USMLE Step 2 CS Minicases

INSOMNIA - Key history - Key Physical Exam

Key history Primary vs. secondary, duration, description (trouble falling asleep vs. multiple awakenings vs. early morning awakening); daytime sleepiness; other medical problems keeping patient awake at night, such as arthritis (pain) or diabetes (polyuria); associated symptoms, including loud snoring, nightmares, and depression; caffeine use, recreational drug use; work or lifestyle (jet lag or shift work), stressors, sleep hygiene, presence of psychiatric symptoms (eg delusions of grandeur), daytime effects Key Physical Exam Vital signs; mental status exam, thyroid exam

55 yo F c/o dizziness that started this morning and of "not hearing well." She feels nauseated and has vomited once in the past day. She had a URI two days ago.

Labyrinthitis Vestibular neuronitis Ménière's disease Acoustic neuroma Vertebrobasilar insufficiency Workup Audiometry Electronystagmography CT-head MRI—brain

30 yo F presents with watery diarrhea and abdominal cramping and bloating. Her symptoms are aggravated by milk ingestion and are relieved by fasting.

Lactose intolerance Gastroenteritis Inflammatory bowel disease Irritable bowel syndrome Hyperthyroidism Workup Rectal exam Stool leukocytes and culture Hydrogen breath test TSH

55 yo M presents with pain in the elbow when he plays tennis. His grip is impaired as a result of the pain. There is tenderness over the lateral epicondyle as well as pain on resisted wrist dorsiflexion (Cozen's test) with the elbow in extension.

Lateral epicondylitis (Tennis elbow) Stress fracture Workup XR—arm Bone scan MRI—elbow

45 yo F presents with low back pain that started after she cleaned her house. The pain does not radiate, and there is no sensory deficit or weakness in her legs. Paraspinal muscle tenderness and spasm are also noted.

Lumbar muscle strain Disk herniation Abdominal aortic aneurysm Vertebral compression fracture Workup XR-L-spine MRI-L-spine

45 yo M presents with pain in the lower back and legs during prolonged standing and walking. The pain is relieved by sitting and leaning forward (e.g., pushing a grocery cart).

Lumbar spinal stenosis Lumbar muscle strain Tumor in the vertebral canal Peripheral vascular disease Workup MRI-L-spine XR-L-spine CT-L-spine Ankle-brachial index

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 (eg, granulomatosis with polyangiitis) Interstitial lung disease CHF Workup CBC CXR CT-chest QuantiFERON-TB Gold ANCA

42 yo F presents with a four-week history of excessive fatigue, insomnia, and anhedonia. She states that she thinks constantly about death. She has suffered fi ve similar episodes in the past, the fi rst in her 20s, and has made two previous suicide attempts. She further admits to increased alcohol use in the past month.

Major depressive disorder Substance-induced mood disorder Dysthymic disorder Workup Beck depression inventory PHQ-9 QIDS-SR16 Alcohol blood level TSH CBC Urine toxicology

17 yo M presents with low back pain that radiates to the left leg and began after he fell on his knee during gym class. He also describes areas of loss of sensation in his left foot. The pain and sensory loss do not match any known distribution. He insists on requesting a week off from school because of his injury.

Malingering Lumbar muscle strain Disk herniation Knee or leg fracture Ankylosing spondylitis Workup XR—L-spine/knee MRI—L-spine ESR, CRP

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 Workup CBC Viral antibodies/titers Throat swab for culture LP-CSF analysis

55 yo M presents with crampy bilateral thigh and calf pain, fatigue, and dark urine. He is on simvastatin and clofibrate for hyperlipidemia.

Medication induced myopathy Rhabdomyolysis Polymyositis Inclusion body myositis Workup CBC CPK CMP, calcium, phosphate, uric acid Aldolase UA Urine myoglobin

25 yo M presents with high fever, severe headache, confusion, photophobia, and nuchal rigidity. Kernig's and Brudzinski's signs are positive.

Meningitis Subarachnoid hemorrhage Encephalitis Sinusitis Migraine Intracranial or epidural abscess Workup LP—CSF analysis (cell count, protein, glucose, Gram stain, PCR for specific pathogens, culture) Blood culture CBC CT—head MRI—brain PT/PTT/INR

48 yo F presents with amenorrhea for the past six months accompanied by hot flashes, night sweats, emotional lability, and dyspareunia.

Menopause Pregnancy Pituitary tumor Thyroid disease Workup Pelvic exam Urine hCG LH/FSH, TSH, prolactin, testosterone, DHEAS CBC MRI—brain

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 fibrillation, for which she has received digitalis. Her pain is out of proportion to the exam.

Mesenteri ischemia Diverticulitis Peptic ulcer disease Gastroenteritis Acute pancreatitis Cholecystitis Workup Rectal exam CBC Amlylase, Lipase, lactate ECG AXR CT-abdomen Mesenteric angiography Barium enema

21 yo F presents with several episodes of throbbing left temporal pain that lasts for 2-3 hours. Prior to its onset, she sees flashes of light in her right visual field and feels weakness and numbness on the right side of her body for a few minutes. Headaches are often associated with nausea and vomiting. She has a family history of migraine.

Migraine (with motor aura) Tension headache Cluster headache Pseudotumor cerebri Trigeminal neuralgia CNS vasculitis Partial seizure Intracranial neoplasm Workup CT—head MRI—brain CBC ESR

34 yo F presents with episodic palpitations accompanied by lightheadedness and sharp, atypical chest pain.

Mitral valve prolaps Cardiac arrhythmias Panic attack Pheochromocytoma Workup TEE ECG Event monitor Holter monitor 24 hour urinary catecholamines

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 flexing her head. Examination reveals left lower limb weakness and ataxia.

Multiple sclerosis Stroke CNS vasculitis Conversion disorder Malingering CNS tumor Vitamin B12 deficiency Neurosyphilis Workup CBC ESR ANA, ANCA VDRL/RPR MRI—brain LP—CSF analysis Retinal evoked potentials

40 yo F presents with occasional double vision and droopy eyelids at night with normalization by morning.

Myasthenia gravis Multiple sclerosis Intracranial tumor compressing CN III, IV, or VI Horner's syndrome Botulism Workup Ice pack test Tensilon test ACh receptor antibodies (in serum) Electromyography Nerve conduction studies CXR CT—chest MRI—brain

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 GERD Angina Chostochondritis Aortic dissection Pericarditis Pulmonary edema Pneumothorax Workup ECG CPK-MB, troponin CXR CBC, electrolytes Echocardiography Cardiac catheterization

35 yo F presents with intermittent episodes of vertigo, tinnitus, nausea, and hearing loss over the past week.

Ménière disease Benign paroxysmal positional vertigo Labyrinthitis Vestibular neuronitis Acoustic neuroma Workup Dix-Hallpixe maneuver Audiometry Electronystagmography CBC VDLR/RPR (syphilis is a cause of Meniere disease) MRI-brain

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 Workup CBC Electrolytes Blood culture LP—CSF analysis CXR UA Urine culture

45 yo M presents with sudden onset of colicky right-sided flank pain that radiates to the testicles, accompanied by nausea, vomiting, hematuria, and CVA tenderness.

Nephrolithiasis Renal cell carcinoma Pyelonephritis GI etiology (e.g., appendicitis) Workup UA, Urine culture and sensitivity, urine cytology BUN/Cr CT—abdomen U/S—renal KUB (=AXR) IVP Blood culture

68 yo M presents with a two-month history of crying spells, excessive sleep, poor hygiene, and a 7-kg weight loss, all following his wife's death. He cannot enjoy time with his grandchildren and reluctantly admits to thinking he has seen his dead wife in line at the supermarket or standing in the kitchen making dinner.

Normal bereavement Adjustment disorder with depressed mood Major depressive disorder with psychotic features Schizoaffective disorder Depressive disorder not otherwise specified (NOS) Workup TSH CBC Urine toxicology Beck depression inventory PHQ-9 QIDS-SR16

72 yo M presents with memory loss, gait disturbance, and urinary incontinence for the past six months.

Normal pressure hydrocephalus Alzheimer's disease Vascular dementia Chronic subdural hematoma Intracranial neoplasm Depression B12 deficiency Neurosyphilis Hypothyroidism Workup CT—head MRI-brain LP—opening pressure and CSF analysis Serum B12 VDRL/RPR TSH

55 yo obese M presents with several months of poor sleep and daytime fatigue. His wife reports that he snores loudly.

Obstructive sleep apnea Daytime fatigue in primary hypersomnia Insomnia with circadian rhythm sleep disorder Insomnia related to major depressive disorder Workup Polysomnography ECG CBC TSH

50 yo obese F presents with fatigue and daytime sleepiness. She snores heavily and naps 3-4 times per day but never feels refreshed. She also has hypertension.

Obstructive sleep apnea Hypothyroidism Chronic fatigue syndrome Narcolepsy Workup CBC TSH Nocturnal pulse oximetry Polysomnography ECG

55 yo F c/o dizziness for the past day. She feels faint and has severe diarrhea that started two days ago. She takes furosemide for her hypertension.

Orthostatic hypotension due to dehydration (diarrhea, diuretic use) Vertebrobasilar insufficiency Cardiac arrhythmias Vestibular neuronitis Labyrinthitis Benign positional vertigo Workup Orthostatic vital signs Rectal examination CBC Urea, Electrolytes ECG Stool exam (occult blood, fecal leukocytes)

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 difficulty walking

Osteoarthritis Pseudogout Gout Meniscal or ligament damage Workup XR—knee CBC ESR Knee arthrocentesis and synovial fluid analysis (cell count, Gram stain, culture, crystals) MRI—knee

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 Pelvic inflammatory disease Bowel infarction or perforation Workup Pelvic exam Rectal exam Urine beta-hCG UA CBC Doppler U/S - abdomen/pelvis CT-abdomen Laparoscopy Chlamydia and gonorrhea testing VDRL/RPR

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. He appears jaundiced on exam.

Pancreatic cancer Cholangiocarcinoma Primary sclerosing cholangitis Chronic pancreatitis Cholecystitis/choledocholithiasis Acute viral hepatitis Acute alcoholic hepatitis Abdominal aortic aneurysm Peptic ulcer disease Workup CT - abdomen CBC Electrolytes Amylase, Lipase Liver function tests U/S - abdomen

35 yo M presents with several episodes of palpitations, sweating and rapid breathing. Episodes occur unexpectedly and he does not recall any triggers. He has had four to five episodes per month for several months. Each episode lasts 2 to 3 minutes. He does not have any history of psychiatric illness except for separation anxiety as a child.

Panic attack Generalized anxiety disorder Specific phobia Acute stress disorder Hyperthyroidism Substance abuse/dependence Pheochromocytoma Workup CBC Electrolytes TSH, FT4 ECG Echocardiography Urine toxicology 24 hour urine catecholamines

24 yo F presents with bilateral lower abdominal pain that started with the first 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.

Pelvic inflammatory disease Endometriosis Dysmenorrhea Vaginitis Cystitis Spontaneous abortion Pyelonephritis Workup Pelvic exam Urine beta-hCG Cervical cultures CBC ESR UA, urine culture U/S - pelvis

35 yo M presents with burning epigastric pain that starts 2-3 hours after meals. The pain is relieved by food and antacids.

Peptid ulcer disease Gastritis GERD Cholecystitis Chronic pancreatitis Mesenteric ischemia Workup Rectal exam for occult blood Amylase, lipase, lactate AST/ALT/bilirubin/alkaline phosphatase Upper endoscopy (including H. pylori testing) Upper GI series (x-ray examination of the esophagus, stomach and first the duodenum. An x-ray examination that evaluates only the pharynx and esophagus is called a barium swallow)

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.

Perforated peptic ulcer Acute pancreatitis Hepatitis Cholecystitis Gallstone cholangitis Mesenteric ischemia Workup Rectal exam CBC Electrolytes Amylase, Lipase, lactate ALT/AST/bilirubin/alkaline phosphatase CXR KUB (=AXR) CT-abdomen Upper endoscopy including H pylori testing Blood culture

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 Workup ECG CPK-MB, troponin CXR Echocardiography CBC Upper endoscopy ESR

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 Workup Ankle-Brachial-Index Doppler U/S - lower extremity Angiography MRI - L-spine

46 yo F presents with fever and sore throat.

Pharyngitis (bacterial or viral) Mycoplasma pneumonia Acute HIV infection Infectious mononucleosis Workup Centor criteria Throat swab for culture and rapid streptococcal antigen test Monospot test CBC Serologic test (cold agglutinin titer) for Mycoplasma HIV antibody and viral load

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.

Pituitary infarction (Sheehan syndrome) Premature ovarian failure Pituitary tumor Hypothyroidism Asherman syndrome (=acquired uterine condition that occurs when scar tissue (adhesions) form inside the uterus and/or the cervix. It is characterized by variable scarring inside the uterine cavity, where in many cases the front and back walls of the uterus stick to one another) Workup Pelvic exam ACTH Urine beta-hCG LH/FSH, prolactin CBC TSH, FT4 MRI-brain Hysteroscopy

65 yo M presents with pain in the heel of the right foot that is most notable with his first few steps and then improves as he continues walking. He has no known trauma.

Plantar fasciitis Heel fracture Splinter/foreign body Workup XR—heel Bone scan

45 yo F presents with dysphagia for two weeks together with fatigue and a craving for ice and clay.

Plummer-Vinson syndrome Esophageal cancer Esophagitis Achalasia Systemic sclerosis Workup CBC Serum iron, ferritin, TIBC Barium swallow Upper endoscopy Esophageal manometry

58 yo M presents with pleuritic chest pain, fever, chills, and cough with purulent yellow sputum. He is a heavy smoker with COPD.

Pneumonia COPD exacerbation Bronchitis Lung abscess Lung cancer Tuberculosis Pericarditis Workup CBC Sputum gram stain and culture CXR CT-chest ECG QuantiFERON-TB Gold

35 yo M presents with painless hematuria. He has a family history of kidney problems.

Polycystic kidney disease Nephrolithiasis Acute glomerulonephritis (e.g., IgA nephropathy) UTI Coagulation disorder Bladder cancer Workup Genitourinary exam UA BUN/Cr, CBC, PT/PTT U/S—renal CT—abdomen/pelvis

23 yo obese F presents with amenorrhea for six months, facial hair, and infertility for the past three years.

Polycystic ovary syndrome Thyroid disease Hyperprolactinemia Pregnancy Ovarian or adrenal malignancy Premature ovarian failure Workup Pelvic exam Urine hCG U/S—pelvis LH/FSH, TSH, prolactin Testosterone, DHEAS (Most patients with PCOS will have increased testosterone levels, but 25% to 50% of them will also have elevated DHEAS)

44 yo M presents with fatigue, insomnia, and nightmares about a murder that he witnessed in a mall one year ago. Since then, he has avoided that mall and has not gone out at night.

Post-traumatic stress disorder (PTSD) Depression Generalized anxiety disorder Psychotic or delusional disorder Hypothyroidism Workup PHQ-9 Beck Depression Inventory CBC TSH Urine toxicology

40 yo F presents with amenorrhea, morning nausea and vomiting, fatigue, and polyuria. Her last menstrual period was six weeks ago, and her breasts are full and tender. She uses the rhythm method for contraception.

Pregnancy Anovulatory cycle Hyperprolactinemia UTI Hypothyroidism Workup Pelvic exam Urine hCG U/S—pelvis CBC UA, urine culture Prolactin, TSH Baseline Pap smear Cervical cultures, rubella antibody, HIV antibody, hepatitis B surface antigen, and VDRL/RPR

20 yo F presents with nausea, vomiting (especially in the morning), fatigue, and polyuria. Her last menstrual period was six weeks ago, and her breasts are full and tender. She is sexually active with her boyfriend, and they use condoms for contraception.

Pregnancy Gastritis Hypercalcemia Diabetes mellitus UTI Depression Workup Urine beta-hCG Pelvic exam U/S—pelvis CBC Electrolytes, calcium, glucose, liver function test UA, urine culture

35 yo F presents with amenorrhea, galactorrhea, visual field defects, and headaches for the past six months.

Prolactinoma Pregnancy Thyroid disease Premature ovarian failure Pituitary tumor Workup Breast and pelvic exam Urine beta-hCG TSH LH/FSH, Prolactin MRI-brain

71 yo M presents with nocturia, urgency, weak stream, terminal dribbling, hematuria, and lower back pain over the past four months. He has also experienced weight loss and fatigue.

Prostate cancer Benign prostatic hypertrophy Renal cell carcinoma UTI Nephrolithiasis Workup Rectal exam CBC, CMP PSA UA U/S-prostate (transrectal) CT-pelvis MRI-spine

40 yo F presents with watery diarrhea and abdominal cramps. Last week she was on antibiotics for a UTI

Pseudomembranous colitis (Clostridium difficile) Gastroenteritis Cryptosporidiosis Food poisoning Inflammatory bowel syndrome Workup Rectal exam Stool for C. difficile toxin Stool leukocytes and culture CBC CMP

18 yo obese F presents with a pulsatile headache, vomiting, and blurred vision for the past 2-3 weeks. She is taking OCPs.

Pseudotumor cerebri Migraine Tension headache Intracranial venous thrombosis Intracranial neoplasm Cluster headache Meningitis Workup Urine hCG LP—opening pressure and CSF analysis Fundoscopic eye examination MRI-brain Visual field testing

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 Gout Workup ESR, CRP, RF, anti-CCP, ANA CBC XR-hands XR-pelvis/sacroiliac joints Uric acid

60 yo M presents with worsening dyspnea of 6 hours duration and a cough that is accompanied by pink, frothy sputum.

Pulmonary edema Pneumonia CHF Mitral valve stenosis Arrhythmia Asthma Workup CXR ECG CBC ABG PFT BNP D-Dimer CT angiography

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 Workup D-Dimer CBC Electrolytes, BUN/Cr, glucose CPK-MB, troponin CXR ECG ABG Doppler U/S - legs CTA-chest with IV contrast

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.

Pyelonephritis Lower UTI Nephrolithiasis Renal cell carcinoma Workup CBC, CMP Blood culture UA, urine culture U/S-renal CT-abdomen

1 mo infant is brought in because she has been spitting up her milk for the past 10 days. The vomiting episodes have increased in frequency and forcefulness. Emesis is nonbloody and nonbilious. The episodes usually occur immediately after breast-feeding. She hast stopped gaining weight.

Pyloric stenosis Partial duodenal atresia GERD Gastroenteritis Hepatitis UTI Workup CBC Electrolytes U/S-abdomen Barium swallow Esophageal pH probe Endoscopy LFTs U/A, urine culture

30 yo F presents with multiple facial and physical injuries. She was attacked and raped by two men.

Rape Domestic violence Workup Forensic exam (sexual assault forensic evidence (SAFE) collection kit) Pelvic exam Urine hCG Wet mount, KOH prep Cervical cultures Chlamydia and gonorrhea testing XR—skeletal survey CBC HIV antibody Viral hepatitis serologies

55 yo M presents with flank pain and blood in his urine without dysuria. He has experienced weight loss and fever over the past two months.

Renal cell carcinoma Pyelonephritis Acute glomerulonephritis Bladder cancer Nephrolithiasis Workup U/S—renal CT-abdomen/pelvis Cytoscopy UA, urine cytology

73 yo M presents with acute loss of vision in his left eye, palpitations, and shortness of breath. He has a history of atrial fibrillation and cataracts in his right eye. He has no eye pain, discharge, redness, or photophobia. He has not experienced headache, weakness, or numbness.

Retinal artery occlusion Retinal vein occlusion Acute angle-closure glaucoma Retinal detachment Temporal arteritis Workup Fluorescein angiogram Echocardiography Doppler U/S - carotid Intraocular tonometry ESR, CRP Temporal artery biopsy CBC

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 inflammatory bowel disease Osteoarthritis Workup ANA, anti-dsDNA, ESR RF, anti CCP CBC XR—hands, left knee Cervical culture Arthrocentesis and synovial fluid analysis

48 yo F presents with a one-week history of auditory hallucinations, stating, "I am worthless" and "I should kill myself." She also reports a two-week history of weight loss, early-morning awakening, decreased motivation, and overwhelming feelings of guilt.

Schizoaffective disorder Mood disorder with psychotic features Schizophrenia Schizophreniform disorder Psychotic disorder due to a general medical condition Workup Mental status exam Beck Depression Inventory Urine toxicology TSH CBC Electrolytes

19 yo M c/o receiving messages from his television set. He reports that he did not have many friends in high school. In college, he started to suspect his roommate of bugging the phone. In the same time frame, he stopped going to classes because he felt that his professors were saying horrible things about him that no one else noticed. He rarely showered or left his room and has recently been hearing a voice from his television set telling him to "guard against the evil empire."

Schizophrenia Schizoid or schizotypal personality disorder Schizophreniform disorder Psychotic disorder due to a general medical condition Substance-induced psychosis Depression with psychotic features Workup Mental status exam Urine toxicology TSH CBC Electrolytes

45 yo M presents with right knee pain with swelling and redness.

Septic arthritis Gout Pseudogout Lyme arthritis Trauma Reiter syndrome (reactive arthritis) Workup CBC Knee arthrocentesis and synovial fluid analysis (cell count, gram stain, culture, crystals) Blood, urethral cultures XR—knee Uric acid Lyme titers - IgG and IgM

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 Workup XR—shoulder XR—arm MRI—shoulder

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 - acute chest syndrome Pulmonary embolism Pneumonia Myocardial infarction Pneumothorax Aortic dissection Workup CBC, reticulocyte count and peripheral smear LDH ABG D-dimer CXR CPK-MB, troponin ECG CTA—chest with IV contrast

30 yo F presents with 1 week of frontal headache, fever, and nasal discharge, the headache worsens when she bends forward. There is pain on palpation of the frontal and maxillary sinuses. She has a history of allergies.

Sinusitis Migraine Tension headache Meningitis Intracranial neoplasm Workup CBC XR—sinus CT—sinus

35 yo M policeman c/o feeling tired and sleepy during the day. He changed to the night shift last week.

Sleep deprivation Sleep apnea Depression Anemia Workup CBC Nocturnal pulse oximetry Polysomnography

44 yo F presents with a weight gain of > 11 kg over the past two months. She quit smoking three months ago and is on amitriptyline for depression. She also reports cold intolerance and constipation.

Smoking cessation Drug side effect Hypothyroidism Cushing syndrome Polycystic ovary syndrome Diabetes mellitus Atypical depression Workup CBC Electrolytes, glucose, BUN/Cr TSH 24 hour urine free cortisol Dexamethasone suppression test

19 yo F presents with episodic palpitations especially during presentations in front of her class. Episodes include heart pounding, facial blushing, and hand shaking. She also states she experiences excessive sweating and rapid breathing. She complains of intense worry and trouble sleeping for days or weeks before upcoming social situation. Now she avoids all social events because she is always afraid of humiliating herself.

Social phobia Avoidant personality disorder Agoraphobia/specific phobia Panic attack Generalized anxiety disorder Substance abuse/dependence Hyperthyroidism Workup CBC Electrolytes ECG TSH, FT4

7 yo M presents with abdominal pain that is generalized, crampy, worse in the morning , and seemingly less prominent during weekend and holidays. He has missed many school days because of the pain. Growth and develpment are nomal His parents recently divorced.

Somatoform disorder Malingering Irritable bowel syndrome Lactose intolerance Strangulated hernia Testicular torsion Gastroenteritis Workup CBC Electrolytes U/S-abdomen Amylase, lipase Stool exam

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 Workup CBC Electrolytes CXR U/S - abdomen CT - abdomen

28 yo F who is eight weeks pregnant presents with lower abdominal pain and vaginal bleeding.

Spontaneous abortion Ectopic pregnancy Molar pregnancy Workup Pelvic exam Urine hCG U/S—pelvis CBC, PT/PTT Quantitative serum hCG

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.

Stable Angina Esophageal spasm Esophagitis Workup ECG CPK-MB, troponin CXR Exercise stress test Upper endoscopy Cardiac catheterization

65 yo M presents with right foot pain. He has been training for a marathon.

Stress fracture Plantar fasciitis Foot sprain or strain Workup XR—foot Bone scan—foot MRI—foot

55 yo F presents with urinary leakage after exercise. She loses a small amount of urine when she coughs, laughs, or sneezes. She also complains of vague low back pain. She has a history of multiple C-section and her other had the same problem after the onset of menopause

Stress incontinence Mixed incontinence Overflow incontinence Urge incontinence Functional incontinence UTI Workup Postvoid residual Bladder stress test UA, urine culture CMP Cystourethroscopy Urodynamic testing

25 yo F presents with a three-week history of difficulty falling asleep. She sleeps seven hours per night without nightmares or snoring. She recently began college and is having trouble with her boyfriend. She drinks 3-4 cups of coffee a day.

Stress-induced insomnia Caffeine-induced insomnia Insomnia with circadian rhythm sleep disorder Insomnia related to major depressive disorder Workup Polysomnography Urine toxicology CBC TSH

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 he has weakness of the right side of his body and his deep tendon reflexes are brisk. He has a history of hypertension, diabetes mellitus, and heavy smoking.

Stroke TIA Seizure with Todd paresis Intracranial neoplasm Subdural or epidural hematoma Hypoglycemia Workup CT-head CBC Electrolytes, glucose PT/PTT/INR Fasting lipid panel MRI-brain with DWI MRA Doppler U/S - carotid ECG Echocardiography

35 yo M presents with sudden severe headache, vomiting, confusion, left hemiplegia, and nuchal rigidity.

Subarachnoid hemorrhage Migraine Meningitis/encephalitis Intracranial hemorrhage Vertebral artery dissection Intracranial venous thrombosis Acute hypertension Intracranial neoplasm Workup CT without contrast—head LP-opening pressure and CSF analysis CBC PT/PTT/INR Urine toxicology MRI—brain CT-angigraphy

55 yo F presents with gradual altered mental status and headache. Two weeks ago she slipped, hit her head on the ground, and lost consciousness for two minutes.

Subdural hematoma SIADH (causing hyponatremia) Creutzfeldt-Jakob disease Intracranial neoplasm Workup CT—head CBC Electrolytes, TSH MRI—brain LP-CSF analysis

15 yo M presents with a one-year history of failing grades, school absenteeism, and legal problems, including shoplifting. His parents report that he spends most of his time alone in his room, adding that when he does go out, it is with a new set of friends.

Substance abuse Conduct disorder Oppositional defiant disorder Adjustment disorder Workup Urine toxicology Mental status exam

28 yo F c/o seeing bugs crawling on her bed over the past two days and reports hearing loud voices when she is alone in her room. She has never experienced symptoms such as these in the past. She recently ingested an unknown substance.

Substance-induced psychosis Brief psychotic disorder Schizophreniform disorder Schizophrenia Psychotic disorder due to a general medical condition Workup Urine toxicology Mental status exam TSH CBC Electrolytes, BUN/Cr, AST/ ALT

28 yo F presents with pain in the interphalangeal joints of her hands together with hair loss and a butterfly rash on her face.

Systemic lupus erythematosus (SLE) Rheumatoid arthritis Psoriatic arthritis Parvovirus B19 infection Workup ANA, anti-dsDNA, Anti-Sm, ESR, C3, C4, antiphospholipid antibodies Rheumatoid factor (RF), anti CCP ESR, CRP CBC XR—hands UA, urine sediment Antibody titers for parovirus B19

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.

TIA Stroke Migraine with sensory aura Seizure with Todd paresis Hypoglycemia Workup CT-head CBC Electrolytes, glucose Fasting lipid panel ECG MRI-brain with DWI Doppler U/S - carotid Echocardiography EEG

65 yo F presents with severe, intermittent right temporal headache, fever, blurred vision in her right eye, and pain in her jaw when chewing.

Temporal arteritis (giant cell arteritis) Migraine Cluster headache Tension headache Meningitis Carotid artery dissection Pseudotumor cerebri Trigeminal neuralgia Intracranial neoplasm Workup Temporal artery biopsy ESR CRP CBC Doppler U/S—carotid MRI—brain

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 significant stress in her life.

Tension headache Migraine Depression Caffeine or analgesic withdrawal Hypertension Cluster headache Pseudotumor cerebri Intracranial neoplasm Workup CBC Electrolytes ESR MRI-brain LP-CSF analysis

25 yo M presents with hemiparesis (after a tonic-clonic seizure) that resolves over a few hours.

Todd paralysis TIA Stroke Intracranial neoplasm Hemiplegic migraine Head injury Hypoglycemia Malingering Workup CBC Glucose, electrolytes Toxin levels EEG CT-brain MRI—brain Doppler U/S—carotid

25 yo M presents with watery diarrhea and abdominal cramps. He was recently in Mexico.

Traveler's diarrhea Giardiasis Amebiasis Food poisoning Hepatitis A Workup Rectal exam Stool leukocytes and culture Giardia antigen Entamoeba histolytica antigen CBC CMP Viral hepatitis serologies

57 yo M c/o daily pain in the right cheek over the past month. The pain is electric and stabbing in character and occurs while he is shaving. Each episode lasts 2-4 minutes.

Trigeminal neuralgia Tension headache Migraine Cluster headache TMJ dysfunction Intracranial neoplasm Workup MRI—brain CBC ESR

30 yo M presents with night sweats, cough, and swollen glands of one month's duration.

Tuberculosis Acute HIV infection Lymphoma Leukemia Hyperthyroidism Workup PPD skin test QuantiFERON-TB Gold CBC CXR Sputum Gram stain, acid-fast stain, and culture HIV antibody, RNA levels TSH, FT4 CT-chest

34 yo F nurse presents with worsening cough of six weeks' duration together with weight loss, fatigue, night sweats, and fever. She has a history of contact with tuberculosis patients at work.

Tuberculosis Pneumonia Lung abscess Vasculitis Lymphoma Metastatic cancer HIV/AIDS Sarcoidosis Workup CBC PPD/QuantiFERON-TB Gold Sputum Gram stain, acid-fast stain, and culture CXR CT—chest Bronchoscopy HIV antibody Lymph node biopsy

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 Asthma Acute HIV infection CHF (cardiomyopathy) Workup CBC PDD/QuantiFERON-TB Gold Sputum gram stain, acid fast stain and culture CXR PFTs HIV antibody Echocardiography

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 disease Hemorrhoids Anal fissure Proctitis Diverticulosis Dysentery Workup Rectal exam CBC PT/PTT/INR Colonoscopy CT-abdomen/pelvis

18 yo M presents with a burning sensation during urination and urethral discharge. He recently had unprotected sex with a new partner.

Urethritis Cystitis Prostatitis Workup NAAT urine for chlamydia and gonorrhea screening VDRL/RPR UA, urine culture Gram stain and culture of urethral discharge HIV CBC, BMP

33 yo F presents with urinary leakage. She is unable to suppress the urge to urinate. She loses large amounts of urine w/o warning. She has a history of UTI's and a family history of diabetes mellitus. She drinks 8 cups of coffee per daa. She has been under a lot of stress since her sister died a few months ago.

Urge incontinence Mixed incontinence Overflow incontinence Stress incontinence Functional incontinence UTI Workup Postvoid residual Bladder stress test UA, urine culture CBC, CMP Cystourethroscopy Urodynamic testing

30 yo F presents with a thick, white, cottage cheese-like, odorless vaginal discharge and vaginal itching.

Vaginitis - candidal Bacterial vaginosis Vaginitis—trichomonal Workup Pelvic exam KOH prep, Wet mount, whiff test Cervical cultures pH of vaginal fluid

35 yo F presents with a malodorous, profuse, frothy, greenish vaginal discharge with intense vaginal itching and discomfort.

Vaginitis—trichomonal Vaginitis—candidal Bacterial vaginosis Cervicitis (chlamydia, gonorrhea) Workup Pelvic exam Wet mount, KOH prep, whiff test Cervical cultures pH of the vaginal fluid

81 yo M presents with progressive confusion over the past several years together with forgetfulness and clumsiness. He has a history of hypertension, diabetes mellitus, and two strokes with residual left hemiparesis. His mental status has clearly worsened after each stroke (stepwise decline in cognitive function).

Vascular ("multi-infarct") dementia Alzheimer's disease Normal pressure hydrocephalus Chronic subdural hematoma Intracranial tumor Depression B12 deficiency Neurosyphilis Hypothyroidism Workup CBC VDRL/RPR Serum B12 TSH MRI—brain CT—head LP—CSF analysis

55 yo F c/o dizziness that started this morning. She is nauseated and has vomited once in the past day. She had a URI two days ago and has experienced no hearing loss.

Vestibular neuronitis Labyrinthitis Benign positional vertigo Ménière's disease Vertigo associated with cervical spine disease/injury Vertebrobasilar stroke/TIA Workup Audiometry Electronystagmography CT-head MRI-brain Note: Vestibular neuritis refers to inflammation of the vestibular nerve only. Labyrinthitis refers to inflammation of both the vestibular nerve and the cochlear nerve, which transmits information about your hearing. This means that labyrinthitis also causes hearing problems, including trouble hearing and ringing in your ears, in addition to vertigo. Vestibular neuritis, on the other hand, only causes vertigo symptoms.

48 yo F presents with dysphagia for both solid and liquid foods that has slowly progressed in severity over the past year. It is associated with regurgitation of undigested food, especially at night.

Achalasia Plummer-Vinson syndrome Esophageal cancer Esophagitis Systemic sclerosis Mitral valve stenosis Esophageal stricture Zenker's diverticulum Workup CXR Upper Endoscopy Barium swallow Esophageal manometry

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 Workup CBC AST/ALT, bilirubin, alkaline phosphatase, GGT U/S - abdomen CT-abdomen Blood culture

25 yo M presents with RUQ pain, fever, anorexia, nausea, and vomiting. He has dark urine and clay-colored stool.

Acute hepatitis Acute cholecystitis Ascending cholangitis Choledocholithiasis Pancreatitis Primary sclerosing cholangitis Primary biliary cirrhosis Acute glomerulonephritis Workup CBC Amylase, lipase AST/ALT/bilirubin/alkaline phosphatase Viral hepatitis serologies UA U/S—abdomen MRCP ERCP

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 Workup CBC Blood culture LP-CSF analysis UA, urine culture

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 Boerhaave syndrome Workup CBC Electrolytes, BUN/Cr Amylase, lipase, AST/ALT/ bilirubin/alkaline phosphatase U/S—abdomen CT—abdomen Upper endoscopy ECG

12 yo F presents with a two-month history of fighting in school, truancy, and breaking curfew. Her parents recently divorced, and she just started school in a new district. Before her parents divorced, she was an average student with no behavioral problems.

Adjustment disorder Substance intoxication/abuse/ dependence Manic episode Oppositional defiant disorder Conduct disorder Workup Physical exam Mental status exam Urine toxicology

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.

Age-appropriate behavior ADHD Oppositional defiant disorder Workup Physical exam Mental status exam

84 yo F brought by her son c/o forgetfulness (e.g., forgets phone numbers, loses her way back home) along with difficulty performing some of her daily activities (e.g., bathing, dressing, managing money, using the phone). The problem has gradually progressed over the past few years.

Alzheimer's disease Vascular dementia Depression Hypothyroidism Chronic subdural hematoma Normal pressure hydrocephalus Intracranial neoplasm B12 defi ciency Neurosyphilis Workup CBC VDRL/RPR Serum B12 TSH MRI—brain CT—head LP—CSF analysis

60 yo F c/o left arm pain that started while she was swimming and was relieved by rest.

Angina/MI Tendinitis Osteoarthritis Workup CPK-MB, troponin CBC ECG ESR XR—shoulder CXR Echocardiography Stress test

18 yo F presents with amenorrhea for the past four months. She has lost 95 pounds and has a history of vigorous exercise and heat intolerance.

Anorexia nervosa Pregnancy Hyperthyroidism Workup CBC TSH FT4 ACTH FSH LH

29 yo F presents with amenorrhea for the past six months. She has a history of occasional palpitations and dizziness. She lost her fiancé in a car accident.

Anxiety-induced amenorrhea Pregnancy Posttraumatic stress disorder Depression Hyperthyroidism Workup Urine beta-hCG CBC TSH, FT4 Urine cortisol level Progesterone challenge test FSH/LH/estradiol levels

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 Workup TTE ECG CPK-MB, troponin CXR CBC Amylase, lipase CTA - chest with IV contrast MRI/MRA - aorta Aortic angiography Upper endoscopy

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.

Appendicitis Gastroenteritis Diverticulitis Crohn's disease Nephrolithiasis Volvulus or other intestinal obstruction/perforation Perforation Acute cholecystitis Workup CBC Electrolytes AXR U/S-abdomen CT-abdomen Blood culture

43 yo obese F presents with RUQ abdominal pain, fever, and jaundice. She was diagnosed with asymptomatic gallstones one year ago.

Ascending cholangitis Acute gallstone cholangitis Acute cholecystitis Hepatitis Primary sclerosing cholangitis Workup CBC Liver function tests Blood culture Viral hepatitis serologies U/S - abdomen MRCP ERCP

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 Workup CBC CXR Peak flow measurement PFTs Methacholine challenge test

54 yo F c/o painful intercourse. Her last menstrual period was nine months ago. She has hot flashes.

Atrophic vaginitis Endometriosis Cervicitis Domestic violence Workup Pelvic exam LH/FSH Wet mount, KOH prep, Cervical cultures U/S—pelvis

9 yo M presents with a two-year history of angry outbursts both in school and at home. His mother complains that he runs around "as if driven by a motor." His teacher reports that he cannot sit still in class, regularly interrupts his classmates, and has trouble making friends.

Attention-deficit hyperactivity disorder (ADHD) Oppositional defiant disorder Manic episode Conduct disorder Workup Physical exam Mental status exam

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 Workup CBC Sputum gram stain and culture CXR IgM detection for Mycoplasma pneumoniae Urine Legionella antigen

3 yo F presents with a 3-day history of "pink eye." It began in the right eye but now involves both eyes. She has mucoid discharge, itching, and difficulty opening her eyes in the morning. Her mother had the flu last week. She has a history of asthma and atopic dermatitis.

Bacterial conjunctivitis Viral conjunctivitis Allergic conjunctivitis Keratitis Uveitis Orbital cellulitis Preseptal cellulitis Workup Ophthalmoscopic eye exam CBC Electrolytes Discharge cultures Slit lamp exam CT-orbit

28 yo F presents with a thin, grayish-white, foul-smelling vaginal discharge

Bacterial vaginosis Vaginitis-candidal Vaginitis-trichomonal Cervicitis (chlamydia, gonorrhea) Workup Pelvic exam Wet mount, KOH prep, whiff test pH of vaginal fluid Cervical cultures

44 yo F c/o dizziness on moving her head to the left. She feels that the room is spinning around her head. Tilt test results in nystagmus and nausea

Benign positional vertigo Ménière's disease Vestibular neuronitis Labyrinthitis Acoustic neurinoma Workup Audiometry Electronystagmography MRI-brain

60 yo M presents with nocturia, urgency, weak stream, and terminal dribbling. He denies any weight loss, fatigue, or bone pain. He has had two episodes of urinary retention that required catheterization.

Benign prostatic hypertrophy Prostate cancer Urolithiasis UTI Workup Rectal exam CBC, BUN/Cr, PSA UA U/S—prostate (transrectal)

26 yo F presents with a 3-kg weight loss over the past two months, accompanied by early-morning awakening, excessive guilt, and psychomotor retardation. She does not identify a trigger for the depressive episode but reports several weeks of increased energy, sexual promiscuity, irresponsible spending, and racing thoughts approximately six months before her presentation.

Bipolar I disorder Bipolar II disorder (only hypomanic episodes) Cyclothymic disorder Major depressive disorder Schizoaffective disorder Workup Mood Disorder Questionnaire Urine toxicology TSH CBC

65 yo M presents with painless hematuria. He is a heavy smoker and works as a painter.

Bladder cancer Renal cell carcinoma Nephrolithiasis Prostate cancer Acute glomerulonephritis Coagulation disorder Workup CBC, CMP PT/PTT UA, urine cytology Cystoscopy U/S - renal/bladder CT-abdomen/pelvis

45 yo F presents with coffee-ground emesis for the last three days. Her stool is dark and tarry. She has a history of intermittent epigastric pain that is relieved by food and antacids

Bleeding peptic ulcer Gastritis Gastric cancer Esophageal varices Workup Rectal exam CBC, type and cross Electrolytes AST/ALT/bilirubin/alkaline phosphatase INR Endoscopy (including H. pylori testing if ulcer is confirmed)

50 yo M presents with a cough that is exacerbated by lying down at night and improved by propping up on three pillows. He also reports exertional dyspnea.

CHF Cardiac valvular disease GERD Pulmonary fibrosis COPD Postnasal drip Workup CBC CXR ECG Echocardiography PFTs BNP CT-chest

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 Lung cancer Pneumonia URI CHF Workup CBC CXR ABG PFTs Sputum Gram stain and culture CT-chest Echocardiography

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 COPD-emphysema Bronchiectasis Lung cancer Tuberculosis Workup CBC Sputum Gram stain and culture CXR PFTs CT—chest QuantiFERON-TB Gold

65 yo M presents after falling and losing consciousness for a few seconds. He had no warning prior to passing out but recently had palpitations. His past history includes coronary artery bypass grafting (CABG).

Cardiac arrhythmia (causing syncope) Severe aortic stenosis Syncope (other causes) Seizure Pulmonary embolism Workup ECG Holter monitoring CBC Electrolytes, Glucose Echocardiography CT—head

30 yo F secretary presents with wrist pain and a sensation of numbness and burning in her palm and the first, second, and third fingers of her right hand. The pain worsens at night and is relieved by loose shaking of the hand. There is sensory loss in the same fingers. Exam reveals a positive Tinel's sign.

Carpal tunnel syndrome Median nerve compression syndrome Radiculopathy of nerve roots C6 or C7 De Quervain tenosynovitis Workup Nerve conduction studies EMG U/S-wrist MRI-spine

56 yo obese F c/o tingling and numbness of her thumb, index finger, and middle finger for the past 5 months. Her symptoms are constant, have progressively worsened, and are relieved with rest. She works as a secretary. She has a history of fatigue and a 20-lb (9-kg) weight gain over the same period.

Carpal tunnel syndrome (due to overuse) Overuse injury of median nerve Cervical disc disease Medial epicondylitis Workup TSH (Hypothyroidism can cause carpal tunnel syndrome) CBC Electromyography Nerve conduction studies

Sheehan syndrome - Cause - Signs and symptoms - Diagnosis - Treatment

Cause → pituitary necrosis → usually happens after postpartum hemorrhage Signs and symptoms → Agalactorrhea → Amenorrhea → Hypothyroidism → Adrenal insufficiency (due to lack of ACTH secretion from pituitary gland) Diagnosis → Hormonal assays are conducted to determine if a patient has low levels of T4, TSH, estrogen, gonadotropin, cortisol, and ACTH depending on the extent of necrosis

45 yo G5P5 F presents with postcoital bleeding. She is a cigarette smoker and takes OCPs.

Cervical cancer Cervical polyp Cervicitis Trauma (e.g., cervical laceration) Workup Pelvic exam Pap smear Colposcopy and biopsy HPV testing Endometrial biopsy

26 yo M presents with severe right temporal headaches associated with ipsilateral rhinorrhea, eye tearing, and redness. Episodes have occurred at the same time every night for the past week and last for 45 minutes.

Cluster headache Migraine Tension headache Sinusitis Pseudotumor cerebri Trigeminal neuralgia Intracranial neoplasm Workup CT—head MRI—brain CBC ESR

2 mo M presents with persistent crying for 2 weeks. The episodes subside after passing flatus or eructation. There is no change in appetite, weight or growth. There is no vomiting, constipation or fever.

Colic Formula allergy GERD Lactose intolerance Strangulated hernia Testicular torsion Gastroenteritis Workup Rectal exam, stool for occult blood U/S-abdomen U/S-testicular

67 yo M presents with blood in his stool, weight loss, and constipation. He has a family history of colon cancer.

Colon cancer Diverticulosis Hemorrhoids Anal fissure Angiodysplasia Upper GI bleeding Inflammatory bowel disease Ischemic bowel disease Workup Rectal exam CBC AST/ALT/bilirubin/alkaline phosphatase PT/PTT/INR CEA Colonoscopy CT-abdomen/pelvis

55 yo M presents with fatigue, weight loss, and constipation. He has a family history of colon cancer.

Colon cancer Hypothyroidism Renal failure Hypercalcemia Depression Workup Rectal exam, stool for occult blood CBC Electrolytes, calcium, BUN/Cr, AST/ALT TSH Colonoscopy Barium enema

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-fiber diet and has a family history of colon cancer.

Colon cancer Irritable bowel syndrome Diverticulosis GI parasitic infection (ascariasis, giardiasis) Inflammatory bowel disease Angiodysplasia Workup Rectal exam CBC with differential CMP (Albumin, TProtein, Electrolytes, BUN/Cr, ALT/AST/bilirubin/alkaline phosphatase) Colonoscopy Barium enema CT—abdomen/pelvis Stool for ova and parasitology

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 due to low fiber diet Depression Substance abuse Irritable bowel syndrome Hypothyroidism Workup Rectal exam TSH, FT4 BMP

14 yo M presents with short stature and lack of sexual development. His birth weight and length were normal, but he is the shortest child in his class. His father and uncles had the same problem when they were young, but they are now of normal stature.

Constitutional short statue Growth hormone deficiency Hypothyroidism Chronic renal insufficiency Genetic causes Workup CBC with differential Electrolytes GH stimulation test IGF-1, IGFBP-3 levels TSH, FT4 XR-hand U/S-renal and cardiac BUN/Cr

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 Pleuritis Muscle strain Workup ECG CPK-MB, troponin CXR CBC

55 yo M presents with a rapidly progressive change in mental status, inability to concentrate, and memory impairment for the past two months. His symptoms are associated with myoclonus and ataxia.

Creutzfeldt-Jakob disease Vascular dementia Lewy body dementia Wernicke's encephalopathy Normal pressure hydrocephalus Chronic subdural hematoma Intracranial neoplasm Depression Delirium B12 deficiency Neurosyphilis Workup CBC Electrolytes, calcium Serum B12 VDRL/RPR MRI—brain (preferred) CT—head EEG LP—CSF analysis Brain biopsy

33 yo M presents with watery diarrhea, diffuse abdominal pain, and weight loss over the past three weeks. He has a history of aphthous ulcers. He has not responded to antibiotics.

Crohn disease Gastroenteritis Ulcerative colitis Celiac disease Pseudomembranous colitis Hyperthyroidism Small bowel lymphoma Carcinoid syndrome Workup Rectal exam, stool for occult blood Stool leukocytes, culture Stool lactoferrin CBC Electrolytes Colonoscopy with biopsy CT-abdomen TSH AXR

45 yo F presents with right calf pain. Her calf is tender, warm, red, and swollen compared to the left side. She was started on OCPs two months ago for dysfunctional uterine bleeding.

DVT Baker's cyst rupture Myositis Cellulitis Superficial venous thrombosis Workup CBC CPK PT/PTT/INR D-Dimer Doppler U/S - lower extremity

40 yo F c/o feeling tired, hopeless, and worthless and of having suicidal thoughts. She recently discovered that her husband is homosexual.

Depression Adjustment disorder Hypothyroidism Anemia Workup PHQ-9 Beck depression inventory TSH CBC

20 yo M presents with fatigue, thirst, increased appetite, and polyuria.

Diabetes mellitus Atypical depression Primary polydipsia Diabetes insipidus Workup HbA1c Glucose tolerance test UA CBC Electrolytes, BUN/Cr Glucose

55 yo M presents with tingling and numbness in the hands and feet (gloveand- stocking distribution) over the past two months. He has a history of diabetes mellitus, hypertension, and alcoholism. There is decreased soft touch, vibratory, and position sense in the feet.

Diabetic peripheral neuropathy Alcoholic peripheral neuropathy B12 deficiency Uremic nephropathy Hypocalcemia Hyperventilation Paraproteinemia/myeloma Workup HbA1C Glucose ESR Calcium Vitamin B12 UA TSH, fT4 Urea, electrolytes Serum and urine protein electrophoresis Electromyography Nerve conduction studies

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.

Disk herniation Lumbar muscle strain Tumor in the vertebral canal Workup XR-L-spine MRI-L-spine

27 yo F presents with painful wrists and elbows, a swollen and hot knee joint that is painful on flexion, 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 Workup Knee arthrocentesis and synovial fluid analysis (cell count, Gram stain, culture) ANA, anti-dsDNA ESR, RF, anti-CCP CBC Blood, cervical cultures XR—knee

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-fiber, high-fat diet.

Diverticulitis Crohn's disease Ulcerative colitis Gastroenteritis Abscess Workup Rectal exam CBC Electrolytes CXR AXR U/S-abdomen CT-abdomen Blood culture

58 yo M presents with bright red blood per rectum and chronic constipation. He consumes a low-fiber diet.

Diverticulosis Hemorrhoids Anal fissure Colorectal cancer Angiodysplasia Workup Rectal exam CBC PT/PTT Electrolytes Colonoscopy CT—abdomen/pelvis

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 Workup XR—wrist CT—head Urine toxicology

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 Workup XR—skeletal survey CT—maxillofacial Urine toxicology CBC

47 yo M presents with impotence that started three months ago. He has hypertension and was started on atenolol four months ago. He also has diabetes and is on insulin.

Drug related erectile dysfunction ED caused by hypertension ED caused by diabetes mellitus Psychogenic ED Peyronie's disease Workup CBC, CMP Fasting glucose Testosterone level TSH

65 yo M presents with postural dizziness and unsteadiness. He has hypertension and was started on hydrochlorothiazide two days ago.

Drug-induced orthostatic hypotension Vestibular neuronitis Labyrinthitis Benign positional vertigo Brain stem or cerebellar tumor Acute renal failure Workup Orthostatic vital signs CBC BUN/Cr, Electrolytes ECG Echocardiography MRI—brain

55 yo M c/o falling after feeling dizzy and unsteady. He experienced transient LOC. He has hypertension and is on numerous antihypertensive drugs.

Drug-induced orthostatic hypotension (causing syncope) Cardiac arrhythmia Syncope (vasovagal, other causes) Stroke Hypoglycemia MI Pulmonary embolism Workup Orthostatic vital signs CBC Electrolytes, glucose CT—head ECG V/Q scan CT—chest with IV contrast

17 yo F presents with prolonged, excessive menstrual bleeding occurring irregularly over the past six months.

Dysfunctional uterine bleeding Coagulation disorders (e.g., von Willebrand's disease, hemophilia) Cervical cancer Molar pregnancy Hypothyroidism Diabetes mellitus Workup Pelvic exam CBC, ESR, glucose Prolactin, LH/FSH TSH PT/PTT Urine hCG Cervical cultures Pap smear U/S—pelvis

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 five weeks ago. She has a history of PID and unprotected intercourse.

Ectopic pregnancy Ruptured ovarian cyst Ovarian torsion PID Workup Pelvic exam Urine beta-hCG Quantitative serum beta-hCG U/S-abdomen/pelvis Cervical cultures

61 yo obese F presents with profuse vaginal bleeding over the past month. Her last menstrual period was 10 years ago. She has a history of hypertension and diabetes mellitus. She is nulliparous.

Endometrial cancer Cervical cancer Atrophic endometrium Endometrial hyperplasia Endometrial polyps Atrophic vaginitis Workup Pelvic exam Pap smear Endometrial biopsy Endometrial curettage U/S—pelvis Colposcopy Hysteroscopy

37 yo F presents with dyspareunia, inability to conceive, and dysmenorrhea

Endometriosis Cervicitis Vaginismus Vulvodynia PID Depression Domestic violence Workup Pelvic exam U/S-pelvis Laparoscopy Wet mount, KOH prep Cervical cultures Endometrial biopsy

75 yo M presents with dysphagia that started with solids and progressed to liquids. He is an alcoholic and a heavy smoker. He has had an unintentional weight loss of 7 kg over the past four months.

Esophageal cancer Achalasia Esophagitis Systemic sclerosis Esophageal stricture Workup CBC CXR Upper endoscopy with biopsy Barium swallow CT-chest

38 yo M presents with dysphagia and pain on swallowing solids more than liquids. Exam reveals oral thrush.

Esophagitis (CMV, HSV, HIV, pill-induced) Systemic sclerosis GERD Esophageal stricture Workup CBC Upper endoscopy Barium swallow HIV antibody and viral load CD4 count

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 Peptid ulcer disease Esophageal spasm MI Anging Workup ECG Barium swallow Upper endoscopy Esophageal pH monitoring H pylori stool antigen

40 yo F presents with epigastric pain and coffee-ground emesis. She has a history of rheumatoid arthritis that has been treated with aspirin. She is an alcoholic.

Gastritis Bleeding peptic ulcer Mallory-Weiss tear Esophageal varices Gastric cancer Workup Rectal exam CBC INR Electrolytes AST/ALT/bilirubin/alkaline phosphatase Upper endoscopy

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 Food poisoning UTI URI Volvulus Intussusception Workup Stool exam and culture CBC Electrolytes UA, urine culture AXR

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).

Generalized tonic-clonic seizure Convulsive syncope Substance abuse/overdose Malingering Hypoglycemia Workup CBC Electrolytes, glucose Urine toxicology EEG MRI—brain CT—head LP—CSF analysis ECG

33 yo F presents with ascending loss of strength in her lower legs over the past two weeks. She had a recent URI.

Guillain Barre Syndrome Multiple sclerosis Transverse myelitis Spinal cord compression Peripheral neuropathy Workup CBC Electrolytes MRI—spine CPK Electromyography Nerve conduction study LP—CSF analysis PFTs Serum B12

26 yo M presents with sore throat, fever, rash, and weight loss. He has a history of IV drug abuse and sharing needles.

HIV infection, acute retroviral syndrome Infectious mononucleosis Hepatitis Viral pharyngitis Streptococcal tonsillitis/ scarlet fever Secondary syphilis Workup CBC with differential and peripheral smear Throat swab for culture HIV antibody and viral load CD4 count Monospot test ALT/AST, Bilirubin, Alkaline phosphatase, Gamma-GT VDRL/RPR

40 yo M presents with pain in the right groin after a motor vehicle accident. His right leg is flexed at the hip, adducted, and internally rotated.

Hip dislocation—traumatic Hip fracture Workup XR—hip CT or MRI—hip CBC PT/PTT Blood type and cross-match Urine toxicology and blood alcohol level U/S-abdomen (FAST)

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 Workup XR—hip/pelvis CT or MRI—hip CBC, type and cross Serum calcium and vitamin D Bone density scan (DEXA)

3 yo M presents with constipation. The child has had 1 bowel movement per week since birth despite the use of stool softeners. At birth, he did not pass meconium for 48 hours. He has poor weight gain. There is a family history of this problem.

Hirschsprung disease Low fiber diet Anal stenosis Hypothyroidism Lead poisoning Celiac disease Workup Rectal exam Barium enema Suction rectal biopsy Anorectal manometry TSH, FT4 CBC Electrolytes Serum lead level Anti-tissue transglutaminase Antiendomysial and total IgA antibodies

39 yo F presents with a single 2-cm mass on the right side of her neck along with night sweats, fever, weight loss, loss of appetite, and early satiety. The mass is painless and movable and has not changed in size. She does not report heat intolerance, tremor, palpitations, hoarseness, cough, difficulty breathing, difficulty swallowing, or abdominal pain. Her husband was recently discharged from prison, and her mother has a history of gastric cancer.

Hodgkin/non-Hodgkin lymphoma Tuberculosis HIV Thyroid nodule Metastatic GI or head and neck malignancy Workup CBC with differential Electrolytes, calcium, glucose, BUN/Cr (BMP) ESR, CRP Lymph node biopsy PPD/QuantiFERON-TB Gold CXR TSH HIV antibody/RNA U/S neck Upper endoscopy Fine needle aspiration

42 yo F presents with a 7-kg weight loss over the past two months. She has a fine tremor, and her pulse is 112.

Hyperthyroidism Cancer HIV infection Dieting/diet drugs Anorexia nervosa Malabsorption Workup TSH, FT4 CBC, Electrolytes, glucose, BUN/Cr HIV antibody Urine toxicology Age appropriate cancer screenings

45 yo F presents with excessive sweating, unintentional weight loss, palpitations, diarrhea and shortness of breath.

Hyperthyroidism Pheochromocytoma Carcinoid syndrome Tuberculosis Workup TSH, FT4 24 hour urinary catecholamines 5-HIAA CBC PDD skin test

70 yo diabetic M presents with episodes of palpitations and diaphoresis. He is on insulin.

Hypoglycemia Cardiac arrhythmia Angina Hyperthyroidism Hyperventilation episodes Panic attack Pheochromocytoma Carcinoid syndrome Workup Glucose CBC Electrolytes TSH BUN/Cr ECG Holter monitor 24 hour urinary catecholamines 5-HIAA

70 yo insulin-dependent diabetic M presents with episodes of confusion, dizziness, palpitation, diaphoresis, and weakness.

Hypoglycemia Transient ischemic attack Arrhythmia Delirium Angina Workup Glucose CBC Electrolytes, TSH CPK-MB, troponin Echocardiography ECG MRI—brain Doppler U/S—carotid

40 yo F presents with fatigue, weight gain, sleepiness, cold intolerance, constipation, and dry skin.

Hypothyroidism Depression Diabetes Anemia Workup TSH, FT3, FT4 CBC Fasting glucose HbA1c

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 Workup CBC with differential and peripheral smear Monospot test Throat culture AST/ALT/bilirubin/alkaline phosphatase HIV antibody and viral load Anti-EBV antibodies VDRL/RPR

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) Food poisoning Workup Rectal exam Stool leukocytes and culture CBC BMP CT-abdomen/pelvis

33 yo F c/o three weeks of fatigue and trouble sleeping. She states that she falls asleep easily but wakes up at 3 A.M. and cannot return to sleep. She also reports an unintentional weight loss of 3.5 kg along with an inability to enjoy the things she once liked to do.

Insomnia related to major depressive disorder Primary hypersomnia Insomnia with circadian rhythm sleep disorder Workup TSH CBC Polysomnography

30 yo F presents with weight gain over the past3 months. She also reports tremor, palpitations, anxiety and hunger that are relieved by eating. She exhibits proximal muscle weakness and easy bruising.

Insulinoma Reactive postprandial hypoglycemia Cushing syndrome Pregnancy Workup Blood glucose Plasma insulin after induced hypoglycemia Glucose tolerance test 24 hour urine free cortisol Urine beta-hCG

40 yo M presents with crampy abdominal pain, vomiting, abdominal distention, and inability to pass flatus or stool. He has a history of multiple abdominal surgeries.

Intestinal obstruction Small bowel or colon cancer Volvulus Gastroenteritis Food poisoning Ileus Hernia Workup Rectal exam CBC Electrolytes AXR CT - abdomen with contrast Colonoscopy

8 mo F presents with sudden-onset colicky abdominal pain with vomiting. The episodes are 20 minutes apart and the child is completely well between episodes. She had loose stools several hours before pain, but her stools are now bloody.

Intussusception Appendicitis Meckel diverticulum Volvulus Gastroenteritis Enterocolitis Blunt abdominal trauma Workup Rectal exam, stool for occult blood CBC Electrolytes Contrast enema U/S-abdomen CT-abdomen

30 yo F presents with periumbilical pain for six months. The pain never awakens her from sleep. It is relieved by defecation and worsens when she is upset. She has alternating constipation and diarrhea but no nausea, vomiting, weight loss, or anorexia.

Irritable bowel syndrome Crohn's disease Celiac disease Chronic pancreatitis GI parasitic infection (amebiasis, giardiasis) Endometriosis Workup Rectal exam, stool for occult blood Pelvic exam Urine hCG CBC Electrolytes CT—abdomen/pelvis Stool for ova and parasitology, Entamoeba histolytica antigen

30 yo F presents with alternating constipation and diarrhea and abdominal pain that is relieved by defecation. She has no nausea, vomiting, weight loss, or blood in her stool.

Irritable bowel syndrome Inflammatory bowel disease Celiac disease Chronic pancreatitis GI parasitic infection (ascariasis, giardiasis) Lactose intolerance Workup Rectal exam CBC with differential CMP (Albumin, TProtein, Electrolytes, BUN/Cr, ALT/AST/bilirubin/alkaline phosphatase) Colonoscopy tTG antibody test (tissue transglutaminase antibody) Stool for ova and parasitology CT-abdomen/pelvis Hydrogen breath test

NAUSEA/VOMITING - Key History - Key Physical Exam

Key History Acuity of onset, ± abdominal pain, relation to meals, sick contacts, possible food poisoning, possible pregnancy; neurologic symptoms (headache, stiff neck, vertigo, focal numbness or weakness), other associated symptoms (GI, chest pain), exacerbating and alleviating factors; medications. Key Physical Exam Vital signs; ENT; consider funduscopic exam (increased intracranial pressure); complete abdominal exam; consider heart, lung, and rectal exams.

COUGH/SHORTNESS OF BREATH - Key History - Key Physical Exam

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).

VAGINAL DISCHARGE - Key History - Key Physical Exam

Key History Amount, color, consistency, odor, duration; associated vaginal burning, pain, or pruritus; recent sexual activity; onset of last menstrual period; use of contraceptives, tampons, and douches; history of similar symptoms; history of STDs. Key Physical Exam Vital signs; abdominal exam; complete pelvic exam.

UPPER GI BLEEDING - Key History - Key Physical Exam

Key History Amount, duration, context (after severe vomiting, alcohol ingestion, nosebleed), associated symptoms (constitutional, nausea, abdominal pain, dyspepsia); medications (especially warfarin, NSAIDs); history of peptic ulcer disease, liver disease, abdominal aortic aneurysm repair, easy bleeding. Key Physical Exam Vital signs, including orthostatics; ENT, heart, lung, abdominal, and rectal exams.

HEMATURIA - Key History - Key Physical Exam

Key History Amount, duration, presence of clots, associated symptoms (constitutional, renal colic, dysuria, irritative voiding symptoms); medications; history of vigorous exercise, trauma, smoking, stones, cancer, or easy bleeding Key Physical Exam Vital signs; lymph nodes; abdominal exam; genitourinary and rectal exams; extremities.

WEIGHT GAIN - Key History - Key Physical Exam

Key History Amount, duration, timing (relation to medication changes, smoking cessation, depression); diet history; hypothyroid symptoms (fatigue, constipation, skin/hair/nail changes); menstrual irregularity; past medical history; alcohol and drug use. Key Physical Exam Vital signs; complete exam, including signs of Cushing's syndrome (hypertension, central obesity, moon face, buffalo hump, supraclavicular fat pads, purple abdominal striae).

WEIGHT LOSS - Key History - Key Physical Exam

Key History Amount, duration, ± intentional; diet history, body image, anxiety or depression; other constitutional symptoms; palpitation, tremor, diarrhea, family history of thyroid disease; HIV risk factors; alcohol and drug use; medications; history of cancer. Key Physical Exam Vital signs; complete physical.

CHILD WITH SHORT STATUE - Key History - Key Physical Exam

Key History Associated symptoms (constitutional, GI, cardiac, pulmonary, renal, pelvic, endocrine) Key Physical Exam Vital signs, height, weight, HEENT, heart, lung, abdominal and neurologic exam

DIZZINESS - Key History - Key Physical Exam

Key History Clarify the dizziness, Lightheadedness vs. vertigo (sensation of movement) ± auditory symptoms (hearing loss, tinnitus), duration of episodes, context (occurs with positioning, following head trauma), other associated symptoms (visual disturbance, URI, nausea); neck pain or injury; medications; history of atherosclerotic vascular disease. Key Physical Exam Vital signs; complete neurologic exam, including Romberg test, nystagmus, tilt test (e.g., Dix-Hallpike maneuver), gait, hearing, and Weber and Rinne tests; HEENT exam; cardiovascular exam.

NUMBNESS/WEAKNESS - Key History - Key Physical Exam

Key History Distribution (unilateral, bilateral, proximal, distal), duration, ± progressive, pain (especially headache, neck or back pain); constitutional symptoms, other neurologic symptoms; history of diabetes, alcoholism, atherosclerotic vascular disease. Key Physical Exam Vital signs; neurologic and musculoskeletal exams; relevant vascular exam.

SORE THROAT - Key History - Key Physical Exam

Key History Duration, fever, other ENT symptoms (ear pain, nasal or sinus congestion, URI), odynophagia, swollen glands, ± cough, chest pain, SOB, rash; allergies, sick contacts, HIV risk factors. Key Physical Exam Vital signs; ENT exam, including oral thrush, tonsillar exudate, and lymphadenopathy; lung, abdominal (splenomegaly), and skin exams.

ERECTILE DYSFUNCTION (ED) - Key History - Key Physical Exam

Key History Duration, severity, presence of nocturnal erections, libido, stress or depression, trauma, associated incontinence; medications (and recent changes); past medical history (hypertension, diabetes, high cholesterol, known atherosclerotic vascular disease, prior prostate surgery); smoking, alcohol and drug use Key Physical Exam Vital signs; cardiovascular exam; genital and rectal exams.

DYSPAREUNIA - Key History - Key Physical Exam

Key History Duration, timing, associated symptoms (vaginal discharge, rash, painful menses, GI symptoms, hot fl ashes), adequacy of lubrication; libido; sexual history; history of sexual trauma or domestic violence; history of endometriosis, PID, or prior abdominal/pelvic surgeries. Key Physical Exam Vital signs; abdominal exam; complete pelvic exam.

FATIGUE AND SLEEPINESS - Key History - Key Physical Exam

Key History Duration; sleep hygiene, snoring, waking up choking/gasping, witnessed apnea; overexertion; stress, depression, or other emotional problems; lifestyle changes, shift changes at work; diet, weight changes; other constitutional symptoms; symptoms of thyroid disease; history of bleeding or anemia; medications; alcohol. caffeine and drug use. Key Physical Exam Vital signs; head and neck exam (conjunctival pallor, oropharynx/palate, lymphadenopathy, thyroid exam); heart, lung, abdominal, and neurologic exams; consider rectal exam and occult blood testing.

ABUSE - Key History - Key Physical Exam

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; firearms in the home Key Physical Exam Vital signs; complete exam + pelvic.

CONSTIPATION/DIARRHEA - Key History - Key Physical Exam

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 fiber and fluid 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

PALPITATIONS - Key History - Key Physical Exam

Key History Gradual vs. acute onset/offset, context (exertion, caffeine, anxiety), associated symptoms (lightheadedness, chest pain, dyspnea); hyperthyroid symptoms; history of bleeding or anemia; history of heart disease, hypertension or diabetes Key Physical Exam Vital signs; endocrine/thyroid exam, including exophthalmos, lid retraction, lid lag, gland size, bruit, and tremor; complete cardiovascular exam.

HEADACHE - Key history - Key physical exam

Key History Location (especially unilateral vs. bilateral) Intensity, duration, timing (does it disturb sleep?); Quality, Presence of associated symptoms -neurologic (paresthesias, visual stigmata, weakness, numbness, ataxia, photophobia, dizziness, nausea/vomiting; auras, neck stiffness); jaw claudication; recent trauma, dental surgery, sinusitis symptoms exacerbating (stress, fatigue, menses, exercise, certain foods) and alleviating factors (rest, medications); past history of headache; family history of migraines. Key Physical Exam Vital signs; Inspection and palpation of entire head; ENT inspection; Complete neurologic exam, including funduscopic exam Meningeal signs for an acute headache

JOINT/ LIMB PAIN - Key History - Key Physical Exam

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

ABDOMINAL PAIN - Key History - Key Physical Exam

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).

LOW BACK PAIN - Key History - Key Physical Exam

Key History Location, quality, intensity, radiation, context (moving furniture, bending/twisting, trauma), timing (disturbs sleep), associated symptoms (especially constitutional, incontinence), exacerbating and alleviating factors; history of cancer, recurrent UTIs, diabetes, renal stones, IV drug use, smoking. Key Physical Exam Vital signs; neurologic exam (especially L4-S1 nerve roots); back palpation and range of motion (although rarely of diagnostic utility); hip exam (can refer pain to the back); consider rectal exam.

CHEST PAIN - Key History - Key Physical Exam

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, lower extremity exam (inspection for signs of DVT)

BLOOD IN STOOL - Key History - Key Physical Exam

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, renal disease, aortic aneurysm repair, family history of colon cancer Key Physical Exam Vital signs + orthostatics; abdominal and rectal exams

CONFUSION/MEMORY LOSS - Key History - Key Physical Exam

Key History Must include history from family members/caregivers. Detailed time course of cognitive deficits (acute vs. chronic/gradual onset) associated symptoms (constitutional, incontinence, ataxia, hypothyroid symptoms, depression); screen for delirium (waxing/waning level of alertness); falls, medications (and recent medication changes); history of stroke or other atherosclerotic vascular disease, syphilis, HIV risk factors, alcohol use, or vitamin B12 deficiency; family history of Alzheimer's disease Key Physical Exam Vital signs; complete neurologic exam, including mini-mental status exam and gait; general physical exam, including ENT, heart, lungs, abdomen, and extremities

NIGHT SWEATS - Key History - Key Physical Exam

Key History Onset, duration, severity, frequency, timing, patterns; recent URIs, associated cough, hemoptysis, pleuritic chest pain; lymphadenopathy, fever, rash, malaise, weight loss, itching; diarrhea, nausea/vomiting, early satiety, anorexia; alcohol history, sexual exposure, sick contacts, exposure to high-risk populations; menstrual history, perimenopause. Key Physical Exam Vital signs; HEENT exam, including throat inspection for lymphadenopathy; heart and lung exam; abdominal exam for hepatosplenomegaly; skin exam; musculoskeletal exam for joint pain.

DEPRESSED MOOD - Key History - Key Physical Exam

Key History Onset, duration; Somatic symptoms (fatigue, headache, abdominal distress) Sleep patterns; appetite and weight change; drug and alcohol use; life stresses, excessive guilt, suicidality, social function, decreased interest (anhedonia), decreased energy, decreased concentration, psychomotor agitation or retardation; family history of mood disorders; prior episodes; medications Key Physical Exam Vital signs; head and neck exam; neurologic exam; mental status exam, including documentation of appearance, behavior, speech, mood, affect, thought process, thought content, cognition (measured by the 30-point mini-mental status exam), insight, and judgment

CHILD WITH GI PROBLEMS - Key History - Key Physical Exam

Key History Onset, location, quality, intensity, duration, timing, associated symptoms (constitutional, GI, cardiac, pulmonary, renal, pelvic), changes in weight, skin rash, bloody/mucoid stools, changes in stool color, exacerbating and alleviating factors, history of similar symptoms, history of abdominal surgeries, medications, sick contacts, day care immunizations Key Physical Exam Vital signs, exam for signs of dehydration (BP, HR, mucous membranes, sunken fontanelle, capillary refill time), heart and lung exam, abdominal exam, rectal exam, pelvic exam)

BEHAVIORAL PROBLEMS I N C H I LDHOOD - Key History - Key Physical Exam

Key History Onset, severity, duration, triggers; physical violence or use of weapons; substance use, developmental history, changes in environment, school performance Key Physical Exam Vital signs; neurologic exam.

PSYCHOSIS - Key History - Key Physical Exam

Key History Positive symptoms (delusions, hallucinations, disorganized thoughts, disorganized or catatonic behavior) Negative symptoms (blunted affect, social withdrawal, decreased motivation, decreased speech/thought), Cognitive symptoms (disorganized speech or thought patterns, paranoia); Self-reference symptoms (people watching you, people talking about you, receiving messages from the media) Age of first symptoms and/or hospitalization; previous psychiatric medications; alcohol and substance use. Key Physical Exam Vital signs; mental status exam

VAGINAL BLEEDING - Key History - Key Physical Exam

Key History Pre- vs. postmenopausal, duration, amount; menstrual history and relation to last menstrual period; associated discharge, pelvic or abdominal pain, or urinary symptoms; trauma; medications (especially warfarin, contraceptives); history of easy bleeding or bruising; history of abnormal Pap smears. Key Physical Exam Vital signs; abdominal exam; complete pelvic exam.

LOSS OF CONSCIOUSNESS (LOC) - Key History - Key Physical Exam

Key History Presence or absence of preceding symptoms (nausea, diaphoresis, palpitation, pallor, lightheadedness), context (exertional, postural, traumatic; stressful, painful, or claustrophobic experience; dehydration); associated tongue biting, incontinence, tonic-clonic movements, prolonged confusion; dyspnea or pulmonary embolism risk factors; history of heart disease, arrhythmia, hypertension, or diabetes; alcohol and drug use. Key Physical Exam Vital signs, including orthostatics; complete neurologic exam; carotid and cardiac exam; lung exam; exam of the lower extremities.

AMENORRHEA - Key History - Key Physical Exam

Key History Primary vs. secondary, duration, possible pregnancy, associated symptoms (headache, decreased peripheral vision, galactorrhea, hirsutism, virilization, hot flashes, vaginal dryness, symptoms of thyroid disease); history of anorexia nervosa, excessive dieting, vigorous exercise, pregnancies, D&Cs, uterine infections; drug use; medications. Key Physical Exam Vital signs; breast exam; complete pelvic exam.

CHILD WITH FEVER - Key History - Key Physical Exam

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

DYSPHAGIA - Key History - Key Physical Exam

Key History Solids vs. both solids and liquids, ± progressive, constitutional symptoms (especially weight loss), drooling, regurgitation, odynophagia, GERD symptoms; medications; HIV risk factors, history of smoking, history of Raynaud's phenomenon. Key Physical Exam Vital signs; head and neck exam; heart, lung, and abdominal exams; skin exam (for signs of scleroderma/ CREST)

LOSS OF VISION - Key history - Key physical exam

Key history Acute vs chronic, progression Ability to see light Associated symptoms (eye pain, discharge, itching, tearing, photophobia, redness, headache, weakness, numbness, floaters, sparks) History of cardiac, rheumatic, thrombotic, autoimmune or neurologic disorders, jaw claudication, medications, trauma Key physical exam Vital signs, HEENT, fundoscopic, neurologic and cardiovascular exam

CHILD WITH RED EYE - Key History - Key Physical Exam

Key history Onset, location, duration, affecting one or both eyes, eye discharge, itching, pain, photophobia, tearing, associated symptoms (constitutional, dermatologic, GI, cardiac, pulmonary, renal, pelvic, rheumatology), exacerbating and alleviating factors, medications, sick contacts, day care, immunizations, history of similar symptoms Key physical exam Vital signs, HEENT exam

NECK MASS - Key history - Key Physical exam

Key history Onset, progression over time, size location, mobility, pain, movement with swallowing, obstructive symptoms (dysphagia, SOB), other masses, associated symptoms (constitutional, hematologic, GI, endocrine, pulmonary), ill contacts, tobacco/alcohol/IV drug use, sexual history Key Physical exam Vital signs, HEENT exam, exam of lymph nodes, spleen and tonsils, heart, lung and abdominal exams including checking for splenomegaly