Minicases Flashcards
21 F episodes of throbbing L temporal pain that last 2-3 hours. Before onset, she sees flashes of light in her R visual field and feels weakness and numbness on the right side of her body for a few minutes. Her headaches are often associated with n/v and she feels bothered by light. She has a family history of migraines.
DDx:
Hemiplegic MIGRAINE (migraine with motor aura)
Tension headache
Cluster headache
TIA Partial Seizures Pseudotumor cerebri CNS vasculitis Focal Seizure (occipito-parietal) Intracranial neoplasm
Workup: MRI Brain CT Head CBC ESR
26 M SEVERE R 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
DDx: CLUSTER Heachache Migraine Trigeminal Neuralgia Intracranial neoplasm Tension headache
Workup: MRI Brain CT Head CBC ESR
65 F new onset severe intermittent R temporal headache, fever, blurred vision, in her R eye, weight loss and pain in her jaw when chewing. She has a hx of shoulder stiffness. On examination, she has R temporal tenderness to palpation and reduced R eye visual acuity
DDx: TEMPORAL Arteritis (Giant cell arteritis) Vasculitis Migraine Cerebral abscess Cluster headache Tension migraine Meningitis Carotid artery dissection Pseudotumor cerebri Trigeminal neuralgia Intracranial neoplasm Temporomandibular joint TMJ disorder
Workup: Temporal artery biopsy ESR CRP CBC Doppler US Carotid MRI brain
30 F 1 week frontal headache, fever, nasal discharge. Headache worsens when she bends forward. There is pain on palpation of the frontal and maxillary sinuses. She has a history of allergies.
DDx: ACUTE SINUSITIS Migraine Tension headache Cerebral abscess Meningitis Intracranial neoplasm/Pseudotumor cerebri
Workup:
CBC
XR Sinus
CT Sinus
50 F recurrent episodes of bilateral squeezing headaches that occur 3-4 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 exam is normal.
DDx: TENSION HEADACHE Migraine Caffeine or analgesic withdrawal Depression Intracranial neoplasm/Pseudotumor cerebri Cluster headache
Workup: CBC Electrolytes ESR MRI Brain LP CSF analysis MRI Brain
35 M sudden severe headache, vomiting, confusion, L hemiplegia and nuchal rigidity
DDx: SUBARACHNOID HEMORRHAGE Meningitis/Encephalitis Intracranial hemorrhage Vertebral artery dissection Intracranial venous thrombosis Migraine Hypertensive encephalopathy Intracranial neoplasm /Pseudotumor cerebri
Workup: CT head w/o contrast LP opening pressure and CSF analysis CBC PT/PTT/INR Urine toxicology Digital subtraction angiography (DSA) MRI - Brain CT Angiography
25 M military recruit with high fever, severe headache, confusion, photophobia and nuchal rigidity
DDx: MENINGITIS Subarachnoid hemorrhage Encephalitis Sinusitis Migraine Intracranial or epidural abscess
Workup: 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 F obese, daily pulsatile headache, vomiting, and blurred vision for the past 2-3 months. She is taking OCPs.
DDx: PSEUDOTUMOR CEREBRI Migraine Tension headache Intracranial venous thrombosis Intracranial neoplasm Cluster headache Meningitis
Workup: Urine hCG LP - opening pressure and CSF analysis DIlated fundoscopy MRI - brain Visual field testing
57 M daily pain in the R cheek for the past month. The pain is electric and stabbing in character and occurs while he is shaving. Each episode lasts 1-2 minutes
DDx: TRIGEMINAL NEURALGIA Cluster headache Tension headache Migraine TMJ disorder Temportal arteritis Intracranial neoplasm/pseudotumor cerebri
Workup:
MRI Brain
CBC
ESR
81 M 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 L hemiparesis. His mental status has worsened after each stroke. (stepwise decline in cognitive function)
DDx: VASCULAR (Multi-infarct) DEMENTIA Alzheimer disease Normal pressure hydrocephalus Chronic subdural hematoma Intracranial neoplasm Depression B12 deficiency Neurosyphiliis Hypothyrodism
Workup: CBC VDRL/RPR Serum B12 TSH MRI Brain CT Head LP CSF Analysis
84 F brought by her son for forgetfulness (phone numbers, loses her way back home) and difficulty performing some of her daily activities (bathing, dressing, managing money, using the phone). Problem has progressed gradually over the past few years.
DDx: ALZHEIMER DISEASE Vascular dementia Depression Hypothyroidism Chronic subdural hematoma Normal pressure hydrocephalus Intracranial neoplasm B12 deficiency Neurosyphilis
Workup: CBC VDRL B12 TSH MRI Brain CT Head LP CSF Analysis
72 M memory loss, gait disturbance and urinary incontinence for the past 6 months
DDx: NORMAL PRESSURE HYDROCEPHALUS Alzheimer disease Vascular dementia Chronic subdural hematoma Intracranial neoplasm Depression B12 deficiency Neurosyphilis Hypothyroidism
Workup: CT Head MRI Brain LP Opening pressure and CSF Analysis Serum B12 VDRL/RPR TSH
55 M rapidly progressive chance in mental status, inability to concentrate, and memory impairment for the past 2 months. His symptoms are associated with myoclonus, ataxia and startle response
DDx: CREUTZFELDT-JAKOB DISEASE disease (Prion disease) Vascular dementia Lewy Body Dementia Wernicke encephalopathy Normal pressure hydrocephalus Chronic subdural hematoma Intracranial neoplasm Depression Delirium B12 deficiency Neurosyphilis
Workup:
CBC
Electrolytes, calcium
Serum B12
VDRL/RPR
MRI Brain
CT Head
EEG ("Spikes")
LP CSF Analysis
Brain Biopsy
70 M insulin dependent diabetic with episodes of confusion, dizziness, palpitations, diaphoresis and weakness
DDx: Hypoglycemia Transient ischemic attack Arrhythmia Delirium Angina Medication-induced
Workup: Glucose CBC Electrolytes TSH CPK-MR Troponin Echocardiography ECG MRI Brain Doppler US - Carotid Urine toxicology
55 F gradual altered mental status and headache. Two weeks ago she slipped, hit her head on the ground, and lost consciousness for 2 minutes
DDx: SUBDURAL HEMATOMA SIADH (--> Hyponatremia) Creutzfeldt-Jakob disease Intracranial Neoplasm/Pseudotumor cerebri CNS Infection (eg encephalitis)
Workup: CT Head CBC Electrolytes TSH MRI Brain LP CSF Analysis (Gram stain, culture)
73 M with acute vision loss in his L eye, palpitations and shortness of breath. He has a history of atrial fibrillation and cataracts in his R eye. He has no eye pain, discharge, redness, or photophobia. He has not experienced headache, weakness or numbness.
DDx: RETINAL ARTERY OCCLUSION Retinal vein occlusion Acute angle closure glaucoma Retinal detachment Temporal arteritis (giant cell arteritis)
Workup: Fluorescein angiogram Echo cardiography Doppler US carotid Intraocular tonometry ESR CRP Temporal artery biopsy CBC
68 M
- 2mo hx of crying spells, excessive sleep, poor hygiene, and 15lb wt loss all following his wife’s death.
- He cannot enjoy time with family and admits to thinking he has seen his dead wife in line at the supermarket or standing in the kitchen making dinner.
DDx
NORMAL BEREAVEMENT
Adjustment disorder with depressed mood
Major depressive disorder
Schizoaffective disorder
Depressive disorder not otherwise specified
Workup TSH Urine toxicology Beck Depression PHQ 9 QIDS SR 16
42 F with 4 week history of excessive fatigue, insomnia and anhedonia. She states that she constantly thinks about death. She has suffered five similar episodes in the past, first in her 20s and two previous suicide attempts. She further admits to increased alcohol use in the past.
DDx
MAJOR DEPRESSIVE DISORDER
Substance induced mood disorder
Persistent depressive disorder (dysthymia)
Workup Beck depression inventory PHQ 9 QIDS SR16 Blood alcohol level TSH CBC Urine Toxicology
26 F with 6.5lb 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.
DDx BIPOLAR I DISORDER Bipolar II disorder Cyclothymic disorder Major depressive disorder Schizoaffective disorder
Workup Mood disorder questionaire Urine toxicology TSH CBC
19 M complains of receiving messages from his television set. He reports that he did not have many friends in high school. In college, he started to suspect that his roommate of bugging the phone. He stopped going to class 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”
DDx SCHIZOPHRENIA Schizoid Schizotypical Schizophreniform disorder Psychotic disorder due to general medical condition Substance induced psychosis Depression with psychotic features
Workup Menta status exam Urine toxicology TSH CBC Electrolytes
28 F complains of 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.
DDx SUBSTANCE INDUCED PSYCHOSIS Brief psychotic disorder Schizohreniform disorder Schizophrenia Psychotic disorder due to a general medical condition
Workup Urine toxicology Mental status exam TSH CBC Electrolytes BUN/Crea AST/ALT
35 F with intermittent episodes of vertigo, tinnitus and hearing loss within the past week. PE is normal.
DDx Meniere disease Benign positional vertigo Labyrinthitis Vestibular neuronitis Acoustic neuroma
Workup Dix Hallpike maneuver Audiometry Electron nystagmography CBC VDRL RPR (Syphilis causes Meniere) MRI
55 F with 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.
DDx ORTHOSTATIC HYPOTENSION d/t dehydration Vertebrobasilar insufficiency Cardiac arrhythmias Vestibular neuronitis Labyrinthitis Benign positional vertigo
Workup Orthostatic vital signs Rectal examination CBC Urea Crea ECG Stool for occult blood Stool leukocytes
65 M with postural dizziness and unsteadiness. He has hypertension and was started on furosemide 2 days ago.
DDx DRUG INDUCED ORTHOSTATIC HYPOTENSION Furosemide ototoxicity Vertebrobasilar insufficiency Labyrinthitis Benign positional vertigo Brain stem or cerebellar tumor
Workup Orthostatic vital signs CBC Urea Electrolytes ECG Echo cardiography MRI brain
44 F complains of 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
DDx BENIGN POSITIONAL VERTIGO Meniere disease Labyrinthitis Acoustic neuroma
Workup
Audiometry
Electro nystagmograph
MRI Brain
55 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 experiened no hearing loss or tinnitus
DDx VESTIBULAR NEURONITIS Labyrinthitis Benign positional vertigo Meniere disease Vertebrobasilar stroke TIA
Workup Audiogram Electro nystagmography CT Head MRI/MRA brain
55 F c/o dizziness that started this morning and “not hearing well”. She feels nauseated and has vomited once in the past day. She had a URI 2 days ago.
DDx LABYRINTHITIS Vestibular neuronitis Meniere disease Acoustic neuroma Vertbrobasilar stroke/TIA
Workup AUdiogram Electro-nystagmography CT Head MRI/MRA Brain
26 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)
DDx GENERALIZED TONIC CLONIC SEIZURE Convulsive syncope Substance abuse/overdose Malingering Hypoglycemia
Workup CBC Electrolytes Glucose Urine toxicology EEG MRI Brain CT Head LP CSF analysis, gram stain and culture ECG
55 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.
DDx DRUG INDUCED HYPOTENSION (Causing SYNCOPE) Hypoglycemia Cardiac arrhythmia Syncope (vasovagal etc) Stroke MI Pulmonary embolism
Workup Orthostatic vital signs CBC Electrolytes Glucose Echo cardiography CT Head ECG VQ Scan CTA chest with contrast D Dimer
65 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
DDx CARDIAC ARRHYTHMIA (causing syncope) Severe aortic stenosis Syncope (other causes) Seizure Pulmonary embolism
Workup ECG Holter monitoring CBC Electrolytes Glucose Echo cardiography CT Head
53 M present following a 20 min episodes of R 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. PE within normal limits.
DDx TRANSIENT ISCHEMIC ATTACK Stroke Migraine with sensory aura Hypoglycemia Seizure with Todd paresis
Workup CT Head CBC Electrolytes Glucose Fasting lipid panel ECG MRI Brain Doppler US Carotid Echo cardiography EEG
58 M presents with slurred speech, R facial drooping and numbness and R hand weakness. Babinski sign is present on the R, weakness of the R side of his body, DTRs are brisk. He has a history of hypertension, diabetes mellitus and heavy smoking.
DDx Stroke TIA Seizure with Todd paresis Intracranial neoplams/Pseudotumor cerebri Subdural hematoma Epidural hematoma Hypoglycemia
Workup CT Head CBC Electrolytes Glucose PT/PTT/INR Fasting lipid panel MRI Brain MRA Doppler US carotid Echo cardiography ECG
33 F 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.
DDx Guillain Barre syndrome Multiple sclerosis Transverse myelitis Spinal cord compression Peripheral neuropathy
Workup CBC Electrolytes MRI Spine CPK Electro myography Nerve conduction studies LP CSF analysis PFTs Serum B12 Neurosyphilis
30 F with weakness, loss of sensation, and tingling in her L leg that started this morning. She also experiened R eye pain with reduced vision that resolved transiently 3 months ago. She reports feeling “electric shocks” down her spine upon flexing her head. Exam reveals L lower limb weakness and ataxia.
DDx MULTIPLE SCLEROSIS Stroke CNS vasculitis Conversion disorder Malingering CNS tumor Vitamin B deficiency Neurosyphilis
Workup CBC ESR ANA ANCA VDRL/RPR Serum B12 MRI Brain & Spine LP CSF analysis Visual evoked potentials
55 M with tingling and numbness in his hands and feet (gloves and stocking) for the past 2 months. He has a history of diabetes mellitus and hypertension and alcoholism. There is decreased soft touch, vibratory and position sense in the feet, reflexes are absent.
DDx DIABETIC PERIPHERAL NEUROPATHY Alcoholic peripheral neuropathy B12 deficiency Uremic nephropathy Hypocalcemia Hyperventilation Paraproteinemia/myeloma
Workup HbA1c Glucose ESR Calcium Serum B12 UA Thyroid function test Urea Electrolytes Serum and urine protein electrophoresis Electromyography Nerve conduction studies
40 F presents with occasional double vision and droopy eyelids at night with normalization by morning. Her past medical history is significant for hypothyroidism.
DDx MYASTHENIA GRAVIS Intracranial neoplasm compressing CN III IV or VI Horner syndrome Botulism
Workup Ice pack test Tensilon (endrophonium test) Anti ACh receptor antibodies Electromyography Nerve conduction studies CXR CT Chest MRI Brain
25 M hemiparesis after a tonic clonic seizure that resolved within a few hours.
DDx TODD paralysis TIA Stroke Intracranial neoplasm Hemiplegic migraine Head injury Hypoglycemia Malingering
Workup CBC Glucose Electrolytes Toxin levels EEG CT Brain MRI Brain Doppler US Carotid
56 Obese F c/o tingling and numbness of her thumb, index 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 20lb weight gain over the same period.
DDx CARPAL TUNNEL SYNDROME SECONDARY TO OVERUSE Overuse injury of median nerve Cervical disc disease Medial epicondylitis
Workup TSH CBC Electromyography Nerve conduction study
40 F feeling tired, hopelessness and worthlessness and having suicidal thoughts. She lost her job and has been having fights with her husband about money.
DDx DEPRESSION Adjustment disorder Hypothyroidism Anemia
Workup PHQ 9 Beck Depression Inventory TSH CBC
