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1
Q

48yo F epigastric pain: DD and workup

A
  1. PUD
  2. Cholecystitis
  3. Gastritis
  4. Functional or nonulcer dyspepsia
  5. Perforated ulcer
  6. Gastric CA

PUD
Rectal exam, occult blood (PUD)
Upper endoscopy (PUD, Gastric CA, Perforation)

Acute Chole
AST/ALT/Bili/Alk Phos/Lipase (Acute chole)
U/S Abd (acute chole)
HIDA (acute chole)

Gastritis
H.Pylori antibody testing (gastritis)

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2
Q

21yo F RLQ pain: DD and workup

A
  1. PID
  2. Appendicitis
  3. Ruptured ectopic
  4. Ruptured ovarian cyst
  5. Adnexal torsion
  6. Gastroenteritis
  7. Abortion
  8. Endometriosis

Appi

  1. Rectal exam (Appi)
  2. CBC (Api)

PID

  1. Pelvic exam (PID)
  2. Cervical cultures (PID)

Ectopic

  1. Urine HCG (ectopic)
  2. U/S abd/pelvis (GI/GU)
  3. CT abd/pelvis (GI/GU)
  4. Laparoscopy (GI/GU)

UTI
5. UA (UTI)

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3
Q

21yo F RLQ pain: PE

A

Appi

  • psoas
  • obturator
  • rovsing’s

UTI/Pyleo
-CVA tenderness

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4
Q

74yo M with pain in R arm: DD and workup

A
  1. humeral fracture
  2. osteoporosis
  3. shoulder dislocation
  4. elder abuse
  5. rotator cuff tear

Humeral fracture/shoulder dislocation
1. XR: R shoulder/arm AP and lateral

Rotator Cuff tear
2. MRI: shoulder

Osteoporosis
3. DEXA bone scan

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5
Q

21yo M with sore throat: DD and workup

A
  1. infectious mononucleosis
  2. acute HIV infection
  3. viral pharyngitis
  4. bacterial pharyngitis

Infectious Mononucleosis

  1. CBC
  2. Peripheral Smear
  3. Monospot
  4. Anti-EBV antibodies

Bacterial/Viral Pharyngitis

  1. Rapid streptococcal antigen
  2. Throat culture

Acute HIV infection
7. HIV antibody and viral load

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6
Q

55yo M with blood in stool: DD and workup

A
  1. Colorectal CA
  2. Hemorrhoids
  3. Diverticulosis
  4. Angiodysplasia
  5. Pseudomembranous Colitis (C. Diff)
  6. Other infectious colitis
  7. UC

Colorectal CA

  1. Rectal exam (occult blood)
  2. CBC
  3. Colonoscopy
  4. Flexible proctosigmoidoscopy

Hemorrhoids
5. Anoscopy

Diverticulosis

  1. CT abd/pelvis
  2. Double-contrast (air contrast) barium enema

Infection/Inflammatory Bowel Disease

  1. Stool for C. Difficile toxin
  2. Fecal leukocytes
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7
Q

46yo M with chest pain: DD and workup

A
  1. Myocardial ischemia or infarction
  2. Cocaine-induced myocardial ischemia
  3. GERD
  4. Aortic Dissection
  5. Pericarditis
  6. Pneumothorax
  7. Pulmonary embolism
  8. Costochondritis

Myocardial Ischemia

  1. EKG
  2. Cardiac enzymes (CPK, CPK-MB, troponin)
  3. Transthoracic echo (TTE)
  4. Cardiac catheterization
  5. Cholesterol panel

Aortic Dissection

  1. CXR
  2. Transesophageal echo (TEE)
  3. CT chest with IV contrast

GERD
8. upper endoscopy

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8
Q

7mo M with 1day h/o fever 101F, runny nose, sick contact brother UTI 1 week ago, attends daycare
DD and workup

A
  1. Viral URI
  2. PNA
  3. Meningitis
  4. UTI
  5. Otitis Media
  6. Gastroenteritis
  7. Occult bacteremia

Otitis Media

  1. Pneumatoci otoscopy
  2. Tympanometry

Occult Bacteremia
3. CBC with Diff, blood culture

UTI

  1. UA and urine culture
  2. Renal U/S
  3. Voiding cysturethrogram

Meningitis

  1. LP with CSF analysis
  2. CT Head

PNA

  1. CXR
  2. Bronchoscopy

Viral URI
8. Serum antibody titers

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9
Q

18mo F with 2day h/o fever, pulling R ear, difficulty swallowing, maculopapular facial rash spread to trunk, daycare.
DD and workup

A
  1. otitis media
  2. meningococcal meningitis
  3. Scarlet fever
  4. fifth disease or other viral exanthem
  5. varicella

Otitis Media

  1. Pneumatic Otoscopy
  2. Tympanometry

Meningitis

  1. LP with CSF analysis
  2. Platelets, PT/PTT, D-dimer, fibrin split products, fibrinogen
  3. CBC with diff, blood culture, UA and Urine Culture

Scarlet Fever
6. Throat culture

Fifth Disase
7. Parvovirus B19 IgM antibody

Varicella

  1. Skin Scrapings
  2. Varicella antibody titer
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10
Q

26yo M presents with 1 week h/o cough, fever, runny nose, sore throat. Extensive sexual history. Productive cough. Stabbing pleuritic pain in R chest. On PE tactile fremitus and decreased breath sounds on R side.
DD and workup

A
  1. URI associated cough
  2. Acute bronchitis
  3. Pneumonia
  4. Pleurodynia
  5. Aspiration
  6. CXR
  7. CBC
  8. Sputum gram stain and culture
  9. Urine Leginonella antigen, serum Mycoplasma PCR, cold agglutinin measurement
  10. Bronchoscopy with bronchoalveolar lavage
  11. Pulse oximetry or ABG
  12. HIV antibody
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11
Q

54yo F with PMH chronic bronchitis 2/2 smoking history presents with 1mo h/o productive cough with blood streaks, weight loss, exposed to TB at work.
DD and workup

A
  1. Pulmonary TB
  2. lung CA
  3. Lung abscess
  4. Atypical PNA
  5. Typical PNA
  6. COPD exacerbation
  7. Wegener’s granulomatosis
  8. CBC
  9. C-ANCA
  10. Blood cultures
  11. PPD
  12. Sputum: gram stain, AFB smear, routine cultures, mycobacterial cultures, cytology
  13. CXR: PA and lateral
  14. CT chest
  15. Bronchoscopy
  16. Lung biopsy
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12
Q

52yo F with 3wk h/o jaundice, light stools, dark urine, RUQ pain dull intermittent.
DD and workup

A
  1. Extrahepatic biliary obstruction
    - Pancreatic CA
    - Choledocholithiasis
    - Chonangiocarcinoma
    - Carcinoma of the ampulla
    - sphincter of oddi dysfunction
  2. Viral hepatitis
  3. Acetaminophen liver toxicity
  4. Alcohol hepatitis
  5. Primary Biliary Cirrhosis
  6. AST/ALT/bilirubin/alk phos
  7. CBC (chronic liver dx –> splenomegaly –> low platelets)
  8. PT/PTT (coagulopathy 2/2 liver failure)
  9. Viral hepatitis serologies
  10. Acetaminophen level
  11. Abd U/S
  12. Abd CT
  13. MRCP/ERCP
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13
Q

Neurological Exam

A
  • Mini-mental status exam
  • CNs 2-12: visual acuity, H test, facial sensation + motor, auditory, “ahhh”, twist head, tongue protrusion
  • Motor exam
  • Sensory Exam: sensation, sterognosis, graphesthesia, 2 point discrimination
  • DTRs
  • Gait: tandem, walk on heels and toes
  • Cerebellum: finger-nose, heel-shin, rapid hand mvmts
  • Romberg sign
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14
Q

Mini-mental status exam (folstein)

A
  • Orientation to time, place
  • Name 3 objects, ask patient to repeat all 3
  • Serial 7’s from 100 to 5, spell WORLD backwards
  • Ask to recall 3 objects from before
  • Name objects: pencil, watch, phone
  • Repeat “no ifs, and or buts”
  • Follow 3 step command: put paper in R hand.. etc.
  • Obey the following: CLOSE EYES
  • Write a sentence
  • Copy a design
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15
Q

65yo F with 1yr h/o difficulty remembering after death of husband, progressively worse. Problems with daily activities, frequent falls, weakness in LUE 2/2 stroke
DD and workup

A
  1. Alzheimer’s Disease
  2. Vascular dementia
  3. Depression
  4. Hypothyroidism
  5. Vitamin B12 deficiency
  6. Subdural hematoma
  7. CBC (Vit B12 def macrocytic anemia)
  8. Electrolytes, Calcium, glucose, BUN/Cr (metabolic probs can cause cognitive dysfunction)
  9. Serum B12, TSH, RPR (reversible causes)
  10. CT head or MRI brain (mass, hematoma, stroke, normal pressure hydrocephalus)
  11. EEG
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16
Q

56yo M PMH DM last 25yrs presents with episodes of palpatations and diaphoresis after missing meals, inability to maintain erection, loss of sensation in stocking-like distribution
DD and workup

A
  1. Insulin-induced hypoglycemia
  2. Peripheral neuropathy: diabetic or alcoholic
  3. Multiple myeloma
  4. Diabetic autonomic neuropathy, vascular disease or med-induced ED

Diabetes

  1. Serum glucose, HbA1c
  2. UA, urine microalbumin, BUN/Cr
  3. Nerve conduction studies

Erectile dysfunction

  1. Genital Exam
  2. Doppler U/S penis

Multiple Myeloma
4. CBC, SPEP

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17
Q

53yo M with intermittent dizziness last 2 days. Room spinning around him. Episodes last 20mins, progressively worse. Hearing loss in L ear started yesterday. +N/V
DD and Workup

A
  1. Meniere’s disease (episodic vertigo, low-freq hearing loss, tinnitus, aural fullness. Caused by syphilis and head trauma)
  2. Orthostatis hypotension 2/2 dehydration (diarrhea and loop diuretic use)
  3. Benign Paroxysmal Positional Vertigo (transient vertigo with changes in head movement, no hearing loss)
  4. Labyrinthitis (2/2 viral infection, hearing loss, tinnitus, virtigo continuous lasts days-week)
  5. Perilymphatic fistula (hearing loss 2/2 trauma, virtigo lasts seconds)
  6. Acoustic Neuroma
  7. Dix-Hallpike maneuver (BPPV)
  8. VDRL/PRP (r/o syphilus –> Meniere’s disease)
  9. Audiometry (hearing function)
  10. MRI brain (central vestibular lesions)
  11. Brain stem auditory evoked potentials (help dx central vestibular disease)
  12. electronystagmography
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18
Q

Depression Screening

A 
SIG EM CAPS
Sleep 
Interest 
Guilt
Energy 
Mood 
Concentration 
Appetite 
Psychomotor agitation/retardation
Suicidal Ideation
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19
Q

46yo M c/o fatigue last 3 months started after unsuccessful attempt to save friend after car accident, multiple past sexual partners
DD and workup

A
  1. Depression SIG EM CAPS
  2. Adjustment d/o with depressed mood
  3. hypothyroidism
  4. OSA
  5. PTSD
  6. HIV infection (h/o STDs)
  7. CBC (r/o anemia)
  8. TSH (r/o hypothyroidism)
  9. Ambulatory nocturnal oximetry (r/o OSA)
  10. polysomnography (Dx OSA)
  11. HIV antibody (r/o HIV infection)
  12. MRI brain (intracranial mass)
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20
Q

32yo F c/o fatigue and weakness for 5mo, increases during the day, domestic abuse by husband, reports polyuria/polydypsia/nocturia.
DD and workup

A
  1. Domestic Violence
  2. Depression
  3. DM
  4. Diabetes insipidus
  5. Anemia
  6. Myasthenia Gravis
  7. Hypothyroidism

Anemia
1. CBC, iron level, TIBC, ferritin, serum B12 (investigate anemia)

Diabetes Mellitus

  1. UA
  2. Serum glucose, HbA1c

Hypothyroidism
5. TSH

Central DI

  1. Electrolytes (hypernatremia)
  2. MRI brain (mass lesions in central DI)
  3. DDAVP nasal spray test “vasopressin challenge test”
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21
Q

61yo M c/o fatigue and weakness for 6mo. Weight loss, nausea, epigastric pain radiates to back, feels sad, lost interest, drinks alcohol
DD and workup

A
  1. Depression, SIG EM CAPS
  2. Pancreatic CA: weight loss, epigastric pain to rads to back, depression may be an early finding
  3. Chronic pancreatitis: alcohol use
  4. PUD: epigastric pain (h/e wt loss unusual)
  5. Hypothyroidism: fatigue, weakness
  6. CBC, stool for occult blood: blood loss 2/2 PUD
  7. Glucose: screen for DM 2/2 pancreatic dysfunction
  8. Amylase, lipase
  9. AST/ALT/Bili/Alk Phos
  10. TSH
  11. Abd XR: pancreatic calcification
  12. Abd CT: pancreatic CA
  13. Upper endoscopy: PUD
22
Q

35yo F with headaches 2-3x/day for 2 weeks, last 1-2hrs, pounding, right hemisphere, worse with stress and light, alleviated with darkness.
DD and workup

A
  1. Migraine: POUND criteria
  2. Tension HA
  3. Depression
  4. Pseudotumor cerebri
  5. Intracranial mass lesion
  6. Cluster HA
  7. Sinusitis
  8. CBC: look for leukocytosis
  9. CT head or MRI brain: severe acute HA, chronic unexplained HA or positive neurological exam.
  10. LP: opening pressure in pseudotumor cerebri
  11. CT sinus: sinusitis
23
Q

migraine criteria

A 
POUND
Pulsatile
One day duration
Unilateral 
Nausea/Vomiting
Disabling in intensity
24
Q

57yo M presents to the ER with bloody urine, CVA tenderness R, polyuria, straining, nocturia, weak stream, dribbling
DD and workup

A
  1. Bladder CA: cigarette smoking
  2. Urolithiasis: sudden severe colicky pain
  3. Benign Prostatic Hypertension: usually hematuria is microscopic
  4. Prostate CA
  5. Renal cell CA: hematuria, flank pain, palpable mass
  6. Glomerulonephritis
  7. UTI: hematuria, unusual in males
  8. Genital exam
  9. rectal exam
  10. UA: RBC casts = glomerular dx
  11. Urine Cx r/o UTI
  12. Urine cytology
  13. BUN/Cr
  14. PSA
  15. Renal U/S
  16. Cystoscopy
  17. CT abd/pelvis
  18. IVP
25
Q

differential diagnosis of hematuria:

A 
HITTERS
Hematologic or coagulation d/o
Infection 
Trauma
Tumor
Exercise
Renal d/o 
Stones

clots = bleeding from lower urinary tract
gross blood = malignancy

26
Q

54yo M with HTN f/u started on HCTZ and propronolol, presents with ED and decreased libido
DD and workup

A
  1. Drug induced erectile-dysfunction (antihypertensives, alcohol, Beta-blockers also decrease libido)
  2. Hypogonadism (low testosterone 2/2 age)
  3. ED caused by vascular disease (A/W angina, PVD, diminished pulses, hair loss on legs).
  4. Depression (psychogenic causes can decrease libido and erections)
  5. Alcohol-related ED
  6. Peyronie’s Disease: fibrous plaque of tunica albuginea can cause penile scarring and ED
  7. Genital Exam r/o peyrione’s dx
  8. Rectal exam r/o prostate dx or masses
  9. Serum glucose r/o DM causing ED
  10. Testosterone r/o hypogonadism
  11. LH/FSH r/o hypogonadism
  12. Prolactin, TSH r/o pituitary abnormalities
  13. Ferritin r/o hemochromatosis
  14. MRI brain r/o pitutary lesion
  15. Doppler U/S Penis assess blood flow
  16. Dynamic cavernosography
  17. BUN/Cr, electrolytes, cholesterol, UA, EKG: long term care of HTN and HLD
27
Q

33yo F with 2day h/o knee pain, no trauma, h/o fatigue and painful wrists and fingers, morning stiffness last 6mo, oral ulcers, raynaud’s, weight loss.
DD and workup

A
  1. Gout
  2. Pseudogout
  3. SLE
  4. RA
  5. Gonococcal septic arthritis
  6. Nongonococcal septic arthritis
  7. Osteoarthritis
  8. Pelvic exam and cultures (Gonococcal septic arthritis)
  9. Knee aspiration and synovial fluid analysis (r/o septic arthritis, gout, pseudogout)
  10. XR knee and hands (r/o RA, gout, pseudogout, OA)
  11. CBC (low in SLE, leukocytosis in gout + septic arthritis)
  12. ANA, anti-dsDNA, RF (SLE, RA)
  13. Blood culture (septic arthritis)
28
Q

66yo M presents with R hand tremor occurs at rest, worse with fatigue, bradykinesia, muscle rigiditiy
DD and workup

A
  1. Parkinson’s Disease (resting tremor 6Hz freq, rigidity, bradykinesia, postural instability)
  2. Essential Tremor (worse when hand stretched out or action tremor worse at end of movement FTN)
  3. Physiologic tremor (10hz, worse with meds, anxiety, excitement, caffeine)
  4. midbrain lesion (2/2 trauma, stroke, demyelination)
  5. Drug-induced tremor (BB, nicotine, TCAs, steroids)
  6. Psychogenic tremor
  7. Wilson’s disease (resting tremor
  8. Hypterthyroidism
  9. TSH: screen for hyperthyroidism
  10. Heavy metal screen: mercury, arsenic toxicity
  11. MRI brain (midbrain, BG)
  12. Ceruloplasmin, slit lamp, AST/ALT, CBC, 24-hr urinary copper, liver biopsy
29
Q

49yo M presents with syncope a few hours ago, suddently felt light headed, palpatations, LOC, fell. Unconcious with shaking for 30sec. No confusion or neurological defects following.
DD and Workup

A
  1. Convulsive syncope (seizure-like activity after syncope, no seizure workup required)
  2. Vasovagal syncope (preceded by N/sweating/tachy/feeling faint, postmicturition syncope)
  3. Cardiac arrhythmia: EKG, Holter monitor, ECHO
  4. Drug-induced orthostatic hypotension
  5. Seizure: EEG, MRI
  6. Aortic Stenosis: ECHO

Workup

  1. CBC, electrolytes: r/o anemia, electrolyte imb
  2. CXR r/o lung mass or cardiomyopathy
  3. CT head r/o brain mass/hemorrhage or MRI brain for focal deficits
  4. EKG, Holter r/o arrhythmia
  5. ECHO r/o aortic stenosis or atrial myxoma
  6. Prolactin elevated 1hr following gen seizure
  7. EEG r/o seizure activity
30
Q

30yo F with PMH Bipolar d/o treated with lithium presents with 20lb weight gain over 3months. Recently stopped smoking. Dry skin, cold intol.
DD and workup

A
  1. Smoking cessation (gain 5lbs)
  2. Hypothyroidism: TSH
  3. Lithium-related obesity (wt gain S/E)
  4. Familial obesity: screen for comp (Glu, HLD, TG)
  5. Pregnancy (urine hCG)
  6. Cushing’s syn (dexamethasone suppression test, 24-hr urine free cortisol)
  7. TSH (hypothyroidism)
  8. urine hCG (pregnancy)
  9. Glucose, cholesterol, TG (complications of obesity)
  10. Dexamethasone supp test (cushing)
  11. 24hr urine free cortisol (cushing)
31
Q

36yo F with amenorrhea for 3mo, milky d/c from breast, abnormal facial hair, weight gain.
DD and workup

A
  1. Pregnancy: urine hCG
  2. Hyperprolactinoma: prolactin, MRI brain
  3. PCOS: LH/FSH, testosterone, DHEAS, exam
  4. Thyroid disease: hyper or hypo TSH
  5. Premature ovarian failure: LH/FSH
  6. Asherman’s syndrome
  7. Pelvic/breast exam: visualization
  8. Urine hCG: preg
  9. LH/FSH: PCOS
  10. Prolactin/TSH: thyroid and hyperprolactinemia
  11. Electrolytes, glucose,BUN/Cr, ALT/Bili/Alk Phos: renal and hepatic function, hypercortisolism
  12. Testosterone, DHEAS: hyperandrogenism 2/2 PCOS or ovarian/adrenal tumors
  13. MRI brain: pituitary
  14. Hysteroscopy: Asherman’s
32
Q

28yo F presents with dysparunia superficially and with deep thrusting, white d/c, fishy odor, vaginal pruritus.
DD and Workup

A
  1. Vulvovaginitis: pelvic exam, wet mount, KOH prep, “whiff” test
  2. Cervicitis: cervical cultures
  3. Endometrosis: laparoscopy
  4. Vulvodynia
  5. Domestic violence
  6. Pelvic tumor: Pelvic CT
  7. Vaginismus: fear of intercourse
  8. Pelvic exam
  9. Wet mount, KOH prep, “whiff” test (BV “fishy odor” after KOH, candida hyphae, trichomonas motile)
  10. Cervical cultures
  11. Imaging r/o masses
  12. Laparoscopy: gold standard for endometriosis dx
33
Q

51yo construction worker c/o lower back pain s/p lifting heavy boxes 1 wk ago. Pain is 8/10 sharp and radiates to L thigh and foot. Worse w/ movement. Difficulty urinating and incomplete emptying of bladder 6mo ago.
DD and workup

A
  1. Disk herniation
  2. Lumbar muscle strain
  3. Degenerative arthritis
  4. Lumbar spinal stenosis
  5. Metastatic prostate CA
  6. Multiple myeloma
  7. Malingering
  8. Rectal exam: saddle anesthesia, prostate mass, sphincter tone
  9. XR lumbar spine: degeneration, masses, stenosis
  10. MRI lumbar spine: herniation
  11. PSA: prostate CA
  12. CBC, Ca, BUN/CR: multiple myeloma
  13. serum and urine protein electrophoresis: MM
34
Q

6mo F with 1day h/o diarrhea, weakness, drowsiness, fever 100.5, 6 watery BM/day, no blood, no urination.
DD and workup

A
  1. Rotavirus: causes 60% of acute ped infectious diarrhea
  2. Bacterial diarrhea: Shigella, Salmonella, Campylobacter, Yersinia
  3. Malabsorption: milk intolerance, too young for juice
  4. UTI or pyelonephritis: diarrhea can be a response
  5. Intissusseption: Abd pain, vomiting, bloody stools
  6. Bacteremia: fever, drowsiness, no UOP
  7. Rotavirus enzyme immunoassay
  8. Electrolytes
  9. Stool leukocytes, Culture, Ova and parasitology, pH
  10. UA
  11. Abd XRay
  12. Blood Cx
35
Q

A 75yo M presents with bilateral hearing loss 1 yo progressively worsening. No ear pain, discharge, vertigo, LOB or trauma.
DD and workup

A
  1. Presbycusis = age related hearing loss
  2. Cochlear nerve damage due to loud noise
  3. Otosclerosis = elderly, conductive hearing loss
  4. Meniere’s disease (2/2 trauma, syphilis)
  5. Ototoxicity (asprin, ABX)
  6. Acoustic neuroma
  7. Audiometry (assess hearing)
  8. Tympanography (conduction of sound in middle ear)
  9. Brain stem auditory evoked potentials
  10. CT head r/o intracranial process, bleed
  11. VDRL/RPR r/o syphilis a/w meneire’s dx
36
Q

8yo M continuing to wet the bed, never had continence, no dysuria, hematuria, fever or urgency. No abd pain or constipation. No recent stress in family.
DD and workup

A
  1. Monosymptomatic primary nocturnal enuresis
  2. Secondary enuresis
  3. UTI
  4. Constipation (may put pressure on bladder)
  5. Sleep apnea (enuresis a/w sleep apnea + narcolepsy)
  6. Functional bladder disorder
  7. Genital exam (examine genitals for abnormalities)
  8. UA
  9. Urine culture
  10. First-morning urine specific gravity (indicates if ADH released)
  11. Renal U/S (look for structural abnormalities)
  12. BUN/Cr to evaluate renal function
37
Q

25yo M presents hours after MVA with L chest pain, LUQ pain, L pleuritic pain with decreased breath sounds, recent diagnosis of infectious mononucleosis. Reports dyspnea and productive cough with low grade fever.
DD and workup

A
  1. Pneumothorax = trauma, dyspnea
  2. Hemothroax = trauma, dyspnea
  3. Pneumonia = resp distress, cough, fever
  4. Rib fracture = L chest pain and pleuritic pain
  5. Splenic rupture 2/2 mono
  6. Pleuritis = viral inflammation of pleura
  7. CXR r/o pneumothorax and hemothroax
  8. CT abd r/o free air in abd and splenic laceration
  9. Pulse Oximetry
  10. Urine toxicology
  11. Blood alcohol level
  12. Sputum gram stain and culture (PNA)
38
Q

25yo F presents to the ED after being sexually assaulted. Presents with SOB and palpitations. R chest pain is non-radiating, exacerbated by movement and deep breaths and relieved by sitting still.
DD and workup

A
  1. Rib/bone fracture (2/2 trauma, causes pain on inspiration and cough)
  2. Pneumothorax/hemathorax: CXR
  3. STDs: sexual assault victims require Trichomoniasis, chlamydia, gonorrhea, HIV and Hep B
  4. Pregnancy: all sexual assault victims
  5. Pelvic exam: evaluate for trauma
  6. Urine hCG: preg
  7. Wet mount, KOH prep, cervical culture
  8. XR skeletal survey: look for broken bones
  9. HIV antibody, VDRL, HBV antigen
  10. CXR: pneumothorax, pleural effusions, rib fractures
  11. Evidence collection using rape kit
39
Q

” PEARLS”

A

Partnership, Empathy, Apology, Respect, Legitimization, Support

Partnership: work together with ur patient to identify the main concerns ( let’s deal with this together, …or we can do this…use these type of sentence )

Empathy: acknowledge and show understanding of the patient’s feelings (that sounds hard,…you look upset…)

Apology: take personal responsibility when it is appropriate to do so ( I’m sorry I was late,…or even I’m sorry this happened to you)

Respect: value the patient’s choices, behaviors, and decisions ( you have obviously worked hard on this…)

Legitimization: validates and shows understanding for the patient’s feelings and choices ( Anyone would be confused or sad or upset by this situation )

Support: should be continually offered to the patient ( I’ll be here when you need me…)

40
Q

28yo G0 presents with positive pregnancy test. FH of diabetes, thyroid problems and obesity.
DD and workup

A
  1. Normal pregnancy
  2. Ectopic pregnancy
  3. Molar pregnancy
  4. Breast/pelvic exam
  5. Urine hCG
  6. U/S pelvis (intraurterine vs. extrauterine)
  7. CBC, serum glucose (FH diabetes and anemia)
  8. TSH (FH thyroid problems).
  9. RPR, rubella IgG, HBsAg, HIV antibody (prenatal trans)
  10. Blood type, Rh, antibody screen (Rho antibody)
  11. Pap smear (r/o cervical dysplasia and CA)
  12. Cervical GC DNA testing
  13. UA, urine culture (pregnant women at risk UTIs)
41
Q

20yo F college student presents with insomnia. Very stressed about about school performance. She drinks 5 cups of coffee/day, has lost weight, sweaty palms.
DD and workup

A
  1. Anxiety
  2. Caffeine-induced insomina
  3. Hyperthyroidism
  4. Insomnia due to depression
  5. Adjustment insomnia 2/2 any significant life event
  6. Illicit drug use
  7. OSA
  8. TSH, free T4 r/o hyperthyroidism
  9. CBC with diff, chem 8 r/o cancer (wt loss, fatigue)
  10. Urine toxicology r/o stimulant use
  11. Polysomnography r/o OSA
  12. ECG: changes 2/2 hyperthyroid and anxiety d/o
42
Q

27yo M presents with hearing voices and seeing strange writing on the wall since yesterday. Believes someone may be sending him messages. Admits to illicit drug use 2 days before. Has h/o PCP, MDMA (ecstacy).
DD and workup

A
  1. Substance-induced psychosis
  2. Brief psychotic d/o 2/2 stressful event
  3. Psychosis 2/2 medical condition
  4. Narcolepsy: visual hallucinations before falling asleep
  5. Seizure: visual hallucinations of epileptic origin
  6. Urine toxicology
  7. Mental status exam: neurologic d/o
  8. electrolytes: detect underlying medical condition
  9. LFT: detect underlying medical condition
  10. TSH, free T4: detect underlying medical condition
  11. EEG: seizure activity
  12. Polysomnogram: narcolepsy
43
Q

10yo F presents with 1mo diagnosis of DM (unknown type), presented with excessive thirst and urination. Mom comes to the office because she is concerned.
DD and workup

A
  1. T1 DM
  2. T2 DM
  3. Secondary cause of DM such as Cushing’s
  4. Basal metabolic profile: serum electrolytes and glucose
  5. HgA1C
  6. UA, urine microalbumin
  7. Insulin and C-peptide levels: can identify T1DM
  8. Islet cell antibodies: identify T1DM
  9. 24-hour urine free cortisol (r/o coexisting Cushing’s)
44
Q

35yo F presents with R calf pain few days duration. Constant pain, aggravated by walking and extending knee. A/w swelling, redness, warmth. Recent 15hr flight. Bandage on skin from recent fall. +Homan’s sign. FH of DVT
DD and workup

A
  1. DVT
  2. Cellulitis
  3. Rupture of Baker’s cyst
  4. Hematoma
  5. Rupture of medial head of gastrocnemius
  6. spasm due to injury or sprain
  7. Doppler U/S: DVT
  8. D-dimer: DVT
  9. Hypercoagulability testing: underlying condition
  10. CBC with diff: infection, leukocytosis
  11. CPK and myoglobin levels: muscle injury
  12. CT venography: DVT
  13. MRI: DVT
45
Q

31yo M presents with pain on plantar surface of R heel, training for a marathon, worse in the morning and after prolonged sitting.
DD and workup

A
  1. Plantar Fasciitis
  2. Calcaneal stress fracture
  3. Achilles Tendinitis
  4. Retrocalcaneal Bursitis
  5. Tarsal tunnel syndrome
  6. Foreign body
  7. Ankle sprain
  8. XR right ankle: check for bone spurs or calcification
  9. Bone Scan r/o calcaneal stress fracture
  10. MRI r/o soft tissue involvement
46
Q

5day old M presents with yellow discoloration of the eyes and skin for 2 days
DD and workup

A
  1. Physiologic Jaundice
  2. ABO or Rh incompatibility
  3. Neonatal sepsis
  4. Cephalohematoma
  5. Breast-FEEDING jaundice
  6. Polycythemia
  7. Familial neonatal hyperbilirubinemia
  8. Total and indirect bilirubin: phototherapy when >15
  9. Blood typing
  10. Direct Coombs test
  11. CRP: infection
  12. CBC: H/H for hemolysis, infection
  13. Titers for CMV, toxo, rubella: TORCH infections
47
Q

DD for 1-2week old infant jaundice (late onset)

DD and workup

A
  1. Breast milk jaundice
  2. Biliary atresia
  3. Metabolic disorders: hypothyroid, galactosemia, spherocytosis, G6PD
48
Q

2yo F c/o sudden noisy breathing progressively worse, was playing with toys, consistent sound heard best on inhalation.
DD and workup

A
  1. Foreign body aspiration
  2. Croup: barking cough, 6mo-3yrs
  3. Laryngitis: hoarse voice, 5+yrs
  4. Epiglottitis: drooling, better leaning forward, 2-6yo
  5. Retropharyngeal abscess: muffled, drooling, less than 6yo
  6. Angioedema: stridor and facial edema
  7. Peritonsillar abscess: sore throat and tonsillitis, 10+
  8. Laryngeal papilloma: hoarse voice, 3mo-3yo
  9. ABG: assess ventilation
  10. CXR: PA and lateral
  11. XR neck: AP and lateral (steeple sign, thumbprint sign)
  12. CBC with diff: r/o infection
  13. Direct laryngoscopy: laryngomalacia or lesions
  14. Bronchoscopy: foreign body aspiration
49
Q

32yo M presents for pre-employment medical exam. Chronic cough for many years, productive white sputum 1/2 tsp. Immigrated from Africa 1 mo ago. Chronic smoker. Past work history of coal miner. Never tested for TB.
DD and workup

A
  1. Pulmonary TB (immigrant)
  2. COPD/chronic bronchitis (smoking history)
  3. Pulmonary silicosis (h/o coal mining)
  4. Asthma (can cause chronic cough)
  5. GERD (can cause chronic cough)
  6. CXR: PA and lateral: TB, silicosis, cough, asthma
  7. PPD: TB
  8. Sputum gram stain, AFB smear, routine and mycobacterial sputum cultures: infection
  9. CBC: infection
50
Q

62yo M presents with hoarseness x3mo, weight loss, fatigue, smoking and drinking history, FH hypothyroidism and lung cancer. Flu 1 wk ago.
DD and workup

A
  1. Laryngeal cancer (drinking, smoking)
  2. Vocal cord polyps/nodules (overuse voice)
  3. Laryngitis (flu, viral infection)
  4. Hypothyroidism (causes hoarseness, FH)
  5. Mitral valve stenosis (LAE, compress recurrent laryn n)
  6. CBC: infection, anemia a/w hypothyroidism
  7. Laryngoscopy: gold standard for larynx evaluation
  8. TSH: hypothyroidism
  9. CT chest/neck: mass growth
  10. ECHO (MVS)
51
Q

67yo F presents with 2day h/o neck pain/stiffness and LUE numbness. Happened after quick rotation to the left. Recent weight loss. PMH osteopenia on DEXA.
DD and workup

A
  1. disk herniation: radiculopathy
  2. cervical fracture 2/2 osteopenia
  3. neck muscle strain
  4. osteoarthritis: compression of nerves
  5. cervical spondlosis
  6. metastatic cancer: wt loss, spinal lesion, metastatic CA
  7. multiple myelomaL spinal lesions
  8. C-spine X-ray: radiculopathy
  9. C-spine MRI:
  10. Nerve conduction studies: cause of loss of sensation
  11. CBC, calcium, BUN/Cr: multiple myeloma
  12. Serum and urine protein electrophoresis
52
Q

11mo F presents with tonic-clonic seizure, 2 day h/o fever 102.9, decreased PO and UOP, postictal drowsiness
DD and workup

A
  1. simple febrile seizures: isolated seizure
  2. meningitis: kid 102
  3. LP: meningitis
  4. CBC, electrolytes: infection, electrolyte ab
  5. Blood Cx, UA, Urine Cx: septic
  6. CT head: brain abscess, encephalitis, hemorrhage
  7. EEG: epileptic activity

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