STEP 2 CS CASES Flashcards
3 yo M presents with a two-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.
Acute otitis media URI Meningitis UTI W/U: Physical exam (including pneumatic otoscopy) CBC UA
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.
Gastroenteritis (viral, bacterial, parasitic) Food poisoning UTI URI Volvulus Intussusception W/U: Physical exam Stool exam and culture CBC Electrolytes UA urine culture AXR
5 yo M presents with a six-month history of temper tantrums that last 5-10 minutes and immediately follow a disappointment or a discipline. He has no trouble sleeping, has had no change in appetite, and does not display thesebehaviors when he is at day care.
Age-appropriate behavior ADHD Oppositional defiant disorder W/U: Physical exam Mental status exam
9 yo M presents with a two-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 class, regularly interrupts his classmates, and has trouble making friends.
Attention-deficit hyperactivity disorder (ADHD) Oppositional defiant disorder Manic episode Conduct disorder W/U: Physical exam Mental status exam TSH, FT4 EEG
12-month-old M presents with fever for the last two days accompanied by a maculopapular rash on his face and body. He has not yet received the MMR vaccine.
Measles (or other viral exanthem) Rubella Roseola Fifth disease (parvovirus B19) Varicella Scarlet fever Meningitis W/U: Physical exam CBC Viral antibodies/titers Throat swab for culture LP
12 yo F presents with a two-month history of fi ghting 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.
Adjustment disorder Substance intoxication/abuse/dependence Manic episode Oppositional defiant disorder Conduct disorder W/U: Physical exam Mental status exam Urine toxicology
15 yo M presents with a one-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.
Substance abuse Conduct disorder Oppositional defiant disorder Adjustment disorder W/U: Urine toxicology Mental status exam
17 yo F presents with prolonged, excessive menstrual bleeding occurring irregularly over the past six months.
Dysfunctional uterine bleeding
Coagulation disorders (e.g., von Willebrand’s disease, hemophilia)
Cervical cancer
Molar pregnancy
Hypothyroidism
Diabetes mellitus
W/U: Pelvic exam, Urine hCG, Cervical cultures, Pap smear CBC, ESR, glucose, PT/PTT, Prolactin, LH/FSH TSH U/S—pelvis.
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.
Malingering Lumbar muscle strain Disk herniation Knee or leg fracture Ankylosing spondylitis W/U: XR—L-spine/knee MRI—L-spine
18 yo F presents with amenorrhea for the past four months. She has lost 95 pounds and has a history of vigorous exercise and cold intolerance.
Anorexia nervosa W/U: CBC TSH FT4 ACTH FSH LH
18 yo M boxer presents with severe LUQ abdominal pain that radiates to the left scapula. He had infectious mononucleosis three weeks ago.
Splenic rupture Kidney stone Rib fracture Pneumonia Perforated peptic ulcer Splenic infarct W/U: Rectal exam CBC electrolytes CXR CT—abdomen U/S—abdomen
18 yo M presents with a burning sensation during urination and urethral discharge. He recently had unprotected sex with a new partner.
Urethritis Cystitis Prostatitis W/U: Genital ± rectal exam UA Urine culture Gram stain and culture of urethral discharge Chlamydia and gonorrhea PCR
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.
Psoriatic arthritis Rheumatoid arthritis SLE W/U: RF, ANA, ESR, CBC XR—hands XR—pelvis/sacroiliac joints Uric acid
18 yo obese F presents with a pulsatile headache, vomiting, and blurred vision for the past 2-3 weeks. She is taking OCPs.
Pseudotumor cerebri Tension headache Migraine headache Cluster headache Meningitis Intracranial venous thrombosis Intracranial neoplasm W/U: Urine hCG CBC CT—head LP—opening pressure and CSF analysis
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. In the same time frame, 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.”
Schizophrenia Schizoid or schizotypal personality disorder Schizophreniform disorder Psychotic disorder due to a general medical condition Substance-induced psychosis Depression with psychotic features W/U: Mental status exam Urine toxicology TSH CBC Electrolytes
20-day-old M presents with fever, decreased breast-feeding, and lethargy. He was born at 36 weeks as a result of premature rupture of membranes.
Neonatal sepsis Meningitis Pneumonia UTI W/U: Physical exam CBC Electrolytes UA Urine culture Blood culture CXR LP—CSF analysis
20 yo African-American F presents with acute onset of severe chest pain. She has a history of sickle cell disease and multiple previous hospitalizations for pain and anemia management.
Sickle cell disease—pulmonary infarction
Pneumonia
Pulmonary embolism
MI
Pneumothorax
Aortic dissection
W/U: CBC, Reticulocyte count, LDH, peripheral smear, ABG, CXR, CPK-MB, troponin, ECG, CT—chest with IV contrast
20 yo F presents with nausea, vomiting (especially in the morning), fatigue, and polyuria. Her last menstrual period was six weeks ago, and her breasts are full and tender. She is sexually active with her boyfriend, and they use condoms for contraception.
Pregnancy Gastritis Hypercalcemia Diabetes mellitus UTI Depression W/U: Urine hCG, Pelvic exam, U/S—pelvis, CBC, electrolytes, calcium, glucose, UA, urine culture, Baseline Pap smear, cervical cultures, rubella antibody, HIV antibody, hepatitis B surface antigen, and VDRL/RPR
20 yo M presents with fatigue, thirst, increased appetite, and polyuria.
Diabetes mellitus Atypical depression Primary polydipsia Diabetes insipidus W/U: Glucose tolerance test, HbA1c UA CBC, electrolytes, glucose, BUN/Cr
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’s and psoas signs are positive.
Acute appendicitis
Gastroenteritis
Diverticulitis
Crohn’s disease
Nephrolithiasis
Volvulus or other intestinal obstruction/perforation
W/U: Rectal exam, CBC, electrolytes, AXR, CT—abdomen U/S—abdomen
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.
Ovarian torsion Appendicitis Nephrolithiasis Ectopic pregnancy Ruptured ovarian cyst PID Bowel infarction or perforation W/U: Pelvic exam, Rectal exam, Urine hCG, UA, CBC, Doppler U/S—pelvis, CT—abdomen, Laparoscopy
21 yo F presents with several episodes of throbbing left temporal pain that lasts for 2-3 hours. Prior to its onset, she sees fl ashes of light in her right visual fi eld and feels weakness and numbness on the right side of her body for a few minutes. Headaches are often associated with nausea and vomiting. She has a family history of migraine.
Migraine (complicated) Tension headache Cluster headache Pseudotumor cerebri Trigeminal neuralgia CNS vasculitis Partial seizure Intracranial neoplasm W/U: CBC, ESR, CT—head, MRI—brain, LP with opening pressure.
23 yo obese F presents with amenorrhea for six months, facial hair, and infertility for the past three years.
Polycystic ovary syndrome Thyroid disease Hyperprolactinemia Pregnancy Ovarian or adrenal malignancy Premature ovarian failure W/U: Pelvic exam, Urine hCG, U/S—pelvis, LH/FSH, TSH, prolactin, Testosterone, DHEAS.
24 yo F presents with bilateral lower abdominal pain that started with the fi rst 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.
PID Endometriosis Dysmenorrhea Vaginitis Cystitis Spontaneous abortion Pyelonephritis W/U: Pelvic exam, Rectal exam, Urine hCG, Cervical cultures, CBC, ESR, UA, urine culture, and U/S—pelvis
25 yo F presents with a three-week history of diffi culty falling asleep. She sleeps seven 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.
Stress-induced insomnia
Caffeine-induced insomnia
Insomnia with circadian rhythm
sleep disorder Insomnia related to major depressive disorder
W/U: Polysomnography, Mental status exam, Urine toxicology, CBC, TSH.
25 yo F presents with two weeks of a nonproductive cough. Three weeks ago she had a sore throat and a runny nose.
Atypical pneumonia
Reactive airway disease
URI-associated ("postinfectious")
Postnasal drip
GERD
W/U: CBC, Induced sputum Gram stain and culture, CXR, IgM detection for Mycoplasma pneumoniae, Urine Legionella antigen25 yo M presents with hemiparesis (after a tonic-clonic seizure) that resolves over a few hours.
Todd's paralysis TIA Stroke Complicated migraine Malingering W/U: CBC, electrolytes, EEG, MRI—brain, Doppler U/S—carotid
25 yo M presents with high fever, severe headache, confusion, photophobia, and nuchal rigidity. Kernig’s and Brudzinski’s signs are positive.
Meningitis Migraine Subarachnoid hemorrhage Sinusitis/encephalitis Intracranial or epidural abscess W/U: CBC, CT—head, MRI—brain, LP—CSF analysis (cell count, protein, glucose, Gram stain, PCR for antigens, culture)
25 yo M presents with RUQ pain, fever, anorexia, nausea, and vomiting. He has dark urine and clay-colored stool.
Acute hepatitis Acute cholecystitis Ascending cholangitis Choledocholithiasis Pancreatitis Acute glomerulonephritis W/U: Rectal exam, CBC, amylase, lipase, AST/ALT/bilirubin/alkaline phosphatase, UA, Viral hepatitis serologies, U/S—abdomen
25 yo M presents with watery diarrhea and abdominal cramps. He was recently in Mexico.
Traveler's diarrhea Giardiasis Amebiasis Food poisoning Hepatitis A W/U: Rectal exam, Stool leukocytes, culture, Giardia antigen, Entamoeba histolytica antigen, Electrolytes, AST/ALT/bilirubin/alkaline phosphatase, Viral hepatitis serology
26 yo F presents with a 3-kg weight loss over the past two 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 six months before her presentation.
Bipolar I disorder Bipolar II disorder Cyclothymic disorder Major depressive disorder Schizoaffective disorder W/U: Physical exam, Mental status exam, Urine toxicology
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 recently experienced similar symptoms.
Infectious mononucleosis
Hepatitis Viral or bacterial pharyngitis
Acute HIV infection
Secondary syphilis
W/U: CBC, 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 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 (as witnessed by his colleagues).
Seizure Complex tonic-clonic seizure Convulsive syncope Substance abuse/overdose Malingering Hypoglycemia W/U: CBC, electrolytes, glucose, Urine toxicology, EEG, MRI—brain, CT—head, LP—CSF analysis, ECG
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.
Cluster headache Migraine Tension headache Sinusitis Pseudotumor cerebri Trigeminal neuralgia Intracranial neoplasm W/U: CBC, ESR, CT—head, MRI—brain LP
26 yo M presents with sore throat, fever, rash, and weight loss. He has a history of IV drug abuse and sharing needles.
HIV Acute retroviral syndrome Infectious mononucleosis Hepatitis Viral pharyngitis Streptococcal tonsillitis/scarlet fever Secondary syphilis W/U: CBC, Peripheral smear, HIV antibody and viral load CD4 count, Monospot test, Throat culture, VDRL/RPR AST/ALT/bilirubin/alkaline phosphatas
27 yo F presents with painful wrists and elbows, a swollen and hot knee joint that is painful on fl exion, a rash on her limbs, and vaginal discharge. She is sexually active with multiple partners and occasionally uses condoms.
Disseminated gonorrhea Rheumatoid arthritis SLE Psoriatic arthritis Reiter's arthritis W/U: Knee arthrocentesis and synovial fluid analysis (cell count, Gram stain, culture), ANA, anti-dsDNA, ESR, RF, CBC, Blood and cervical cultures XR—knee
28 yo F c/o multiple facial and bodily injuries. She claims that she fell on the stairs. She was hospitalized for some physical injuries seven months ago. She presents with her husband.
Domestic violence Osteogenesis imperfecta Substance abuse Consensual violent sexual behavior W/U: XR—skeletal survey, CT—maxillofacial, Urine toxicology, CBC
28 yo F c/o seeing bugs crawling on her bed over the past two days and reports hearing loud voices when she is alone in her room. She has never experienced symptoms such as these in the past. She recently ingested an unknown substance.
Substance-induced psychosis
Brief psychotic disorder
Schizophreniform disorder
Schizophrenia
Psychotic disorder due to a general medical condition
W/U: Urine toxicology, Mental status exam, TSH, CBC, Electrolytes, BUN/Cr, AST/ ALT
28 yo F presents with a thin, grayish white, foul-smelling vaginal discharge.
Bacterial vaginosis
Vaginitis—candidal
Vaginitis—trichomonal
Cervicitis (chlamydia, gonorrhea)
W/U: Pelvic exam, Wet mount, Cervical cultures, KOH prep ("whiff test"), pH of vaginal fluid28 yo F presents with pain in the interphalangeal joints of her hands together with hair loss and a butterfly rash on her face.
Systemic lupus erythematosus (SLE) Rheumatoid arthritis Psoriatic arthritis Parvovirus B19 infection W/U: ANA, anti-dsDNA, ESR, C3, C4, rheumatoid factor (RF), CBC, XR—hands UA
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.
Rheumatoid arthritis SLE Disseminated gonorrhea Arthritis associated with infl ammatory bowel disease Osteoarthritis W/U: ANA, anti-dsDNA, ESR, RF, CBC XR—hands, left knee Cervical culture Arthrocentesis and synovial fl uid analysis
28 yo F who is eight weeks pregnant presents with lower abdominal pain and vaginal bleeding.
Spontaneous abortion
Ectopic pregnancy
Molar pregnancy
W/U: Pelvic exam, Urine hCG, U/S—pelvis, CBC, PT/PTT, Quantitative serum hCG
28 yo M presents with constipation (very hard stool) for the last three weeks. Since his mother died two months ago, he and his father have eaten only junk food.
Low-fiber diet Irritable bowel syndrome Substance abuse (e.g., heroin) Depression Hypothyroidism W/U: Rectal exam, TSH, Electrolytes, Urine toxicology
29 yo F presents with amenorrhea for the past six months. She has a history of occasional palpitations and dizziness. She lost her fiancé in a car accident.
Anxiety-induced amenorrhea
W/U: CBC, TSH, FT4, ACTH, Urine cortisol level, Progesterone challenge test, FSH/LH/estradiol levels
30 yo F presents with alternating constipation and diarrhea and abdominal pain that is relieved by defecation. She has no nausea, vomiting, weight loss, or blood in her stool.
Irritable bowel syndrome
Inflammatory bowel disease
Celiac disease
Chronic pancreatitis
GI parasitic infection (ascariasis, giardiasis)
Lactose intolerance
W/U: Rectal exam, stool for occult blood, CBC, Electrolytes Stool for ova and parasitology, AXR, CT—abdomen/pelvis
30 yo F presents with a thick, white, cottage cheese-like, odorless Vaginal discharge and vaginal itching.
Vaginitis—candidal
Bacterial vaginosis
Vaginitis—trichomonal
W/U: Pelvic exam, KOH prep (“whiff test”), Wet mount Cervical cultures, pH of vaginal fluid
30 yo F presents with frontal headache, fever, and nasal discharge. There is pain on palpation of the frontal and maxillary sinuses. She has a history of sinusitis.
Sinusitis Migraine Tension headache Meningitis Intracranial neoplasm W/U: CBC, XR—sinus, CT—sinus, LP
30 yo F presents with multiple facial and physical injuries. She was attacked and raped by two men.
Rape
W/U: Pelvic exam, Urine hCG, Wet mount, KOH prep, cervical cultures, XR—skeletal survey, CBC, HIV antibody, Viral hepatitis serologies
30 yo F presents with periumbilical pain for six 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.
Irritable bowel syndrome
Crohn’s disease
Celiac disease
Chronic pancreatitis
GI parasitic infection (amebiasis, giardiasis)
Endometriosis
W/U: Rectal exam, stool for occult blood, Pelvic exam, Urine hCG, CBC, Electrolytes, CT—abdomen/pelvis, Stool for ova and parasitology, Entamoeba histolytica antigen
30 yo F presents with watery diarrhea and abdominal cramping and bloating. Her symptoms are aggravated by milk ingestion and are relieved by fasting.
Lactose intolerance Gastroenteritis Inflammatory bowel disease Irritable bowel syndrome Hyperthyroidism W/U: Rectal exam, Stool exam, Hydrogen breath test, TSH
30 yo F presents with weakness, loss of sensation, and tingling in her left leg that started this morning. She is also experiencing right eye pain, decreased vision, and double vision. She reports feeling “electric shocks” down her spine upon fl exing her head.
Multiple sclerosis Stroke Conversion disorder Malingering CNS tumor Neurosyphilis Syringomyelia CNS vasculitis W/U: CBC, ESR, VDRL/RPR, MRI—brain, LP—CSF analysis, Retinal evoked potentials
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.
Domestic violence
Factitious disorder
Substance abuse
W/U: 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 fi rst, 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 fi ngers. Exam reveals a positive Tinel’s sign.
Carpal tunnel syndrome
Median nerve compression in forearm or arm
Radiculopathy of nerve roots C6 and C7 in cervical spine W/U: Nerve conduction study, EMG
30 yo M presents with night sweats, cough, and swollen glands of one month’s duration.
Tuberculosis Acute HIV infection Lymphoma Leukemia Hyperthyroidism W/U: PPD, CBC, CXR, Sputum Gram stain, acid-fast stain and culture, HIV antibody, TSH, FT4
30 yo M presents with shortness of breath, cough, and wheezing that worsen in cold air. He has had several such episodes over the past four months.
Asthma GERD Bronchitis Pneumonitis Foreign body W/U: CBC, CXR, Peak flow measurement PFTs, Methacholine challenge test
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 fi ve weeks ago. She has a history of PID and unprotected intercourse.
Ectopic pregnancy Ruptured ovarian cyst Ovarian torsion PID W/U: Pelvic exam, Urine hCG, Cervical cultures, U/S—pelvis, Quantitative serum hCG
33 yo F c/o three weeks of fatigue and trouble sleeping. She states that she falls asleep easily but wakes up at 3 A.M. and cannot return to sleep. She also reports an unintentional weight loss of 3.5 kg along with an inability to enjoy the things she once liked to do.
Insomnia related to major depressive disorder
Primary hypersomnia
Insomnia with circadian rhythm sleep disorder
W/U: Mental status exam, TSH, CBC, Polysomnography
33 yo F presents with ascending loss of strength in her lower legs over the past two weeks. She had a recent URI.
Guillain-Barré syndrome Multiple sclerosis Polymyositis Myasthenia gravis Peripheral neuropathy Tumor in the vertebral canal W/U: CBC, electrolytes, CPK, LP—CSF analysis, MRI—spine EMG/nerve conduction study, Tensilon test, Serum B12
33 yo F presents with rectal bleeding and diarrhea for the past week. She has had lower abdominal pain and tenesmus for several months.
Ulcerative colitis Crohn's disease Proctitis Anal fissure Hemorrhoids Diverticulosis Dysentery W/U: Rectal exam, CBC, PT/PTT, AXR, Colonoscopy, CT—abdomen/pelvis, Barium enema
33 yo M presents with watery diarrhea, diffuse abdominal pain, and weight loss over the past three weeks. He has not responded to antibiotics.
Crohn's disease Gastroenteritis Ulcerative colitis Celiac disease Pseudomembranous colitis Hyperthyroidism Small bowel lymphoma Carcinoid W/U: Rectal exam, Stool exam and culture, CBC, electrolytes, TSH, CT—abdomen, Colonoscopy, Small bowel serie,s Urinary 5-HIAA
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.
Infectious diarrhea (gastroenteritis)—bacterial, viral, parasitic, protozoal
Food poisoning
Inflammatory bowel disease
W/U: Rectal exam, stool for occult blood, Stool leukocytes and culture, CBC, Electrolytes, CT—abdomen/pelvis
34 yo F nurse presents with worsening cough of six weeks’ duration together with weight loss, fatigue, night sweats, and fever. She has a history of contact with tuberculosis patients at work.
Tuberculosis Pneumonia Lung abscess Vasculitis Lymphoma Metastatic cancer HIV/AIDS Sarcoidosis W/U: CBC, PPD, Sputum Gram stain, acid-fast stain, and culture, CXR, CT—chest, Bronchoscopy, HIV antibody
34 yo F presents with retrosternal stabbing chest pain that improves when she leans forward and worsens with deep inspiration. She had a URI one week ago.
Pericarditis Aortic dissection MI Costochondritis GERD Esophageal rupture W/U: ECG, CPK-MB, troponin, CXR, Echocardiography, CBC, Upper endoscopy
34 yo F presents with stabbing chest pain that worsens with deep inspiration and is relieved by aspirin. She had a URI one week ago. Chest wall tenderness is noted.
Costochondritis Pneumonia MI Pulmonary embolism Pericarditis Muscle strain W/U: ECG, CPK-MB, troponin, CXR, CBC
