesis is nonbloody and nonbilious. The episodes usually occur immediately after breastfeeding. She has stopped gaining weight.
Differentials:
- Pyloric Stenosis
- Partial Duodenal Atresia
- GERD
- Gastroenteritis
- Hepatitis
- UTI
Diagnostics:
- CBC
- Electrolytes
- U/S-abdomen
- Barium Swallow
- Esophageal pH Probe
- Endoscopy
- LFTs, Alkaline Phosphatase
- UA, Urine Culture
3 yo M presents with constipation. The child has had 1 bowel movement per week since birth despite the use of stool softeners. At birth, he did not pass meconium for 48 hours. He has poor weight gain. There is a family history of this problem.
Differentials:
- Hirschsprung Disease
- Low-Fiber Diet
- Anal Stenosis
- Hypothyroidism
- Lead Poisoning
- Celiac Disease
Diagnostics:
- Rectal Exam
- Barium Enema
- Suction Rectal Biopsy
- Anorectal Manometry
- TSH, FT4
- CBC
- Electrolytes
- Serum Lead Level
- Anti-Tissue Transglutaminase, Antiendomysial and Total IgA Antibodies
8 mo F presents with sudden-onset colicky abdominal pain with vomiting. The episodes are 20 minutes apart, and the child is completely well between episodes. She had loose stools several hours before the pain, but her stools are now bloody.
Differentials:
- Intussusception
- Appendicitis
- Meckel Diverticulum
- Volvulus
- Gastroenteritis
- Enterocolitis
- Blunt Abdominal Trauma
Diagnostics:
- Rectal Exam, Stool for Occult Blood
- CBC
- Electrolytes
- Contrast Enema
- U/S-abdomen
- CT-abdomen
7 yo M presents with abdominal pain that is generalized, crampy, worse in the morning, and seemingly less prominent during weekends and holidays. He has missed many school days because of the pain. Growth and development are normal. His parents recently divorced.
Differentials:
- Somatoform Disorder
- Malingering
- Irritable Bowel Syndrome
- Lactose Intolerance
- Child Abuse
Diagnostics:
- CBC
- Electrolytes
- U/S-abdomen
- Amylase, Lipase
- Stool Exam
2 mo M presents with persistent crying for 2 weeks.
The episodes subside after passing flatus or eructation. There is no change in appetite, weight, or growth. There is no vomiting, constipation, or fever.
Differentials:
- Colic
- Formula Allergy
- GERD
- Lactose Intolerance
- Strangulated Hernia
- Testicular Torsion
- Gastroenteritis
Diagnostics:
- Rectal Exam, Stool for Occult Blood
- U/S-abdomen
- U/S-testicular
3 yo F presents with a 3-day history of “pink eye.” It began in the right eye but now involves both eyes. She has mucoid discharge, itching, and difficulty opening her eyes in the morning. Her mother had the flu last week. She has a history of asthma and atopic dermatitis.
Differentials:
- Bacterial Conjunctivitis
- Viral Conjunctivitis
- Allergic Conjunctivitis
- Keratitis
- Uveitis
- Orbital Cellulitis
- Preseptal Cellulitis
Diagnostics:
- Ophthalmoscopic Eye Exam
- CBC
- Electrolytes
- Discharge Cultures
- Slit Lamp Exam
- CT-orbit
14 yo M presents with short stature and lack of sexual development. His birth weight and length were normal, but he is the shortest child in his class. His father and uncles had the same problem when they were young, but they are now of normal stature.
Differentials:
- Constitutional Short Stature
- Growth Hormone (GH) Deficiency
- Hypothyroidism
- Chronic Renal Insufficiency
- Genetic Causes
Diagnostics:
- CBC with differentials
- Electrolytes
- GH Stimulation Test
- IGF-l, IGFBP-3 Levels
- TSH, FT4
- XR-hand
- U/S-renal and cardiac
- BUN/Cr
9 yo M presents with a 2-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 dass, regularly interrupts his classmates, and has trouble making friends.
Differentials:
- Attention-Deficit Hyperactivity Disorder (ADHD)
- Oppositional Defiant Disorder
- Conduct Disorder
- Manic Episode
- Hyperthyroidism
Diagnostics:
- Physical Exam
- Mental Status Exam
- TSH, FT4
12 yo F presents with a 2-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.
Differentials:
- Adjustment Disorder
- Substance Intoxication, Abuse, or Dependence
- Oppositional Defiant Disorder
- Conduct Disorder
- Manic Episode
Diagnostics:
- Physical Exam
- Mental Status Exam
- Urine Toxicology
15 yo M presents with a 1-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.
Differentials:
- Substance Abuse
- Conduct Disorder
- Oppositional Defiant Disorder
- Adjustment Disorder
Diagnostics:
- Urine Toxicology
- Physical Exam
- Mental Status Exam
5 yo M presents with a 6-month history of temper tantrums that last 5 to 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.
Differentials:
- Age·Appropriate Behavior
- ADHD
- Oppositional Defiant Disorder
Diagnostics:
- Physical Exam
- Mental Status Exam
