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Step 2 CS - Mini Cases

Terms in this set (180)

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)
Differential:
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
34 yo F nurse presents with worsening cough of 6 weeks' duration accompanied by weight loss, fatigue, night sweats, and fever. She has a history of contact with tuberculosis at work.
Differential:
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
55 yo F c/o dizziness for the past day. She feels faint and has severe diarrhea that started 2 days ago. She takes furosemide for hypertension. On examination, she feels dizzy upon standing.
Differential:
Orthostatic hypotension due to dehydration (diarrhea, diuretic use)
Vertebrobasilar insufficiency
Cardiac arrhythmias
Vestibular neuronitis
Labyrinthitis
Benign positional vertigo

Workup:
Orthostatic vital signs
Rectal exam
CBC
Urea, electrolytes
Stool for occult blood
Stool leukocytes
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 history includes a coronary artery bypass graft.
Differential:
Cardiac arrhythmia (causing syncope)
Severe aortic stenosis
Syncope (other causes)
Seizure
Pulmonary embolism

Workup:
ECG
Holter monitoring
CBC
Electrolytes, glucose
Echocardiography
CT—head
12 yo F presents with a 2-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.
Differential:
Adjustment disorder
Substance intoxication, abuse, or dependence
Oppositional defiant disorder
Conduct disorder
Manic episode

Workup:
Physical exam
Mental status exam
Urine toxicology
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 episodes usually occur immediately after breastfeeding. She has stopped gaining weight.
Differential:
Pyloric stenosis
Partial duodenal atresia
GERD
Gastroenteritis
Hepatitis
UTI

Workup:
CBC
Electrolytes
U/S—abdomen
Barium swallow
Esophageal pH probe
Endoscopy
LFTs, alkaline phosphatase
UA, urine culture
12-month-old M presents with fever for the past 2 days accompanied by a maculopapular rash on his face and body. He has not yet received the MMR vaccine.
Differential:
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
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.
Differential:
Constitutional short stature
Growth hormone (GH) deficiency
Hypothyroidism
Chronic renal insufficiency
Genetic causes

Workup:
CBC with differentials
Electrolytes
GH stimulation test
IGF-1, IGFBP-3 levels
TSH, FT4
XR—hand
U/S—renal and cardiac
BUN/Cr
15 yo M presents with a 1-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.
Differential:
Substance abuse
Conduct disorder
Oppositional defiant disorder
Adjustment disorder

Workup:
Urine toxicology
Physical exam
Mental status exam
17 yo F presents with prolonged, excessive menstrual bleeding occurring irregularly within the past 6 months.
Differential:
Dysfunctional uterine bleeding
Coagulation disorder (eg, von Willebrand's disease, hemophilia)
Cervical cancer
Molar pregnancy
Hypothyroidism

Workup:
Pelvic exam
Pap smear
CBC
PT/PTT
Urine hCG
Cervical culture
ESR
LH/FSH, TSH, prolactin
U/S—pelvis
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.
Differential:
Malingering
Lumbar muscle strain
Disk herniation
Knee or leg fracture
Ankylosing spondylitis

Workup:
XR—L-spine/knee
MRI—L-spine
ESR, CRP
18 yo F presents with amenorrhea for the past 4 months. BMI is 14.5kg/m2. She attends vigorous exercises classes frequently and has a history of heat intolerance.
Differential:
Anorexia nervosa
Pregnancy
Hyperthyroidism

Workup:
Urine hCG
CBC
Electrolytes
TSH, FT4
LH/FSH
18 yo M boxer presents with severe LUQ abdominal pain that radiates to the left scapula. He had infectious mononucleosis 3 weeks ago.
Differential:
Splenic rupture
Kidney stone
Rib fracture
Pneumonia
Perforated peptic ulcer
Splenic infarct

Workup:
CBC
Electrolytes
CXR
CT—abdomen
U/S—abdomen (if hemodynamically unstable)
18 yo M presents with a burning sensation during urination and urethral discharge. He recently had unprotected sex with a new partner.
Differential:
Urethritis
Cystitis
Prostatitis

Workup:
NAAT urine for chlamydia and gonorrhea screening
RPR
HIV
UA, urine culture
Gram stain and culture of urethral discharge
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.
Differential:
Psoriatic arthritis
Rheumatoid arthritis
SLE
Gout

Workup:
ESR, CRP, RF, anti-CCP, ANA
CBC
XR—hands
XR—pelvis/sacroiliac joints
Uric acid
18 yo obese F presents with a daily pulsatile headache, vomiting, and blurred vision for the past 2-3 weeks. She is taking OCPs.
Differential:
Pseudotumor cerebri
Migraine
Tension headache
Intracranial venous thrombosis
Intracranial neoplasm
Cluster headache
Meningitis

Workup:
Urine hCG
LP—opening pressure and CSF analysis
Dilated fundoscopy examination
MRI-brain
Visual Field Testing
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 or weeks before an upcoming social situation. Now she avoids all social events because she is afraid of humiliating herself.
Differential:
Social phobia
Avoidant personality disorder
Agoraphobia/specific phobia
Panic attack
Generalized anxiety disorder
Substance abuse/ dependence
Hyperthyroidism

Workup:
CBC
Electrolytes
ECG
TSH, FT4
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. 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."
Differential:
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
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.
Differential:
Colic
Formula allergy
GERD
Lactose intolerance
Strangulated hernia
Testicular torsion
Gastroenteritis

Workup:
Rectal exam, stool for
occult blood
U/S—abdomen
U/S—testicular
20 yo African American F presents with acute onset of severe chest pain for a few hours. She has a history of sickle cell disease and multiple hospitalizations for pain and anemia management.
Differential:
Sickle cell disease—acute chest syndrome
Pulmonary embolism
Pneumonia
MI
Pneumothorax
Aortic dissection

Workup:
CBC with reticulocyte count and peripheral smear
LDH
ABG
D-dimer
CXR
CPK-MB, troponin
ECG
CTA—chest with IV contrast
20 yo F presents with nausea, vomiting (especially in the morning), fatigue, and polyuria. Her last menstrual period was 6 weeks ago, and her breasts are full and tender. She is sexually active with her boyfriend, and they occasionally use condoms for contraception.
Differential:
Pregnancy
Hypercalcemia
Diabetes mellitus
Gastritis/GERD
UTI
Depression/eating disorder
Substance use (eg. alcohol)

Workup:
Urine hCG
Pelvic exam
U/S—transvaginal
CBC
Electrolytes, calcium, glucose, LFTs
UA, urine culture
20 yo M presents with fatigue, thirst, increased appetite, and polyuria.
Differential:
Diabetes mellitus
Atypical depression
Primary polydipsia
Diabetes insipidus

Workup:
HbA1c
Glucose tolerance test
UA
CBC
Electrolytes, BUN/Cr,
fasting glucose
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.
Differential:
Acute appendicitis
Gastroenteritis
Diverticulitis
Crohn's disease
Nephrolithiasis
Volvulus or other intestinal obstruction
Perforation
Acute cholecystitis

Workup:
CBC
Electrolytes
CT—abdomen
AXR
U/S—abdomen
Blood culture
20-day-old M presents with fever, decreased breastfeeding, and lethargy. He was born at 36 weeks as a result of premature rupture of membranes.
Differential:
Neonatal sepsis
Meningitis
Pneumonia
Pyelonephritis

Workup:
CBC
Electrolytes
Blood culture
LP—CSF analysis
CXR
UA, urine culture
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. She has been told that she had a cyst on her right ovary.
Differential:
Ovarian torsion
Appendicitis
Nephrolithiasis
Ectopic pregnancy
Ruptured ovarian cyst
Pelvic inflammatory disease
Bowel infarction or perforation

Workup:
Pelvic exam
Urine hCG
Doppler U/S—pelvis/tranvaginal
Rectal exam
UA
CBC
CT—abdomen
Laparoscopy
Chlamydia and gonorrhea testing, VDRL/RPR
21 yo F presents with several episodes of throbbing left temporal pain that last for 2-3 hours. Before 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. Her headaches are often associated with nausea and vomiting and she feels bothered by light. She has a family history of migraine.
Differentials:
hemiplegic migraine (migraine with motor aura)
Tension headache
Cluster headache
TIA
Partial seizures
Pseudotumor cerebri
CNS vasculitis
Focal seizure (occipito-parietal)
Intracranial neoplasm

Workup:
MRI-brain
CT-head
CBC
ESR
23 yo obese F presents with amenorrhea for 6 months, facial hair, and infertility for the past 3 years.
Differential:
Polycystic ovary syndrome
Thyroid disease
Hyperprolactinemia
Pregnancy
Ovarian or adrenal malignancy
Premature ovarian failure

Workup:
Pelvic exam
Urine hCG
Transabdominal and transvaginal US
LH/FSH, TSH, prolactin
Testosterone, DHEAS
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.
Differential:
Pelvic inflammatory disease
Endometriosis
Dysmenorrhea
Vaginitis
Cystitis
Spontaneous abortion
Pyelonephritis

Workup:
Pelvic exam
Urine hCG
Cervical cultures
CBC
ESR
UA, urine culture
U/S—pelvis
25 yo F presents with 2 weeks of nonproductive cough. Three weeks ago, she had a sore throat and a runny nose.
Differential:
Atypical pneumonia
Asthma
URI-associated cough ("postinfectious")
Postnasal drip
GERD

Workup:
CBC
Induced sputum Gram stain and culture
CXR
IgM detection for Mycoplasma pneumoniae
Urine Legionella antigen
25 yo F presents with a 3-week history 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 a day.
Differential:
Stress-induced insomnia
Caffeine-induced insomnia
Insomnia with circadian rhythm sleep disorder
Insomnia related to major depressive disorder

Workup:
Polysomnography
Urine toxicology
CBC
TSH
25 yo M presents with hemiparesis after a tonic-clonic seizure that resolved within a few hours.
Differential:
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 army recruit presents with high fever, severe headache, confusion, photophobia, and nuchal rigidity
Differential:
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
25 yo M presents with RUQ pain, fever, anorexia, nausea, and vomiting. He has dark urine and clay-colored stool.
Differential:
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
ERCP
MRCP
25 yo M presents with watery diarrhea and abdominal cramps. He was recently in Mexico.
Differential:
Traveler's diarrhea
Giardiasis
Amebiasis
Food poisoning
Hepatitis A

Workup:
Rectal exam
Stool leukocytes, culture, Giardia antigen, Entamoeba histolytica antigen
CBC
CMP
Viral hepatitis serologies
26 yo F presents with a 6.5-lb (2.9-kg) weight loss in the past 2 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 6 months before her presentation.
Differential:
Bipolar I disorder
Bipolar II disorder
Cyclothymic disorder
Major depressive disorder
Schizoaffective disorder

Workup:
Mood Disorder Questionnaire
Urine toxicology
TSH
CBC
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.
Differential:
Infectious mononucleosis
Hepatitis
Viral or bacterial pharyngitis
Acute HIV infection
Secondary syphilis

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
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.
Differentials:
Cluster headache
Migraine
Trigeminal neuralgia
Intracranial neoplasm
Tension Headache

Workup:
MRI—brain
CT—head
CBC
ESR
26 yo M presents with sore throat, fever, rash, and weight loss. He has a history of IV drug abuse and sharing needles.
Differential:
HIV, acute retroviral syndrome
Infectious mononucleosis
Hepatitis
Viral pharyngitis
Streptococcal tonsillitis/scarlet fever
Secondary syphilis

Workup:
CBC with differential and peripheral smear
Throat culture
HIV antibody and viral load
CD4 count
Monospot test
LFTs
VDRL/RPR
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.
Differential:
Disseminated gonorrhea
Rheumatoid arthritis
SLE
Reiter's syndrome (reactive arthritis)

Workup:
Knee arthrocentesis and synovial fluid analysis (cell count, Gram stain, culture)
Blood, cervical cultures
RF, anti-CCP, ESR
ANA, anti-dsDNA, CBC
XR—knee
28 yo F c/o multiple facial and bodily injuries. She claims that she fell on the stairs. She was hospitalized for physical injuries 7 months ago. She presents with her husband.
Differential:
Domestic violence
Osteogenesis imperfecta
Substance abuse

Workup:
XR—skeletal survey
CT—maxillofacial
Urine toxicology
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.
Differential:
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 a thin, grayish-white, foul-smelling vaginal discharge.
Differential:
Bacterial vaginosis
Vaginitis—candidal
Vaginitis—trichomonal
Cervicitis (chlamydia, gonorrhea)

Workup:
Pelvic exam
Wet mount, KOH prep, "whiff test"
pH of vaginal fluid
Cervical cultures
28 yo F presents with pain in the interphalangeal joints of her hands accompanied by hair loss and a rash on her face.
Differential:
Systemic lupus erythematosus (SLE)
Rheumatoid arthritis
Psoriatic arthritis
Parvovirus B19 infection

Workup:
ANA, anti-dsDNA, anti-Sm, C3, C4, antiphospholipid antibodies
RF, anti-CCP
ESR, CRP
CBC
XR—hands
UA, urine sediment
Antibody titers for parvovirus B19
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.
Differential:
Rheumatoid arthritis
SLE
Disseminated gonorrhea
Arthritis associated with inflammatory bowel disease

Workup:
XR—hands, left knee
ANA, anti-dsDNA, ESR, RF, anti-CCP
CBC
Cervical culture
Arthrocentesis and synovial fluid analysis
28 yo F who is 8 weeks pregnant presents with lower abdominal pain and vaginal bleeding.
Differential:
Spontaneous abortion
Ectopic pregnancy
Molar pregnancy

Workup:
Urine hCG
Pelvic exam
Quantitative serum hCG
U/S—abdomen/pelvis
CBC
PT/PTT
28 yo M presents with constipation for the past 3 weeks. Since his mother died 2 months ago, he and his father have eaten only junk food.
Differential:
Constipation d/t low-fiber diet
Depression
Substance abuse (eg, heroin)
Irritable bowel syndrome
Hypothyroidism

Workup:
Rectal exam
TSH, free T4
BMP
Urine toxicology
29 yo F presents with amenorrhea for the past 6 months. She has a history of occasional palpitations and dizziness. She lost her fiancé in a car accident in which she was a passenger.
Differential:
Anxiety-induced amenorrhea
Pregnancy
Posttraumatic stress disorder
Depression
Hyperthyroidism

Workup:
Urine hCG
CBC
TSH, FT4
Urine cortisol level
Progesterone challenge test
LH/FSH, estradiol levels
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.
Differential:
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
3 yo M presents with a 2-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.
Differential:
Acute otitis media
URI
Meningitis
Pyelonephritis

Workup:
CBC, Blood culture
LP—CSF analysis
UA, urine culture
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.
Differential:
Hirschsprung's disease
Low-fiber diet
Anal stenosis
Hypothyroidism
Lead poisoning

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
30 yo F presents with a thick, white, cottage cheese- like, odorless vaginal discharge and vaginal itching.
Differential:
Vaginitis—candidal
Bacterial vaginosis
Vaginitis—trichomonal

Workup:
Pelvic exam
Wet mount, KOH prep, "whiff test"
pH of vaginal fluid
Cervical cultures
30 yo F presents with alternating constipation and diarrhea accompanied by abdominal pain that is relieved by defecation. She has no nausea, vomiting, weight loss, or blood in her stool.
Differential:
Irritable bowel syndrome
Inflammatory bowel disease
Celiac disease
Chronic pancreatitis
GI parasitic infection (ascariasis, giardiasis)
Lactose intolerance

Workup:
Rectal exam, stool for occult blood
CBC with diff
CMP
Colonoscopy
tTG antibody test
Stool for ova and parasitology
CT—abdomen/pelvis
Hydrogen breath test
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.
Differentials:
Acute Sinusitis
Migraine
Tension headache
Cerebral abscess
Meningitis
Intracranial neoplasm

Workup:
CBC
XR—sinus
CT—sinus
30 yo F presents with multiple facial and physical injuries. She states that she was attacked and raped by 2 men.
Differential:
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
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.
Differential:
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
Colonoscopy
CT—abdomen/pelvis
Stool for ova and parasitology, Entamoeba histolytica antigen
30 yo F presents with watery diarrhea, abdominal cramping, and bloating. Her symptoms are aggravated by milk ingestion and are relieved by fasting.
Differential:
Lactose intolerance
Gastroenteritis
Inflammatory bowel disease
Irritable bowel syndrome
Hyperthyroidism

Workup:
Rectal exam
Stool leukocytes and culture
Hydrogen breath test
TSH
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 with reduced vision that resolved transiently 3 months. She reports feeling "electric shocks" down her spine upon flexing her head. Examination reveals left lower limb weakness and ataxia.
Differential:
Multiple sclerosis
Stroke
CNS vasculitis
Conversion disorder
Malingering
CNS tumor
Vitamine B12deficiency
Neurosyphilis

Workup:
CBC
ESR
ANA, ANCA
VDRL/RPR
MRI—brain, spine
LP—CSF analysis
Visual evoked potentials
30 yo F presents with weight gain over the past 3 months. She also reports tremor, palpitations, anxiety, and hunger that is relieved by eating. She exhibits proximal muscle weakness and easy bruising.
Differential:
Insulinoma
Reactive postprandial hypoglycemia
Cushing's syndrome
Pregnancy

Workup:
Blood glucose
Plasma insulin after induced hypoglycemia
Glucose tolerance test
24-hour urine free cortisol
Urine Beta-HCG
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.
Differential:
Domestic violence
Factitious disorder
Substance abuse

Workup:
XR—wrist
CT—head
Urine toxicology
30 yo F secretary presents with wrist pain and a sensation of numbness and burning in her palm and the 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.
Differential:
Carpal tunnel syndrome
Median nerve compression in the forearm or arm
Radiculopathy of nerve roots C6 and C7 in the cervical spine
De Quervain's tenosynovitis

Workup:
Nerve conduction studies
EMG
U/S - wrist
MRI - spine
30 yo M presents with night sweats, cough, and swollen glands of 1 month's duration. He recently emigrated from the African subcontinent.
Differential:
Tuberculosis
Acute HIV infection
Lymphoma
Leukemia
Hyperthyroidism

Workup:
PPD/QuantiFERON Gold
CBC
CXR
Sputum Gram stain, acid-fast stain, and culture
HIV antibody/RNA levels
TSH, FT4
CT- chest
30 yo M presents with shortness of breath, cough, and wheezing that worsen in cold air. He has had several such episodes in the past 4 months.
Differential:
Asthma
GERD
Bronchitis
Pneumonitis

Workup:
CBC
CXR
Peak flow measurement
PFTs
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 history of pelvic inflammatory disease and unprotected intercourse.
Differential:
Ectopic pregnancy
Ruptured ovarian cyst
Ovarian torsion
Pelvic inflammatory disease

Workup:
Urine hCG
Quantitative serum hCG
U/S—abdomen/pelvis
Cervical cultures
33 yo F c/o 3 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 8 lbs (3.6 kg) and an inability to enjoy the things she once liked to do.
Differential:
Insomnia related to major depressive disorder
Primary hypersomnia
Insomnia with circadian rhythm sleep disorder

Workup:
TSH
CBC
Polysomnography
33 yo F presents with rectal bleeding and diarrhea for the past week. She has had lower abdominal pain and tenesmus for several months.
Differential:
Ulcerative colitis
Crohn's disease
Hemorrhoids
Anal fissure
Proctitis
Diverticulosis
Dysentery

Workup:
Colonoscopy
Rectal exam with stool guaiac testing
CT-abdomen/pelvis
CBC, CMP
PT/PTT
33 yo F presents with ascending loss of strength in her lower legs over the past 2 weeks. She had a recent URI. Examination shows weakness of her lower limbs with reduced reflexes.
Differential:
Guillain-Barré syndrome
Multiple sclerosis
Transverse myelitis
Spinal cord compression
Peripheral neuropathy

Workup:
CBC
Electrolytes
MRI - spine
CPK
Electromyography
Nerve conduction studies
LP—CSF analysis
PFTs
Serum B12
33 yo F presents with stabbing chest pain that worsens with deep inspiration and is relieved by aspirin. She had a URI 1 week ago. Chest wall tenderness is noted.
Differential:
Costochondritis
Pneumonia
MI
Pulmonary embolism
Pericarditis
Pleurisy
Muscle strain

Workup:
ECG
CXR
CPK-MB, troponin
CBC
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 history of UTIs and a family history of diabetes mellitus. She drinks 8 cups of coffee per day. She has been under stress since her sister passed away a few months ago.
Differential:
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
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.
Differential:
Infectious diarrhea (gastroenteritis)— bacterial, viral, parasitic, protozoal
Food poisoning

Workup:
Rectal exam, stool for occult blood
Stool leukocytes and culture
CBC
BMP
CT—abdomen/pelvis
34 yo F presents with episodic palpitations accompanied by lightheadedness and sharp, atypical chest pain.
Differential:
Mitral valve prolapse
Cardiac arrhythmia
Panic attack
Pheochromocytoma

Workup:
ECG
TEE
Event monitor
Holter monitor
24-hour urinary 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.
Differential:
Pericarditis
Aortic dissection
MI
Costochondritis
GERD
Esophageal rupture

Workup:
ECG
CPK-MB, troponin
CXR
Echocardiography
CBC
Upper endoscopy
ESR
35 yo F presents with a malodorous, profuse, frothy, greenish vaginal discharge with intense vaginal itching and discomfort.
Differential:
Vaginitis—trichomonal
Vaginitis—candidal
Bacterial vaginosis
Cervicitis (chlamydia, gonorrhea)

Workup:
Pelvic exam
Wet mount, KOH prep, "whiff test"
pH of vaginal fluid
Cervical cultures
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 2 years ago.
Differential:
Pituitary infarction (Sheehan's syndrome)
Premature ovarian failure
Pituitary tumor
Thyroid disease
Asherman's syndrome

Workup:
ACTH
Pelvic exam
Urine hCG
LH/FSH, prolactin
CBC
TSH, FT4
MRI—brain
Hysteroscopy
35 yo F presents with amenorrhea, galactorrhea, visual field defects, and headaches for the past 6 months.
Differential:
Amenorrhea secondary to prolactinoma
Pregnancy
Thyroid disease
Premature ovarian failure
Pituitary tumor

Workup:
Pelvic and breast exams
Urine hCG
LH/FSH, TSH, prolactin
MRI—brain
35 yo F presents with intermittent episodes of vertigo, tinnitus, nausea, and hearing loss within the past week. Examination is normal.
Differential:
Ménière's disease
Benign positional vertigo
Labyrinthitis
Vestibular neuronitis
Acoustic neuroma

Workup:
Dix-Hallpike maneuver
Audiometry
Electronystagmography
CBC
VDRL/RPR (syphilis is a cause of Ménière's disease)
MRI—brain
35 yo M policeman c/o feeling tired and sleepy during the day. He changed to the night shift last week.
Differential:
Shift work sleep disorder
Sleep apnea
Depression
Anemia

Workup:
CBC
Nocturnal pulse oximetry
Polysomnography
35 yo M presents with burning epigastric pain that starts 2-3 hours after meals. The pain is relieved by food and antacids.
Differential:
Peptic ulcer disease
Gastritis
GERD
Cholecystitis
Chronic pancreatitis
Mesenteric ischemia

Workup:
Rectal exam, stool for occult blood
Amylase, lipase, lactate
AST/ALT/bilirubin/alkaline phosphatase
Upper endoscopy (including H pylori testing)
Upper GI series
35 yo M presents with painless hematuria. He has a family history of kidney disease.
Differential:
Polycystic kidney disease
Nephrolithiasis
UTI
Acute glomerulonephritis (eg, IgA nephropathy)
Coagulation disorder
Bladder cancer

Workup:
U/S - renal
CT - abdomen/pelvis
UA, urine cytology
CBC, CMP
PT/PTT
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 history of psychiatric illness except for separation anxiety as a child.
Differential:
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 urinary catecholamines
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.
Differential:
Tuberculosis
Pneumonia (including Pneumocystis jiroveci)
Bronchitis
Asthma
Acute HIV infection
CHF (cardiomyopathy)

Workup:
CBC
PPD/QuantiFERON-TB Gold
Sputum Gram stain, acid-fast stain, silver stain, and culture
CXR
HIV antibody
Echocardiography
35 yo M presents with sudden severe headache, vomiting, confusion, left hemiplegia, and nuchal rigidity.
Differential:
Subarachnoid hemorrhage
Meningitis/encephalitis
Intracranial hemorrhage
Vertebral artery dissection
Intracranial venous thrombosis
Migraine
Hypertensive encephalopathy
Intracranial neoplasm

Workup:
Noncontrast CT—head
LP—opening pressure and CSF analysis
CBC
PT/PTT/INR
Urine toxicology
Digital subtraction angiography (DSA)
MRI- brain
CT-angiography
37 yo F presents with dyspareunia, dysmenorrhea, and infertility for the past 2 years.
Differential:
Endometriosis
Cervicitis
Vaginismus
Vulvodynia
Pelvic inflammatory disease
Depression

Workup:
Pelvic exam
Wet mount, KOH prep
Cervical cultures
U/S—pelvis
Laparoscopy
Endometrial biopsy
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 daily basis.
Differential:
Perforated peptic ulcer
Acute pancreatitis
Hepatitis
Cholecystitis
Gallstone cholangitis
Mesenteric ischemia

Workup:
Rectal exam
CBC
Electrolytes
Amylase, lipase, lactate
AST/ALT/bilirubin/alkaline phosphatase
CXR
KUB
CT—abdomen
Upper endoscopy (including H pylori testing)
Blood culture
38 yo M presents with dysphagia and pain on swallowing solids more than liquids. Exam reveals oral thrush.
Differential:
Esophagitis (CMV, HSV, HIV, pill-induced)
Systemic sclerosis
GERD
Esophageal stricture

Workup:
CBC
Upper endoscopy
Barium swallow
HIV antibody and viral load
CD4 count
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.
Differential:
Hodgkin's/non-Hodgkin's lymphoma
Tuberculosis
HIV
Thyroid nodule
Metastatic GI or head and neck malignancy

Workup:
CBC with differential
BMP
ESR, CRP
Lymph node biopsy
PPD/QuantiFERON-TB Gold
CXR
TSH
HIV antibody/RNA
U/S—neck
Upper endoscopy
Fine needle aspiration
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.
Differential:
Gastroenteritis (viral, bacterial, parasitic)
Food poisoning
UTI
URI
Intussusception
Volvulus

Workup:
Stool exam and culture
CBC
Electrolytes
UA, urine culture
Abdominal x-ray
40 yo F c/o feeling tired, hopeless, and worthless and of having suicidal thoughts. She lost her job and has been having fights with her husband about money.
Differential:
Depression
Adjustment disorder
Hypothyroidism
Anemia

Workup:
PHQ-9
Beck Depression Inventory
TSH
CBC
40 yo F presents with amenorrhea, morning nausea and vomiting, fatigue, and polyuria. Her last menstrual period was 6 weeks ago. Her breasts are full and tender. She uses the rhythm method for contraception.
Differential:
Pregnancy
Anovulatory cycle
Hyperprolactinemia
UTI
Hypothyroidism

Workup:
Urine hCG
Pelvic exam
U/S—transvaginal
CBC
UA, urine culture
Prolactin, TSH
Baseline Pap smear, cervical cultures, rubella antibody, HIV antibody, hepatitis B surface antigen, VDRL/RPR
40 yo F presents with epigastric pain and coffeeground emesis. She has a history of rheumatoid arthritis that has been treated with NSAIDs. She is an alcoholic.
Differential:
Gastritis
Bleeding peptic ulcer
Mallory-Weiss tear
Esophageal varices
Gastric cancer

Workup:
Upper endoscopy (including H pylori testing if ulcer is confirmed)
CBC, type and cross
CMP
AST/ALT/bilirubin/alkaline phosphatase
INR
Stool guaiac testing
40 yo F presents with fatigue, weight gain, sleepiness, cold intolerance, constipation, and dry skin.
Differential:
Hypothyroidism
Depression
Diabetes
Anemia

Workup:
TSH, FT3, FT4
CBC
Fasting glucose
HbA1c
40 yo F presents with occasional double vision and droopy eyelids at night with normalization by morning. Her past medical history is significant for hypothyroidism.
Differential:
Myasthenia gravis
Multiple sclerosis
Intracranial neoplasm compressing CN III, IV, or VI
Horner syndrome
Botulism

Workup:
Ice pack test
Tension (edrophonium) test
Anti-ACh receptor antibodies
Electromyography
Nerve conduction studies
CXR
CT-chest
MRI-brain
40 yo F presents with watery diarrhea and abdominal cramps. Last week she was on antibiotics for a UTI.
Differential:
Pseudomembranous (Clostridium difficile) colitis
Gastroenteritis
Cryptosporidiosis
Food poisoning
Inflammatory bowel disease

Workup:
Stool for C difficile toxin
Rectal exam, stool for occult blood
Stool leukocytes and culture
CBC
CMP
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.
Differential:
Intestinal obstruction
Small bowel or colon cancer
Volvulus
Gastroenteritis
Food poisoning
Ileus
Hernia

Workup:
Rectal exam
CBC
Electrolytes
AXR
CT—abdomen/pelvis with contrast
Colonoscopy
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.
Differential:
Hip dislocation—traumatic
Hip fracture

Workup:
XR—hip
CT or MRI—hip
CBC, type and cross
PT/PTT
Urine toxicology and blood alcohol level
U/S- abdomen (FAST exam)
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 ate fatty food. She has had similar but less intense episodes that lasted a few hours. Exam reveals a positive Murphy's sign.
Differential:
Acute cholecystitis
Choledocholithiasis
Hepatitis
Ascending cholangitis
Peptic ulcer disease
Fitz-Hugh-Curtis syndrome
Acute subhepatic appendicitis

Workup:
CBC
AST/ALT/bilirubin/alkaline phosphatase
U/S—abdomen
CT—abdomen
Blood culture
42 yo F presents with a 15.5-lb (7-kg) weight loss within the past 2 months. She has a fine tremor, and her pulse is 112.
Differential:
Hyperthyroidism
Cancer
HIV infection
Dieting/diet drugs
Anorexia nervosa
Malabsorption

Workup:
TSH, FT4
CBC
BMP
HIV antibody
Urine toxicology
Age-appropriate cancer screenings
42 yo F presents with a 4-week history of excessive fatigue, insomnia, and anhedonia. She states that she thinks constantly about death. She has suffered 5 similar episodes in the past, the first in her 20s, and has made 2 previous suicide attempts. She further admits to increased alcohol use in the past month.
Differential:
Major depressive disorder
Substance-induced mood disorder
Persistent depressive disorder (dysthymia)

Workup:
Beck Depression Inventory
PHQ-9
QIDS-SR16
Blood alcohol level
TSH
CBC
Urine toxicology
43 yo obese F presents with RUQ abdominal pain, fever, and jaundice. She was diagnosed with asymptomatic gallstones 1 year ago. She is found to be hypotensive on exam.
Differential:
Ascending cholangitis
Acute gallstone cholangitis
Acute cholecystitis
Hepatitis
Primary Sclerosing cholangitis
Fitz-Hugh-Curtis syndrome

Workup:
CBC
AST/ALT/bilirubin/alkaline phosphatase
Blood culture
Viral hepatitis serologies
U/S—abdomen
MRCP
ERCP
44 yo F c/o dizziness on moving her head to the left. She feels that the room is spinning around her head. Dix-Hallpike maneuver reproduces the symptoms and elicits nystagmus.
Differential:
Benign positional vertigo
Ménière's disease
Vestibular neuronitis
Labyrinthitis
Acoustic neuroma

Workup:
Audiometry
Electronystagmograph
MRI—brain
44 yo F presents with a weight gain of > 25 lbs (11.3 kg) within the past 2 months. She quit smoking 3 months ago and is on amitriptyline for depression. She also reports cold intolerance and constipation.
Differential:
Smoking cessation
Drug side effect
Hypothyroidism
Cushing's syndrome
Polycystic ovary syndrome
Diabetes mellitus
Atypical depression

Workup:
CBC
BMP, glucose
TSH
24-hour urine free cortisol
Dexamethasone suppression test
44 yo M presents with fatigue, insomnia, and nightmares about a murder that he witnessed in a mall 1 year ago. Since then, he has avoided the mall and has not gone out at night.
Differential:
Posttraumatic stress disorder
Depression
Generalized anxiety disorder
Psychotic or delusional disorder
Hypothyroidism

Workup:
PHQ-9
Beck Depression Inventory
CBC
TSH
Urine toxicology
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.
Differential:
Acute pyelonephritis
Lower UTI (cystitis, urethritis)
Nephrolithiasis
Renal cell carcinoma

Workup:
UA, urine culture and sensitivity
Blood cultures
U/S—renal
CT—abdomen
45 yo F presents with a retrosternal burning sensation that occurs after heavy meals and when lying down. Her symptoms are relieved by antacids.
Differential:
GERD
Esophagitis
Peptic ulcer disease
Esophageal spasm
MI
Angina

Workup:
ECG
Barium swallow
Upper endoscopy
Esophageal pH monitoring
H pylori stool antigen
45 yo F presents with coffee-ground emesis for the past 3 days. Her stool is dark and tarry. She has a history of intermittent epigastric pain that is relieved by food and antacids.
Differential:
Bleeding peptic ulcer
Gastritis
Gastric cancer
Esophageal varices

Workup:
Upper endoscopy (including H pylori testing if ulcer is confirmed)
CBC, type and cross
CMP
AST/ALT/bilirubin/alkaline phosphatase
INR
Rectal exam, stool guaiac testing
45 yo F presents with dysphagia for 2 weeks accompanied by mouth and throat pain, fatigue, and a craving for ice and clay.
Differential:
Plummer-Vinson syndrome
Esophageal cancer
Diffuse esophageal spasm
Esophagitis
Achalasia
Systemic sclerosis

Workup:
CBC
Serum iron, ferritin, TIBC
Barium swallow
Upper endoscopy
Esophageal manometry
45 yo F presents with excessive sweating, unintentional weight loss, palpitations, diarrhea, and shortness of breath.
Differential:
Hyperthyroidism
Pheochromocytoma
Carcinoid syndrome
Tuberculosis

Workup:
TSH, FT4
24-hour urinary catecholamines
5-HIAA
CBC
PPD
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.
Differential:
Disk herniation
Lumbar muscle strain
Tumor in the vertebral canal

Workup:
XR—L-spine
MRI—L-spine
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.
Differential:
Lumbar muscle strain
Disk herniation
Vertebral compression fracture

Workup:
XR—L-spine
MRI—L-spine
45 yo F presents with right calf pain. Her calf is tender, warm, red, and swollen compared to the left side. She was started on OCPs 2 months ago for dysfunctional uterine bleeding.
Differential:
DVT
Baker's cyst rupture
Myositis
Cellulitis
Superficial venous thrombosis

Workup:
Doppler U/S—right leg
CBC
CPK
D-dimer
45 yo G5P5 F presents with postcoital bleeding. She is a cigarette smoker and takes OCPs.
Differential:
Cervical cancer
Endometrial cancer
Cervical polyp
Cervicitis
Trauma (eg, cervical laceration)

Workup:
Pelvic exam
Pap smear
Colposcopy and biopsy
HPV testing
Endometrial biopsy
45 yo M presents with fevers and right knee pain with swelling and redness.
Differential:
Septic arthritis
Gout
Pseudogout
Lyme arthritis
Trauma
Reiter's 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
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).
Differential:
Lumbar spinal stenosis
Lumbar muscle strain
Tumor in the vertebral canal
Peripheral vascular disease

Workup:
MRI—L-spine (preferred)
XR—L-spine
CT—L-spine
Ankle-brachial index
45 yo M presents with sudden onset of colicky rightsided flank pain that radiates to the testicles, accompanied by nausea, vomiting, hematuria, and CVA tenderness.
Differential:
Nephrolithiasis
Renal cell carcinoma
Pyelonephritis
GI etiology (eg, appendicitis)

Workup:
UA, urine culture and sensitivity, urine cytology
BUN/Cr
CT—abdomen
U/S—renal
KUB
IVP
Blood culture
46 yo F presents with fever and sore throat.
Differential:
Pharyngitis (bacterial or viral)
Mycoplasma pneumonia
Acute HIV infection
Infectious mononucleosis

Workup:
Centor criteria
Throat swab for culture and rapid streptococcal antigen
Monospot test
CBC
Serologic test (cold agglutinin titer) for Mycoplasma
HIV antibody and viral load
47 yo M presents with impotence that started 3 months ago. He has hypertension and was started on atenolol 4 months ago. He also has diabetes and is on insulin.
Differential:
Drug-related Erectile dysfunction (ED)
ED caused by hypertension
ED caused by diabetes mellitus
Psychogenic ED
Peyronie's disease

Workup:
CMP
CBC
Fasting glucose level
TSH
48 yo F presents with a 1-week history of auditory 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.
Differential:
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
48 yo F presents with amenorrhea for the past 6 months accompanied by hot flashes, night sweats, emotional lability, and dyspareunia.
Differential:
Menopause
Pregnancy
Pituitary tumor
Thyroid disease

Workup:
Pelvic exam
Urine hCG
LH/FSH, TSH, prolactin
Testosterone, DHEAS
CBC
MRI—brain
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 (2.5 kg) in the past 2 months.
Differential:
Achalasia
Plummer-Vinson syndrome
Esophageal cancer
Esophagitis
Systemic sclerosis
Esophageal stricture
Zenker's diverticulum

Workup:
CXR
Upper endoscopy
Barium swallow
Esophageal manometry
5 yo M presents with a 6-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.
Differential:
Age-appropriate behavior
ADHD
Oppositional defiant
disorder

Workup:
Physical exam
Mental status exam
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 and recently decreased her intake of caffeine. Neurological examination is normal.
Differential:
Tension headache
Migraine
Caffeine or analgesic withdrawal
Depression
Intracranial neoplasm
Cluster headache
Pseudotumor cerebri

Workup:
CBC
Electrolytes
ESR
MRI-brain
LP—CSF analysis
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.
Differential:
Shoulder dislocation
Fracture of the humerus
Rotator cuff injury

Workup:
XR—shoulder
XR—arm
MRI—shoulder
55 yo obese M presents with several months of poor sleep, daytime fatigue, and morning headaches. His wife reports that he snores loudly.
Differential
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.
Differential:
Obstructive sleep apnea
Hypothyroidism
Chronic fatigue syndrome
Narcolepsy

Workup:
CBC
TSH
Nocturnal pulse oximetry
Polysomnography
ECG
54 yo F c/o painful intercourse. Her last menstrual period was 9 months ago. She has hot flashes.
Differential:
Atrophic vaginitis
Endometriosis
Cervicitis
Domestic violence

Workup:
Pelvic exam
LH/FSH
Wet mount, KOH prep
Cervical cultures
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 2 days ago and has experienced no hearing loss or tinnitus.
Differential:
Vestibular neuronitis
Labyrinthitis
Benign positional vertigo
Ménière's disease
Vertebrobasilar insufficiency/TIA

Workup:
Audiogram
Electronystagmography
CT-head
MRI/MRA—brain
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 2 days ago.
Differential:
Labyrinthitis
Vestibular neuronitis
Ménière's disease
Acoustic neuroma
Vertebrobasilar insufficiency/TIA

Workup:
Audiogram
Electronystagmography
CT-head
MRI/MRA—brain
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 2 minutes.
Differential:
Subdural hematoma
SIADH (causing hyponatremia)
Creutzfeldt-Jakob disease
Intracranial neoplasm
CNS infection (eg, encephalitis)

Workup:
CT—head
CBC
Electrolytes, TSH
MRI—brain
LP—CSF analysis
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 vaginal deliveries, and her mother had the same problem after the onset of menopause.
Differential:
Stress incontinence
Mixed incontinence
Overflow incontinence
Urge incontinence
Functional incontinence
UTI

Workup:
Postvoid residual
Bladder stress test
UA, urine culture
CMP
Cystourethroscopy
Urodynamic testing
55 yo M c/o falling after feeling dizzy and unsteady. He experienced transient loss of consciousness. His past medical history is significant for hypertension and diabetes mellitus.
Differential:
Drug-induced orthostatic hypotension (causing syncope)
Hypoglycemia
Cardiac arrhythmia
Syncope (vasovagal, other causes)
Stroke
MI
Pulmonary embolism

Workup:
Orthostatic vital signs
CBC
Electrolytes, glucose
Echocardiography
CT—head
ECG
V/Q scan
CTA—chest with IV contrast
D-dimer
55 yo M presents with a rapidly progressive change in mental status, inability to concentrate, and memory impairment for the past 2 months. His symptoms are associated with myoclonus, ataxia, and a startle response.
Differential:
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
55 yo M presents with crampy bilateral thigh and calf pain, fatigue, and dark urine. He is on simvastatin and clofibrate for hyperlipidemia.
Differential:
Rhabdomyolysis due to statins
Polymyositis
Inclusion body myositis

Workup:
CPK
CBC
CMP, calcium, phosphate, uric acid
Aldolase
UA
Urine myoglobin
55 yo M presents with fatigue, weight loss, and constipation. He has a family history of colon cancer.
Differential:
Colon cancer
Hypothyroidism
Renal failure
Hypercalcemia
Depression

Workup:
Rectal exam with stool guaiac test
CBC
CMP
TSH
Colonoscopy
Barium enema
CT—abdomen/pelvis
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.
Differential:
Renal cell carcinoma
Pyelonephritis
Acute glomerulonephritis
Bladder cancer
Nephrolithiasis

Workup:
U/S—renal
CT—abdomen/pelvis
Cystoscopy
UA, urine cytology
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.
Differential:
COPD exacerbation (bronchitis)
Lung cancer
Pneumonia
URI
CHF

Workup:
CBC
CXR
ABG
PFTs
Sputum Gram stain and culture
CT—chest
Echocardiography
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.
Differential:
Tennis elbow (lateral epicondylitis)
Stress fracture

Workup:
XR—arm
Bone scan
MRI—elbow
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.
Differential:
Stable angina
Esophageal spasm
Esophagitis

Workup:
ECG
CPK-MB, troponin
CXR
CBC
Electrolytes
Exercise stress test
Upper endoscopy/pH monitor
Cardiac catheterization
55 yo M presents with sudden onset of severe chest pain that radiates to his back. He has a history of uncontrolled hypertension.
Differential:
Aortic dissection
MI
Pericarditis
Esophageal rupture
Esophageal spasm
GERD
Pancreatitis
Fat embolism

Workup:
Transesophageal echocardiography (TEE)
ECG
CPK-MB, troponin
CXR
CBC
Amylase, lipase
CTA—chest with IV contrast
MRI/MRA—aorta
Aortic angiography
Upper endoscopy
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 history of diabetes mellitus, hypertension, and alcoholism. There is decreased soft touch, vibratory, and position sense in the feet.
Differential:
Diabetic peripheral neuropathy
Alcoholic peripheral neuropathy
B12 deficiency
Hypocalcemia
Hyperventilation
Paraproteinemia/myeloma

Workup:
HbA1c
ESR
Calcium
Serum B12
UA
Serum and urine protein electrophoresis
56 yo F presents with shortness of breath and a productive cough that has lasted for at least 3 months each year over the past 2 years. She is a heavy smoker.
Differential:
COPD - Chronic Bronchitis
COPD - emphysema
Bronchiectasis
Lung Cancer
Tuberculosis

Workup:
CBC
Sputum Gram stain and culture
CXR
PFTs
CT-Chest
QuantiFERON-TB Gold
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 3 days binge drinking.
Differential:
Acute pancreatitis
Peptic ulcer disease
Cholecystitis/choledocholithiasis
Gastritis
Abdominal aortic aneurysm
Mesenteric ischemia
Alcoholic hepatitis
Boerhaave syndrome

Workup:
CBC
Electrolytes, BUN/Cr
Amylase, lipase
AST/ALT/bilirubin/alkaline phosphatase
U/S—abdomen
CT—abdomen
Upper endoscopy
ECG
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.
Differential:
Carpal tunnel syndrome secondary to hypothyroidism
Overuse injury of median nerve
Cervical disk disease
Medial epicondylitis

Workup:
TSH
CBC
Electromyography
Nerve conduction study
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 has noticed swelling and deformity of the joint and is having difficulty walking.
Differential:
Osteoarthritis
Pseudogout
Gout
Meniscal or ligament damage

Workup:
XR—knee
CBC
ESR
Knee arthrocentesis and synovial fluid analysis (cell count, Gram stain, culture, crystals)
Uric acid
MRI—knee
57 yo M c/o daily pain in the right cheek for the past month. The pain is electric and stabbing in character and occurs while he is shaving. Each episode lasts 1-2 minutes.
Differential:
Trigeminal neuralgia
Tension headache
Migraine
Cluster headache
TMJ disorder
Temporal arteritis
Intracranial neoplasm

Workup:
MRI—brain
CBC
ESR
58 yo M presents with 1 week of pleuritic chest pain, fever, chills, and cough with purulent yellow sputum. He is a heavy smoker with COPD.
Differential:
Pneumonia
COPD exacerbation (bronchitis)
Lung abscess
Lung cancer
Tuberculosis
Pericarditis

Workup:
CBC
Sputum Gram stain and culture
CXR
CT—chest
ECG
QuantiFERON-TB Gold
58 yo M presents with painless bright red blood per rectum and chronic constipation. He consumes a low-fiber diet.
Differential:
Diverticulosis
Hemorrhoids
Anal fissure
Colorectal cancer
Angiodysplasia

Workup:
CT—abdomen/pelvis
Colonoscopy
Rectal exam with guaiac testing
CBC, CMP
PT/PTT
Tagged RBC scan
60 yo F c/o left arm pain that started while she was swimming and was relieved by rest.
Differential:
Angina/MI
Tendinitis
Osteoarthritis

Workup:
ECG, troponin, CK-MB
CBC
XR—shoulder
CXR
Echocardiography
Stress test
60 yo F presents with pain in both legs that is induced by walking and is relieved by rest. She had cardiac bypass surgery 6 months ago and continues to smoke heavily.
Differential:
Peripheral vascular disease (intermittent claudication)
Leriche syndrome (aortoiliac occlusive disease)
Lumbar spinal stenosis (pseudoclaudication)
Osteoarthritis

Workup:
Ankle-brachial index
Doppler U/S—lower extremity
Angiography
MRI—L-spine
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.
Differential:
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
AST/ALT/bilirubin/alkaline phosphatase
U/S—abdomen
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.
Differential:
Benign prostatic hypertrophy (BPH)
Prostate cancer
Urolithiasis
UTI

Workup:
U/S—prostate (transrectal)
PSA
UA
CBC/CMP
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.
Differential:
Myocardial infarction (MI)
GERD
Angina
Costochondritis
Aortic dissection
Pericarditis
Pulmonary embolism
Pneumothorax

Workup:
ECG
CPK-MB, troponin × 3
CXR
CBC
Helical CT
Echocardiography
Cardiac catheterization
D-dimer
60 yo M presents with worsening dyspnea of 6 hours' duration and a cough that is accompanied by pink, frothy sputum.
Differential:
Pulmonary edema
Pneumonia
CHF
Mitral valve stenosis
Arrhythmia
Asthma

Workup:
CXR
ECG
CBC
ABG
PFTs
BNP
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 hypertension and diabetes mellitus. She is nulliparous.
Differential:
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
Hydro-ultrasonography
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 or calcium supplements. Her left leg is externally rotated, shortened, and adducted, and there is tenderness in her left groin.
Differential:
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)
65 yo F presents with severe, intermittent right temporal headache, fever, blurred vision in her right eye, and pain in her jaw when chewing.
Differential:
Temporal arteritis (giant cell arteritis)
Vasculitis
Migraine
Cerebral abscess
Cluster headache
Tension headache
Meningitis
Carotid artery dissection
Pseudotumor cerebri
Trigeminal neuralgia
Intracranial neoplasm
Temporomandibular joint (TMJ) disorder

Workup:
Temporal artery biopsy
ESR
CRP
CBC
Doppler U/S—carotid
MRI—brain
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.
Differential:
Plantar fasciitis
Heel fracture
Splinter/foreign body

Workup:
XR—heel
Bone scan—foot
65 yo M presents with painless hematuria. He is a heavy smoker and works as a painter.
Differential:
Bladder cancer
Renal cell carcinoma
Nephrolithiasis
Prostate cancer
Acute glomerulonephritis
Coagulation disorder (ie, factor VIII antibodies)

Workup:
Cystoscopy
U/S—renal/bladder
CT—abdomen/pelvis
UA, urine cytology
Prostate biopsy
CBC, CMP
PT/PTT, PSA
65 yo M presents with postural dizziness and unsteadiness. He has hypertension and was started on furosemide 2 days ago.
Differential:
Drug-induced orthostatic hypotension
Furosemide ototoxicity
Vertebrobasilar insufficiency
Vestibular neuronitis
Labyrinthitis
Benign positional vertigo
Brain stem or cerebellar tumor

Workup:
Orthostatic vital signs
CBC
Urea, Electrolytes
Echocardiography
MRI—brain
65 yo M presents with right foot pain. He has been training for a marathon.
Differential:
Stress fracture
Plantar fasciitis
Foot sprain or strain

Workup:
XR—foot
Bone scan—foot
MRI—foot
65 yo M presents with worsening cough for the past 6 months accompanied by hemoptysis, dyspnea, weakness, and weight loss. He is a heavy smoker.
Differential:
Lung cancer
Tuberculosis
Lung abscess
COPD
Vasculitis (eg, Wegener's granulomatosis/granulomatosis with polyangiitis)
Interstitial lung disease
CHF

Workup:
CBC
Sputum Gram stain, culture, and cytology
CXR
CT—chest
QuantiFERON-TB Gold
ANCA
Bronchoscopy
Echocardiography
67 yo M presents with alternating diarrhea and constipation, decreased stool caliber, and blood in the stool for the past 8 months. He also reports unintentional weight loss. He is on a low-fiber diet and has a family history of colon cancer. His last colonoscopy was 12 years ago.
Differential:
Colorectal cancer
Irritable bowel syndrome
Diverticulosis
GI parasitic infection (ascariasis, giardiasis)
Inflammatory bowel disease

Workup:
Rectal exam, stool for occult blood
CBC with diff
CMP
Colonoscopy
Barium enema
CT—abdomen/pelvis
Stool for ova and parasitology
67 yo M presents with blood in his stool, weight loss, and constipation. He has a family history of colon cancer.
Differential:
Colorectal cancer
Diverticulosis
Hemorrhoids
Anal fissure
Angiodysplasia
Upper GI bleeding
Inflammatory bowel disease
Ischemic bowel disease

Workup:
Colonoscopy
Rectal exam with stool guaiac testing
CT—abdomen/pelvis
CBC, CMP
AST/ALT/bilirubin/alkaline phosphatase
PT/PTT
CEA
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 emergency department. He has a history of hypertension, diabetes mellitus, and heavy smoking.
Differential:
Transient ischemic attack (TIA)
Stroke
Migraine with sensory aura
Hypoglycemia
Seizure with Todd paresis

Workup:
CT—head
CBC
Electrolytes, glucose
Fasting lipid panel
ECG
MRI—brain, with DWI
Doppler U/S—carotid
Echocardiography
EEG
68 yo M presents with a 2-month history of crying spells, excessive sleep, poor hygiene, and a 15-lb (6.8-kg) 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.
Differential:
Normal bereavement
Adjustment disorder with depressed mood
Major depressive disorder
Schizoaffective disorder
Depressive disorder not otherwise specified

Workup:
TSH
CBC
Urine toxicology
Beck Depression Inventory
PHQ-9
QIDS-SR16
68 yo M presents with LLQ abdominal pain, fever, and chills for the past 3 days. He also reports recent onset of alternating diarrhea and constipation. He consumes a low-fiber, high-fat diet.
Differential:
Diverticulitis
Crohn's disease
Ulcerative colitis
Gastroenteritis
Abscess

Workup:
Rectal exam
CBC
Electrolytes
CXR
AXR
CT—abdomen
Blood culture
33 yo M 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.
Differential
Crohn Disease
Gastroenteritis
Ulcerative colitis
Celiac disease
Pseudomembranous colitis
Hyperthyroidism
Small bowel lymphoma
Carcinoid syndrome

Workup:
Rectal exam, stool for occult blood
Stool leukocytes and culture
CBC
Electrolytes
Colonoscopy with biopsy
CT-abdomen
TSH
AXR
68 yo M presents with slurred speech, right facial drooping and numbness, and right hand weakness. Babinski's sign is present on the right. He has a history of hypertension, diabetes mellitus, and heavy smoking.
Differential:
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
Echocardiography
ECG
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 recently divorced.
Differential:
Somatoform disorder
Malingering
Irritable bowel syndrome
Lactose intolerance
Child abuse

Workup:
CBC
Electrolytes
U/S—abdomen
Amylase, lipase
Stool exam
70 yo insulin-dependent diabetic M presents with episodes of confusion, dizziness, palpitations, diaphoresis, and weakness.
Differential:
Hypoglycemia
Transient ischemic attack
Arrhythmia
Delirium
Angina
Medication-induced

Workup:
Glucose
CBC
Electrolytes, TSH
CPK-MB, troponin
Echocardiography
ECG
MRI-brain
Doppler U/S - carotid
Urine toxicology
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.
Differential:
Mesenteric ischemia/infarction
Diverticulitis
Peptic ulcer disease
Gastroenteritis
Acute pancreatitis
Cholecystitis

Workup:
Rectal exam
CBC
Amylase, lipase, lactate
ECG
AXR
CT—abdomen
Mesenteric angiography
Barium enema
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 exertion dyspnea.
Differential:
CHF
Cardiac valvular disease
GERD
Pulmonary fibrosis
COPD
Postnasal drip

Workup:
CBC
CXR
ECG
Echocardiography
PFTs
BNP
CT-chest
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.
Differential:
Pulmonary embolism
Pneumonia
Costochondritis
MI
CHF
Aortic dissection

Workup:
D-dimer
CTA—chest with IV contrast
CXR
ECG
ABG
CPK-MB, troponin
CBC
Electrolytes, BUN/Cr, glucose
Doppler U/S—legs
70 yo diabetic M presents with episodes of palpitations and diaphoresis. He is on insulin
Differential:
Hypoglycemia
Cardiac arrhythmia
Angina
Hyperthyroidism
Hyperventilation episodes
Panic attack
Pheochromocytoma
Carcinoid syndrome

Workup:
Glucose
CBC
Electrolytes
TSH
ECG
24-hour urinary catecholamines
5-HIAA
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.
Differential:
Prostate cancer
BPH
Renal cell carcinoma
UTI
Urolithiasis

Workup:
U/S—prostate (transrectal)
CT—pelvis
MRI—spine
Prostate biopsy
PSA
UA
CBC, CMP
72 yo M presents with memory loss, gait disturbance, and urinary incontinence for the past 6 months.
Differential:
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
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.
Differential:
Retinal artery occlusion
Retinal vein occlusion
Acute angle-closure glaucoma
Retinal detachment
Temporal arteritis (giant cell arteritis)

Workup:
Fluorescein angiogram
Echocardiography
Doppler U/S—carotid
Intraocular tonometry
ESR, CRP
Temporal artery biopsy
CBC
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 15 lbs (6.8 kg) within the past 4 months.
Differential:
Esophageal cancer
Achalasia
Esophagitis
Systemic sclerosis
Esophageal stricture

Workup:
CBC
CXR
Upper endoscopy with biopsy
Barium swallow
CT—chest
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.
Differential:
Intussusception
Appendicitis
Meckel's diverticulum
Volvulus
Gastroenteritis
Enterocolitis
Blunt abdominal trauma

Workup:
Rectal exam, stool for occult blood
CBC
Electrolytes
Contrast enema
U/S—abdomen
CT—abdomen
81 yo M presents with progressive confusion for the past several years accompanied by forgetfulness and clumsiness. He has a history of hypertension, diabetes mellitus, and 2 strokes with residual left hemiparesis. His mental status has worsened after each stroke (stepwise decline in cognitive function).
Differential:
Vascular ("multiinfarct") dementia
Alzheimer's disease
Normal pressure hydrocephalus
Chronic subdural hematoma
Intracranial neoplasm
Depression
B12 deficiency
Neurosyphilis
Hypothyroidism

Workup:
CBC
VDRL/RPR
Serum B12
TSH
MRI—brain
CT—head
LP—CSF analysis
84 yo F brought by her son c/o forgetfulness (eg, forgets phone numbers, loses her way back home) and difficulty performing some of her daily activities (eg, bathing, dressing, managing money, using the phone). The problem has progressed gradually over the past few years.
Differential:
Alzheimer's disease
Vascular dementia
Depression
Hypothyroidism
Chronic subdural hematoma
Normal pressure hydrocephalus
Intracranial neoplasm
B12 deficiency
Neurosyphilis

Workup:
CBC
VDRL/RPR
Serum B12
TSH
MRI—brain (preferred)
CT—head
LP—CSF analysis
9 yo M presents with a 2-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.
Differential:
Attention-deficit hyperactivity disorder (ADHD)
Oppositional defiant disorder
Manic episode
Conduct disorder
Hyperthyroidism

Workup:
Physical exam
Mental status exam
TSH, FT4
EEG
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