FA Step 2 CS Minicases

Joint/Limb Pain Key Hx

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, morning stiffness); exacerbating and alleviating factors; trauma (including vigorous exercise); medications; DVT risk factors; alcohol and drug use; family history of rheumatic disease.

Abdominal Pain Key History

Location, quality, intensity, duration, radiation, timing (relation to meals); associated symptoms (constitutional, GI, cardiac, pulmonary, renal, pelvic); exacerbating and alleviating factors; history of similar symptoms; history of abdominal surgeries, trauma, gallstones, renal stones, atherosclerotic vascular disease; medications (eg, NSAIDs, corticosteroids); alcohol and drug use; domestic violence, stress/anxiety, sexual history, pregnancy history.

Low Back Pain Key Hx

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.

Chest Pain Key History

Location, quality, severity, radiation, duration, context (exertional, postprandial, positional, cocaine use, trauma); associated symptoms (sweating, nausea, dyspnea, palpitations, sense of doom, fever); exacerbating and alleviating factors (especially medications); 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).

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 vertebral compression fracture XR, 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. (eg, pushing a grocery cart)

Lumbar spinal stenosis lumbar muscle strain tumor in the vertebral canal peripheral muscle disease MRI (preferred), XR, CT L spine ankle-brachial index

12 month old M presents with fever x 2 days accompanied by a maculopapular rash on his face and body. He has not yet received his MMR vaccine.

Measles (or other viral exanthem) Rubella roseola fifths disease varicella scarlet fever meningitis physical exam CBC viral antibodies / titer throat swab for cx LP, CSF analysis

Blood in Stool Key History

Melena vs. bright red blood; amount, duration; associated symptoms (constitutional, abdominal or rectal pain, tenesmus, constipation/diarrhea); menstrual cycle; trauma; history of similar symptoms; prior colonoscopy; medications (especially blood thinners); history of easy bleeding or atherosclerotic vascular disease, renal disease, aortic valve disease, liver disease, alcoholism, or abdominal aortic aneurysm repair; family history of colon cancer.

Confusion/Memory Loss Key History

Must include history from family members/caregivers when available. 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 or other neurologic disorders.

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 PNA pyelonephritis physical exam CBC, blood cx electrolytes LP CSF analysis CXR UA, Ucx

Headache key history

Onset (acute vs. chronic) location (unilateral vs. bilateral) quality (dull vs. stabbing) intensity (is it the "worst headache of their life"?) duration, timing (does it disturb sleep?) paresthesias, visual stigmata, weakness, numbness, ataxia, photophobia, dizziness, auras, neck stiffness); nausea/vomiting, jaw claudication, recent trauma, dental surgery, sinusitis symptoms; exacerbating factors (stress, fatigue, menses, exercise, certain foods) and alleviating factors (rest, medications); patient and family history of headache; history of trauma.

Depressed Mood Key History

Onset, duration; sleep patterns; appetite and weight change; drug and alcohol use; SIGECAPS family history of mood disorders; prior episodes; medications.

Neck Mass Key History

Onset, size, location, mobility, pain, movement with swallowing; obstructive symptoms (dysphagia, shortness of breath); other masses; associated symptoms (constitutional, hematologic, GI, endocrine, pulmonary); ill contacts.

Child with fever ddx

PASS GUUM P - Pneumonia A - Acute Otitis Media S - Scarlet fever S - Sepsis G - Gastroenteritis U - Upper Respiratory Infection U - Urinary Tract Infection M - Meningitis, Measles, Mumps

Vaginal Discharge W/U

Pelvic exam Wet mount, KOH "whiff" vaginal pH Cervical Cx

Vaginal Bleeding Key History

Pre- vs. postmenopausal status, duration, amount; menstrual history and relation to last menstrual period; associated discharge, pelvic or abdominal pain, or urinary symptoms; trauma; medications (especially blood thinners, contraceptives); history of easy bleeding or bruising; history of abnormal Pap smears.

Loss of Consciousness Key History

Presence or absence of preceding symptoms (nausea, diaphoresis, palpitations, pallor, lightheadedness), context (exertional, postural, traumatic; stressful, painful, or claustrophobic experience; dehydration); associated tongue biting or incontinence, tonic-clonic movements, prolonged confusion; dyspnea or pulmonary embolism risk factors; history of heart disease, arrhythmia, hypertension, or diabetes; alcohol and drug use.

Amenorrhea 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

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 RA.

RA SLE disseminated gonorrhea arthritis associated with IBD XR hands and left knee ANA, anti-dsDNA, ESR, C3, C4, RF, CCP CBC cervical cx athrocentesis and synovial fluid analysis

Upper GI Bleeding W/U

Rectal Exam CBC, type and cross Electrolytes AST/ALT/bili/ALP INR, PT, PTT Upper Endoscopy

Constipation/Diarrhea W/U

Rectal exam, Fecal occult blood test, abdominal XR, CBC, electrolytes, stool ova/parasites, stool culture/C diff toxins, fecal leukocytes, CTabdomen, C-scope, barium enema, ASCA-antibodies, urinary 5HIAA, AST/ALT/bili/Alkphos, TSH, urine toxicology, ASCA antibodies, anti-TTG antibodies

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

SLE RA psoriatic arthritis parvovirus B19 infection ANA, anti-dsDNA, ESR, C3, C4, RF, CCP CBC XR hands UA antibody titers for parvovirus B19

Child with Fever Key Hx

Severity, duration; associated localizing symptoms such as rash, wheezing, cough, and ear discharge; poor appetite, convulsions, lethargy, sleepiness; sick contacts, day care, immunizations.

50 yo M presents with R should pain after falling onto his outstretched arm while skiing. He noticed deformity of his shoulder and had to hold his right arm.

Shoulder dislocation fracture of the humerous rotator cuff injury XR shoulder, arm MRI shoulder

Dysphagia Key History

Solids or liquids vs. both solids and liquids, +/- progression, occurring at the beginning or middle of swallow; constitutional symptoms (especially weight loss); hoarseness, drooling, regurgitation of liquids vs. undigested food, odynophagia, GERD symptoms; medications; HIV risk factors; history of anxiety, smoking, Raynaud's phenomenon.

Insomnia DDX

Stress induce insomnia, caffiene induced, circadian rhythm sleep disorder, MDD,

Vaginal Discharge Key PE

VS Ab exam Complete pelvic

Dyspareunia ddx

Vaginal atrophy (peri-menopausal), Endometriosis, cervicitis, depression, domestic abuse

Chest Pain - 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

Upper GI Bleeding Key PE

Vital signs, including orthostatics; ENT, heart, lung, abdominal, and rectal exams.

Loss of Consciousness Key PE

Vital signs, including orthostatics; complete neurologic exam; carotid and cardiac exam; lung exam; exam of the lower extremities.

Palpitation Key PE

Vital signs; endocrine/thyroid exam, including exophthalmos, lid retraction, lid lag, gland size, bruit, and tremor; complete cardiovascular exam.

Nausea/Vomiting Key PE

Vital signs; ENT; consider funduscopic exam (increased intracranial pressure); complete abdominal exam; consider heart, lung, and rectal exams.

Abdominal Pain Key PE

Vital signs; heart and lung exams; abdominal exam, including tenderness, guarding, rebound, Murphy's sign, psoas and obturator signs, and CVA percussion; bowel sounds, aortic bruits; rectal exam; pelvic exam (women).

Fatigue and Sleepiness Key PE

Vital signs; ENT exam (conjunctival pallor, oropharynx/palate, lymphadenopathy, thyroid exam); heart, lung, abdominal, neurologic, and extremity (pallor, coolness at distal extremities) exams; consider rectal exam and occult blood testing.

Loss of Vision Key PE

Vital signs; cardiovascular, HEENT, funduscopic, and neurologic exams.

Confusion/Memory Loss Key PE

Vital signs; complete neurologic exam, including mini-mental status exam and gait; general physical exam, including ENT, heart, lungs, abdomen, and extremities.

Depressed Mood Key PE

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.

Headache Key Physical Exam

Vital signs; inspection and palpation of entire head; ENT inspection; complete neurologic exam, including funduscopic exam.

Numbness/Weakness Key PE

Vital signs; neurologic and musculoskeletal exams; relevant vascular exam.

3 yo M presents with 2 day hx of fever and pulling at his R 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 pyelonephritis physical exam, incl. pneumatic otoscopy CBC blood cx tympanocentesis cx LP CSF UA, Ucx

3 yo F presents with 3 day hx of "pink eye." it began in the R 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 hx of asthma and atopic dermatitis.

bacterial conjunctivitis viral conjunctivitis keratitis seasonal allergies uveitis physical exam ophthalmoscopic eye exam CBC electrolytes discharge cx slit lamp exam

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

carpel tunnel syndrome median nerve compression in the forearm or arm radiculopathy of nerve roots C6 C7 in the cervical spine de quervain's tenosynovitis phalen's maneuver (pressing dorsum of hands together reproduces pain) and tinel's sign (tapping produces parathesias) finkelstein's test nerve conduction studies EMG

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

cervical cancer endometrial cancer cervical polyp cervicitis trauma pelvic exam pap smear colposcopy and biopsy HVP testing endometrial bx

2 month old 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 physical exam rectal exam, stool for occult blood US abdomen, US testicular

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 problems when there were young, but now they are of normal stature.

constitutional short stature growth hormone deficiency hypothyroidism chronic renal insufficiency genetic causes cystic fibrosis physical exam CBC electrolytes GH stimulation test IGF-1, IGFBP-3 levels TSH, FT4 XR hand US renal and cardiac sweat chloride testing BUN/Cr karyotype

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

ddx: esophagitis (CMV, HSV, HIV, pill-induced) systemic sclerosis GERD esophageal stricture zenker's diverticulum CBC upper endoscopy barium swallow HIV antibody and viral load CD4 count

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 reiter's syndrome (reactive arthritis) knee arthrocentesis and synovial fluid analysis (cekk count, gram stain, cx) ANA, and-dsDNA, ESR, RF, CCP CBC blood, cervical cx XR - knee

30 F presents with wrist pain and black eye after tripping, falling, and hitting her head of the edge of a table. She looks anxious and gives an inconsistent story.

domestic violence factitious disorder substance abuse XR - affected body part CT head urine tox forensic exam (if rape) wet mount, koh (if rape) cervical cx

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 5 weeks ago. She has a hx of PID and unprotected intercourse.

ectopic pregnancy ruptured ovarian cyst ovarian torsion PID urine hCG quantitative serum hCG U/S abd/pelvis pelvic exam cervical cx

4 yo M presents with diarrhea, vomiting, lethargy, weakness, and fever. The child attends a day care center where several children have had similar symptoms.

gastroenteritis (viral, bacterial, parasitic) food poisoning UTI URI volvulus intussusception physical exam stool exam and cx CBC lytes UA, Ucx AXR

65 yo F presents with inability to use her left leg or bear weight on it after tripping on a carpet. Onset of menopause was 20 years ago, and she did not receive HRT of calcium supplements. Her left leg is externally rotated, shortened, and adducted, and there is tenderness in her left groin.

hip fracture hip dislocation pelvic fracture XR hip/pelvis CT or MRI CBC, type and cross serum Ca and vit D DEXA

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

hirshsprung's disease low fiber diet anal stenosis hypothyroidism lead poisoning physical exam rectal exam stool exam and cx barium enema suction rectal bx anorectal manometry TSH, FT4 CBC lytes serum lead level

8 month old 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 the pain, but her stools are now bloody.

intussusception appendicitis meckel's diverticulum volvulus gastroenteritis enterocolitis blunt abdominal trauma physical exam rectal exam, stool for occult blood CBC electrolytes constrast enema U/S abdomen CT abdomen

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 of school because of his injury.

malingering lumbar muscle strain disk herniation knee or leg fracture ankylosing spondylitis XR - L spine/knee MRI L spine

56 yo obese F presents with R knee stiffness and pain that increases with movement. Her sx have gradually worsened over the past 10 years. She has noticed swelling and deformity of the joint and is having difficulty walking.

osteoarthritis pseudogout gout meniscal or ligament damage XR knee CBC ESR knee arthrocentesis and synovial joint analysis (cell count, gram stain, cx, crystals) uric acid MRI knee

60 yo F presents with pain in both legs that is induced by walking and is relieved by rest. She had a CABG 6 months ago and continues to smoke heavily.

peripheral vascular disease (intermittent claudication) leriche syndrome (aortoiliac occlusive disease) lumbar and spinal stenosis (psuedoclaudication) osteoarthritis ankle-brachial index doppler US lower extremities angiography MRI L-spine

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

plantar fasciitis heel fracture splinter/foreign body XR heel, bone scan - foot

18 yo M presents with pain in the interphalangeal joints of both hands. He also has a scaly, salmon-pink lesions on the extensor surface of his elbows and knees

psoriatic arthritis RA SLE gout ANA, ESR, RF, CCP CBC XR hands, pelvic sacro-iliac joints uric acid

1 month old F is brought in because she has been spitting up her milk for the last 10 days. The vomiting episodes have increased in frequency and forcefulness. Emesis is nonbloody and nonbilious. the episode usually occur immediately after feeding. She has stopped gaining weight.

pyloric stenosis partial duodenal atresia GERD gastroenteritis hepatitis UTI otitis media physical exam CBC electrolytes U/S abdomen barium swallow pH probe endoscopy AST/ALT/bili/alk phos UA, Ucx

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

rhabdomyolysis due to statins polymyositis inclusion body syndrome CBC phosphate, K, BUN/Cr, uric acid CPK aldolase UA urine myoglobin

45 yo M presents with fevers and R knee pain with swelling and redness.

septic arthritis gout pseudogout lyme arthritis trauma reiter's syndrome (reactive arthritis) CBC knee arthrocentesis and synovial joint analysis (cell count, gram stain, cx, crystals) blood, urethral cx XR knee uric acid lyme tests - IgG, IgM

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

somatoform disorder malingering IBS lactose intolerance child abuse physical exam CBC electrolytes US abdomen CT abdomen amylase, lipase stool exam

28 yo F who is 8 weeks pregnant presents with lower abdominal pain and vaginal bleeding.

spontaneous abortion ectopic pregnancy molar pregnancy urine hCG quantitative serum hCG U/S abd/pelvis pelvic exam CBC PT/PTT

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

stress fracture plantar fasciitis foot sprain or strain XR foot bone scan - foot MRI foot

55 yo M presents with pain 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.

tennis elbow (lateral epicodylitis) stress fracture XR arm bone scan MRI elbow

Insomnia: key hx? key PE?

trouble falling asleep vs. multiple awakenings vs. early-morning awakening Multiple awakenings Daytime sleepiness Snoring, nightmares Depression Lifestyle/work changes Caffeine, Substance use MMSE

33 yo F presents with urinary leakage. She is unable to suppress the urge to urinate and loses large amounts of urine without warning. She has a hx of UTIs and a family hx of DM. She drinks 8 cups of coffee per day. She has been under stress since her sister passed away a few months ago.

urge incontinence mixed incontinence stress incontinence overflow incontinence functional incontinence UTI DM work up: electrolytes, glucose UA, ucx BUN/Cr Urodynamic testing IVP cystourethroscopy

Cough/Shortness of Breath (SOB) Physical Exam

• VS: State (or WNL or WNL except...) • General: Patient is in no acute distress • HEENT: Examine mouth, throat, lymph nodes => Nose, mouth and pharynx WNL • Neck Exam: No JVD, no lympadenopathy • Chest Exam: Palpation, Percussion, Auscultation => Tactile fremitus normal, Clear breath sounds bilaterally/Clear breath sounds bilaterally, no rhonchi, rales, or wheezing; (Increase in tactile fremitus, and decrease in breath sounds on right side. No rhonchi, rales, or wheezing) • Heart Exam: Palpation, Auscultation => Apical impulse not displaced, RRR, S1, S2 wnl, No murmurs, rubs, or gallops heard • Abd Exam: Palpation, Auscultation • Extremities: Inspect => No cyanosis, or edema

Psychosis: key hx? key PE?

+Sx (delusions, hallucinations, catatonia) -Sx (blunted affect, dec speech, withdrawal) Hospitalizations Substance use MMSE

Cough/Shortness of Breath (SOB) DDX

- Asthma (especially Exercise-Induced Asthma) - Chronic Obstructive Pulmonary Disease (COPD) - Chronic Bronchitis - COPD Exacerbation - Pneumonia - Atypical pneumonia - Lung Neoplasm/Cancer - Tuberculosis (TB) - Congestive Heart Failure (CHF) - ACE inhibitors use - Paroxysmal Nocturnal Dysnea (PND) - Gastroesophageal Reflux Disease (GERD) - HIV

Vaginal Discharge DDX

- Bacterial Vaginosis - Vaginitis (trich vs candida) - Cervicitis

Other Urinary Symptoms DDX

- Benign Prostatic Hyperplasia (BPH) - Prostate Cancer - Urethritis - Urinary Tract Infection (UTI) - Acute Pyelonephritis - Bladder stone

Hematuria DDX

- Bladder Cancer - PKD - Renal cell carcinoma - Nephrolithiasis - Glomerulonephritis - Pyelonephritis - Coagulatuib disorder

Dysphagia Work-Up

- CBC with diff - Chest X-ray (CXR) - (Upper) Endoscopy - Barium Swallow - CT

Cough/Shortness of Breath (SOB) Work-Up

- CBC with diff - Chest X-ray (CXR) - Peak Flow measurement - PFT's - Methacholine Challenge Test - Sputum Grain Stain, Acid-fast stain, Culture - CT—chest - Bronchoscopy (Bronchoalveolar lavage (BAL)) - PPD - HIV antibody

Weight Gain Work-Up

- CBC with diff - Electrolytes - Glucose - TSH - 24 hour Free Cortisol - Dexmatheasone Suppresion Test

Fatigue/Sleepiness Work-up

- CBC with diff - TSH/Free T4 (FT4) - HIV/STD - Urine Toxicology (Urine Tox) - Glucose/HbA1c - Urine Analysis

Sore Throat Work-up

- CBC with diff, peripheral smear - Monospot test (Heterophile antibody test for EBV) - Rapid Strep Test - Rapid Streptococcal Antigen - Throat Culture/ Throat Swab Culture - LFTs - AST/ALT/Bili/ALP - HIV antibody/Viral Load

Blood in Stool DDX

- Colon Cancer - Ulcerative Colitis - Diverticulosis - Hemorrhoids - Crohns Disease - Angiodysplasia - Ischemic Bowel - Dysentery

Constipation/Diarrhea ddx

- Colorectal Cancer - Low-Fiber Diet - IBS - Infectious Diarrhea - C Diff colitis - Travelers Diarrhea - Lactose intolerance - Crohn's Disease - UC

Fatigue/Sleepiness DDX

- Depression - Post-Traumatic Stress Disorder(PTSD) - Colon Cancer - Hypothyroid - Obstructive Sleep Apnea (OSA) - Diabetes Mellitus (DM) - Sleep deprivation

Low Back Pain Ddx

- Disk herniation - Lumbar muscle strain - Lumbar spinal stenosis - Malingering - Ankylosing Spondylitis - Cancer - AAA

Vaginal Bleeding DDX

- Dysfunctional Uterine Bleeding (DUB) - Endometrial Cancer → Post-menopausal bleeding = endometrial cancer until otherwise proven - Cervical Cancer → intermenstrual or post-coital bleeding r/o cervical cancer - Spontaneous Abortion - Ectopic Pregnancy/Rupture - Trauma - Endometrial Hyperplasia - Molar Pregnancy - Ruptured Uterine Pregnancy

Dysphagia DDX

- Esophageal cancer - Plummer-Vinson - Achalasia - Esophagitis

Hematuria Work-Up

- Genitourinary Exam - Urine Analysis/Urine Cytology - Urine Culture - BUN/Cr - PSA - CBC with diff - PT/PTT - Cyotoscopy - Ultrasound (U/S) Renal/Bladder - CT Abdomen/Pelvis

Weight Loss DDX

- Hyperthyroid - Cancer - HIV - Diet - Drugs - Anorexia - Malabsorption

Sore Throat DDX

- Infectious mononucleosis - Pharyngitis (bacterial (strep) or viral) - Acute HIV infection - Streptococcal tonsillitis/scarlet fever - Atypical Pneumonia (Mycoplasma pneumonia)

Abdominal Pain Ddx

- Nephrolithiasis - Pancreatic Cancer - Acute Pancreatitis - Acute Cholecystitis - Ascending Cholangitis - Acute Hepatitis - PUD - Perforated ulcer - Splenic rupture - Intestinal Obstruction - Mesenteric Ischemia - Ovarian Torsion - Diverticulitis - Appendicitis - IBS - PID - Stomach Cancer - Func. Dyspepsia

Amenorrhea Work-Up

- Pelvic Exam - Urine B-HCG - Ultrasound (U/S) Pelvis - CBC with diff - Electrolytes - Urine Analysis/Urine Culture - LH/FSH/TSH/Prolactin - MRI Brain

Insomnia Work-Up

- Polysomnography - Mental Status Exam (MSE) - Urine Toxicology (Urine Tox) - CBC with diff - TSH

Nausea/Vomiting DDx

- Pregnancy - Gastritis - Hypercalcemia - DM - UTI - Infection - Gatroenteroritis - Bowel Obstruction (Large or Small)

Amenorrhea DDX

- Pregnancy - PCOS - Prolactinoma - Menopause - Sheehan's - Anorexia - Anxiety - Asherman's - Hypothyroid

Other Urinary Symptoms Work-Up

- Rectal Exam - Genitourinary Exam - Urine Analysis - Urine Gram stain and Culture - Chlamydia and Gonorrhea PCR - CBC with diff - BUN/Cr - PSA - Ultrasound (U/S) Prostate (transrectal) - CT Pelvis

Joint/Limb Pain DDX

- Rheumatoid Arthritis (RA) - Systemic Lupus Erythematosus (SLE) - Domestic Violence - Carpal Tunnel - Psoriatic Arthritis - Fracture - Dislocation - Osteoarthritis (OA) - Septic Arthitis - Stress Fracture - Inflammation - Peripheral Vascular Disease (PVD) - Deep Vein Thrombosis‎ (DVT) - Myocardial Infarction (MI) - Rhabdomyolysis

Loss of Consciousness (LOC) DDX

- Seizure, grand mal - Vasovagal - Cardiac arrhythmia - Drug/orthostatic - Convulsive syncope - Aortic stenosis

Weight Gain DDX

- Smoking cessation - Drugs (Lithium) - Hypothyroid - Cushings Syndrome/Disease/Syndrome - PCOS - DM - Atypical depression - Familial - Pregnancy

Numbness/Weakness DDX

- TIA - Stroke - Guillain Barre - MS - DM peripheral - Myasthenia Gravis - Todds Paralysis

Night Sweats Work-Up

- TSH, FT4 - 24 hr. urine metaneph. - 5-HIAA - PPD - Chest X-ray (CXR) - CBC with diff - Sputum Gram Stain and Acid Fast Stain - (Bronchoalveolar lavage (BAL))

Night Sweats DDX

- Tuberculosis (TB) - Acute HIV infection - Lymphoma - Leukemia - Hyperthyroid - Pheochromocytoma - Carcinoid Syndrome

Vaginal Bleeding Physical Exam

- VS - General - Abdominal Exam - Complete pelvic exam

Other Urinary Symptoms Physical Exam

- VS - General - Heart - Chest - Abdominal Exam (Including suprapubic, percuss to assess for a distended bladder) - Focused neurologic exam - Genital and rectal exam

Blood in Stool Physical Exam

- VS - General - Heart - Chest - Complete Abdomen - Rectal Exam

Nausea/Vomiting 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); urinary symptoms; other associated symptoms (GI, chest pain); exacerbating and alleviating factors; medications; history of prior abdominal surgery

Loss of Vision 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.

Cough/Shortness of Breath Key History

Acute/subacute vs. chronic, increased frequency of cough if chronic, timing; presence/description of sputum, presence of hemoptysis; associated symptoms (constitutional, URI, postnasal drip, dyspnea, wheezing, chest pain, heartburn); exacerbating and alleviating factors, exposures; smoking history; history of lung disease, posttussive emesis, or heart failure; allergies; medications (especially ACE inhibitors).

Vaginal Discharge Key Hx

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.

Hematuria Key History

Amount, duration, +/- clots; associated symptoms (constitutional, renal colic, dysuria, irritative voiding symptoms); point along the stream (initial vs. terminal vs. throughout); medications; history of vigorous exercise, trauma, smoking, stones, cancer, or easy bleeding; skin bruising (purpura).

Weight Loss Key History

Amount, duration, +/- intention; diet and exercise history; body image, anxiety or depression; other constitutional symptoms; hyperthyroid symptoms (palpitations, tremor, diarrhea); family history of thyroid disease; HIV risk factors; tobacco, alcohol, and drug use; medications; history of cancer; blood in urine or stool

Upper GI Bleeding Key History

Amount, duration, context (after severe vomiting, alcohol ingestion, nosebleed); associated symptoms (constitutional, nausea, abdominal pain, dyspepsia); medications (especially blood thinners, NSAIDs, and corticosteroids); history of peptic ulcer disease, liver disease, abdominal aortic aneurysm repair, easy bleeding.

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

Angina/MI Tendonitis Osteoarthritis ECG CBC XR-shoulder CXR Echo stress test

Upper GI Bleeding ddx

Bleeding peptic ulcer, gastritis, gastric cancer, esophageal varices, Mallory-Weiss Tear

Weight Loss (W/U)

CBC, TSH/freeT4, CT chest, CXR, CT ABD, colonoscopy, fecal occult blood test, urine toxicology, HIV antibody and viral load

Dizziness: key hx? key PE?

Context (lightheaded vs vertigo) Auditory (tinnitus, hearing loss) Neck pain/injury Meds, Substance use Atherosclerotic dz Complete neuro (inc. Romberg, nystagmus, Dix-Hallpike, gait, hearing, Weber & Rinne) Head/neck Orthostatics

Night sweats: key hx? key PE?

Cough, hemoptysis, CP xGI (early satiety, N/V/D) Sexual hx, menstrual hx, menopause High-risk contacts (Travel, IVDU, prisoner/homeless) HEENT Abd (HSmeg) Skin MS (joints)

48 yo F presents with amenorrhea for the past 6months accompanied by hot flashes, night sweats, emotional lability, and dyspareunia.

DDX: - Menopause - Pregnancy - Pituitary Tumor - Thyroid Disease W/U: - Urine hCG - LH/FSH, TSH, prolactin - Testosterone, DHEAS - Pelvic Exam - CBC - MRI (brain)

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

DDx: - Colorectal Cancer - Anal Fissure - Hemorrhoids - Diverticulosis - Ischemic Bowel Disease - Angiodysplasia - Upper GI Bleed - Inflammatory Bowel Disease W/U: - Rectal exam - CBC - AST/ALT/bilirubin/alkaline phosphatase - INR - Colonoscopy - CEA - CT—abdomen/pelvis

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

DDx: - Diverticulosis - Anal fissure - Hemorrhoids - Angiodysplasia - Colorectal cancer W/U: - Rectal exam - CBC, type and cross - PT/PTT - Electrolytes - Colonoscopy - Tagged RBC scan - CT—abdomen/pelvis

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

DDx: - Endometriosis - Cervicitis - Vaginismus - Vulvodynia - PID - Depression - Domestic Violence W/U: - Pelvic exam - Wet mount, KOH - Cervical Cx - U/S (pelvis) - Laparoscopy - Endometrial Bx

33 yo F presents with rectal bleeding and diarrhea for the past week. She has had lower abdominal pain and tenesmus for several months.

DDx: - Ulcerative colitis - Crohn's disease - Proctitis - Anal fissure - Hemorrhoids - Diverticulosis - Dysentery W/U: - Rectal exam - CBC - PT/PTT - Colonoscopy - CT—abdomen/pelvis

45 yo F presents with R calf pain. Her calf is tender, warm, red, and swollen compared to the left side. She was started on OCPs 2 months ago for dysfunctional uterine bleeding.

DVT baker's cyst myositis cellulitis superficial venous thrombus doppler US R leg CBC d-dimer

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.

Ddx: - Anorexia nervosa - Pregnancy - Hyperthyroidism W/U: - Urine hCG - CBC - TSH, FT4 - LH/FSH

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.

Ddx: - Anxiety-induced amenorrhea - PTSD - Depression - Hyperthyroidism W/U: - CBC - TSH, FT4 - Urine [cortisol] - Progesterone challenge - LH/FSH, estradiol

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

Ddx: - Atrophic vaginitis - Endometriosis - Cervicitis - Depression - Domestic Violence W/U: - Pelvic exam - LH/FSH - Wet mount, KOH prep - Cervical Cx

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.

Ddx: - Sheehan - Premature ovarian failure - Pituitary Tumor - Thyroid Disease - Asherman's Syndrome W/U: - Urine hCG - LH/FSH, prolactin - CBC - Pelvic Exam - TSH, FT4 - ACTH - MRI (brain) - Hysteroscopy

48 yo F presents with dysphagia for both solids and liquids that has slowly progressed in severity within the past year. It is associated with difficulty belching and regurgitation of undigested food, especially at night. She has lost 5.5 lbs in the past 2 months.

Ddx: Achalasia Plummer-vinson syndrome esophageal cancer esophagitis systemic sclerosis mitral valve stenosis esophageal stricture zenker's diverticulum work up: CBC upper endoscopy barium swallow esophageal manometry XR - neck

20 yo M presents with severe RLQ abdominal pain, N/V, 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.

Ddx: Acute appendicitis gastroenteritis diverticulitis crohn's disease nephrolithiasis volvulus or other intestinal obstruction perforation acute cholecystitis work up: CBC, lytes CT abdomen AXR U/S abdomen blood cx

41 yo obese F presents with RUQ abdominal pain that radiates to the right scapula and is assoicated with nausea, vomiting, and a fever of 101.5F. The pain started after she ate fatty food. She has had similar but less intense episodes that lasted a few hours. Exam reveals a positive Murphy's sign.

Ddx: Acute cholecystitis choledocolithiasis hepatitis ascending cholangitis PUD fitz-hugh-curtis syndrome acute appendicitis work up: CBC AST/ALT/bili/alk phos US abdomen CT abdomen blood cx

56 yo M presents with severe mid-epigastric 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 3 days binge drinking.

Ddx: Acute pancreatitis PUD cholecystitis/choledocolithiasis gastritis AAA mesenteric ischemia alcoholic hepatitis boerhaave syndrome work up: CBC lytes amylase, lipase AST/ALT/bilirubin/alk phos CT abdomen U/S abdomen upper endoscopy ECG

25 yo F presents with 2 weeks of nonproductive cough. Three weeks ago she had a sore throat and a runny nose.

Ddx: Atypical PNA Reactive airway disease URI associated cough (post infectious) postnasal drip GERD Work up: CBC, induced sputum gram stain and cx CXR IgM for mycoplasma pneumoniae Urine legionella antigen

60 yo M presents with nocturia, urgency, weak stream, and terminal dribbling. He denies any weight loss, fatigue, or bone pain. He has had 2 episodes of urinary retention that required catheterization.

Ddx: BPH prostate ca UTI bladder stones work up: rectal exam UA CBC BUN/Cr alk phos US prostate (transrectal) PSA

26 yo F presents with 6.5 lb weight loss in the past 2 months, accompanied by early-morning awakening, excessive guilt, and psychomotor retardation. She does not identify a triffer for the depressive episode but reports several weeks of increased energy, sexual promiscuity, irresponsible spending, and racing thoughts approximately 6 months before her presentation.

Ddx: Bipolar d/o 1 Bipolar d/o 2 Cyclothymic d/o Major depressive d/o Schizoaffective d/o Work up: Physical exam, MSE, Urine tox

50 yo M presents with cough that is exacerbated by lying down at night and improved by propping up on 3 pillows. He also reports exertional dyspnea.

Ddx: CHF cardiac valvular disease GERD pulmonary fibrosis COPD postnasal drip CBC, CXR, ECG, echo, PFTs, BNP, Ct chest

56 yo F presents with SOB and productive cough that has lasted for at least 3 months each year over past 2 years. She is a heavy smoker.

Ddx: COPD (chronic bronchitis) bronchiectasis lung cancer TB work up: CBC sputum GS and Cx CXR PFTs CT chest PPD

55 yo M presents with increased dyspnea and sputum production for the past 3 days. He has COPD and stopped using his inhalers last week. He stopped smoking 2 days ago.

Ddx: COPD exacerbation (bronchitis) Lung cancer PNA URI CHF Work up: CBC, CXR, ABG, PFTs, sputum gram staina dn cx, CT chest, echo

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

Ddx: Carpel tunnel syndrome 2/2 hypothyroidism Overuse injury of median nerve Medial epicondylitis Work up: Phalen's maneuver and tinel's sign Nerve conduction studies TSH CBC

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

Ddx: Cluster headache Migraine Tension headache Intracranial neoplasm Psuedotumor cerebri Work up: - CBC, CT head, MRI brain, LP CSF analysis, ESR

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

Ddx: Colon cancer Hypothyroidism Renal failure Hypercalcemia Depression Work up: Rectal exam, stool for occult blood, CBC, lytes, BUN/Cr, Ca, AST/ALT, TSH, colonoscopy, barium enema, CT abd/pelvis

67 yo M presents with alternating diarrhea and constipation, decreased stool caliber, and blood in the stool for 8 months. He also reports unintentional weight loss. He is on a low fiber diet and has a family hx of colon cancer. His last colonoscopy was 12 years ago.

Ddx: Colorectal cancer IBS diverticulosis GI parasitic infection (ascariasis, giardiasis) IBD work up: rectal exam, stool for occult blood CBC, lytes, AST/ALT/bili/alk phos colonoscopy barium enema CT abdomen/pelvis

55 yo M presents with rapidly progressive change in mental status, inability to concentrate, and memory impairment for the past 2 months. His sx are associated with myoclonus, ataxia, and a startle response

Ddx: Creutzfeldt-Jakob's Disease Vascular dementia Lewy Body dementia Wernike's encephalopathy NPH Chronic SDH Intracrancial neoplasm Depression Delirium B12 deficiency Neurosyphilis Work up: CBC, electrolytes, CA, Serum B12, VDRL/RPR, MRI brain (preferred), CT head, EEG, LP CSF, Brain bx

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

Ddx: DM atypical depression Primary polydipsia DI Work up: Glucose tolerance test, HBA1c, UA, CBC, lytes, BUN/Cr, glucose

40 yo F c/o feeling tired, hopeless, and worthless and having suicidal thoughts. She lost her job and has been having fights with her husband about money.

Ddx: Depression Adjustment d/o Hypothyroidism Anemia Work up: CBC, TSH, HIV/STD testing Beck depression inventory

55 yo M presents with tingling and numbness in his hands and feet (glove and stocking distribution) for the past 2 months. He has a hx of DM, HTN, and alcoholism. There is decreased soft touch, vibratory, and position sense in his feet.

Ddx: Diabetic peripheral neuropathy Alcoholic related neuropathy B12 deficiency kyperkalemia hyperventilation paraproteinemia/myeloma work up: HbA1c, ESR, Ca, B12, UA, serum and urine protein electrophoresis

68 yo M presents with LLQ abdomianl pain, fever, and chills for the past 3 days. He also reports recent onsest of alternating diarrhea and constipation. He consumes a low-fiber, high-fat diet.

Ddx: Diverticulitis Crohn's disease ulcerative colitis gastroenteritis abscess work up: rectal exam CBC lytes CXR,AXR CT abdomen blood cx

45 yo F presents with retrosternal burning sensation that occurs with heavy meals and when lying down. Her sx are relieved by antacids.

Ddx: GERD esophagitis PUD Esophageal spasm MI, angina work up: ECG, barium swallow, upper endoscopy, esophageal ph monitoring

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

Ddx: Gastritis bleeding peptic ulcer gastric cancer esophageal varices mallory weiss tear work up: rectal exam CBC, type and cross lytes AST/ALT/bili/alk phos INR upper endoscopy

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 after regaining consciousness (as witnessed by his colleagues).

Ddx: Generalized tonic-clonic seizure Convulsive syncope Substance abuse/overdose Malingering Hypoglycemia work up: CBC, lytes, glucose, urine tox, EEG, MRI brain, CT head, LP CSF, ECG

33 yo F presents with ascending loss of strength in her lower legs over the past 2 weeks. She had a recent URI.

Ddx: Guillain-Barre syndrome Multiple sclerosis Polymyositis Myasthenia gravis peripheral neuropathy tumor in the vertebral canal work up: CBC, lytes, CPK, LP CSF, MSI spine, EMG, nerve conduction studies, Tensilon (edrophonium) test, serum B12

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

Ddx: HIV, acute retroviral syndrome Infectious mononucleosis Hepatitis Viral pharyngitis Streptococcal tonsilitis/ scarlet fever Secondary syphilis Work up: CBC with peripheral smear HIV antibody and viral load CD4 Monospot throat cx VDRL/RPR LFTs

39 yo F presents with a single 2-cm mass on the R side os her neck along with night sweats, fever, weight loss, loss of appetite, and early satiety.The mass is painless and moveable 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 hx of gastric cancer.

Ddx: Hodgkin's/ non-hodgkin's lymphoma TB thyroid nodule gastric carcinoma work up: CBC with diff lytes ESR, CRP LN bx PPD CXR TSH U/S thyroid Upper endoscopy

45 yo F presents with excessive sweating, unintentional weight loss, palpitations

Ddx: Hyperthyroidism Pheochromocytoma Carcinoid syndrome TB work up: TSH, FT4, 24-hour urine catecholamines, 5-HIAA, CBC, PPD

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

Ddx: Hypoglycemia TIA Arrhythmia Delirium Angina Work up: Glucose, CBC, lytes, CPK-MB, troponin, ECG, echo, MRI brain, doppler UTS carotid

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

Ddx: Hypothyroidism Depression Diabetes Anemia Work up: TSH, FT3, FT4 CBC, fasting glucose, HBA1c

30 yo F presents with alternating constipation and diarrhea accompanied by abdominal pain that is relieved with defecation. She has no N/V/weight loss/blood in stool.

Ddx: IBS IBD celiac chronic pancreatitis GI parasitic infection (ascariasis, giardiasis) lactose intolerance work up: rectal exam, stool for occult blood CBC, lytes colonoscopy stool for O/P CT abdomen/pelvis

33 yo M presents with watery diarrhea, vomiting, and diffuse abdominal pain that began yesterday. He also reports feeling hot. Several of his coworkers are also ill.

Ddx: Infectious diarrhea (gastroenteritis - viral, bacterial, parasitic, protozoal) food poisoning work up: rectal exam, stool for occult blood stool leukocytes and cx CBC, lytes CT abdomen/pelvis

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 sx.

Ddx: Infectious mononucleosis Hepatitis Viral or bacterial pharyngitis Acute HIV infection Secondar syphilis Work up: CBC with peripheral smear, monospot test, throat culture, LFTs, HIV antibody and viral load, Anti-EBV antibodies, VDRL/RPR

33 yo F c/o 3 weeks of fatigue and trouble sleeping. She states that she falls asleep easily but wakes up at 3 AM and cannot return to sleep. She also reports unintentional weight loss of 8 lbs. and an inability to enjoy the things she used to.

Ddx: Insomnia related to MDD Primary hypersomnia Insomnia with circadian rhythm sleep d/o

30 yo F presents with periumbilical pain for 6 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.

Ddx: Irritable bowel syndrome crohn's disease celiac disease chronic pancreatitis GI parasitic infection endometriosis work up: rectal exam, stool for occult blood pelvic exam urine hCG CBC lyes colonoscopy CT abd/pelvis Stool for O/P, entamoeba histolytica antigen

55 yo F c/o dizziness that started this morning and or "not hearing well." She feels nauseated and has vomited once in the past day. She had a URI 2 days ago.

Ddx: Labyrinthitis Vestibular neuronitis Menieres dx Acoustic neuroma Vertebrobasilar insufficiency Work up: audiogram, electronystagmography, MRI/MRA brain

65 yo M presents with worsening cough for past 6 months accompanied by hemoptysis, dyspnea, weakness, and weight loss. He is a heavy smoker.

Ddx: Lung cancer TB Lung abscess COPD Vasculitis (wegners) ILD CHF work up: CBC Sputum stain, cx, and cytology CXR CT chest PPD ANCA Bronchoscopy echo

60 yo M presents with sudden onset of substernal chest pain that has lasted for 30 minutes and radiates to his left arm. The pain is accompanied by dyspnea, diaphoresis, and nausea. He has a hx of HTN, HLD, and smoking.

Ddx: MI GERD angina costochondritis aortic dissection pericarditis PE pneumothorax Work up: ECG CPK-MB, toponin x 3 CXR CBC lytes echo cardiac catheterization d-dimer helical CT

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

Ddx: Menieres dx Vestibular neuronitis Labryinthitis Benign positional vertigo Acoustic neuroma Work up: CBC, VDRL/RPR (syphylis a cuase of menieres), MRI brain, dix-hallpike maneuver

25 yo M presents with high fever, severe headache, confusion, photophobia, and nuchal rigidity.

Ddx: Meningitis Migraine SAH Sinusitis/encephalitis ICH or epidural abcess WOrk up: CBC, CT head, MRI brain, LP CSF w cell count, glucose, protein, gram stain, PCR for specific pathogens, culture

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

Ddx: Migraine (complicated) Tension headache Cluster headache Psuedotumor cerebri CNS vasculitis Partial seizure Intracranial neoplasm Work up: - CBC, ESR, CT head, MRI brain, LP CSF analysis

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

Ddx: Mitral valve prolapse cardiac arrhythmia panic attack pheochromocytoma work up ECG echocardiography holter monitor 24-hour urine catecholamines

30 yo F presents with weakness, loss of sensation, and tingling in her left leg that started this morning. She is also experiencing R eye pain, decreased vision, and double vision. She reports feeling "electric shocks" down her spine upon flexing her head.

Ddx: Multiple sclerosis Stroke conversion d/o malingering CNS tumor neurosyphilis syringomyelitis CNS vasculitis work up: CBC, ESR, VRL/RPR, MRI brain/spine, LP CSF, retinal evoked potentials

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

Ddx: Myasthenia gravis Horner's syndrome MS intracranial neoplasm compressing CN III< IV, or VI AML Work up: Tensilon (edrophonium test) Serum ACh receptor antibodies CXR CT chest MRI brain EMG

72 yo M presents with memory loss, gait disturbance, and urinary incontinence for the past 6 months

Ddx: NPH Alzheimers disease vascular dementia chronic SDH Intracranial neoplasm Depression B12 deficiency Neurosyphilis Hypothyroidism Work up: CT brain MRI brain LP - opening pressure and CSF analysis serum B12, VDRL/RPR, TSH

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

Ddx: Nephrolithiasis renal cell carcinoma pyelonephritis GI etiology (eg appendicitis) work up: UA cx and sensitivity, cytology BUN/Cr CT abdomen U/S renal KUB IVP blood cx

68 yo M presents with 2 month hx of crying spells, excessive sleep, poor hygiene, and a 15 lb weight loss, all following his wife's death. He cannot enjoy time with his grandchildren and admits to thinking he has seen his dead wife in line at the supermarket or standing in the kitchen making dinner

Ddx: Normal bereavement Adjustment d/o w/ depressed mood Major depressive disorder w/ psychotic features Schizoaffective d/o Depressive d/o NOS Work up: Physical exam TSH CBC Urine tox Beck depression inventory

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

Ddx: Obstructive sleep apnea Daytime fatigue in hypersomnia Insomnia with circadian rhythm sleep d/o Insomnia related to major depressive d/o Work up: CBC, TSH, polysomnography, ECG

50 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.

Ddx: Obstructive sleep apnea Hypothyroidism Chronic fatigue syndrome Narcolepsy Work up: CBC, TSH, nocturnal pulse ox, polysomnogrpahy, ECG

55 yo F c/o dizziness for past day. She feels faint and has severe diarrhea that started 2 days ago. She takes furosemide for HTN.

Ddx: Orthostatic hypotension due to dehydration Vestibular neuronitis Labyrinthitis Benign positional vertigo Vestibular insufficiency Work up: orthostatic vital signs, CBC, lytes, rectal exam stool for occult blood, stool leukocyts

70 yo F presents with acute onset of shortness of breath at rest and pleuritic chest pain. She also presents with tachycadia, hypotension, tachypnea, and mild fever. She is recovering from a hip replacement surgery.

Ddx: PE PNA Costocondritis MI CHF Aortic dissection Work Up: d-dimer ECG CXR ABG CPK-MB, troponin CBC electrolytes, BUN/Cr, glucose CTA - chest with IV constrast LE doppler

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.

Ddx: PID endometriosis dysmenorrhea vaginitis cystitis spontaneous abortion pyelonephritis work up: pelvic exam urine hCG cervical cx CBC, ESR UA, urine cx US pelvis

44 yo M presents w fatigue, insomnia, and nightmares about a murder that he has witnessed in a mall 1 year ago. Since then, he has avoided the mall and has not gone out at night.

Ddx: PTSD Depression Generalized anxiety d/o Psychotic or delusional mood d/p Hypothyroidism Work Up: CBC, TSH, utox, beck depression inventory

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

Ddx: PUD GERD cholecystitis chronic pancreatitis mesenteric ischemia work up: rectal exam, stool for occult blood amylase, lipase, lactate AST/ALT/bilirubin/alk phos upper endoscopy (incl H pylori testing) upper Gi series

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 4-5 episodes per month for several months. Each episode lasts 2-3 minutes. He does not have any hx of psychiatric illness except separation anxiety as a child.

Ddx: Panic attack GAD acute stress d/o specific phobia hyperthyroidism agoraphobia substance abuse, dependence mitral valve prolapse pheochromocytoma work up: CBC, lytes TSH, FT4 ECG echo urine tox 24-hour urine catecholamines

34 yo F presents with retrosternal stabbing chest pain that improves when she leans forward and worsens with deep inspiration. She had a URI 1 week ago.

Ddx: Pericarditis aortic dissection MI costrochondritis GERD esophageal rupture Work up: ECG CPK-MB, troponin CXR echo CBC upper endoscopy ESR

45 yo F presents with dysphagia for 2 weeks accompanied by mouth and throat pain, fatigue, and a craving for ice and clay.

Ddx: Plummer-Vinson syndrome esophageal cancer esophagitis achalasia systemic sclerosis mitral valve stenosis work up: CBC serum iron, ferritin, TIBC Barium swallow upper endoscopy video fluoroscopy

58 yo M presents with 1 week of pleuritic CP, F, chills, and cough with purulent sputum. He is a heavy smoker with COPD.

Ddx: Pneumonia COPD exacerbation Lung abscess lung cancer TB pericarditis Work up: CBC sputum GS and Cx CXR CT chest ECG PPD

23 yo F presents with amenorrhea for 6 months, facial hair, and infertility for the past 3 years.

Ddx: Polycystic ovarian syndrome thyroid disease hyperprolactinemia pregnancy ovarian or adrenal insufficiency premature ovarian failure work up: urine hCG LH/FSH, TSH, prolactin pelvic exam testosterone, DHEAS

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

Ddx: Pseudotumor cerebri Tension headache Migraine Cluster HA Meningitis Intracranial venous thrombus Intracranial neoplasm Work up: Urine hCG CBC CT head LP - opening pressure and CSF analysis

73 yo M presents with acute loss of vision in his left eye, palpitations, and SOB. He has a hx of afib, and cataracts in his R eye. He has no eye pain, discharge, redness, or photophobia,. He has not experienced HA, weakness, or numbness.

Ddx: Retinal artery occlusion Retinal vein occlusion Acute angle closure glaucoma Retinal detachment Temporal arteritis Work up: Fluorescein angiogram Echo, doppler UTS carotid Intraoccular tonometry ESR Temporal artery bx CBC

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

Ddx: SAH Migraine Meningitis/encephalitis ICH Vertebral artery dissection Intracranial venous thrombosis Acute HTN Intracranial neoplasm Work up: Non-con head CT LP CSF PT/PTT/INR Urine tox

55 yo F presents with gradual altered mental status and headache. Two weeks ago she slipped, hit her head on the ground, and loss consciousness for 2 minutes.

Ddx: SDH SIADH (causing hyponatremia) CJD Intracranial neoplasm Work up: CT head, CBC, lytes, MRI brain, LP CSF

48 yo F presents with 1 week hx of auditroy hallucinations that state "I am worthless" and "I should kill myself." She also reports a 2-week history of weight loss, early morning awakening, decreased motivation, and overwhelming feelings of guilt.

Ddx: Schizoaffective d/o Mood d/o w psychotic features Schizophreniform d/o Schizophrenia Psychotic d/o due to general medical condition Work up: MSE, Beck depression inventory, TSH, CBC, lytes

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

Ddx: Schizophrenia Schizoid or schizotypal personality d/o Schizophreniform d/o Psychotic d/o due to a general medical d/o Substance induced psychosis Depression w psychotic features Work up: Urine tox, MSE, TSH, CBC, lytes,

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

Ddx: Shift work d/o Sleep apnea Depression Anemia work-up: CBC, nocturnal pulse ox polysomnography

30 yo F w frontal headache, fever, and nasal discharge. There is pain on palpation of the frontal and axillary sinuses. She has a history of allergies.

Ddx: Sinusitis Migraine Tension headache Meningitis Intracranial neoplasm Work up: CBC, XR sinus, CT sinus, LP CSF

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

Ddx: Social phobia avoidant personality d/o agoraphobia specific phobia Panic attack GAD substance abuse hyperthyroidism

60 yo M presents with slurred speech, R facial drooping and numbness, and R hand weakness. Babinski's sign is present on the right. He has a hx of HTN, DM, and heavy smoking.

Ddx: Stroke TIA Seizure Intracranial neoplasm Subdural or epidural hematoma Work up: CT head, CBC, lytes, coags, fasting lipids, MRI brain, doppler UTS carotid, echo, ECG

28 yo F c/o seeing bugs crawling on her bed for the past 2 days and hearing loud voices when she is alone in her room. She has never experienced anything similar in the past. She recently ingested an unknown substance.

Ddx: Substance induced psychosis Brief psychotic d/o Schizophreniform d/o Schizophrenia Psychotic d/o due to general medical condition Work up: Urine tox, MSE, TSH, CBC, lytes, AST/ALT

30 yo M presents with night sweats, cough, and swollen glands of 1 month's duration. He recently emigrated from the African subcontinent.

Ddx: TB Acute HIV infection Lymphoma Leukemia Hyperthyroidism Work up: PPD/Quantiferon GOLD CBC, CXR, sputum gram stain, acid fast stain, and cx HIV antibody TSH, FT4

35 yo M presents with SOB and cough. He has had unprotected sex with multiple sexual partners and was recently exposed to a patient with active TB.

Ddx: TB PNA (including PCP PNA) Bronchitis Asthma Acute HIV infection CHF (cardiomyopathy) Work up: CBC PPD/Quantiferon Gold Sputum gram stain, cx, AFB CXR HIV antibody Echo

34 yo F nurse presents with worsening cough of 6 week's duration accompanied by weight loss, fatigue, night sweats, and fever. She has a history of contact with TB patients at work.

Ddx: TB lung abscess, vasculitis, lymphoma, metastatic cancer, HIV/AIDS, sarcoidosis Work up: CBC PPD/Quantiferon Gold Sputum gram stain, cx, AFB CXR Bronchoscopy HIV antibiody Lymph node bx

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

Ddx: Temporal arteritis (giant cell) Migraine Cluster headache Meningitis Coratid artery dissection Psuedotumor cerebri Trigeminal neuralgia Intracranial neoplasm TMJ disorder Work up: ESR, CBC, CRP, temp art bx, doppler UTS of coratid, MRI brian, LP CSF analysis

50 yo F presents with recurrent episodes of bilateral squeezing headaches that occur 3-4x/week typically towards the end of the work day. She is experiencing significant stress in her life and recent decreased her intake of caffeine.

Ddx: Tension headache Migraine Depression Caffeine or analgesic withdrawal HTN Cluster headache Psuedotumor cerebri Intracranial neoplasm Work up: CBC electrolytes ESR CT head LP CSF

25 yo M presents with hemiparesis after a tonic-clonic seizure that resolved within a few hours.

Ddx: Todd's paralysis TIA Stroke Complicated migraine Malingering Work up: CBC, lytes, EEG, MRI brain, doppler UTS carotid

68 yo M presents following a 20-minute episode of slurred speech, R facial dropping and numbness, and R hand weakness. His sx had totally resolved by the time he got the ED. He has a hx of HTN, DM, and heavy smoking.

Ddx: Transient ischemic attack Hypoglycemia Seizure Stroke Facial nerve palsy Work up: CT head, CBC, lytes, fasting lipids, ECG, MRI brain, doppler UTS carotid, echo, EEG

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

Ddx: Trigeminal neuralgia Tension HA Migraine Cluster HA TMJ disorder Intracranial neoplasm Work up: CBC, ESR, MRI brain

81 yo M presents with progressive confusion for the past several years accompanied by forgetfulness and clumsiness. He has a hx of HTN, DM2, and 2 strokes with residual L hemiparesis. His mental status has worsened after each stroke (stepwise decline in cognitive function).

Ddx: Vascular dementia Alzheimers NPH Chronic subdural hematoma Depression B12 deficiency Neurosyphilis Hypothyroidism Work up: CBC, VDRL/RPR, Serum B12, TSH, MRI brain, CT head, LP CSF

55 yo F c/o dizziness that started this morning. She is nauseated and vomited once in the past day. She had a URI 2 days ago and has experienced no hearing loss.

Ddx: Vestibular neuronitis Labyrinthitis Menieres dx Benign positional vertigo Vertigo associated with a cervical spine dsieas or injury Vertebrobasilar insufficiency

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

Ddx: acute hepatitis acute cholecystitis ascending cholangitis choledocolithiasis pancreatitis acute glomerularnephritis work up: CBC, lytes amylase, lipase AST/ALT/bilirubin/alk phos U/S abdomen UA viral hepatitis serologies

45 yo diabetic F presents with dysuria, urinary frequency, fever, chills, and nausea for the past 3 days. There is left CVA tenderness on exam.

Ddx: acute pyelonephritis nephrolithiasis lower UTI (cystitis, urethritis) renal cell carcinoma work up: UA, ucx and sensitivity blood cx CBC BUN/Cr US renal CT abdomen

35 yo F presents with amenorrhea, galactorrhea, visual field defects, and headaches for the past 6 months.

Ddx: amenorrhea 2/2 prolactinoma pregnancy thyroid disease premature ovarian failure pituitary tumor work up: urine hCG LH/FSH, TSH, prolactin MRI brain pelvic and breast exam

55 yo M presents with sudden onset of severe chest pain that radiates to his back. He has a hx of uncontrolled HTN.

Ddx: aortic dissection MI pericarditis esophageal rupture esophageal spams GERD pancreatitis fat embolism Work up: ECG CPK-MB, troponin CXR CBC amylase, lipase CTA chest w contrast TEE MRI/MRA of aorta aortic angiography upper endoscopy

42 obese F presents with RUQ abdominal pain, fever, and jaundice. She was dx with asymptomatic gall stones 1 year ago. She is found to be hypotensive on exam.

Ddx: ascending cholangitis acute gallstone cholangitis acute cholecystitis hepatitis sclerosising cholangitis fitz-hugh-curtis syndrome work up: CBC, lytes amylase, lipase AST/ALT/bilirubin/alk phos U/S abdomen ERCP, MRCP viral hepatitis serologies

30 yo M presents with SOB, cough, and wheezing that worsens with cold air. He has had several such episodes in the past 4 months.

Ddx: asthma GERD bronchitis pneumonitis foreign body Work up: CBC CXR Peak flow measurement PFTs Methacholine challenge test

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

Ddx: bladder cancer renal cell carcinoma nephrolithiasis acute glomerulonephritis prostate cancer coagulation d/o (ie factor VII antibodies) work up: genitourinary exam UA, urine cytology BUN/Cr PSA CBC PT/PTT cystoscopy US renal/bladder CT abdomen/pelvis prostate bx

45 yo F presents with coffee ground emesis for the past 3 days. Her stool is dark and tarry. She has a hx of intermittent epigastric pain that is relieved by food and antacids.

Ddx: bleeding peptic ulcer gastritis gastric cancer esophageal varices work up: rectal exam CBC, type and cross lytes AST/ALT/bili/alk phos INR upper endoscopy (incl h pylori testing if ulcer is confirmed)

65 yo M presents after falling and losing consciousness for a few seconds. He had no warning before passing out but recently had palpitations. His hx includes a coronary artery bipass graft.

Ddx: cardiac arrhythmia Severe aortic stenosis Syncope Seizure Pulmonary embolism Work up: ECG, holter monitor, CBC, lytes, glucose, echo, CT head

33 yo F presents with stabbing chest pain that worsens with deep inspiration and is relieved with ASA. She had a URI 1 weeks ago. Chest wall tenderness is noted.

Ddx: costrochondritis PNA MI PE pericarditis pleurisy muscle strain work up: ECG, CPK.MB, troponin, CXR, CBC

30 yo F presents with watery diarrhea, diffuse abdominal pain, and weight loss within the past 3 weeks. He has a history of aphthous ulcers. He has not responded to antibiotics.

Ddx: crohn's disease gastroenteritis ulcerative colitis celiac disease pseudomembranous colitis hyperthyroidism small bowel lymphoma carcinoid syndrome work up: rectal exam, stool for occult blood stool leukocytes and cx CBC, lytes colonoscopy CT abdomen TSH small bowel series 5-HIAA

55 yo M c/o falling after feeling dizzy and unsteady. He experienced transient loss of consciousness. His past medical hx significant for HTN and DM2.

Ddx: drug induced orthostatic hypotension (causing syncope) Hypoglycemia Cardiac arrhythmia syncope (vasovagal, other causes) stroke MI Pulmonary embolism Work up: Orthostatis VS CBC, lytes, glucose Echo, ECG CT head VQ scan, d-dmier CTA

47 yo M presents with impotence that started 3 months ago. He has hypertension and was started in atenolol 4 months ago. He also has diabetes and is on insulin.

Ddx: drug related ED ED caused by HTN ED caused by DM psychogenic ED Peyonies disease work up: genital exam rectal exam glucose, CBC testosterone

17 yo F presents with prolonged, excessive menstrual bleeding occurring irregularly within the past 6 months.

Ddx: dysfunctional uterine bleeding coagulation disorder cervical cancer molar pregnancy hypothyroidism DM work up: Urine hCG pelvic exam cervical cx, pap smear CBC, ESR glucose PT/PTT LH/FSH, TSH, prolactin U/S pelvis

42 yo female presents with 15.5 lb weight loss within the past 2 months. She has a fine tremor and her pulse is 112.

Ddx: hyperthyroidism cancer HIV dieting/diet drugs anorexia nervosa malabsorption work up: TSH, FT4 CBC lytes HIV antibody urine tox

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

Ddx: hypoglycemia cardia arrhythmia angina hyperthyroidism hyperventilation episodes panic attack pheochromocytoma carcinoid syndrome work up: glucose CBC, lytes TSH ECG holter monitor 24-urinary catecholamines 5-HIAA

30 yo F presents with weight gain over the past 3 months. She also reports tremor, palpitations, anxiety, and hunger relieved by eating. She exhibits proximal muscle weakness and easy bruising.

Ddx: insulinoma reactive postprandial hypoglycemia cushing syndrome work up: blood glucose and plasma insulin glucose tolerance test 24-hour urine free cortisol

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

Ddx: intenstinal obstruction small bowel or colon CA volvulus gastroenteritis food poisoning ileus hernia work up: rectal exam CBC amylase, lipase, lactate ECG AXR CT abdomen mesenteric angioography barium enema

28 yo M presents with constipation (hard stool) for the past 3 weeks. Since his mother died 2 months ago, he and his father have only eaten junk food.

Ddx: low fiber diet depression substance abuse (ie heroin) IBS hypothyroidism work up: rectal exam TSH lytes, utox

42 yo F presents with 4 week hx of excessive fatigue, insomnia, and anhedonia. She states that she thinkgs constantly about death. She has suffered 5 similar episodes in the past, the first in her 20s , and made 2 previous suicide attempts. She further admits to increased alcohol use in the past month.

Ddx: major depressive disorder substance-induced d/o dysthymic d/o Work up: physical exam, MSE, beck depression inventory, blood etoh level, TSH, CBC, urine tox

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 hx of CHF and afib, for which she has received digitalis. Her pain is out of proportion to her exam.

Ddx: mesenteric ischemia/infarction diverticulitis PUD gastroenteritis acute pancreatitis cholecystitis work up: rectal exam CBC amylase/lipase ECG AXR CT abdomen mesenteric angiography barium enema

21 yo F presents with acute onset of severe RLQ pain, nausea, and vomiting. She has no fever, urinary sx, or vaginal bleeding and has never taken OCPs. Her last menstrual period was regular and she has no hx of STDs. She has been told that she had a cyst on her R ovary.

Ddx: ovarian torsion appendicitis nephrolithiasis ectopic pregnancy ruptured ovarian cyst PID bowel infarction of perforation work up: pelvic exam urine hCG doppler US pelvis UA CBC, lytes CT abdomen laproscopy GC and CT, VDRL/RPR

60 yo M presents with dull epigastric pain that radiates to the back, accompanied by weight loss, dark urine, and clay colored stool. He is a heavy drinker and smoker. He appears jaundiced on exam.

Ddx: pancreatic CA cholangiocarcinoma acute viral hepatitis chronic pancreatitis cholecystitis/choledocolithiasis AAA PUD work up: CBC lytes amylase, lipase AST/ALT/bilirubin/alk phos CT abdomen U/S abdomen

37 yo M presents with severe epigastric pain, nausea, vomiting and mild fever. He appears toxic. He has a hx of intermittent epigastric pain that is relieved by food and antacids. He also smokes heavily and takes ASA on a daily basis.

Ddx: perforated peptic ulcer acute pancreatitis hepatitis cholecystitis gallstone cholangitis mesenteric ischemia work up: rectal exam CBC, lytes AST/ALT/bilirubin/alk phos CXR KUB CT abdomen upper endoscopy (incl h pylori) blood cx

46 yo F presents with fever and sore throat

Ddx: pharyngitis mycoplasma pneumonia Acute HIV infection Infectious mono Work up: Throat swab for cx and rapid strep antigen monospot test CBC Serologic (cold agglutinin test) for mycoplasma HIV antibody and VL

35 yo M presents with painless hematuria. He has a family hx of kidney disease.

Ddx: polycystic kidney disease nephrolithiasis acute glomerulonephritis (IgA nephropathy) UTI coagulation d/o bladder cancer work up: genitourinary exam UA, urine cytology BUN/Cr PSA CBC PT/PTT US renal/bladder CT abdomen/pelvis

40 yo F presents with amenorrhea, morning nausea and vomiting, fatigue and polyuria. Her LMP was 6 weeks ago, and her breasts are full and tender. She uses the rhythm method for contraception.

Ddx: pregnancy anovulatory cycle hyperprolactinemia UTI hypothyroidism work up: urine hCG U/S abd/pelvis pelvi exam CBC UA, urine cx prolactin, TSH baseline pap smear, cervical cx, rubella antibody, HIV antibody, Hep B surface antigen, VDRL/RPR

20 yo F presents with N/V (especially in the morning), fatigue, and polyuria. Her last MP was 6 weeks ago and her breasts are full and tender. She is sexually active with her BF and that occasionally use condoms for contraception.

Ddx: pregnancy gastritis hypercalcemia DM UTI depression work up: urine hCG pelvic exam U/S pelvis CBC lyes Ca glucose UA, urine cx HIV antibody

71 yo M presents with nocturia, urgency, a weak stream, terminal dribbling, hematuria, and lower back pain for the past 4 months. He has also experienced weight loss and fatigue.

Ddx: prostate cancer BPH renal cell carcinoma UTI bladder stones work up: rectal exam UA CBC BUN/Cr PSA US prostate (transrectal) prostate bx alk phos CT pelvis MRI spine

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

Ddx: psuedomenbranous colitis (c. diff) gastroenteritis cryptosporidiosis food poisoning IBD work up: stool for c. iff toxin rectal exam, stool for occult blood stool leukocytes and cx CBC, lytes

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

Ddx: pulmonary edema CHF mitral valve stenosis arrhythmia asthma PNA Work up: ECG, CXR, CBC, ABG, PFTs, BNP

55 yo M presents with flank pain and blood in his urine without dysuria. He has experienced weight loss and fever over the past 2 months. Exam reveals a flank mass.

Ddx: renal cell carcinoma bladder cancer nephrolithiasis acute glomerulonephritis pyelonephritis prostate CA genitourinary exam UA, urine cytology BUN/Cr PSA CBC PT/PTT US renal/bladder CT abdomen/pelvis cystoscopy

20 yo AA F presents with acute onset of severe CP for a few hours. She was a hx of sickle cell dx and multiple hospitalizations for pain and anemia management.

Ddx: sickle cell dx - acute chest syndrome PE PNA MI pneumothorax aortic dissection Work up: CBC with retic count and smear LDH ABG d-dimer CXR CPK-MB, troponin ECG CTA - chest with IV contrast

44 yo F presents with weight gain of >25 lbs within past 2 months. She quit smoking 3 months ago and is on anitriptyline for depression. She also reports cold intolerance and constipation.

Ddx: smoking cessation drug side effect hypothyroidism cushing syndrome diabetes mellitus atypical depression work up: CBC lytes, glucose TSH 24-hour urine for free cortisol dexamethasone suppression test

18 yo M boxer presents with severe LUQ abdominal pain that radiates to the left scapula. He had infections mononucleosis 3 weeks ago.

Ddx: splenic rupture kidney stone rib fracture PNA perforated peptic ulcer splenic infarct work up: CBC, lytes CXR CT abdomen US abdomen

55 yo M presents with retrosternal squeezing pain that lasts for 2 minutes and occurs with exercise. It is relieved by rest and is not related to food intake.

Ddx: stable angina esophageal spasm esophagitis work up: ECG CPK-MB, troponin CBC, lytes stress test upper endoscopy/ph monitor cardiac catheterization

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 hx of multiple vaginal deliveries, and her mother had the same problem after the onset of menopause.

Ddx: stress incontinence mixed incontinence urge incontinence overflow incontinence functional incontinence UTI DM work up: UA, ucx BUN/Cr Urodynamic testing IVP cystourethroscopy

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

Ddx: traveler's diarrhea giardiasis amebiasis food poisoning hepatitis A work up: rectal exam stool leukocytes, cx, giardia antigen, entamoeba histolytica antigen CBC, lytes AST/ALT/bili/alk phos viral hepatitis serologies

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

Ddx: urethritis cystitis prostatitis work up: genital, rectal exam UA, ucx gram stain and culture of urethral discharge CT and GC PCR

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

Ddx: Benign positional vertigo Vestibular neuronitis Labyrinthitis Menieres dx Work up: Dix-Hallpike, MRI brain, audiogram

65 yo M presents with postural dizziness and unsteadiness. He has HTN and was started on HCTZ 2 days ago.

Ddx: Drug induced Orthostatic hypotension Vestibular neuronitis Labyrinthitis Benign positional vertigo Brain stem or cerebral tumor Acute renal failure Work up: orthostatic vital signs, CB, lytes, echo, brain MRI

25 yo F presents with a 3-week hx of difficulty falling asleep. She sleeps 7 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 per day.

Ddx: Stress induced insomnia Caffeine induced insomnia Insomnia with circadian rhythm sleep disorder Insomnia related to major depressive d/o Work up: Polysomnography, MSE, urine tox, CBC, TSH

84 yo F BIB son c/o forgetfulness and difficulty performing some of her ADLs. The problem has progressed gradually over the past few years.

Ddx: alzheimers vascular dementia depression hypothyroidism chronic SDH NPH Intracranial neoplasm B12 deficiency Neurosyphilis Work up: CBC, VDRL/RPR, Serum B12, TSH, MRI brain, CT head, LP CSF

75 yo M presents w/ 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 15 lbs within the past 4 months.

Ddx: esophageal cancer achalasia esophagitis systemic sclerosis esophageal stricture amyotrophic lateral sclerosis work up: CBC CXR upper endoscopy with bx barium swallow CT - chest

45 yo F presents with low back pain that radiates to the lateral aspect of her left foot. The straight leg raise is positive. The patient is unable to tiptoe.

Disk herniation lumbar muscle strain tumor in the vertebral canal XR L spine MRI L spine

Numbness/Weakness Key History

Distribution (unilateral, bilateral, proximal, distal), duration w/ or w/o progression, pain (especially headache, neck or back pain); constitutional symptoms, other neurologic symptoms; history of diabetes, alcoholism, atherosclerotic vascular disease

Sore throat: key hx? key PE?

Duration Fever, ear pain, congestion Glands HIV RF Sick contacts HEENT (thrush, exudate) Abd (splenomegaly) Skin

Other Urinary Symptoms Key History

Duration, obstructive symptoms (hesitancy, diminished stream, sense of incomplete bladder emptying, straining, postvoid dribbling, leakage with cough or sneeze, incontinence), irritative symptoms (urgency, frequency, nocturia), constitutional symptoms; bone pain; medications; history of UTIs, urethral stricture, or urinary tract instrumentation; stones, diabetes, alcoholism.

Erectile Dysfunction Key History

Duration, severity, +/- nocturnal erections, libido, stress or depression, trauma, associated incontinence; gynecomastia or loss of body hair; medications (and recent changes); medical history (hypertension, diabetes, high cholesterol, known atherosclerotic vascular disease, prior prostate surgery, liver disease, thyroid disease, neurologic disease); smoking, alcohol, and drug use

Dyspareunia Key Hx

Duration, timing; associated symptoms (vaginal discharge, rash, painful menses, GI symptoms, hot flashes); adequacy of lubrication, menopausal status, libido; sexual history, history of sexual trauma or domestic violence; history of endometriosis, pelvic inflammatory disease, or prior abdominal/pelvic surgeries.

Fatigue and Sleepiness 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.

Erectile Dysfunction Ddx

ED secondary to Drugs HTN DM Psychogenic ED Peyronie's Disease

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

Endometrial cancer Cervical cancer atrophic endometrium endometrial hyperplasia endometrial polyps atrophic vaginitis pelvic exam pap smear endometrial bx endometrial cutterage U/S pelvis colonoscopy hysteroscopy

Abuse Key History

Establish confidentiality; 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

Constipation/Diarrhea Key History

Frequency, color, odor, and volume of stools; presence of mucus or flatulence; whether stools float in bowl; duration of change in bowel habits; associated symptoms (constitutional, abdominal pain, bloating, tenesmus, sense of incomplete evacuation, melena or hematochezia); thyroid disease symptoms (eg, feeling hot, palpitations, weight loss); 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.

Palpitations (W/U)

Glucose, ECG, CBC, electrolytes, TSH and free T4, Holter monitor, urine toxicology, echocardiography

Palpitations Key History

Gradual vs. acute onset/offset, context (exertion, caffeine, anxiety); associated symptoms (lightheadedness, loss of consciousness, chest pain, dyspnea, fever, sweating, pale skin, flushing, diarrhea); hyperthyroid symptoms; history of bleeding or anemia; history of heart disease, hypertension, or diabetes.

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

Hip dislocation - traumatic Hip fracture XR hip CT or MRI of hip CBC, T/X PT/PTT urine tox and blood alcohol level

Palpitations DDx

Hypoglycemia, AFIB, Hyperthyroidism, GAD, Panic disorder, Cardiac arrhythmias, angina, pheochromocytoma, carcinoid, acute stress disorder, agoraphobia, substance abuse/dependence, Mitral valve prolapse, specific phobia (social), anxious avoidant personality disorder