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
35 yo F presents with a malodorous, profuse, frothy, greenish vaginal discharge with intense vaginal itching and discomfort.
Vaginitis—trichomonal
Vaginitis—candidal
Bacterial vaginosis
Cervicitis (chlamydia, gonorrhea)
W/U: Pelvic exam, Wet mount, Cervical cultures, pH of the vaginal fluid, KOH prep ("whiff test")35 yo F presents with amenorrhea, cold intolerance, coarse hair, weight loss, and fatigue. She has a history of abruptio placentae followed by hypovolemic shock and failure of lactation two years ago.
Sheehan's syndrome Premature ovarian failure Pituitary tumor Thyroid disease Asherman's syndrome W/U: Pelvic exam, Urine hCG, CBC, LH/FSH, prolactin TSH, FT4, ACTH, MRI—brain, Hysteroscopy
35 yo F presents with amenorrhea, galactorrhea, visual field defects, and headaches for the past six months.
Amenorrhea secondary to prolactinoma Pregnancy Thyroid disease Premature ovarian failure Pituitary tumor W/U: Pelvic and breast exam Urine hCG Prolactin LH/FSH, TSH MRI—brain
35 yo F presents with intermittent episodes of vertigo, tinnitus, nausea, and hearing loss over the past week.
Ménière’s disease Vestibular neuronitis Labyrinthitis Benign positional vertigo Acoustic neuroma W/U: CBC VDRL/RPR (syphilis is a cause of Ménière’s disease) MRI—brain
35 yo M policeman c/o feeling tired and sleepy during the day. He changed to the night shift last week.
Sleep deprivation
Sleep apnea
Depression Anemia
W/U: CBC, Nocturnal pulse oximetry, Polysomnography
35 yo M presents with burning epigastric pain that starts 2-3 hours after meals. The pain is relieved by food and antacids.
Peptic ulcer disease Gastritis GERD Cholecystitis Chronic pancreatitis Mesenteric ischemia W/U: Rectal exam, Amylase, lipase, lactate AST/ALT/bilirubin/alkaline phosphatase, Endoscopy (including H. pylori testing), Upper GI series
35 yo M presents with painless hematuria. He has a family history of kidney problems.
Polycystic kidney disease
Nephrolithiasis
Acute glomerulonephritis (e.g., IgA nephropathy)
UTI
Coagulation disorder
Bladder cancer
W/U: Genitourinary exam, UA, BUN/Cr, PSA, CBC, PT/PTT, U/S—renal, CT—abdomen/pelvis, IVP
35 yo M presents with shortness of breath and cough. He has had unprotected sex with multiple sexual partners and was recently exposed to a patient with active tuberculosis.
Tuberculosis
Pneumonia (including Pneumocystis jiroveci)
Bronchitis
CHF (cardiomyopathy)
Asthma
Acute HIV infection
W/U: CBC, PPD, Sputum Gram stain, acid-fast stain, silver stain, and culture, CXR, HIV antibody
35 yo M presents with sudden severe headache, vomiting, confusion, left hemiplegia, and nuchal rigidity.
DDX: 1 - Subarachnoid hemorrhage 2 - Migraine 3 - Meningitis/encephalitis 4 - Intracranial hemorrhage 5 - Intracranial neoplasm, vertebral a. dissection, intracranial venous thrombosis, acute htn W/U: 1 - CBC, PT/PTT, CT head w/o contrast, MRI/MRA brain 3 - LP
37 yo F presents with dyspareunia, inability to conceive, and dysmenorrhea.
Endometriosis Cervicitis Vaginismus Vulvodynia PID Depression Domestic violence W/U: Pelvic exam, Wet mount, KOH prep, cervical cultures, U/S—pelvis, Laparoscopy
37 yo M presents with severe epigastric pain, nausea, vomiting, and mild fever. He appears toxic. He has a history of intermittent epigastric pain that is relieved by food and antacids. He also smokes heavily and takes aspirin on a regular basis.
Peptic ulcer perforation Acute pancreatitis Hepatitis Cholecystitis Choledocholithiasis Mesenteric ischemia W/U: Rectal exam, CBC, electrolytes, amylase, lipase, lactate AST/ALT/bilirubin/alkaline phosphatase, AXR, Upright CXR, Endoscopy (including H. pylori testing)
38 yo M presents with dysphagia and pain on swallowing solids more than liquids. Exam reveals oral thrush.
Esophagitis (CMV, HSV, pillinduced) Systemic sclerosis GERD Esophageal stricture Zenker's diverticulum W/U: CBC, Endoscopy, Barium swallow, HIV antibody CD4 count
40 yo F c/o feeling tired, hopeless, and worthless and of having suicidal thoughts. She recently discovered that her husband is homosexual.
Depression Adjustment disorder Hypothyroidism Anemia W/U: CBC, TSH, HIV/STD testing (given husband's possible risk factors)
40 yo F presents with amenorrhea, morning nausea and vomiting, fatigue, and polyuria. Her last menstrual period was six weeks ago, and her breasts are full and tender. She uses the rhythm method for contraception.
Pregnancy Anovulatory cycle Hyperprolactinemia UTI Thyroid disease W/U: Pelvic exam, Urine hCG, U/S—pelvis, CBC, electrolytes, UA, urine culture, Prolactin, TSH, Baseline Pap smear, cervical cultures, rubella antibody, HIV antibody, hepatitis B surface antigen, and VDRL/ RPR
40 yo F presents with epigastric pain and coffee-ground emesis. She has a history of rheumatoid arthritis that has been treated with aspirin. She is an alcoholic.
Gastritis Bleeding peptic ulcer Gastric cancer Esophageal varices Mallory-Weiss tear W/U: Rectal exam, CBC, electrolytes, AST/ALT/bilirubin/alkaline phosphatase, Barium swallow, Endoscopy
40 yo F presents with fatigue, weight gain, sleepiness, cold intolerance, constipation, and dry skin.
Hypothyroidism Depression Diabetes Anemia W/U: TSH, FT3, FT4, CBC, Glucose, HbA1c
40 yo F presents with occasional double vision and droopy eyelids at night with normalization by morning.
Myasthenia gravis
Horner’s syndrome
Multiple sclerosis
Intracranial tumor compressing CN III, IV, or VI
Amyotrophic lateral sclerosis
W/U: Tensilon test, ACh receptor antibodies (in serum), CXR, CT—chest, MRI—brain, EMG
40 yo F presents with watery diarrhea and abdominal cramps. Last week she was on antibiotics for a UTI.
Pseudomembranous (Clostridium difficile) colitis
Gastroenteritis
Cryptosporidiosis
Food poisoning
Inflammatory bowel disease
W/U: Rectal exam, Stool leukocytes, culture, occult blood, C. difficile toxin in stool, Electrolytes.
40 yo M presents with crampy abdominal pain, vomiting, abdominal distention, and inability to pass fl atus or stool. He has a history of multiple abdominal surgeries.
Intestinal obstruction Small bowel or colon cancer Volvulus of the bowel Gastroenteritis Food poisoning Ileus Hernia W/U: Rectal exam, CBC, electrolytes, AXR, CT—abdomen/pelvis, CXR
40 yo M presents with pain in the right groin after a motor vehicle accident. His right leg is fl exed at the hip, adducted, and internally rotated.
Hip dislocation—traumatic
Hip fracture
W/U: XR—hip, CT or MRI—hip, CBC, PT/PTT, Blood type and cross-match, Urine toxicology, and blood alcohol level
41 yo obese F presents with RUQ abdominal pain that radiates to the right scapula and is associated with nausea, vomiting, and a fever of 101.5°F. The pain started after she had eaten fatty food. She has had similar but less intense episodes that lasted a few hours. Exam reveals positive Murphy’s sign.
Acute cholecystitis Hepatitis Choledocholithiasis Ascending cholangitis Peptic ulcer disease Fitz-Hugh-Curtis syndrome W/U: Rectal exam, CBC, AST/ALT/bilirubin/alkaline phosphatase, U/S—abdomen, HIDA scan
42 yo F presents with a 7-kg weight loss over the past two months. She has a fi ne tremor, and her pulse is 112.
Hyperthyroidism Cancer HIV infection Dieting/diet drugs Anorexia nervosa Malabsorption W/U: TSH, FT4, CBC, electrolytes, HIV antibody, Urine toxicology
42 yo F presents with a four-week history of excessive fatigue, insomnia, and anhedonia. She states that she thinks constantly about death. She has suffered fi ve similar episodes in the past, the fi rst in her 20s, and has made two previous suicide attempts. She further admits to increased alcohol use in the past month.
Major depressive disorder
Substance-induced mood disorder
Dysthymic disorder
W/U: Physical exam, Mental status exam, Blood alcohol level, TSH, CBC, Urine toxicology
43 yo obese F presents with RUQ abdominal pain, fever, and jaundice. She was diagnosed with asymptomatic gallstones one year ago.
Ascending cholangitis Acute cholecystitis Hepatitis Choledocholithiasis Sclerosing cholangitis Fitz-Hugh-Curtis syndrome W/U: Rectal exam, CBC, AST/ALT/bilirubin/alkaline phosphatase, Viral hepatitis serologies, U/S—abdomen, MRCP, ERCP
44 yo F c/o dizziness on moving her head to the left. She feels that the room is spinning around her head. Tilt test results in nystagmus and nausea.
Benign positional vertigo Vestibular neuronitis Labyrinthitis Ménière's disease W/U: MRI—brain, Audiogram
44 yo F presents with a weight gain of > 11 kg over the past two months. She quit smoking three months ago and is on amitriptyline for depression. She also reports cold intolerance and constipation.
Smoking cessation Drug side effect Hypothyroidism Cushing's syndrome Polycystic ovary syndrome Diabetes mellitus Atypical depression W/U: CBC, electrolytes, glucose, TSH, 24-hour urine free cortisol, Dexamethasone suppression test
44 yo M presents with fatigue, insomnia, and nightmares about a murder that he witnessed in a mall one year ago. Since then, he has avoided that mall and has not gone out at night.
Post-traumatic stress disorder (PTSD) Depression Generalized anxiety disorder Psychotic or delusional disorder Hypothyroidism W/U: CBC, TSH, Calcium, Urine toxicology
45 yo diabetic F presents with dysuria, urinary frequency, fever, chills, and nausea over the past three days. There is left CVA tenderness on exam.
Acute pyelonephritis Nephrolithiasis Renal cell carcinoma Lower UTI (cystitis, urethritis) W/U: UA, Urine culture and sensitivity, CBC, BUN/Cr, U/S—renal, CT—abdomen
45 yo F presents with a retrosternal burning sensation that occurs after heavy meals and when lying down. Her symptoms are relieved by antacids.
GERD Esophagitis Peptic ulcer disease Esophageal spasm MI Angina W/U: ECG, Barium swallow, Upper endoscopy, Esophageal pH monitoring
45 yo F presents with coffee-ground emesis for the last three days. Her stool is dark and tarry. She has a history of intermittent epigastric pain that is relieved by food and antacids.
Bleeding peptic ulcer Gastritis Gastric cancer Esophageal varices W/U: Rectal exam, CBC, electrolytes, AST/ALT/bilirubin/alkaline phosphatase, Endoscopy (including H. pylori testing if ulcer is confirmed)
45 yo F presents with dysphagia for two weeks together with fatigue and a craving for ice and clay.
Plummer-Vinson syndrome Esophageal cancer Esophagitis Achalasia Systemic sclerosis Mitral valve stenosis W/U: CBC, Serum iron, ferritin, TIBC, Barium swallow, Endoscopy
45 yo F presents with low back pain that radiates to the lateral aspect of her left foot. Straight leg raising is positive. Thepatient is unable to tiptoe.
Disk herniation
Lumbar muscle strain
Tumor in the vertebral canal
W/U: XR—L-spine MRI—L-spine
45 yo F presents with low back pain that started after she cleaned her house. The pain does not radiate, and there is no sensory deficit or weakness in her legs. Paraspinal muscle tenderness and spasm are also noted.
Lumbar muscle strain Disk herniation Abdominal aortic aneurysm Vertebral compression fracture W/U: XR—L-spine
45 yo F presents with right calf pain. Her calf is tender, warm, red, and swollen compared to the left side. She was started on OCPs two months ago for dysfunctional uterine bleeding.
DVT Baker's cyst rupture Myositis Cellulitis Superficial venous thrombosis W/U: Doppler, U/S—right leg, CBC, CPK, D-dimer, PT, aPTT, fibrinogen, XR—right leg
45 yo G5P5 F presents with postcoital bleeding. She is a cigarette smoker and takes OCPs.
Cervical cancer
Cervical polyp
Cervicitis Trauma (e.g., cervical laceration)
W/U: Pelvic exam, Pap smear, Colposcopy and biopsy
45 yo M presents with pain in the lower back and legs during prolonged standing and walking. The pain is relieved by sitting and leaning forward (e.g., pushing a grocery cart).
Lumbar spinal stenosis Lumbar muscle strain Tumor in the vertebral canal Peripheral vascular disease W/U: XR—L-spine, MRI—L-spine (preferred), CT—L-spine, Ankle-brachial index
45 yo M presents with right knee pain with swelling and redness.
Septic arthritis Gout Pseudogout Lyme arthritis Trauma Reiter's arthritis W/U: CBC, Knee arthrocentesis and synovial fluid analysis, Blood and urethral cultures, XR—knee, Uric acid, Lyme antibody
45 yo M presents with sudden onset of colicky right-sided fl ank pain that radiates to the testicles, accompanied by nausea, vomiting, hematuria, and CVA tenderness.
Nephrolithiasis Renal cell carcinoma Pyelonephritis GI etiology (e.g., appendicitis) W/U: Rectal exam, UA, Urine culture and sensitivity, BUN/Cr CT—abdomen, U/S—renal IVP
46 yo F presents with fever and sore throat.
Pharyngitis (bacterial or viral) Mycoplasma pneumonia Acute HIV infection Infectious mononucleosis W/U: Throat swab for culture and rapid streptococcal antigen, Monospot test, CBC, HIV antibody and viral load
47 yo M presents with impotence that started three months ago. He has hypertension and was started on atenolol four months ago. He also has diabetes and is on insulin.
Drug-related ED ED caused by hypertension ED caused by diabetes mellitus Psychogenic ED Peyronie's disease W/U: Genital exam, Rectal exam, Glucose, CBC
48 yo F presents with amenorrhea for the past six months accompanied by hot fl ashes, night sweats, emotional lability, and dyspareunia.
Menopause Pregnancy Pituitary tumor Thyroid disease W/U: Pelvic exam, Urine hCG, LH/FSH, TSH, prolactin, testosterone, DHEAS, CBC, MRI—brain
48 yo F presents with a one-week history of auditory hallucinations, stating, “I am worthless” and “I should kill myself.” She also reports a two-week history of weight loss, early-morning awakening, decreased motivation, and overwhelming feelings of guilt.
Schizoaffective disorder
Mood disorder with psychotic features
Schizophrenia
Schizophreniform disorder
Psychotic disorder due to a general medical condition
W/U: Mental status exam, Beck Depression Inventory, TSH, CBC, Electrolytes
48 yo F presents with dysphagia for both solid and liquid foods that has slowly progressed in severity over the past year. It is associated with regurgitation of undigested food, especially at night.
Achalasia Plummer-Vinson syndrome Esophageal cancer Esophagitis Systemic sclerosis Mitral valve stenosis Esophageal stricture Zenker's diverticulum W/U: CXR, Endoscopy, Barium swallow, Esophageal manometry
50 yo F presents with recurrent episodes of bilateral squeezing headaches that occur 3-4 times a week, typically toward the end of her work day. She is experiencing signifi cant stress in her life.
Tension headache Migraine Depression Caffeine or analgesic withdrawal Hypertension Cluster headache Pseudotumor cerebri Intracranial neoplasm W/U: CBC, Electrolytes, ESR, CT—head, LP
50 yo M presents with a cough that is exacerbated by lying down at night and improved by propping up on three pillows. He also reports exertional dyspnea.
CHF Cardiac valvular disease GERD Pulmonary fibrosis COPD Postnasal drip W/U: CBC, CXR, ECG, Echocardiography, PFTs, BNP
50 yo M presents with right shoulder pain after falling onto his outstretched hand while skiing. He noticed deformity of his shoulder and had to hold his right arm.
Shoulder dislocation
Fracture of the humerus
Rotator cuff injury
W/U: XR—shoulder, XR—arm, MRI—shoulder
50 yo obese F presents with fatigue and daytime sleepiness. She snores heavily and naps 3-4 times per day but never feels refreshed. She also has hypertension.
Obstructive sleep apnea Hypothyroidism Chronic fatigue syndrome Narcolepsy W/U: CBC, TSH, Nocturnal pulse oximetry, Polysomnography, ECG
54 yo F c/o painful intercourse. Her last menstrual period was nine months ago. She has hot fl ashes.
Atrophic vaginitis Endometriosis Cervicitis Depression Domestic abuse W/U: Pelvic exam, Wet mount, KOH prep, cervical cultures U/S—pelvis
55 yo F c/o dizziness for the past day. She feels faint and has severe diarrhea that started two days ago. She takes furosemide for her hypertension.
Orthostatic hypotension due to dehydration (diarrhea, diuretic use)
Vestibular neuronitis
Labyrinthitis
Benign positional vertigo
Vertebrobasilar insufficiency
W/U: Orthostatic vital signs, CBC, Electrolytes, Stool exam (occult blood, fecal leukocytes)
55 yo F c/o dizziness that started this morning and of “not hearing well.” She feels nauseated and has vomited once in the past day. She had a URI two days ago.
Labyrinthitis Vestibular neuronitis Ménière's disease Acoustic neuroma Vertebrobasilar insufficiency W/U: Audiogram, Electronystagmography, MRI/MRA—brain
55 yo F c/o dizziness that started this morning. She is nauseated and has vomited once in the past day. She had a URI two days ago and has experienced no hearing loss.
Vestibular neuronitis
Labyrinthitis
Ménière’s disease
Benign positional vertigo
Vertigo associated with cervical spine disease/injury
Vertebrobasilar insufficiency
W/U: CBC, Electrolytes, Electronystagmography, MRI/MRA—brain
55 yo F presents with gradual altered mental status and headache. Two weeks ago she slipped, hit her head on the ground, and lost consciousness for two minutes.
Subdural hematoma SIADH (causing hyponatremia) Creutzfeldt-Jakob disease Intracranial neoplasm W/U: Electrolytes, CT—head, MRI—brain, LP
55 yo M c/o falling after feeling dizzy and unsteady. He experienced transient LOC. He has hypertension and is on numerous antihypertensive drugs.
Drug-induced orthostatic hypotension (causing syncope)
Cardiac arrhythmia
Syncope (vasovagal, other causes)
Stroke
MI
Pulmonary embolism
W/U: Orthostatic vital signs, CBC, Electrolytes, CT—head, ECG, V/Q scan, CT—chest with IV contrast
55 yo M presents with a rapidly progressive change in mental status, inability to concentrate, and memory impairment for the past two months. His symptoms are associated with myoclonus and ataxia.
Creutzfeldt-Jakob disease Vascular dementia Lewy body dementia Wernicke's encephalopathy Normal pressure hydrocephalus Chronic subdural hematoma Intracranial neoplasm Depression Delirium B12 deficiency Neurosyphilis W/U: CBC, electrolytes, calcium, Serum B12, VDRL/RPR, MRI—brain (preferred), CT—head, EEG, LP—CSF analysis, Brain biopsy
55 yo M presents with crampy bilateral thigh and calf pain, fatigue, and dark urine. He is on simvastatin and clofibrate for hyperlipidemia.
Rhabdomyolysis due to simvastatin or clofibrate
Polymyositis
Inclusion body myositis
Thyroid disease
W/U: CBC, CPK, Aldolase, UA, Urine myoglobin, TSH
55 yo M presents with fatigue, weight loss, and constipation. He has a family history of colon cancer.
Colon cancer Hypothyroidism Renal failure Hypercalcemia Depression W/U: Rectal exam, stool for occult blood, CBC, electrolytes, calcium, BUN/Cr, AST/ALT, TSH Colonoscopy, Barium enema
55 yo M presents with fl ank pain and blood in his urine without dysuria. He has experienced weight loss and fever over the past two months.
Renal cell carcinoma Bladder cancer Nephrolithiasis Acute glomerulonephritis Pyelonephritis Prostate cancer W/U: Genitourinary and rectal exam, UA, urine cytology, BUN/Cr, PSA, CBC, PT/PTT U/S—renal CT—abdomen/pelvis, IVP
55 yo M presents with increased dyspnea and sputum production over the past three days. He has COPD and stopped using his inhalers last week. He also stopped smoking two days ago.
COPD exacerbation (bronchitis) Lung cancer Pneumonia URI CHF W/U: CBC, CXR, PFTs, Sputum Gram stain and culture, CT—chest
55 yo M presents with pain in the elbow when he plays tennis. His grip is impaired as a result of the pain. There is tenderness over the lateral epicondyle as well as pain on resisted wrist dorsiflexion (Cozen’s test) with the elbow in extension.
Tennis elbow (lateral epicondylitis)
Stress fracture
W/U: XR—arm, Bone scan, MRI—elbow
55 yo M presents with retrosternal squeezing pain that lasts for two minutes and occurs with exercise. It is relieved by rest and is not related to food intake.
Angina
Esophageal spasm
Esophagitis
W/U: ECG, CPK-MB, troponin, CXR, CBC, electrolytes, Exercise stress test, Upper endoscopy/pH monitor, Cardiac catheterization
55 yo M presents with sudden onset of severe chest pain that radiates to the back. He has a history of uncontrolled hypertension.
Aortic dissection MI Pericarditis Esophageal rupture Esophageal spasm GERD Pancreatitis Fat embolism W/U: ECG, CPK-MB, troponin CXR, CBC, amylase, lipase, Transesophageal echocardiography (TEE), MRI/MRA—aorta Aortic angiography, Upper endoscopy
55 yo M presents with tingling and numbness in the hands and feet (gloveand- stocking distribution) over the past two months. He has a history of diabetes mellitus, hypertension, and alcoholism. There is decreased soft touch, vibratory, and position sense in the feet.
Diabetic peripheral neuropathy Alcoholic peripheral neuropathy B12 deficiency Hypocalcemia Hyperventilation Paraproteinemia/myeloma W/U: HbA1c, ESR, Calcium, Serum B12, Serum and urine protein electrophoresis
55 yo obese M presents with several months of poor sleep and daytime fatigue. His wife reports that he snores loudly.
Obstructive sleep apnea
Daytime fatigue in primary hypersomnia
Insomnia with circadian rhythm sleep disorder
Insomnia related to major depressive disorder
W/U: CBC, TSH, Polysomnography, ECG
56 yo F presents with shortness of breath as well as with a productive cough that has occurred over the past two years for at least three months each year. She is a heavy smoker.
COPD—chronic bronchitis Bronchiectasis Lung cancer Tuberculosis W/U: CBC, Sputum Gram stain and culture, CXR, PFTs, CT—chest PPD
56 yo M presents with severe midepigastric 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 three days binge drinking.
Acute pancreatitis Peptic ulcer disease Cholecystitis/choledocholithiasis Gastritis Abdominal aortic aneurysm Mesenteric ischemia Alcoholic hepatitis Mallory-Weiss tear W/U: Rectal exam, CBC, electrolytes, BUN/Cr, amylase, lipase, AST/ALT/bilirubin/alkaline phosphatase, U/S—abdomen, CT—abdomen, Upper endoscopy, ECG
56 yo obese F presents with right knee stiffness and pain that increases with movement. Her symptoms have gradually worsened over the past 10 years. She noticed swelling and deformity of the joint and is having diffi culty walking.
Osteoarthritis
Pseudogout
Gout Meniscal or ligament damage
W/U: XR—knee, CBC, ESR, Knee arthrocentesis and synovial fluid analysis (cell count, Gram stain, culture, crystals), MRI—knee
57 yo M c/o daily pain in the right cheek over the past month. The pain is electric and stabbing in character and occurs while he is shaving. Each episode lasts 2-4 minutes.
Trigeminal neuralgia Tension headache Migraine Cluster headache TMJ dysfunction Intracranial neoplasm W/U: CBC, ESR, MRI—brain
58 yo M presents with bright red blood per rectum and chronic constipation. He consumes a low-fiber diet.
Diverticulosis Anal fissure Hemorrhoids Angiodysplasia Colorectal cancer W/U: Rectal exam, CBC, PT/PTT, Electrolytes, Colonoscopy, CT—abdomen/pelvis
58 yo M presents with pleuritic chest pain, fever, chills, and cough with purulent yellow sputum. He is a heavy smoker with COPD.
Pneumonia Bronchitis Lung abscess Lung cancer Tuberculosis Pericarditis W/U: CBC, Sputum Gram stain and culture, CXR, CT—chest ECG, PPD
60 yo F c/o left arm pain that started while she was swimming and was relieved by rest.
Angina/MI
Tendonitis
Osteoarthritis Shoulder dislocation
W/U: CPK-MB, troponin, ECG, CBC, ESR, XR—shoulder, CXR, Echocardiography, Stress test
60 yo F presents with pain in both legs that is induced by walking and is relieved by rest. She had cardiac bypass surgery six months ago and continues to smoke heavily.
Peripheral vascular disease (intermittent claudication), Leriche’s syndrome (aortoiliac occlusive disease),
Lumbar spinal stenosis (pseudoclaudication),
Osteoarthritis
W/U: Ankle-brachial index, Doppler U/S—lower extremity, Angiography, MRI—lumbar spine
60 yo M presents with dull epigastric pain that radiates to the back, together with weight loss, dark urine, and clay-colored stool. He is a heavy drinker and smoker.
Pancreatic cancer Acute viral hepatitis Chronic pancreatitis Cholecystitis/choledocholithiasis Abdominal aortic aneurysm Peptic ulcer disease W/U: Rectal exam, CBC, electrolytes, Amylase and lipase AST/ALT/bilirubin/alkaline phosphatase, U/S—abdomen, CT—abdomen
60 yo M presents with nocturia, urgency, weak stream, and terminal dribbling. He denies any weight loss, fatigue, or bone pain. He has had two episodes of urinary retention that required catheterization.
Benign prostatic hyperplasia (BPH) Prostate cancer UTI Bladder stones W/U: Rectal exam, UA, CBC, BUN/Cr, PSA, U/S—prostate (transrectal)
60 yo M presents with sudden onset of substernal heavy chest pain that has lasted for 30 minutes and radiates to the left arm. The pain is accompanied by dyspnea, diaphoresis, and nausea. He has a history of hypertension, hyperlipidemia, and smoking.
Myocardial infarction (MI) GERD Angina Costochondritis Aortic dissection Pericarditis Pulmonary embolism Pneumothorax W/U: ECG, CPK-MB, troponin, CXR, CBC, electrolytes, Echocardiography, Cardiac catheterization
61 yo obese F presents with profuse vaginal bleeding over the past month. Her last menstrual period was 10 years ago. She has a history of hypertension and diabetes mellitus. She is nulliparous.
Endometrial cancer Cervical cancer Atrophic endometrium Endometrial hyperplasia Endometrial polyps Atrophic vaginitis W/U: Pelvic exam, Pap smear, Endometrial biopsy, U/S—pelvis, Endometrial curettage, Colposcopy, Hysteroscopy
65 yo F presents with inability to use her left leg and bear weight on it after tripping on a carpet. Onset of menopause was 20 years ago, and she did not receive HRT or calcium supplements. Her left leg is externally rotated, shortened, and adducted, and there is tenderness in her left groin.
Hip fracture
Hip dislocation
Pelvic fracture
W/U: XR—hip/pelvis, CT or MRI—hip, CBC, Serum calcium and vitamin D, Bone density scan (DEXA)
65 yo F presents with severe, intermittent right temporal headache, fever, blurred vision in her right eye, and pain in her jaw when chewing.
Temporal arteritis (giant cell arteritis) Migraine Cluster headache Tension headache Meningitis Carotid artery dissection Pseudotumor cerebri Trigeminal neuralgia Intracranial neoplasm W/U: CBC, ESR, CRP, Temporal artery biopsy, Doppler U/S—carotid, MRI—brain
65 yo M presents after falling and losing consciousness for a few seconds. He had no warning prior to passing out but recently had palpitations. His past history includes coronary artery bypass grafting (CABG).
Cardiac arrhythmia (causing syncope) Severe aortic stenosis Syncope (other causes) Seizure Pulmonary embolism W/U: ECG, Holter monitoring, CBC, electrolytes, Glucose, Echocardiography, CT—head
65 yo M presents with pain in the heel of the right foot that is most notable with his first few steps and then improves as he continues walking. He has no known trauma.
Plantar fasciitis
Heel fracture
Splinter/foreign body
W/U: XR—heel, Bone scan
65 yo M presents with painless hematuria. He is a heavy smoker and works as a painter.
Bladder cancer Renal cell carcinoma Nephrolithiasis Acute glomerulonephritis Prostate cancer Coagulation disorder (i.e., factor VIII antibodies) Polycystic kidney disease Genitourinary exam W/U: UA, urine cytology, BUN/Cr, PSA, CBC, PT/PTT, Cystoscopy, U/S—renal/bladder, CT—abdomen/pelvis, IVP
65 yo M presents with postural dizziness and unsteadiness. He has hypertension and was started on hydrochlorothiazide two days ago.
Drug-induced orthostatic hypotension Vestibular neuronitis Labyrinthitis Benign positional vertigo Brain stem or cerebellar tumor Acute renal failure W/U: Orthostatic vital signs, CBC, Electrolytes, BUN/Cr, MRI—brain
65 yo M presents with right foot pain. He has been training for a marathon.
Stress fracture
Plantar fasciitis
Foot sprain or strain
W/U: XR—foot, Bone scan—foot, MRI—foot
65 yo M presents with worsening cough over the past six months together with hemoptysis, dyspnea, weakness, and weight loss. He is a heavy smoker.
Lung cancer Tuberculosis Lung abscess COPD Vasculitis (i.e., Wegener's) Interstitial lung disease CHF W/U: CBC, Sputum Gram stain, culture, and cytology, CXR, CT—chest, PPD, Bronchoscopy
67 yo M presents with alternating diarrhea and constipation, decreased stool caliber, and blood in the stool for the past eight months. He also reports unintentional weight loss. He is on a low-fi ber diet and has a family history of colon cancer.
Colorectal cancer
Irritable bowel syndrome
Diverticulosis
GI parasitic infection (ascariasis, giardiasis)
Inflammatory bowel disease
Angiodysplasia
W/U: Rectal exam, CBC, AST/ALT/bilirubin/alkaline phosphatase, Colonoscopy, Barium enema, CT—abdomen/pelvis
67 yo M presents with blood in his stool, weight loss, and constipation. He has a family history of colon cancer.
Colorectal cancer Anal fissure Hemorrhoids Diverticulosis Ischemic bowel disease Angiodysplasia Upper GI bleeding Inflammatory bowel disease W/U: Rectal exam, CBC, PT/PTT, AST/ALT/bilirubin/alkaline phosphatase, CEA, Colonoscopy, CT—abdomen/pelvis, Barium enema
68 yo M presents following a 20-minute episode of slurred speech, right facial drooping and numbness, and right hand weakness. His symptoms had totally resolved by the time he got to the ER. He has a history of hypertension, diabetes mellitus, and heavy smoking.
Transient ischemic attack (TIA) Hypoglycemia Seizure Stroke Facial nerve palsy W/U: CBC, Glucose, Electrolytes, ECG, CT—head, MRI—brain, Doppler U/S—carotid, Echocardiography, EEG
68 yo M presents with a two-month history of crying spells, excessive sleep, poor hygiene, and a 7-kg weight loss, all following his wife’s death. He cannot enjoy time with his grandchildren and reluctantly admits to thinking he has seen his dead wife in line at the supermarket or standing in the kitchen making dinner.
Normal bereavement
Adjustment disorder with depressed mood
Major depressive disorder with psychotic features
Schizoaffective disorder
Depressive disorder not otherwise specified (NOS)
W/U: Physical exam, Mental status exam, TSH, CBC, Urine toxicology
68 yo M presents with LLQ abdominal pain, fever, and chills for the past three days. He also reports recent onset of alternating diarrhea and constipation. He consumes a low-fi ber, high-fat diet.
Diverticulitis Crohn's disease Ulcerative colitis Gastroenteritis Abscess W/U: Rectal exam, CBC, electrolytes, CXR, AXR, CT—abdomen
68 yo M presents with slurred speech, right facial drooping and numbness, and right hand weakness. Babinski’s sign is present on the right. He has a history of hypertension, diabetes mellitus, and heavy smoking.
Stroke TIA Seizure Intracranial neoplasm Subdural or epidural hematoma W/U: CBC, electrolytes, PT/PTT, CT—head, MRI—brain (preferred,) Doppler U/S—carotid, Echocardiography
70 yo diabetic M presents with episodes of palpitations and diaphoresis. He is on insulin.
Hypoglycemia Cardiac arrhythmias Angina Hyperthyroidism Hyperventilation episodes Panic attacks Pheochromocytoma Carcinoid W/U: Glucose, CBC, electrolytes, TSH, BUN/Cr, ECG, Holter monitor
70 yo F presents with acute onset of severe, crampy abdominal pain. She recently vomited and had a massive dark bowel movement. She has a history of CHF and atrial fi brillation, for which she has received digitalis. Her pain is out of proportion to the exam.
Mesenteric ischemia/infarction Diverticulitis Peptic ulcer disease Gastroenteritis Acute pancreatitis Cholecystitis/choledocholithiasis MI W/U: Rectal exam, CBC, amylase, lipase, lactate, ECG, CPK-MB, troponin, AXR, CT—abdomen, Mesenteric angiography, Barium enema
70 yo F presents with acute onset of shortness of breath at rest and pleuritic chest pain. She also presents with tachycardia, hypotension, tachypnea, and mild fever. She is recovering from hip replacement surgery.
Pulmonary embolism Pneumonia Costochondritis MI CHF Aortic dissection W/U: ECG, CXR, ABG, CPK-MB, troponin, CBC, electrolytes, CT—chest with IV contrast, Doppler U/S—legs, D-dimer
70 yo insulin-dependent diabetic M presents with episodes of confusion, dizziness, palpitation, diaphoresis, and weakness.
Hypoglycemia Transient ischemic attack Arrhythmia Delirium Angina W/U: Glucos,e CBC, electrolytes, Echocardiography, ECG MRI—brain, Doppler U/S—carotid
71 yo M presents with nocturia, urgency, weak stream, terminal dribbling, hematuria, and lower back pain over the past four months. He has also experienced weight loss and fatigue.
Prostate cancer BPH Renal cell carcinoma UTI Bladder stones W/U: Rectal exam, UA, CBC, BUN/Cr, PSA, U/S—prostate (transrectal), CT—pelvis, IVP
72 yo M presents with memory loss, gait disturbance, and urinary incontinence for the past six months.
Normal pressure hydrocephalus Alzheimer's disease Vascular dementia Chronic subdural hematoma Intracranial neoplasm Depression B12 deficiency Neurosyphilis Hypothyroidism W/U: CT—head, LP—opening pressure and CSF analysis, Serum B12, VDRL/RPR, TSH
75 yo M presents with dysphagia that started with solids and progressed to liquids. He is an alcoholic and a heavy smoker. He has had an unintentional weight loss of 7 kg over the past four months.
Esophageal cancer Achalasia Esophagitis Systemic sclerosis Esophageal stricture Amyotrophic lateral sclerosis W/U: CBC, CXR, Endoscopy with biopsy, Barium swallow, CT—chest
81 yo M presents with progressive confusion over the past several years together with forgetfulness and clumsiness. He has a history of hypertension, diabetes mellitus, and two strokes with residual left hemiparesis. His mental status has clearly worsened after each stroke (stepwise decline in cognitive function).
Vascular ("multi-infarct") dementia
Alzheimer's disease
Normal pressure hydrocephalus
Chronic subdural hematoma
Intracranial tumor
Depression
B12 deficiency
Neurosyphilis
Hypothyroidism
W/U: CBC, VDRL/RPR, Serum B12, TSH, MRI—brain, CT—head, LP—CSF analysis (rare)84 yo F brought by her son c/o forgetfulness (e.g., forgets phone numbers, loses her way back home) along with diffi culty performing some of her daily activities (e.g., bathing, dressing, managing money, using the phone). The problem has gradually progressed over the past few years.
Alzheimer's disease Vascular dementia Depression Hypothyroidism Chronic subdural hematoma Normal pressure hydrocephalus Intracranial neoplasm B12 deficiency Neurosyphilis W/U: CBC, VDRL/RPR, Serum B12, TSH, MRI—brain (preferred), CT—head, LP—CSF analysis (rare)
