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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 |
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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 |
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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 |
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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 |
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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 |
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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 |
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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) |
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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 |
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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 |
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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) |
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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) |
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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 |
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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 |
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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 |
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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 |
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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 |
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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 |
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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 |
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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 |
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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 |
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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 |
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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 |
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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) |
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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 |
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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 |
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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 |
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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 |
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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 |
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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 |
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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 |
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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 |
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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 |
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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 |
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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 |
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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 |
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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 |
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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 |
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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) |
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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 |
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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 |
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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 |
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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 |
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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 |
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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 |
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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 |
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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 |
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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 |
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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 |
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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. |
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 |
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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. |
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 |
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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 |
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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. |
COUGH/SHORTNESS OF BREATH
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. |
COUGH/SHORTNESS OF BREATH
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. |
COUGH/SHORTNESS OF BREATH
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. |
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 |
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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. |
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 |
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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. |
COUGH/SHORTNESS OF BREATH
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. |
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 |
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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. |
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 |
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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. |
COUGH/SHORTNESS OF BREATH
CHF Cardiac valvular disease GERD Pulmonary fi brosis COPD Postnasal drip |
CBC
CXR ECG Echocardiography PFTs BNP |
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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. |
CHEST PAIN
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. |
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 |
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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. |
CHEST PAIN
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. |
CHEST PAIN
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. |
CHEST PAIN
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. |
CHEST PAIN
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. |
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 |
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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. |
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 |
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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 |
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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 |
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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 |
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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 |
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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 |
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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 |
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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 |
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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 |
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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. |
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 |
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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. |
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 |
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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. |
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 |
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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. |
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 |
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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. |
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 |
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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 |
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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. |
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 |
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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. |
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) |
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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. |
ABDOMINAL PAIN
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. |
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 |
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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. |
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 |
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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. |
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 |
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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 |
ABDOMINAL PAIN
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. |
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 |
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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. |
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 |
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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. |
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 |
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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. |
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 |
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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. |
CONSTIPATION/DIARRHEA
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. |
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 |
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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. |
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 |
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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 |
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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 |
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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. |
CONSTIPATION/DIARRHEA
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. |
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 |
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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) |
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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 |
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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. |
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 |
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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 |
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 |
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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 |
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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 |
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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 |
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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 |
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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) |
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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 |
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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 |
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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 |
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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 |
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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 |
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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 |
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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 |
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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 |
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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 |
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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 |
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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 |
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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 |
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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 |
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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 |
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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 |
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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 |
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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 |
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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 |
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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”) |
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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 |
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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 |
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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. |
ABUSE
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. |
ABUSE
Rape |
Pelvic exam
Urine hCG Wet mount, KOH prep, cervical cultures XR—skeletal survey CBC HIV antibody Viral hepatitis serologies |
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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. |
JOINT/ LIMB PAIN
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. |
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 |
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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. |
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 |
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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. |
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 |
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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. |
JOINT/ LIMB PAIN
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. |
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) |
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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. |
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 |
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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 |
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 |
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|
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 |
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|
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 |
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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. |
JOINT/ LIMB PAIN
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. |
JOINT/ LIMB PAIN
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. |
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 |
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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. |
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 |
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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. |
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 |
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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 |
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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. |
JOINT/ LIMB PAIN
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 |
JOINT/ LIMB PAIN
Rhabdomyolysis due to simvastatin or clofi brate Polymyositis Inclusion body myositis Thyroid disease |
CBC
CPK Aldolase UA Urine myoglobin TSH |
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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 |
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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
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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 |
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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 |
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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. |
CHILD WITH FEVER
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 |
CHILD WITH FEVER
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. |
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 |
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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. |
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 |
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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 |
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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 |
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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 |
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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 |
