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
44M fatigue, insomnia and nightmares about a murder he witnessed in a mall 1 year ago. Since then he has avoided the mall and has not gone out at night.
DDx POST TRAUMATIC STRESS DISORDER Depression Generalized anxiety disorder Psychotic or delusional disorder Hypothyroidism
Workup PHQ 9 Beck depression inventory CBC TSH Urine toxicology
55 M fatigue, weight loss, and constipation. He has a family history of colon cancer.
DDx COLON CANCER Hypothyroidism Renal failure Hypercalcemia Depression
Workup Rectal exam with stool guaiac test CBC CMP TSH Colonoscopy Barium enema CT Abdomen/Pelvis
40 F fatigue, weight gain, sleepiness, cold intolerance, constipation and dry skin.
DDx HYPOTHYROIDISM Depression Diabetes Anemia
Workup TSH FT3 FT4 CBC Fasting glucose HbA1c
50 obese F presents with fatigue and daytime sleepiness. She snores heavily and naps 3-4 times a day but never feels refreshed. She also has hypertension.
DDx OBSTRUCTIVE SLEEP APNEA Hypothyroidism Chronic fatigue syndrome Narcolepsy
Workup CBC TSH Nocturnal pulse oximetry Polysomnography ECG
20M presents with fatigue, thirst, increased appetite, polyuria,
DDx DIABETES MELLITUS Atypical depression Primary polydipsia Diabetes insipidus
Workup HbA1c Glucose tolerance test UA CBC Electrolytes BUN Crea Fasting glucose
35 M policeman feeling tired and sleepy during the day. He changed to the night shift last week.
DDx Shift Work Sleep disorder Sleep Apnea Depression Anemia Circadium rhythm disorder?
Workup
CBC
Nocturnal pulse oximetry
Polysomnography
30M presents with night sweats, cough, and swollen glands of 1 month duration. He recently immigrated from the African subcontinent.
DDx TUBERCULOSIS Acute HIV infection Lymphoma Leukemia Hyperthyroidism
Workup PPD QuantiFERON-TB Gold CBC CXR Sputum Gram stain, acid fast stain and culture HIV Antibody & RNA levels TSH FT4 CT Chest
45 F presents with excessive sweating, unintentional weight loss, palpitations, diarrhea and shortness of breath
DDx HYPERTHYROIDISM Pheochromocytoma Carcinoid syndrome Tuberculosis
Workup TSH, FT4 24h urinary catecholamines 5 HIAA CBC PPD
25 F presents with 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 3-4 cups of coffee a day.
DDx
STRESS INDUCED insomnia
Caffeine induced insomnia
Insomnia with circadian rhythm sleep disorder
Insomnia related to major depressive disorder
Workup Polysomnography Urine toxicology CBC TSH
55 M obese with several months of poor sleep, daytime fatigue, and morning headaches. His wife reports that he snores loudly
DDx
OBSTRUCTIVE SLEEP APNEA
Daytime fatigue in primary hypersomnia
Insomnia with circadian rhythm sleep disorder
Insomnia related to major depressive disorder
Workup Polysomnography ECG CBC TSH
33 F 3 weeks fatigue and trouble sleeping. She falls asleep easily and wakes up at 3am and cannot return to sleep. She also reports an unintentional weight loss of 8lbs and an inability to enjoy the things she once liked to do.
DDx
INSOMNIA RELATED TO MAJOR DEPRESSIVE DISORDER
Primary hypersomnia
Insomnia with circadian rhythm sleep disorder
Workup
TSH
CBC
Polysomnography
26 F with sore throat, fever, severe fatigue, loss of appetite for the past week. She also reports epigastric and LUQ discomfort. She has cervical lymphadenopathy and a rash. Her boyfriend recently experienced similar symptoms.
DDx INFECTIOUS MONONUCLEOSIS Hepatitis Viral or bacterial pharyngitis Acute HIV infection Secondary syphilis
Workup CBC w differential and peripheral smear Mnospot test Throat culture AST/ALT/Bilirubin/alkaline phosphatase HIV antibody and viral load Anti EBV antibodies VDRL/RPR
26 M sore throat, fever, rash and weight loss. History of IV drug abuse
DDx HIV acute retroviral syndrome Infectious mononucleosis Hepatitis Viral pharyngitis Streptococcal tonsilitis/scarlet fever Secondary syphilis
Workup CBC with differential and peripheral smear Throat culture HIV antibody and viral load CD4 count Monospot test LFTs VDRL/RPR
46 F fever and sore throat
DDx PHARYNGITIS (Bacterial or viral) Mycoplasma pneumonia Acute HIV infection Infectious mononucleosis
Workup
Centor criteria
Throat swab for culture and rapid strepococcal antigen
Monospot test
CBC
Serology test (cold agglutinin titer) for mycoplasma
HIV antibody and viral load
30 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.
DDx ASTHMA GERD Bronchitis Pneumonitis
Workup CBC CXR Peak flow measurement PFTs
56 F 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.
COPD - chronic bronchitis COPD - emphysema Bronchiectasis Lung cancer Tuberculosis
Workup CBC Sputum gram stain and culture CXR PFTs CT Chest QuantiFERON TB Gold
58 M with 1 week of pleuritic chest pain, fever, chills, and cough with purulent yellow sputum. He is a heavy smoker with preexisting COPD
DDx PNEUMONIA COPD exacerbation (bronchitis) Lung abscess Lung Cancer Tuberculosis Pericarditis
Workup CBC Sputum gram stain and culture CXR CT Chest ECG QuantiFERON TB Gold
25 F 2 weeks of nonproductive cough. Three weeks ago, she had a sore throat and runny nose.
DDx ATYPICAL PNEUMONIA Asthma URI Associated cough (post infectious) Post nasal drip GERD
Workup CBC Induced sputum Gram stain and culture CXR IgM detection for Mycoplasma pneumoniae Urine Legionella antigen
65 M with 6 months of worsening cough, accompanied by hemoptysis, dyspnea, weakness, and weight loss. He is a heavy smoker.
DDx LUNG CANCER Tuberculosis Lung Abscess COPD Vasculitis Interstitial Lung disease CHF
Workup CBC Sputum Gram stain culture and cytology CXR CT Chest QuantiFERON TB Gold ANCA Broncoscopy Echocardiography
55 M 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.
DDx COPD EXACERBATION (bronchitis) Lung Cancer Pneumonia URI CHF
Workup CBC CXR ABG PFTs Sputum gram stain and culture CT Chest Echo cardiography
34 F Nurse with worsening cough for 6 weeks duration accompanied by weight loss, fatigue, night sweats and fever. She has a history of contact with tuberculosis patients at work.
DDx TUBERCULOSIS Pneumonia Lung Abscess Vasculitis Lymphoma Metastatic Cancer HIV AIDS Sarcoidosis
Workup CBC PPD/QuantiFERON Gold Sputum gram stain, acid fast stain and culture CXR CT Chest Broncoscopy HIV Antibody Lymph node biopsy
35 M shortness of breath and cough. He has had unprotected sex with multiple sexual partners and was recently exposed to a patient with active tuberculosis.
DDx TUBERCULOSIS Pneumonia (including PCP) Bronchitis Asthma Acute HIV infection CHF (cardiomyopathy)
Workup CBC PPD/QuantiFERON TB Gold Sputum gram stain, acid fast stain and culture CXR HIV antibody and viral load Echo cardiography
50 M with cough that is exacerbated by lying down at night and improved by propping himself up on three pillows. He also reports exertional dyspnea
DDx CONGESTIVE HEART FAILURE Cardiac valvular disease GERD Pulmonary fibrosis COPD Post nasal drip
Workup CBC CXR ECG Echo cardiography PFTs BNP CT Chest
60 M with worsening dyspnea of 6 hours duration and a cough that is accompanied by pink, frothy sputum
DDx PULMONARY EDEMA Pneumonia CHF Mitral Valve stenosis Arrythmia Asthma
Workup CXR ECG CBC ABG PFTs BNP
60 M sudden onset of substernal heavy cheset pain that lasted for 30mins and radiates to the left arm. The pain is accompanied by dyspnea, diaphoresis and nausea. He has a history of hypertension, hyperlipidemia and smoking.
DDx MYOCARDIAL INFARCTION GERD Angina Costochondritis Aortic dissection Pericarditis Pulmonary embolism Pneumothorax
Workup ECG CPK MB Troponin CXR CBC Electrolytes Helical CT Echo cardiography Cardiac catherization D Dimer
20 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.
DDx SICKLE CELL DISEASE - Acute chest syndrome Pulmonary embolism Pneumonia Myocardial infarction Pneumothorax Aortic dissection
Workup CBC with reticulocyte count and peripheral smear LDH ABG D Dimer CXR CPK MB Troponin ECG CTA chest with IV Contrast
45 F presents with retrosternal burning sensation that occurs after heavy meals and when lying down. Her symptoms are relieved by antacids.
DDx GERD Esophagitis Peptic ulcer disease Esophageal spasm MI Angina
Workup ECG Barium swallow Upper endoscopy Esophageal pH monitoring H pylori stool antigen
55 M 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.
DDx
STABLE ANGINA
Esophageal spasm
Esophagitis
Workup ECG CPK MD Troponin CXR CBC Electrolytes Exercise stress test Upper endoscopy pH Monitor Cardiac catheterization
34 F retrosternal stabbing chest pain that improves when she leans forward and worsens when with deep inspiration. She had a URI 1 week ago
DDx PERICARDITIS Aortic dissection MI Costochondritis GERD Esophageal rupture
Workup ECG CPK MB Troponin CXR Echo cardiography CBC Upper endoscopy ESR
33 F 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.
DDx Costochondritis Pneumonia MI Pulmonary embolism Pericarditis Pleurisy Muscle strain
Workup ECG CXR CPK MB Troponin CBC
70 F acute onset 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.
DDx PULMONARY EMBOLISM Pneumonia Costochondritis MI CHF Aortic Dissection
Workup D Dimer CTA Chest CXR ECG ABG CPK MB Troponin CBC Electrolytes BUN Crea Glucose Doppler US - legs
55 M sudden onset of severe chest pain that radiates to his back. History of uncontrolled hypertension.
DDx AORTIC DISSECTION MI Pericarditis Esophageal rupture GERD Pancreatitis Fat Embolism
Workup Transthoracic Echocardiogram ECG CPK MB Troponin CXR CBC Amylase/Lipase CTA Chest MRI MRA Aorta Aortic Angiography Upper endoscopy
70 diabetic M episodes of papitations and diaphoresis. He is on insulin.
DDx HYPOGLYCEMIA Cardiac arrhythmia Angina Hyperthyroidism Hyperventilation episodes Panic attack Pheochromocytoma Carcinoid syndrome
Workup Glucose CBC Electrolytes TSH ECG 24 urinary catecholamines 5 HIAA
35 M 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 2-3 minutes. He does not have any history of psychiatric illness except for separation anxiety as a child.
DDx PANIC ATTACK Generalized anxiety disorder Specific phobia Acute stress disorder Hyperthyroidism Substance abuse/dependence Pheochromocytoma
Workup CBC Electrolytes TSH FT4 ECG Echo cardiography Urine toxicology 24 H urinary catecholamines
19 F with episodic palpitations, esp during presentations in front of her class. Episodes include heart pounding, facial blushing and hand tremor. She also experiences excessive sweating 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.
DDx SOCIAL PHOBIA Avoidant personality disorder Agoraphobia/Specific phobia Panic attack Generalized anxiety disorder Substance abuse/dependence Hyperthyroidism
Workup CBC Electrolytes ECG TSH FT4
34 F episodic palpitations accompanied by lightheadedness and sharp, atypical chest pain.
DDx MITRAL VALVE PROLAPSE Cardiac Arrhythmia Panic Attack Pheochromocytoma
Workup ECG TEE Event monitor Holter Monitor 24 h urinary catecholamines
42 F with 15.5lb weight loss within the past 2 months. She has a fine tremor and pulse is 112
DDx HYPERTHYROIDISM Cancer HIV Dieting/Diet Drugs Anorexia nervosa Malabsorption
Workup TSH FT4 CBC BMP HIV antibody Urine toxicology Age appropriate cancer screening
44 F weight gain of >25 lbs in 2 months. She quit smoking 3 months ago and is on amitriptyline for depression. She also reports cold intolerance and constipation.
DDx SMOKING CESSATION Drug side effect Hypothyroidism Cushing Syndrome PCOS Diabetes mellitus Atypical Depression
Workup CBC BMP Glucose TSH 24 H urine free cortisol Dexamethasone suppression test
30 F weight gain over the past 3 months. Also reports tremor, palpitations anxiety and hunger that are relieved by eating. She exhibits proximal muscle weakness and easy bruising.
DDx INSULINOMA Reactive postprandial hypoglycemia Cushing syndrome Pregnancy
Workup Blood glucose Plasma insulin after induced hypoglycemia Glucose tolerance test 24 H urine free cortisol Urine B HCG
75 M dysphagia that started with solids that progressed to liquids. He is an alcoholic and a heavy smoker. He has had unintentional weight loss of 15lbs within the past 4 months.
DDx ESOPHAGEAL CANCER Achalasia Esophagitis Systemic Sclerosis Esophageal stricture
Workup CBC CXR Upper endoscopy with biopsy Barium swallow CT Chest
45 F presents with dysphagia for 2 weeks accompanied by mouth and throat pain, fatigue and craving for ice and clay.
DDx PLUMMER VINSON SYNDROME Esophageal Cancer Diffuse Esophageal Spasm Esophagitis Achalasia Systemic sclerosis
Workup CBC Serum Iron, TIBC Barium Swallow Upper endoscopy Esophageal manometry
48 F 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, esp at night. She has lost 5.5lbs in the past 2 months.
DDx ACHALASIA Plummer Vinson Syndrome Esophageal cancer Esophagitis Systemic sclerosis Esophageal stricture Zenker Diverticulum
Workup CXR Upper endoscopy Barium Swallow Esophageal manometry
38 M with dysphagia and pain on swallowing solids more than liquids. Exam reveals oral thrush.
DDx ESOPHAGITIS (CMV, HSV, HIV, Pill induced) Systemic sclerosis GERD Esophageal stricture
Workup CBC Upper endoscopy Barium swallow HIV antibody and viral load CD4 count
39 F with 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 moveable and has not changed in size. She does NOT report heat intolerance, tremor, palpitations, hoarseness, cough, difficulty breathing, difficulty swallowing or abdominal pain. Her husband was recently discharged from prison and her mother has a history of gastric cancer.
DDx Hodgkin/non-Hodgkin lymphoma Tuberculosis HIV Thyroid nodule Metastatic GI or Head and Neck Malignancy
Workup CBC w differential BMP ESR CRP Lymph node biopsy PPD/QuantiFERON TB Gold CXR TSH HIV Antibody/RNA US Neck Upper endoscopy Fine needle aspiration
20 F nausea, vomiting, (esp in the morning) fatigue and polyuria. Her last menstrual period 6 weeks ago. She is sexually active with her boyfriend and they use condoms.
DDx PREGNANCY Hypercalcemia Diabetes Mellitus Gastritis/GERD UTI Depression Eating disorder Substance use (e.g. alcohol)
Workup Urine HCG Pelvic exam US Transvaginal CBC Electrolytes (Ca, glucose) Liver function test UA Urine culture
45 M sudden onset colicky R sided flank pain that radiates to the testicles, accompanied by N/V hematuria and CVA tenderness
DDx NEPHROLITHIASIS Renal cell carcinoma Pyelonephritis GI Etiology (appendicitis)
Workup UA Urine culture, sensitivity and cytology BUN Crea CT Abdomen US Renal KUB IVP Blood culture
60 M with dull epigastric pain that radiates to the back, accompanied by weight loss, dark urine, and clay colored stool. He is heavy drinker and smoker. He appears jaundiced on exam.
DDx PANCREATIC CANCER Cholangiocarcinoma Primary sclerosing cholangitis Chronic pancreatitis Cholecystitis/choledocholithiasis Acute viral hepatitis Abdominal aortic aneurysm Peptic ulcer disease
Workup CT Abdomen CBC Electrolytes Amylase, lipase AST/ALT/Biliruben/alkaline phosphatase US Abdomen
56 M 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
DDx ACUTE PANCREATITIS Peptic ulcer disease Cholecystitis/Choledocholithiasis Gastritis Abdominal aortic aneurysm Mesenteric ischemia Alcoholic pancreatitis Boerhaave syndrome
Workup CBC Electrolytes BUN Crea Amylase, lipase AST, ALT, Bilurubin, alkaline phosphatase US Abdomen CT Abdomen Upper endoscopy ECG
41 Obese F with RUQ abdominal pain that radiates to the R scapula and is associated with N/V and fever of 101.5. The pain started after she ate fatty food. She has had similar but less intense episodes that lasted a few hours. Exam reveals positive Murphy sign
DDx ACUTE CHOLECYSTITIS Choledocholithiasis Hepatitis Ascending cholangitis Peptic Ulcer Disease Fitz Hugh Curtis syndrome Acute Subhepatic appendicitis
Workup CBC AST ALT Bilirubin Alkaline Phosphatase US Abdomen CT Abdomen Blood culture
43 Obese F presents with RUQ abdominal pain, fever, jaundice. She was diagnosed with asymptomatic gallstones 1 year ago. She is found to be hypotensive on exam.
DDx ASCENDING CHOLANGITIS Acute gallstone cholangitis Acute Cholecystitis Hepatitis Primary sclerosing cholangitis Fitz Hugh Curtis syndrome
Workup CBC AST ALT bilirubin alkaline phosphatase Blood culture Viral hepatitis serologies US Abdomen MRCP ERCP
25 M w RUQ pain, fever, anorexia nausea and vomiting. He has dark urine and clay colored stools
DDx ACUTE HEPATITIS Acute cholecystitis Ascending cholangitis Choledocholithiasis Pancreatitis Primary sclerosing cholangitis Primary biliary cirrhosis Acute glomerulonephritis
Workup CBC Amylase Lipase AST ALT Biliruben Alkaline phosphatase Viral hepatitis serologies UA US Abdomen ERCP MRCP
35 M w burning epigastric pain that starts 2-3 hours after meals. Pain is relieved by food and antacids.
DDx PEPTIC ULCER DISEASE Gastritis GERD Cholecystitis Mesenteric ischemia
Workup Rectal exam, stool for occult blood Amylase, lipase, Lactate AST ALT Bilirubin Alkaline phosphatase CXR KUB CT Abdomen Upper endoscopy H pylori testing Blood culture
18 M boxer w severe LUQ abdominal pain that radiates to the L scapula. He had infectious mononucleosis 3 weeks ago.
DDx SPLENIC RUPTURE Kidney stone Rib fracture Pneumonia Perforated peptic ulcer Splenic infarct
Workup CBC Electrolytes CXR CT Abdomen US abdomen (if hemodynamically unstable)
40M cc crampy abdominal pain, vomiting, adb distension and inability to pass flatus or stool. Hx of multiple abdominal surgeries
DDx
INTESTINAL OBSTRUCTION
Small bowel or colon cancer
Vovulus
Gastroenteritis
Food poisoning
Ileus
Hernia
Workup Rectal exam CBC Electrolytes Abd XR CT abdomen/pelvis w/contrast Colonoscopy
70F cc acute onest severe, crampy abd pain. Recently vomited and had a massive dark bowel movement. Hx of CHF and atrial fibrillation for which she received digitalis.. Pain is out of proportion to exam.
DDx
Mesenteric ischemia/infarction
Diverticulitis
Peptic Ulcer Disease
Gastroenteritis
Acute Pancreatitis
Cholecystitis
Workup Rectal exam CBC Amylase, lipase, lactate ECG XR abd CT abd Mesenteric angiography Barium Enema
21F acute onset of severe RLQ pain, nausea and vomiting. No fever, urinary symptoms, or vaginal bleeding and has never taken OCPs. LMP was regular and no hx of STIs. She has been told that she has a cyst on her R ovary
DDx
OVARIAN TORSION
Appendicitis
Nephrolithiasis
Ectopic Pregnancy
Ruptured Ovarian Cyst
PID
Bowel Infarction or perforation
Workup Pelvic Exam Urine HCG Doppler US Pelvis/transvaginal Rectal Exam UA CBC CT Abdomen Laproscopy Chlamydia and Gonorrhea Testing VDRL/RPR
68M cc LLQ abdominal pain, fever, and chills x3 days. Recent onset of alternating diarrhea and constipation. Consumes low fiber, high fat diet
DDx
Diverticulitis
Crohn Disease
Ulcerative colitis
Gastroenteritis
Abscess
Workup Rectal exam CBC Electrolytes CXR XR Abdominal Blood culture
20M cc severe RLQ abdominal pain, nausea and vomiting. Started yesterday as vague pain around umbilicus. As pain worsened, it became sharp and migrated to RLQ. + Mcburney and psoas
DDx APPENDICITIS Gastroenteritis Diverticulitis Crohn Dse Nephrolithiasis Volvulus or other intestinal obstruction Perforation Acute cholecystitis
Workup CBC w diff Electrolytes XR Abd CT Abd US abd Blood culture
30F cc periumbilical pain x6months. Does not awaken her from sleep. Releived by defecation and worsens when she is upset. Alternating constipation and diarrhea but no N/V/wt loss or anorexia
DDx Irritable Bowel syndrome Crohn dse Celiac dse Chronic pancreatitis GI parasitic infection (amebiasis, giardiasis) Endometriosis
Workup Rectal exam FOBT Pelvic exam Urine HCG CBC Electrolytes Colonoscopy CT Abd pelvis Stool for Ova E histolytica antigen
24F cc bilateral lower abdominal pain started on frist day of menstrual period, associated with fever and thick greenish yellow vaginal discharge. Hx of unprotected sex with multiple partners.
DDX
PID
Endometriosis
Dysmenorrhea
Vaginitis
Cystitis
Spontaneous abortion
Pyelonephritis
Workup Pelvic Exam Urine HCG Cervical cultures CBC ESR UA w culture US pelvis
