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90 Cards in this Set

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ABDOMINAL PAIN
Key History
Location, quality, intensity, duration, radiation, timing (relation to meals), associated symptoms (constitutional,
GI, cardiac, pulmonary, renal, pelvic, other), exacerbating and alleviating factors; prior history of
similar symptoms; history of abdominal surgeries, gallstones, renal stones, atherosclerotic vascular disease;
medications; alcohol and drug use; domestic violence.
Key Physical Exam
Vital signs; heart and lung exams; abdominal exam, including guarding, rebound, Murphy’s sign, and
CVA palpation; rectal exam; pelvic exam (women).
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)
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
PID
Endometriosis
Dysmenorrhea
Vaginitis
Cystitis
Spontaneous abortion
Pyelonephritis
Pelvic exam
Rectal exam
Urine hCG
Cervical cultures
CBC/ESR
UA, urine culture
U/S—pelvis
SORE THROAT
Key History
Duration, fever, other ENT symptoms (ear pain, URI), odynophagia, swollen glands, ± cough, rash; sick
contacts, HIV risk factors.
Key Physical Exam
Vital signs; ENT exam, including oral thrush, tonsillar exudate, and lymphadenopathy; lung, abdominal,
and skin exams.
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
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.
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.
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
BLOOD IN STOOL
Key History
Melena vs. bright blood; amount, duration, associated symptoms (constitutional, abdominal or rectal
pain, tenesmus, constipation/diarrhea); trauma; prior history of similar symptoms; prior colonoscopy;
medications (especially warfarin); history of easy bleeding or atherosclerotic vascular disease.
Key Physical Exam
Vital signs ± orthostatics; abdominal and rectal exams.
67 yo M presents with blood in his stool,
weight loss, and constipation. He has a
family history of colon cancer.
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.
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.
Diverticulosis
Anal fi ssure
Hemorrhoids
Angiodysplasia
Colorectal cancer
Rectal exam
CBC, PT/PTT
Electrolytes
Colonoscopy
CT—abdomen/pelvis
CONSTIPATION/DIARRHEA
Key History
Frequency and volume of stools, duration of change in bowel habits, associated symptoms (constitutional,
abdominal pain, bloating, sense of incomplete evacuation, melena or hematochezia); thyroid disease
symptoms; diet (especially fi ber and fl uid intake); medications (including recent antibiotics); sick
contacts, travel, camping, HIV risk factors; history of abdominal surgeries, diabetes, pancreatitis; alcohol
and drug use; family history of colon cancer.
Key Physical Exam
Vital signs; relevant thyroid/endocrine exam; abdominal and rectal exams; ± female pelvic exam.
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)
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.
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.
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.
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.
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.
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.
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.
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
JOINT/ LIMB PAIN
Key History
Location, quality, intensity, duration, pattern (small vs. large joints; number involved; swelling, redness,
warmth), associated symptoms (constitutional, red eye, oral or genital ulceration, diarrhea, dysuria, rash,
focal numbness/weakness), exacerbating and alleviating factors; trauma (including vigorous exercise);
medications; DVT risk factors; alcohol and drug use; family history of rheumatic disease.
Key Physical Exam
Vital signs; HEENT and musculoskeletal exams; relevant neurovascular exam.
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
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.
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.
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.
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
fluid 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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
Rhabdomyolysis due to
simvastatin or clofi brate
Polymyositis
Inclusion body myositis
Thyroid disease
CBC
CPK
Aldolase
UA
Urine myoglobin
TSH
ABUSE
Key History
Establish confi dentiality; directly question about physical, sexual, or emotional abuse and about fear,
safety, backup plan; history of frequent accidents/injuries, mental illness, drug use; fi rearms in the home.
Key Physical Exam
Vital signs; complete exam ± pelvic.
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
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.
Rape
Pelvic exam
Urine hCG
Wet mount, KOH prep, cervical
cultures
XR—skeletal survey
CBC
HIV antibody
Viral hepatitis serologies
CHEST PAIN
Key History
Location, quality, severity, radiation, duration, context (exertional, postprandial, positional, cocaine use,
trauma), associated symptoms (sweating, nausea, dyspnea, palpitation, sense of doom), exacerbating and
alleviating factors (especially medications); prior history of similar symptoms; known heart or lung disease
or history of diagnostic testing; cardiac risk factors (hypertension, hyperlipidemia, smoking, family history
of early MI); pulmonary embolism risk factors (history of DVT, coagulopathy, malignancy, recent immobilization).
Key Physical Exam
Vital signs ± BP in both arms; complete cardiovascular exam (JVD, PMI, chest wall tenderness, heart
sounds, pulses, edema); lung and abdominal exams.
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
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.
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.
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.
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.
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.
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.
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.
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
CHILD WITH FEVER
Key History
Severity, duration, associated localizing symptoms, appetite, rash, sick contacts, day care, immunizations,
past history.
Key Physical Exam
Vital signs; HEENT, neck, heart, lung, abdominal, and skin exams.
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
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.
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.
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.
Gastroenteritis (viral, bacterial,
parasitic)
Food poisoning
UTI
URI
Volvulus
Intussusception
Physical exam
Stool exam and culture
CBC
Electrolytes
UA, urine culture
AXR
COUGH/SHORTNESS OF BREATH
Key History
Acute vs. chronic; presence/description of sputum; associated symptoms (constitutional, URI, postnasal
drip, dyspnea, wheezing, chest pain, heartburn, other), exacerbating and alleviating factors, timing, exposures;
smoking history; history of lung disease; allergies; medications (especially ACE inhibitors).
Key Physical Exam
Vital signs ± pulse oximetry; exam of nasal mucosa, oropharynx, heart, lungs, lymph nodes, and extremities
(clubbing, cyanosis, edema).
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
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.
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.
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.
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.
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.
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.
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.
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.
CHF
Cardiac valvular disease
GERD
Pulmonary fi brosis
COPD
Postnasal drip
CBC
CXR
ECG
Echocardiography
PFTs
BNP
COUGH/SHORTNESS OF BREATH
Key History
Acute vs. chronic; presence/description of sputum; associated symptoms (constitutional, URI, postnasal
drip, dyspnea, wheezing, chest pain, heartburn, other), exacerbating and alleviating factors, timing, exposures;
smoking history; history of lung disease;
allergies; medications
(especially
ACE inhibitors).
Key Physical Exam
Vital signs ± pulse oximetry; exam of nasal mucosa, oropharynx, heart, lungs, lymph nodes, and extremities
(clubbing, cyanosis, edema).
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
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.
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.
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.
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.
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.
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.
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.
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.
CHF
Cardiac valvular disease
GERD
Pulmonary fi brosis
COPD
Postnasal drip
CBC
CXR
ECG
Echocardiography
PFTs
BNP