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90 Cards in this Set
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ABDOMINAL PAIN
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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). |
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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 |
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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 |
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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 |
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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 |
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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 |
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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 |
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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 |
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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) |
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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 |
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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 |
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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 |
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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 |
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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 |
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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 |
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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 |
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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 |
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SORE THROAT
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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. |
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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 |
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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 |
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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 |
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BLOOD IN STOOL
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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. |
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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 |
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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 |
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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 |
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CONSTIPATION/DIARRHEA
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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. |
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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 |
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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 |
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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 |
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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 |
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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 |
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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 |
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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 |
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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 |
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JOINT/ LIMB PAIN
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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. |
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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 |
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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 |
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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 |
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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 |
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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 |
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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) |
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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 |
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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 |
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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 |
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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 |
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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 |
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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 |
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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 |
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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 |
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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 |
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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 |
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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 |
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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 |
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ABUSE
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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. |
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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 |
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30 yo F presents with multiple facial and
physical injuries. She was attacked and raped by two men. |
Rape
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Pelvic exam
Urine hCG Wet mount, KOH prep, cervical cultures XR—skeletal survey CBC HIV antibody Viral hepatitis serologies |
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CHEST PAIN
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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. |
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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 |
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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 |
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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 |
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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 |
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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 |
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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 |
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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 |
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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 |
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CHILD WITH FEVER
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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. |
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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 |
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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 |
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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 |
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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 |
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COUGH/SHORTNESS OF BREATH
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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). |
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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 |
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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 |
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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 |
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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 |
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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 |
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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 |
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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 |
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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 |
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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 |
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COUGH/SHORTNESS OF BREATH
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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). |
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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 |
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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 |
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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 |
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|
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 |
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|
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 |
