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162 Cards in this Set

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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.

HEADACHE
Migraine (complicated)
Tension headache
Cluster headache
Pseudotumor cerebri
Trigeminal neuralgia
CNS vasculitis
Partial seizure
Intracranial neoplasm
CBC
ESR
CT—head
MRI—brain
LP
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.
HEADACHE
Cluster headache
Migraine
Tension headache
Sinusitis
Pseudotumor cerebri
Trigeminal neuralgia
Intracranial neoplasm
CBC
ESR
CT—head
MRI—brain
LP
65 yo F presents with severe, intermittent
right temporal headache, fever, blurred
vision in her right eye, and pain in her
jaw when chewing.
HEADACHE
Temporal arteritis (giant cell
arteritis)
Migraine
Cluster headache
Tension headache
Meningitis
Carotid artery dissection
Pseudotumor cerebri
Trigeminal neuralgia
Intracranial neoplasm
CBC
ESR
CRP
Temporal artery biopsy
Doppler U/S—carotid
MRI—brain
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.
HEADACHE
Sinusitis
Migraine
Tension headache
Meningitis
Intracranial neoplasm
CBC
XR—sinus
CT—sinus
LP
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.
HEADACHE
Tension headache
Migraine
Depression
Caffeine or analgesic
withdrawal
Hypertension
Cluster headache
Pseudotumor cerebri
Intracranial neoplasm
CBC
Electrolytes
ESR
CT—head
LP
35 yo M presents with sudden severe
headache, vomiting, confusion, left
hemiplegia, and nuchal rigidity.
HEADACHE
Subarachnoid hemorrhage
Migraine
Meningitis/encephalitis
Intracranial hemorrhage
Vertebral artery dissection
Intracranial venous thrombosis
Acute hypertension
Intracranial neoplasm
CT without contrast—head
LP
CBC
PT/PTT
MRI/MRA—brain
25 yo M presents with high fever, severe
headache, confusion, photophobia, and
nuchal rigidity. Kernig’s and Brudzinski’s
signs are positive.
HEADACHE
Meningitis
Migraine
Subarachnoid hemorrhage
Sinusitis/encephalitis
Intracranial or epidural abscess
CBC
CT—head
MRI—brain
LP—CSF analysis (cell count,
protein, glucose, Gram stain,
PCR for antigens, culture)
18 yo obese F presents with a pulsatile
headache, vomiting, and blurred vision
for the past 2–3 weeks. She is taking
OCPs.
HEADACHE
Pseudotumor cerebri
Tension headache
Migraine
Cluster headache
Meningitis
Intracranial venous thrombosis
Intracranial neoplasm
Urine hCG
CBC
CT—head
LP—opening pressure and CSF
analysis
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
HEADACHE
Trigeminal neuralgia
Tension headache
Migraine
Cluster headache
TMJ dysfunction
Intracranial neoplasm
CBC
ESR
MRI—brain
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).
CONFUSION/MEMORY LOSS
Vascular (“multi-infarct”)
dementia
Alzheimer’s disease
Normal pressure hydrocephalus
Chronic subdural hematoma
Intracranial tumor
Depression
B12 defi ciency
Neurosyphilis
Hypothyroidism
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.
CONFUSION/MEMORY LOSS
Alzheimer’s disease
Vascular dementia
Depression
Hypothyroidism
Chronic subdural hematoma
Normal pressure hydrocephalus
Intracranial neoplasm
B12 defi ciency
Neurosyphilis
CBC
VDRL/RPR
Serum B12
TSH
MRI—brain (preferred)
CT—head
LP—CSF analysis (rare)
72 yo M presents with memory loss, gait
disturbance, and urinary incontinence for
the past six months.
CONFUSION/MEMORY LOSS
Normal pressure
hydrocephalus
Alzheimer’s disease
Vascular dementia
Chronic subdural hematoma
Intracranial neoplasm
Depression
B12 defi ciency
Neurosyphilis
Hypothyroidism
CT—head
LP—opening pressure and CSF
analysis
Serum B12
VDRL/RPR
TSH
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.
CONFUSION/MEMORY LOSS
Creutzfeldt-Jakob disease
Vascular dementia
Lewy body dementia
Wernicke’s encephalopathy
Normal pressure hydrocephalus
Chronic subdural hematoma
Intracranial neoplasm
Depression
Delirium
B12 deficiency
Neurosyphilis
CBC, electrolytes, calcium
Serum B12
VDRL/RPR
MRI—brain (preferred)
CT—head
EEG
LP—CSF analysis
Brain biopsy
70 yo insulin-dependent diabetic M
presents with episodes of confusion,
dizziness, palpitation, diaphoresis, and
weakness.
CONFUSION/MEMORY LOSS
Hypoglycemia
Transient ischemic attack
Arrhythmia
Delirium
Angina
Glucose
CBC, electrolytes
Echocardiography
ECG
MRI—brain
Doppler U/S—carotid
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.
CONFUSION/MEMORY LOSS
Subdural hematoma
SIADH (causing hyponatremia)
Creutzfeldt-Jakob disease
Intracranial neoplasm
Electrolytes
CT—head
MRI—brain
LP
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.
DEPRESSED MOOD
Normal bereavement
Adjustment disorder with
depressed mood
Major depressive disorder with
psychotic features
Schizoaffective disorder
Depressive disorder not
otherwise specifi ed (NOS)
Physical exam
Mental status exam
TSH
CBC
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.
DEPRESSED MOOD
Major depressive disorder
Substance-induced mood
disorder
Dysthymic disorder
Physical exam
Mental status exam
Blood alcohol level
TSH
CBC
Urine toxicology
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.
DEPRESSED MOOD
Bipolar I disorder
Bipolar II disorder
Cyclothymic disorder
Major depressive disorder
Schizoaffective disorder
Physical exam
Mental status exam
Urine toxicology
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.”
PSYCHOSIS
Schizophrenia
Schizoid or schizotypal
personality disorder
Schizophreniform disorder
Psychotic disorder due to a
general medical condition
Substance-induced psychosis
Depression with psychotic
features
Mental status exam
Urine toxicology
TSH
CBC
Electrolytes
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.
PSYCHOSIS
Substance-induced psychosis
Brief psychotic disorder
Schizophreniform disorder
Schizophrenia
Psychotic disorder due to a
general medical condition
Urine toxicology
Mental status exam
TSH
CBC
Electrolytes, BUN/Cr, AST/
ALT
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.
PSYCHOSIS
Schizoaffective disorder
Mood disorder with psychotic
features
Schizophrenia
Schizophreniform disorder
Psychotic disorder due to a
general medical condition
Mental status exam
Beck Depression Inventory
TSH
CBC
Electrolytes
35 yo F presents with intermittent
episodes of vertigo, tinnitus, nausea, and
hearing loss over the past week
DIZZINESS
Ménière’s disease
Vestibular neuronitis
Labyrinthitis
Benign positional vertigo
Acoustic neuroma
CBC
VDRL/RPR (syphilis is a cause
of Ménière’s disease)
MRI—brain
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.
DIZZINESS
Orthostatic hypotension due
to dehydration (diarrhea,
diuretic use)
Vestibular neuronitis
Labyrinthitis
Benign positional vertigo
Vertebrobasilar insuffi ciency
Orthostatic vital signs
CBC
Electrolytes
Stool exam (occult blood, fecal
leukocytes)
65 yo M presents with postural dizziness
and unsteadiness. He has hypertension
and was started on hydrochlorothiazide
two days ago.
DIZZINESS
Drug-induced orthostatic
hypotension
Vestibular neuronitis
Labyrinthitis
Benign positional vertigo
Brain stem or cerebellar tumor
Acute renal failure
Orthostatic vital signs
CBC
Electrolytes
BUN/Cr
MRI—brain
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
DIZZINESS
Benign positional vertigo
Vestibular neuronitis
Labyrinthitis
Ménière’s disease
MRI—brain
Audiogram
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.
DIZZINESS
Vestibular neuronitis
Labyrinthitis
Ménière’s disease
Benign positional vertigo
Vertigo associated with cervical
spine disease/injury
Vertebrobasilar insuffi ciency
CBC
Electrolytes
Electronystagmography
MRI/MRA—brain
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.
DIZZINESS
Labyrinthitis
Vestibular neuronitis
Ménière’s disease
Acoustic neuroma
Vertebrobasilar insuffi ciency
Audiogram
Electronystagmography
MRI/MRA—brain
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).
LOSS OF CONSCIOUSNESS
Seizure, grand mal (now called
complex tonic-clonic seizure)
Convulsive syncope
Substance abuse/overdose
Malingering
Hypoglycemia
CBC, electrolytes, glucose
Urine toxicology
EEG
MRI—brain
CT—head
LP—CSF analysis
ECG
55 yo M c/o falling after feeling dizzy
and unsteady. He experienced transient
LOC. He has hypertension and is on
numerous antihypertensive drugs.
LOSS OF CONSCIOUSNESS
Drug-induced orthostatic
hypotension (causing
syncope)
Cardiac arrhythmia
Syncope (vasovagal, other
causes)
Stroke
MI
Pulmonary embolism
Orthostatic vital signs
CBC
Electrolytes
CT—head
ECG
V/Q scan
CT—chest with IV contrast
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).
LOSS OF CONSCIOUSNESS
Cardiac arrhythmia (causing
syncope)
Severe aortic stenosis
Syncope (other causes)
Seizure
Pulmonary embolism
ECG
Holter monitoring
CBC, electrolytes
Glucose
Echocardiography
CT—head
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
NUMBNESS/WEAKNESS
Transient ischemic attack
(TIA)
Hypoglycemia
Seizure
Stroke
Facial nerve palsy
CBC
Glucose
Electrolytes
ECG
CT—head
MRI—brain
Doppler U/S—carotid
Echocardiography
EEG
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.
NUMBNESS/WEAKNESS
Stroke
TIA
Seizure
Intracranial neoplasm
Subdural or epidural hematoma
CBC, electrolytes
PT/PTT
CT—head
MRI—brain (preferred)
Doppler U/S—carotid
Echocardiography
33 yo F presents with ascending loss of
strength in her lower legs over the past
two weeks. She had a recent URI.
NUMBNESS/WEAKNESS
Guillain-Barré syndrome
Multiple sclerosis
Polymyositis
Myasthenia gravis
Peripheral neuropathy
Tumor in the vertebral canal
CBC, electrolytes
CPK
LP—CSF analysis
MRI—spine
EMG/nerve conduction study
Tensilon test
Serum B12
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.
NUMBNESS/WEAKNESS
Multiple sclerosis
Stroke
Conversion disorder
Malingering
CNS tumor
Neurosyphilis
Syringomyelia
CNS vasculitis
CBC, ESR
VDRL/RPR
MRI—brain
LP—CSF analysis
Retinal evoked potentials
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.
NUMBNESS/WEAKNESS
Diabetic peripheral
neuropathy
Alcoholic peripheral neuropathy
B12 defi ciency
Hypocalcemia
Hyperventilation
Paraproteinemia/myeloma
HbA1c
ESR
Calcium
Serum B12
Serum and urine protein
electrophoresis
40 yo F presents with occasional double
vision and droopy eyelids at night with
normalization by morning.
NUMBNESS/WEAKNESS
Myasthenia gravis
Horner’s syndrome
Multiple sclerosis
Intracranial tumor compressing
CN III, IV, or VI
Amyotrophic lateral sclerosis
Tensilon test
ACh receptor antibodies (in
serum)
CXR
CT—chest
MRI—brain
EMG
25 yo M presents with hemiparesis (after
a tonic-clonic seizure) that resolves over
a few hours.
NUMBNESS/WEAKNESS
Todd’s paralysis
TIA
Stroke
Complicated migraine
Malingering
CBC, electrolytes
EEG
MRI—brain
Doppler U/S—carotid
40 yo F c/o feeling tired, hopeless,
and worthless and of having suicidal
thoughts. She recently discovered that
her husband is homosexual.
FATIGUE AND SLEEPINESS
Depression
Adjustment disorder
Hypothyroidism
Anemia
CBC
TSH
HIV/STD testing (given
husband’s possible risk
factors)
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.
FATIGUE AND SLEEPINESS
Post-traumatic stress disorder
(PTSD)
Depression
Generalized anxiety disorder
Psychotic or delusional disorder
Hypothyroidism
CBC
TSH
Calcium
Urine toxicology
55 yo M presents with fatigue, weight
loss, and constipation. He has a family
history of colon cancer
FATIGUE AND SLEEPINESS
Colon cancer
Hypothyroidism
Renal failure
Hypercalcemia
Depression
Rectal exam, stool for occult
blood
CBC, electrolytes, calcium,
BUN/Cr, AST/ALT, TSH
Colonoscopy
Barium enema
40 yo F presents with fatigue, weight
gain, sleepiness, cold intolerance,
constipation, and dry skin.
FATIGUE AND SLEEPINESS
Hypothyroidism
Depression
Diabetes
Anemia
TSH, FT3, FT4
CBC
Glucose, HbA1c
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.
FATIGUE AND SLEEPINESS
Obstructive sleep apnea
Hypothyroidism
Chronic fatigue syndrome
Narcolepsy
CBC
TSH
Nocturnal pulse oximetry
Polysomnography
ECG
20 yo M presents with fatigue, thirst,
increased appetite, and polyuria
FATIGUE AND SLEEPINESS
Diabetes mellitus
Atypical depression
Primary polydipsia
Diabetes insipidus
Glucose tolerance test, HbA1c
UA
CBC, electrolytes, glucose
BUN/Cr
35 yo M policeman c/o feeling tired and
sleepy during the day. He changed to the
night shift last week.
FATIGUE AND SLEEPINESS
Sleep deprivation
Sleep apnea
Depression
Anemia
CBC
Nocturnal pulse oximetry
Polysomnography
30 yo M presents with night sweats,
cough, and swollen glands of one
month’s duration.
NIGHT SWEATS
Tuberculosis
Acute HIV infection
Lymphoma
Leukemia
Hyperthyroidism
PPD
CBC
CXR
Sputum Gram stain, acid-fast
stain, and culture
HIV antibody
TSH, FT4
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.
INSOMNIA
Stress-induced insomnia
Caffeine-induced insomnia
Insomnia with circadian rhythm
sleep disorder
Insomnia related to major
depressive disorder
Polysomnography
Mental status exam
Urine toxicology
CBC
TSH
55 yo obese M presents with several
months of poor sleep and daytime
fatigue. His wife reports that he snores
loudly.
INSOMNIA
Obstructive sleep apnea
Daytime fatigue in primary
hypersomnia
Insomnia with circadian rhythm
sleep disorder
Insomnia related to major
depressive disorder
CBC
TSH
Polysomnography
ECG
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
Insomnia related to major depressive disorder
Primary hypersomnia
Insomnia with circadian rhythm
sleep disorder
Mental status exam
TSH
CBC
Polysomnography
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.
SORE THROAT
Infectious mononucleosis
Hepatitis
Viral or bacterial pharyngitis
Acute HIV infection
Secondary syphilis
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 with sore throat, fever,
rash, and weight loss. He has a history of
IV drug abuse and sharing needles.
SORE THROAT
HIV, acute retroviral
syndrome
Infectious
mononucleosis
Hepatitis
Viral pharyngitis
Streptococcal tonsillitis/
scarlet fever
Secondary syphilis
CBC
Peripheral smear
HIV antibody and viral load
CD4 count
Monospot test
Throat culture
VDRL/RPR
AST/ALT/bilirubin/alkaline
phosphatase
46 yo F presents with fever and sore
throat.
SORE THROAT
Pharyngitis (bacterial
or viral)
Mycoplasma
pneumonia
Acute HIV infection
Infectious
mononucleosis
Throat swab for culture and rapid
streptococcal antigen
Monospot test
CBC
HIV antibody and viral load
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.
COUGH/SHORTNESS OF BREATH
Asthma
GERD
Bronchitis
Pneumonitis
Foreign body
CBC
CXR
Peak fl ow measurement
PFTs
Methacholine challenge test
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.
COUGH/SHORTNESS OF BREATH
COPD—chronic bronchitis
Bronchiectasis
Lung cancer
Tuberculosis
CBC
Sputum Gram stain and culture
CXR
PFTs
CT—chest
PPD
58 yo M presents with pleuritic chest
pain, fever, chills, and cough with
purulent yellow sputum. He is a heavy
smoker with COPD.
COUGH/SHORTNESS OF BREATH
Pneumonia
Bronchitis
Lung abscess
Lung cancer
Tuberculosis
Pericarditis
CBC
Sputum Gram stain and culture
CXR
CT—chest
ECG
PPD
25 yo F presents with two weeks of a
nonproductive cough. Three weeks ago
she had a sore throat and a runny nose.
COUGH/SHORTNESS OF BREATH
Atypical pneumonia
Reactive airway disease
URI-associated (“postinfectious”)
Postnasal drip
GERD
CBC
Induced sputum Gram stain
and culture
CXR
IgM detection for Mycoplasma
pneumoniae
Urine Legionella antigen
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.
COUGH/SHORTNESS OF BREATH
Lung cancer
Tuberculosis
Lung abscess
COPD
Vasculitis (i.e., Wegener’s)
Interstitial lung disease
CHF
CBC
Sputum Gram stain, culture,
and cytology
CXR
CT—chest
PPD
Bronchoscopy
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.
COUGH/SHORTNESS OF BREATH
COPD exacerbation
(bronchitis)
Lung cancer
Pneumonia
URI
CHF
CBC
CXR
PFTs
Sputum Gram stain and culture
CT—chest
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.
COUGH/SHORTNESS OF BREATH
Tuberculosis
Pneumonia
Lung abscess
Vasculitis
Lymphoma
Metastatic cancer
HIV/AIDS
Sarcoidosis
CBC
PPD
Sputum Gram stain, acid-fast
stain, and culture
CXR
CT—chest
Bronchoscopy
HIV antibody
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.
COUGH/SHORTNESS OF BREATH
Tuberculosis
Pneumonia (including
Pneumocystis jiroveci)
Bronchitis
CHF (cardiomyopathy)
Asthma
Acute HIV infection
CBC
PPD
Sputum Gram stain, acid-fast
stain, silver stain, and culture
CXR
HIV antibody
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.
COUGH/SHORTNESS OF BREATH
CHF
Cardiac valvular disease
GERD
Pulmonary fi brosis
COPD
Postnasal drip
CBC
CXR
ECG
Echocardiography
PFTs
BNP
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.
CHEST PAIN
Myocardial infarction (MI)
GERD
Angina
Costochondritis
Aortic dissection
Pericarditis
Pulmonary embolism
Pneumothorax
ECG
CPK-MB, troponin
CXR
CBC, electrolytes
Echocardiography
Cardiac catheterization
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.
CHEST PAIN
Sickle cell disease—pulmonary
infarction
Pneumonia
Pulmonary embolism
MI
Pneumothorax
Aortic dissection
CBC, reticulocyte count, LDH,
peripheral smear
ABG
CXR
CPK-MB, troponin
ECG
CT—chest with IV contrast
45 yo F presents with a retrosternal
burning sensation that occurs after
heavy meals and when lying down. Her
symptoms are relieved by antacids.
CHEST PAIN
GERD
Esophagitis
Peptic ulcer disease
Esophageal spasm
MI
Angina
ECG
Barium swallow
Upper endoscopy
Esophageal pH monitoring
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.
CHEST PAIN
Angina
Esophageal spasm
Esophagitis
ECG
CPK-MB, troponin
CXR
CBC, electrolytes
Exercise stress test
Upper endoscopy/pH monitor
Cardiac catheterization
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.
CHEST PAIN
Pericarditis
Aortic dissection
MI
Costochondritis
GERD
Esophageal rupture
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.
CHEST PAIN
Costochondritis
Pneumonia
MI
Pulmonary embolism
Pericarditis
Muscle strain
ECG
CPK-MB, troponin
CXR
CBC
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.
CHEST PAIN
Pulmonary embolism
Pneumonia
Costochondritis
MI
CHF
Aortic dissection
ECG
CXR
ABG
CPK-MB, troponin
CBC, electrolytes
CT—chest with IV contrast
Doppler U/S—legs
D-dimer
55 yo M presents with sudden onset of
severe chest pain that radiates to the
back. He has a history of uncontrolled
hypertension.
CHEST PAIN
Aortic dissection
MI
Pericarditis
Esophageal rupture
Esophageal spasm
GERD
Pancreatitis
Fat embolism
ECG, CPK-MB, troponin
CXR
CBC, amylase, lipase
Transesophageal
echocardiography (TEE),
MRI/MRA—aorta
Aortic angiography
Upper endoscopy
70 yo diabetic M presents with episodes of
palpitations and diaphoresis. He is on insulin.
PALPITATIONS
Hypoglycemia
Cardiac arrhythmias
Angina
Hyperthyroidism
Hyperventilation
episodes
Panic attacks
Pheochromocytoma
Carcinoid
Glucose
CBC, electrolytes
TSH
BUN/Cr
ECG
Holter monitor
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.
WEIGHT LOSS
Hyperthyroidism
Cancer
HIV infection
Dieting/diet drugs
Anorexia nervosa
Malabsorption
TSH, FT4
CBC, electrolytes
HIV antibody
Urine toxicology
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.
WEIGHT GAIN
Smoking cessation
Drug side effect
Hypothyroidism
Cushing’s syndrome
Polycystic ovary syndrome
Diabetes mellitus
Atypical depression
CBC, electrolytes, glucose
TSH
24-hour urine free cortisol
Dexamethasone suppression test
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.
DYSPHAGIA
Esophageal cancer
Achalasia
Esophagitis
Systemic sclerosis
Esophageal stricture
Amyotrophic lateral sclerosis
CBC
CXR
Endoscopy with biopsy
Barium swallow
CT—chest
45 yo F presents with dysphagia for two
weeks together with fatigue and a craving
for ice and clay
DYSPHAGIA
Plummer-Vinson syndrome
Esophageal cancer
Esophagitis
Achalasia
Systemic sclerosis
Mitral valve stenosis
CBC
Serum iron, ferritin, TIBC
Barium swallow
Endoscopy
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.
DYSPHAGIA
Achalasia
Plummer-Vinson syndrome
Esophageal cancer
Esophagitis
Systemic sclerosis
Mitral valve stenosis
Esophageal stricture
Zenker’s diverticulum
CXR
Endoscopy
Barium swallow
Esophageal manometry
38 yo M presents with dysphagia and pain
on swallowing solids more than liquids.
Exam reveals oral thrush.
DYSPHAGIA
Esophagitis (CMV, HSV, pillinduced)
Systemic sclerosis
GERD
Esophageal stricture
Zenker’s diverticulum
CBC
Endoscopy
Barium swallow
HIV antibody
CD4 count
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.
NAUSEA/VOMITING
Pregnancy
Gastritis
Hypercalcemia
Diabetes mellitus
UTI
Depression
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
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.
ABDOMINAL PAIN
Nephrolithiasis
Renal cell carcinoma
Pyelonephritis
GI etiology (e.g., appendicitis)
Rectal exam
UA
Urine culture and sensitivity
BUN/Cr
CT—abdomen
U/S—renal
IVP
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.
ABDOMINAL PAIN
Pancreatic cancer
Acute viral hepatitis
Chronic pancreatitis
Cholecystitis/choledocholithiasis
Abdominal aortic aneurysm
Peptic ulcer disease
Rectal exam
CBC, electrolytes
Amylase and lipase
AST/ALT/bilirubin/alkaline
phosphatase
U/S—abdomen
CT—abdomen
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.
ABDOMINAL PAIN
Acute pancreatitis
Peptic ulcer disease
Cholecystitis/choledocholithiasis
Gastritis
Abdominal aortic aneurysm
Mesenteric ischemia
Alcoholic hepatitis
Mallory-Weiss tear
Rectal exam
CBC, electrolytes, BUN/Cr,
amylase, lipase, AST/ALT/
bilirubin/alkaline phosphatase
U/S—abdomen
CT—abdomen
Upper endoscopy
ECG
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.
ABDOMINAL PAIN
Acute cholecystitis
Hepatitis
Choledocholithiasis
Ascending cholangitis
Peptic ulcer disease
Fitz-Hugh–Curtis syndrome
Rectal exam
CBC
AST/ALT/bilirubin/alkaline
phosphatase
U/S—abdomen
HIDA scan
43 yo obese F presents with RUQ
abdominal pain, fever, and jaundice. She
was diagnosed with asymptomatic
gallstones one year ago.
ABDOMINAL PAIN
Ascending cholangitis
Acute cholecystitis
Hepatitis
Choledocholithiasis
Sclerosing cholangitis
Fitz-Hugh–Curtis syndrome
Rectal exam
CBC
AST/ALT/bilirubin/alkaline
phosphatase
Viral hepatitis serologies
U/S—abdomen
MRCP
ERCP
25 yo M presents with RUQ pain, fever,
anorexia, nausea, and vomiting. He has
dark urine and clay-colored stool.
ABDOMINAL PAIN
Acute hepatitis
Acute cholecystitis
Ascending cholangitis
Choledocholithiasis
Pancreatitis
Acute glomerulonephritis
Rectal exam
CBC, amylase, lipase
AST/ALT/bilirubin/alkaline
phosphatase
UA
Viral hepatitis serologies
U/S—abdomen
35 yo M presents with burning epigastric
pain that starts 2–3 hours after meals.
The pain is relieved by food and
antacids.
ABDOMINAL PAIN
Peptic ulcer disease
Gastritis
GERD
Cholecystitis
Chronic pancreatitis
Mesenteric ischemia
Rectal exam
Amylase, lipase, lactate
AST/ALT/bilirubin/alkaline
phosphatase
Endoscopy (including H. pylori
testing)
Upper GI series
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.
ABDOMINAL PAIN
Peptic ulcer perforation
Acute pancreatitis
Hepatitis
Cholecystitis
Choledocholithiasis
Mesenteric ischemia
Rectal exam
CBC, electrolytes, amylase,
lipase, lactate
AST/ALT/bilirubin/alkaline
phosphatase
AXR
Upright CXR
Endoscopy (including H. pylori
testing)
18 yo M boxer presents with severe LUQ
abdominal pain that radiates to the left
scapula. He had infectious
mononucleosis three weeks ago.
ABDOMINAL PAIN
Splenic rupture
Kidney stone
Rib fracture
Pneumonia
Perforated peptic ulcer
Splenic infarct
Rectal exam
CBC, electrolytes
CXR
CT—abdomen
U/S—abdomen
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.
ABDOMINAL PAIN
Intestinal obstruction
Small bowel or colon cancer
Volvulus of the bowel
Gastroenteritis
Food poisoning
Ileus
Hernia
Rectal exam
CBC, electrolytes
AXR
CT—abdomen/pelvis
CXR
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.
ABDOMINAL PAIN
Mesenteric ischemia/infarction
Diverticulitis
Peptic ulcer disease
Gastroenteritis
Acute pancreatitis
Cholecystitis/choledocholithiasis
MI
Rectal exam
CBC, amylase, lipase, lactate
ECG, CPK-MB, troponin
AXR
CT—abdomen
Mesenteric angiography
Barium enema
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.
ABDOMINAL PAIN
Ovarian torsion
Appendicitis
Nephrolithiasis
Ectopic pregnancy
Ruptured ovarian cyst
PID
Bowel infarction or perforation
Pelvic exam
Rectal exam
Urine hCG
UA
CBC
Doppler U/S—pelvis
CT—abdomen
Laparoscopy
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
ABDOMINAL PAIN
Diverticulitis
Crohn’s disease
Ulcerative colitis
Gastroenteritis
Abscess
Rectal exam
CBC, electrolytes
CXR
AXR
CT—abdomen
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.
ABDOMINAL PAIN
Acute appendicitis
Gastroenteritis
Diverticulitis
Crohn’s disease
Nephrolithiasis
Volvulus or other intestinal
obstruction/perforation
Rectal exam
CBC, electrolytes
AXR
CT—abdomen
U/S—abdomen
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.
ABDOMINAL PAIN
Irritable bowel syndrome
Crohn’s disease
Celiac disease
Chronic pancreatitis
GI parasitic infection
(amebiasis, giardiasis)
Endometriosis
Rectal exam, stool for occult
blood
Pelvic exam
Urine hCG
CBC
Electrolytes
CT—abdomen/pelvis
Stool for ova and parasitology,
Entamoeba histolytica
antigen
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.
ABDOMINAL PAIN
PID
Endometriosis
Dysmenorrhea
Vaginitis
Cystitis
Spontaneous abortion
Pyelonephritis
Pelvic exam
Rectal exam
Urine hCG
Cervical cultures
CBC/ESR
UA, urine culture
U/S—pelvis
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.
CONSTIPATION/DIARRHEA
Colorectal cancer
Irritable bowel syndrome
Diverticulosis
GI parasitic infection (ascariasis,
giardiasis)
Infl ammatory bowel disease
Angiodysplasia
Rectal exam
CBC
AST/ALT/bilirubin/alkaline
phosphatase
Colonoscopy
Barium enema
CT—abdomen/pelvis
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.
CONSTIPATION/DIARRHEA
Low-fi ber diet
Irritable bowel syndrome
Substance abuse (e.g., heroin)
Depression
Hypothyroidism
Rectal exam
TSH
Electrolytes
Urine toxicology
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.
CONSTIPATION/DIARRHEA
Irritable bowel syndrome
Infl ammatory bowel disease
Celiac disease
Chronic pancreatitis
GI parasitic infection (ascariasis,
giardiasis)
Lactose intolerance
Rectal exam, stool for occult
blood
CBC
Electrolytes
Stool for ova and parasitology
AXR
CT—abdomen/pelvis
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.
CONSTIPATION/DIARRHEA
Infectious diarrhea
(gastroenteritis)—bacterial,
viral, parasitic, protozoal
Food poisoning
Infl ammatory bowel disease
Rectal exam, stool for occult
blood
Stool leukocytes and culture
CBC
Electrolytes
CT—abdomen/pelvis
40 yo F presents with watery diarrhea
and abdominal cramps. Last week she
was on antibiotics for a UTI.
CONSTIPATION/DIARRHEA
Pseudomembranous
(Clostridium diffi cile) colitis
Gastroenteritis
Cryptosporidiosis
Food poisoning
Infl ammatory bowel disease
Rectal exam
Stool leukocytes, culture, occult
blood
C. diffi cile toxin in stool
Electrolytes
25 yo M presents with watery diarrhea
and abdominal cramps. He was recently
in Mexico
CONSTIPATION/DIARRHEA
Traveler’s diarrhea
Giardiasis
Amebiasis
Food poisoning
Hepatitis A
Rectal exam
Stool leukocytes, culture,
Giardia antigen, Entamoeba
histolytica antigen
Electrolytes
AST/ALT/bilirubin/alkaline
phosphatase
Viral hepatitis serology
30 yo F presents with watery diarrhea
and abdominal cramping and bloating.
Her symptoms are aggravated by milk
ingestion and are relieved by fasting.
CONSTIPATION/DIARRHEA
Lactose intolerance
Gastroenteritis
Infl ammatory bowel disease
Irritable bowel syndrome
Hyperthyroidism
Rectal exam
Stool exam
Hydrogen breath test
TSH
33 yo M presents with watery diarrhea,
diffuse abdominal pain, and weight loss
over the past three weeks. He has not
responded to antibiotics.
CONSTIPATION/DIARRHEA
Crohn’s disease
Gastroenteritis
Ulcerative colitis
Celiac disease
Pseudomembranous colitis
Hyperthyroidism
Small bowel lymphoma
Carcinoid
Rectal exam
Stool exam and culture
CBC, electrolytes
TSH
CT—abdomen
Colonoscopy
Small bowel series
Urinary 5-HIAA
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.
UPPER G I BLEEDING
Bleeding peptic ulcer
Gastritis
Gastric cancer
Esophageal varices
Rectal exam
CBC, electrolytes
AST/ALT/bilirubin/alkaline
phosphatase
Endoscopy (including H. pylori
testing if ulcer is confi rmed)
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
UPPER GI BLEEDING
Gastritis
Bleeding peptic ulcer
Gastric cancer
Esophageal varices
Mallory-Weiss tear
Rectal exam
CBC, electrolytes
AST/ALT/bilirubin/alkaline
phosphatase
Barium swallow
Endoscopy
67 yo M presents with blood in his stool,
weight loss, and constipation. He has a
family history of colon cancer.
BLOOD IN STOOL
Colorectal cancer
Anal fi ssure
Hemorrhoids
Diverticulosis
Ischemic bowel disease
Angiodysplasia
Upper GI bleeding
Infl ammatory bowel disease
Rectal exam
CBC, PT/PTT
AST/ALT/bilirubin/alkaline
phosphatase
CEA
Colonoscopy
CT—abdomen/pelvis
Barium enema
33 yo F presents with rectal bleeding and
diarrhea for the past week. She has had
lower abdominal pain and tenesmus for
several months
BLOOD IN STOOL
Ulcerative colitis
Crohn’s disease
Proctitis
Anal fi ssure
Hemorrhoids
Diverticulosis
Dysentery
Rectal exam
CBC, PT/PTT
AXR
Colonoscopy
CT—abdomen/pelvis
Barium enema
58 yo M presents with bright red blood
per rectum and chronic constipation. He
consumes a low-fi ber diet.
BLOOD IN STOOL
Diverticulosis
Anal fi ssure
Hemorrhoids
Angiodysplasia
Colorectal cancer
Rectal exam
CBC, PT/PTT
Electrolytes
Colonoscopy
CT—abdomen/pelvis
65 yo M presents with painless
hematuria. He is a heavy smoker and
works as a painter.
HEMATURIA
Bladder cancer
Renal cell carcinoma
Nephrolithiasis
Acute glomerulonephritis
Prostate cancer
Coagulation disorder (i.e., factor
VIII antibodies)
Polycystic kidney disease
Genitourinary exam
UA, urine cytology
BUN/Cr, PSA, CBC, PT/PTT
Cystoscopy
U/S—renal/bladder
CT—abdomen/pelvis
IVP
35 yo M presents with painless
hematuria. He has a family history of
kidney problems.
HEMATURIA
Polycystic kidney disease
Nephrolithiasis
Acute glomerulonephritis (e.g.,
IgA nephropathy)
UTI
Coagulation disorder
Bladder cancer
Genitourinary exam
UA
BUN/Cr, PSA, CBC, PT/PTT
U/S—renal
CT—abdomen/pelvis
IVP
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.
HEMATURIA
Renal cell carcinoma
Bladder cancer
Nephrolithiasis
Acute glomerulonephritis
Pyelonephritis
Prostate cancer
Genitourinary, rectal exam
UA, urine cytology, BUN/Cr,
PSA, CBC, PT/PTT
U/S—renal
CT—abdomen/pelvis
IVP
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.
URINARY SYMPTOMS
Benign prostatic hyperplasia
(BPH)
Prostate cancer
UTI
Bladder stones
Rectal exam
UA
CBC, BUN/Cr, PSA
U/S—prostate (transrectal)
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.
URINARY SYMPTOMS
Prostate cancer
BPH
Renal cell carcinoma
UTI
Bladder stones
Rectal exam
UA
CBC, BUN/Cr, PSA
U/S—prostate (transrectal)
CT—pelvis
IVP
18 yo M presents with a burning
sensation during urination and urethral
discharge. He recently had unprotected
sex with a new partner.
URINARY SYMPTOMS
Urethritis
Cystitis
Prostatitis
Genital ± rectal exam
UA
Urine culture
Gram stain and culture of
urethral discharge
Chlamydia and gonorrhea PCR
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.
URINARY SYMPTOMS
Acute pyelonephritis
Nephrolithiasis
Renal cell carcinoma
Lower UTI (cystitis, urethritis)
UA
Urine culture and sensitivity
CBC, BUN/Cr
U/S—renal
CT—abdomen
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.
ERECTILE DYSFUNCTION (ED)
Drug-related ED
ED caused by hypertension
ED caused by diabetes mellitus
Psychogenic ED
Peyronie’s disease
Genital exam
Rectal exam
Glucose
CBC
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.
AMENORRHEA
Pregnancy
Anovulatory cycle
Hyperprolactinemia
UTI
Thyroid disease
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
23 yo obese F presents with amenorrhea
for six months, facial hair, and infertility
for the past three years.
AMENORRHEA
Polycystic ovary syndrome
Thyroid disease
Hyperprolactinemia
Pregnancy
Ovarian or adrenal malignancy
Premature ovarian failure
Pelvic exam
Urine hCG
U/S—pelvis
LH/FSH, TSH, prolactin
Testosterone, DHEAS
35 yo F presents with amenorrhea,
galactorrhea, visual fi eld defects, and
headaches for the past six months
AMENORRHEA
Amenorrhea secondary to
prolactinoma
Pregnancy
Thyroid disease
Premature ovarian failure
Pituitary tumor
Pelvic and breast exam
Urine hCG
Prolactin
LH/FSH, TSH
MRI—brain
48 yo F presents with amenorrhea for the
past six months accompanied by hot
fl ashes, night sweats, emotional lability,
and dyspareunia.
AMENORRHEA
Menopause
Pregnancy
Pituitary tumor
Thyroid disease
Pelvic exam
Urine hCG
LH/FSH, TSH, prolactin,
testosterone, DHEAS
CBC
MRI—brain
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.
AMENORRHEA
Sheehan’s syndrome
Premature ovarian failure
Pituitary tumor
Thyroid disease
Asherman’s syndrome
Pelvic exam
Urine hCG
CBC
LH/FSH, prolactin
TSH, FT4
ACTH
MRI—brain
Hysteroscopy
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.
AMENORRHEA
Anorexia nervosa
CBC
TSH
FT4
ACTH
FSH
LH
29 yo F presents with amenorrhea for the
past six months. She has a history of
occasional palpitations and dizziness. She
lost her fi ancé in a car accident.
AMENORRHEA
Anxiety-induced amenorrhea
CBC
TSH
FT4
ACTH
Urine cortisol level
Progesterone challenge test
FSH/LH/estradiol levels
17 yo F presents with prolonged,
excessive menstrual bleeding occurring
irregularly over the past six months.
VAGINAL BLEEDING
Dysfunctional uterine bleeding
Coagulation disorders (e.g., von
Willebrand’s disease,
hemophilia)
Cervical cancer
Molar pregnancy
Hypothyroidism
Diabetes mellitus
Pelvic exam
Urine hCG
Cervical cultures, Pap smear
CBC, ESR, glucose
PT/PTT
Prolactin, LH/FSH
TSH
U/S—pelvis
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.
VAGINAL BLEEDING
Endometrial cancer
Cervical cancer
Atrophic endometrium
Endometrial hyperplasia
Endometrial polyps
Atrophic vaginitis
Pelvic exam
Pap smear
Endometrial biopsy
U/S—pelvis
Endometrial curettage
Colposcopy
Hysteroscopy
45 yo G5P5 F presents with postcoital
bleeding. She is a cigarette smoker and
takes OCPs.
VAGINAL BLEEDING
Cervical cancer
Cervical polyp
Cervicitis
Trauma (e.g., cervical
laceration)
Pelvic exam
Pap smear
Colposcopy and biopsy
28 yo F who is eight weeks pregnant
presents with lower abdominal pain and
vaginal bleeding.
VAGINAL BLEEDING
Spontaneous abortion
Ectopic pregnancy
Molar pregnancy
Pelvic exam
Urine hCG
U/S—pelvis
CBC, PT/PTT
Quantitative serum hCG
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.
VAGINAL BLEEDING
Ectopic pregnancy
Ruptured ovarian cyst
Ovarian torsion
PID
Pelvic exam
Urine hCG
Cervical cultures
U/S—pelvis
Quantitative serum hCG
28 yo F presents with a thin, grayishwhite,
foul-smelling vaginal discharge.
VAGINAL DISCHARGE
Bacterial vaginosis
Vaginitis—candidal
Vaginitis—trichomonal
Cervicitis (chlamydia,
gonorrhea)
Pelvic exam
Wet mount
Cervical cultures
KOH prep (“whiff test”)
pH of vaginal fl uid
30 yo F presents with a thick, white,
cottage cheese–like, odorless vaginal
discharge and vaginal itching.
VAGINAL DISCHARGEVaginitis—candidal
Bacterial vaginosis
Vaginitis—trichomonal
Pelvic exam
KOH prep (“whiff test”)
Wet mount
Cervical cultures
pH of vaginal fl uid
35 yo F presents with a malodorous,
profuse, frothy, greenish vaginal
discharge with intense vaginal itching
and discomfort.
VAGINAL DISCHARGE
Vaginitis—trichomonal
Vaginitis—candidal
Bacterial vaginosis
Cervicitis (chlamydia,
gonorrhea)
Pelvic exam
Wet mount
Cervical cultures
pH of the vaginal fl uid
KOH prep (“whiff test”)
54 yo F c/o painful intercourse. Her last
menstrual period was nine months ago.
She has hot fl ashes.
DYSPAREUNIA
Atrophic vaginitis
Endometriosis
Cervicitis
Depression
Domestic abuse
Pelvic exam
Wet mount, KOH prep, cervical
cultures
U/S—pelvis
37 yo F presents with dyspareunia,
inability to conceive, and dysmenorrhea.
DYSPAREUNIA
Endometriosis
Cervicitis
Vaginismus
Vulvodynia
PID
Depression
Domestic violence
Pelvic exam
Wet mount, KOH prep, cervical
cultures
U/S—pelvis
Laparoscopy
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.
ABUSE
Domestic violence
Osteogenesis imperfecta
Substance abuse
Consensual violent sexual
behavior
XR—skeletal survey
CT—maxillofacial
Urine toxicology
CBC
30 yo F presents with multiple facial and
physical injuries. She was attacked and
raped by two men.
ABUSE
Rape
Pelvic exam
Urine hCG
Wet mount, KOH prep, cervical
cultures
XR—skeletal survey
CBC
HIV antibody
Viral hepatitis serologies
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.
JOINT/ LIMB PAIN
Domestic violence
Factitious disorder
Substance abuse
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 fi ngers 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.
JOINT/ LIMB PAIN
Carpal tunnel syndrome
Median nerve compression in
forearm or arm
Radiculopathy of nerve roots C6
and C7 in cervical spine
Nerve conduction study
EMG
28 yo F presents with pain in the
interphalangeal joints of her hands
together with hair loss and a butterfl y
rash on her face.
JOINT/ LIMB PAIN
Systemic lupus erythematosus
(SLE)
Rheumatoid arthritis
Psoriatic arthritis
Parvovirus B19 infection
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.
JOINT/ LIMB PAIN
Rheumatoid arthritis
SLE
Disseminated gonorrhea
Arthritis associated with
infl ammatory bowel disease
Osteoarthritis
ANA, anti-dsDNA, ESR, RF,
CBC
XR—hands, left knee
Cervical culture
Arthrocentesis and synovial
fl uid analysis
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.
JOINT/ LIMB PAIN
Psoriatic arthritis
Rheumatoid arthritis
SLE
RF, ANA, ESR
CBC
XR—hands
XR—pelvis/sacroiliac joints
Uric acid
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.
JOINT/ LIMB PAIN
Hip fracture
Hip dislocation
Pelvic fracture
XR—hip/pelvis
CT or MRI—hip
CBC
Serum calcium and vitamin D
Bone density scan (DEXA)
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.
JOINT/ LIMB PAIN
Hip dislocation—traumatic
Hip fracture
XR—hip
CT or MRI—hip
CBC
PT/PTT
Blood type and cross-match
Urine toxicology and blood
alcohol level
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
JOINT/ LIMB PAIN
Osteoarthritis
Pseudogout
Gout
Meniscal or ligament damage
XR—knee
CBC
ESR
Knee arthrocentesis and
synovial fl uid analysis (cell
count, Gram stain, culture,
crystals)
MRI—knee
45 yo M presents with right knee pain
with swelling and redness.
JOINT/ LIMB PAIN
Septic arthritis
Gout
Pseudogout
Lyme arthritis
Trauma
Reiter’s arthritis
CBC
Knee arthrocentesis and
synovial fl uid analysis (see
above)
Blood, urethral cultures
XR—knee
Uric acid
Lyme antibody
65 yo M presents with right foot pain. He
has been training for a marathon.
JOINT/ LIMB PAIN
Stress fracture
Plantar fasciitis
Foot sprain or strain
XR—foot
Bone scan—foot
MRI—foot
65 yo M presents with pain in the heel
of the right foot that is most notable with
his fi rst few steps and then improves as
he continues walking. He has no known
trauma.
JOINT/ LIMB PAIN
Plantar fasciitis
Heel fracture
Splinter/foreign body
XR—heel
Bone scan
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 dorsifl exion
(Cozen’s test) with the elbow in
extension.
JOINT/ LIMB PAIN
Tennis elbow (lateral
epicondylitis)
Stress fracture
XR—arm
Bone scan
MRI—elbow
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.
JOINT/ LIMB PAIN
Disseminated gonorrhea
Rheumatoid arthritis
SLE
Psoriatic arthritis
Reiter’s arthritis
Knee arthrocentesis and
synovial fl uid analysis (cell
count, Gram stain, culture)
ANA, anti-dsDNA, ESR, RF,
CBC
Blood, cervical cultures
XR—knee
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.
JOINT/ LIMB PAIN
Peripheral vascular disease
(intermittent claudication)
Leriche’s syndrome (aortoiliac
occlusive disease)
Lumbar spinal stenosis
(pseudoclaudication)
Osteoarthritis
Ankle-brachial index
Doppler U/S—lower extremity
Angiography
MRI—lumbar 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.
JOINT/ LIMB PAIN
DVT
Baker’s cyst rupture
Myositis
Cellulitis
Superfi cial venous thrombosis
Doppler U/S—right leg
CBC
CPK
D-dimer
PT, aPTT, fi brinogen
XR—right leg
60 yo F c/o left arm pain that started
while she was swimming and was relieved
by rest.
JOINT/ LIMB PAIN
Angina/MI
Tendonitis
Osteoarthritis
Shoulder dislocation
CPK-MB, troponin, ECG
CBC
ESR
XR—shoulder
CXR
Echocardiography
Stress test
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.
JOINT/ LIMB PAIN
Shoulder dislocation
Fracture of the humerus
Rotator cuff injury
XR—shoulder
XR—arm
MRI—shoulder
55 yo M presents with crampy bilateral
thigh and calf pain, fatigue, and dark
urine. He is on simvastatin and clofi brate
for hyperlipidemia
JOINT/ LIMB PAIN
Rhabdomyolysis due to
simvastatin or clofi brate
Polymyositis
Inclusion body myositis
Thyroid disease
CBC
CPK
Aldolase
UA
Urine myoglobin
TSH
45 yo F presents with low back pain that
radiates to the lateral aspect of her left
foot. Straight leg raising is positive. The
patient is unable to tiptoe.
LOW BACK PAIN
Disk herniation
Lumbar muscle strain
Tumor in the vertebral canal
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 defi cit or weakness in her legs.
Paraspinal muscle tenderness and spasm
are also noted.
LOW BACK PAIN
Lumbar muscle strain
Disk herniation
Abdominal aortic aneurysm
Vertebral compression fracture
XR—L-spine
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).
LOW BACK PAIN
Lumbar spinal stenosis
Lumbar muscle strain
Tumor in the vertebral canal
Peripheral vascular disease
XR—L-spine
MRI—L-spine
(preferred)
CT—L-spine
Ankle-brachial index
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.
LOW BACK PAIN
Malingering
Lumbar muscle strain
Disk herniation
Knee or leg fracture
Ankylosing spondylitis
XR—L-spine/knee
MRI—L-spine
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.
CHILD WITH FEVER
Neonatal sepsis
Meningitis
Pneumonia
UTI
Physical exam
CBC, electrolytes
UA
Urine culture
Blood culture
CXR
LP—CSF analysis
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
CHILD WITH FEVER
Acute otitis media
URI
Meningitis
UTI
Physical exam (including
pneumatic otoscopy)
CBC
UA
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.
CHILD WITH FEVER
Measles (or other viral
exanthem)
Rubella
Roseola
Fifth disease
Varicella
Scarlet fever
Meningitis
Physical exam
CBC
Viral antibodies/titers
Throat swab for culture
LP
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.
CHILD WITH FEVER
Gastroenteritis (viral, bacterial,
parasitic)
Food poisoning
UTI
URI
Volvulus
Intussusception
Physical exam
Stool exam and culture
CBC
Electrolytes
UA, urine culture
AXR
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.
BEHAVIORAL PROBLEMS I N CHILDHOOD
Attention-defi cit hyperactivity
disorder (ADHD)
Oppositional defi ant disorder
Manic episode
Conduct disorder
Physical exam
Mental status exam
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.
BEHAVIORAL PROBLEMS I N CHILDHOOD
Adjustment disorder
Substance intoxication/abuse/
dependence
Manic episode
Oppositional defi ant disorder
Conduct disorder
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.
BEHAVIORAL PROBLEMS I N CHILDHOOD
Substance abuse
Conduct disorder
Oppositional defi ant disorder
Adjustment disorder
Urine toxicology
Mental status exam
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 these
behaviors when he is at day care.
BEHAVIORAL PROBLEMS I N CHILDHOOD
Age-appropriate behavior
ADHD
Oppositional defi ant disorder
Physical exam
Mental status exam