Quizlet

Step 2 CS - Cases, Differentials, Diagnoses
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1. Headache
DDX
- Migraine (complicated)
- Tension headache
- Cluster headache
- Pseudotumor cerebri
- Trigeminal neuralgia
- CNS vasculitis - Temporal Arteritis
- Subarachnoid hemorrhage (SAH)
- Partial seizure
- Intracranial neoplasm
- Sinusitis
2. Headache
Physical Exam
• VS - state or say wnl (wnl except...)

• General: Patient is in no acute distress
• HEENT: Inspect Nose (Noses, mouth, teeth, and throat) and Palpate entire head (including sinuses (ENT) and
temporomandibular joints (Jaw)), Fundoscopic Exam
=> NC/AT, nontender to palpation, PERRLA, EOMI, no papilledema, no nasal congestion, no pharyngeal erythema or
exudate, good dentition
• Neck: Inspect/Palpate
=> Supple, No lymphadenopathy
• Chest: Auscultate => Clear breath sounds bilaterally
• Heart: Auscultate => RRR, S1, S2 wnl, No murmurs, rubs or gallops (distal pulses intact bilaterally, 2+)
• Neuro Exam: MSE, CN, Motor, DTR => Mental Status: Alert and oriented x 3, good concentration; Cranial Nerves
(CN) 2 - 12 grossly intact; Motor Strength 5/5 throughout; DTR: 2+ intact, symmetric
3. Headaches - CBC with diff
Work-up - ESR
- CT—head
- MRI—brain/MRA—brain
- Lumbar Puncture (LP)
- XR-sinues
4. 21 yo F presents with several episodes of throbbing L temporal
pain that lasts
for 2-3 hours.
Prior to its onset, she sees flashes of light in her right visual
field and feels weakness and numbness on the right side of her
body for a few minutes.
Headaches are often associated with
nausea and vomiting.
She has a family history of migraine.
HEADACHE DDX
DDX? - Migraine (complicated)*
Physical Exam? - Tension headache
Work up? - Cluster headache
- CNS vasculitis - Temporal Arteritis
- Subarachnoid hemorrhage (SAH)
- Partial seizure
- Sinusitis
HEADACHE PHYSICAL EXAM (in general)

- VS
- HEENT: Inspect (Noses, mouth, teeth, and throat) and Palpate
entire head (including sinuses (ENT) and temporomandibular joints
(Jaw)), Fundoscopic Exam,
- Neuro Exam: MSE, CN, Motor, DTR
HEADACHE WORK-UP (in general)

- CBC with diff
- CT—head
- MRI—brain
- LP
- X-Ray of Sinuses
5. Migraine Characteristics (Headache DDX)
Symptoms
- Unilateral throbbing
- Photophobia
- Sonophobia
- Aura
- Recurrent
Physical Exam
- No fever
- No weakness in extremities
6. 26 yo M presents with severe right temporal
headaches associated with ipsilateral rhinorrhea,
eye tearing, and
redness. Episodes have occurred at the same time
every night for the past week and last for 45
minutes.
HEADACHE DDX
- Cluster headache*
- Migraine
- Tension headache
- Sinusitis
HEADACHE WORK-UP
- CBC with diff, ESR
- CT—head
- MRI—brain
- LP
7. Cluster Headache (Headache DDX)
Symptoms
- Unilateral periorbital pain (behind the eye pain), often accompanied by
ipsilateral nasal congestion, rhinorrhea, lacrimation, redness of the eye, and/or
Horner's syndrome
- Episodes of daily pain occur in clusters
- Sudden and intense
- Last a couple of hours and gone
- Recurrent same time of day
- Often awaken patients at night
- Rarely occurs in women (similarity seen in women is termed "chronic
paroxysmal hemicrania")
Physical Exam
- Lacrimation
- Blushing of Face
8. Chronic Paroxysmal Hemicrania (CPH) (aka Sjaastad syndrome)
(Headache DDX)
Symptoms
- Debilitating unilateral headache (usually around eye)
- Multiple severe, yet short, headache attacks affecting only one
side of the cranium
- Women >> Men
- No neurological symptoms associated with it.
• Diagnosis with CPH: ≥ 20 attacks filling the following criteria:

- Attacks of severe unilateral orbital, supraorbital, or temporal
pain lasting between 2 and 30 minutes.
• Headache needs to take place w/ 1 of the following:

- Ipsilateral conjunctival injection and/or lacrimation
- Ipsilateral nasal congestion and/or rhinorrhoea
- Ipsilateral eyelid edema
- Ipsilateral forehead and facial sweating
- Ipsilateral miosis and/or ptosis
• Attacks need to occur > 5 x day for more than half of the time
• Attacks can be prevented completely by therapeutic doses of

indomethacin.
• Symptoms not due to another disorder and neuropathy of the

supraorbital area in the temporal branch of facial nerve r/p
9. 65 yo F presents with severe, intermittent right temporal HEADACHE DDX
headache, fever, blurred vision in her right eye, and pain in her - Temporal arteritis (giant cell arteritis)*
jaw when chewing - Migraine
- Cluster headache
- Tension headache
- Meningitis
- Carotid artery dissection
HEADACHE WORK-UP
- CBC with diff, ESR, CRP
- Temporal Artery Biopsy
- Doppler U/S - carotid
- MRI—brain
- LP
10. Temporal Arteritis (Headache DDX)
Symptoms
- Throbbing one-sided headache
- Fevers
- Jaw pain** -
- Visual changes
Physical Exam
- Tender over temporal artery
- Jaw pain when opening Jaw
- Age over 50 years
- May present with Polymyalgia Rheumatica (syndrome with pain or stiffness,
usually in the neck, shoulders, and hips. The pain can be very sudden, or can
occur gradually over a period.)
11. 30 yo F presents with frontal headache, fever, and HEADACHE DDX
nasal discharge. There is pain on palpation of the - Sinusitis*
frontal and maxillary - Migraine
sinuses. She has a history of sinusitis. - Tension headache
- Meningitis
HEADACHE WORK-UP
- CBC with diff
- XR—sinus
- CT—sinus
- LP
12. Sinusitis (Headache DDX)
Symptoms
- Recent upper respiratory infection
- Pain in cheek below eye
- Dull, constant ache, worse leaning over
- Nasal discharge and stuffiness
- Rare cause of headache (w/o other symptoms)
Physical Exam
- Tenderness to palpation of maxillary sinus
- No weakness in extremities
13. 50 yo F presents with recurrent episodes of bilateral squeezing headaches that occur 3- HEADACHE DDX
4 times a week, typically toward the end of her work day. She is - Tension headache*
experiencing significant stress in her life. - Migraine
- Depression
- Caffeine or analgesic withdrawal
- Hypertension
- Cluster headache
HEADACHE WORK-UP
- CBC with diff, Electrolytes, ESR
- CT—head
- LP
14. Tension Headache (Headache DDX)
Symptoms
- Usually bilateral (bandlike) and
squeezing
- Last hours to days
- Recurrent
- Constant, not throbbing
- Associated with stress
- Gets worse as the day progresses
- Better with massage
Physical Exam
- Normal Vital Signs
- Normal Neuro Exam
15. 35 yo M presents with sudden severe headache, vomiting, confusion, left hemiplegia, HEADACHE DDX
and nuchal rigidity. - Subarachnoid hemorrhage*
- Migraine
- Meningitis/Encephalitis
- Intracranial hemorrhage
- Vertebral artery dissection
- Intracranial venous thrombosis
- Acute hypertension
HEADACHE WORK-UP
- Noncontrast CT - head
- LP
- CBC with diff
- PT/PTT/INR
- MRI/MRA of brain
16. Subarachnoid Bleed/Hemorrhage (Headache DDX) Symptoms
- Headache
- Syncope
- Very severe intensity
- First episode
- Vomiting
Physical Exam
- Mental status change
- Stiff neck
17. Intracranial Mass Lesion (Headache DDX) Symptoms
- 1/3 of patients with brain tumors present with
primary complaint = headache
- Headache = non-specific => mimics migraine
- Certain brain tumors may have familial basis
Physical Exam
- Mental status changes
- Ataxia
- Focal weakness
- Visual Changes
18. 25 yo M presents with high fever, severe headache, confusion, photophobia, and
nuchal rigidity. Kernig's and Brudzinski's signs are positive.
HEADACHE DDX
- Meningitis (bacterial)*
- Meningitis (HSV)*
- Migraine
- Subarachnoid hemorrhage
- Sinusitis/Encephalitis
- Intracranial or epidural abscess
HEADACHE WORK-UP
- CBC with diff
- CT—head
- MRI—brain
- LP— CSF analysis (cell count, protein, glucose,
gram stain, PCR for antigens, culture)
19. 18 yo obese F presents with a pulsatile headache, vomiting, and blurred vision HEADACHE DDX
for the past 2-3 weeks. She is taking OCPs. - Pseudotumor cerebri*
- Tension headache
- Migraine
- Cluster headache
- Meningitis
- Intracranial venous thrombosis
HEADACHE WORK-UP
- Urine B-HCG
- CBC with diff
- CT—head
- LP—opening pressure and CSF analysis
20. Psesudotumor Cerebri (Headache DDX)
Symptoms
- Headaches can be focal but usually
accompanied by diplopia and other visual
symptoms
Physical Exam
- Should reveal papilledema (but can be normal
during the first few days after onset of illness)
21. 57 yo M c/o daily pain in the right cheek over the past month. The pain is HEADACHE DDX
electric and stabbing in character and occurs while he is shaving. Each episode - Trigeminal neuralgia*
lasts 2-4 minutes - Tension headache
- Migraine
- Cluster headache
- TMJ dysfunction
HEADACHE WORK-UP
- MRI—brain
22. Trigeminal Neuralgia (TN) (aka tic douloureux) (Headache DDX) - Pain accompanied by brief facial spasm or tic
- Pain distribution unilateral, follows branch of CN
V (maxillary (V2) or mandibular (V3)) sensory
distribution
- P/E eliminates alternative diagnoses
23. Depression (Headache DDX) Symptoms
- Headaches may be worse on waking up in
morning
- Associated with other depression symptoms
24. Glaucoma (closed angle) (Headache DDX) Symptoms
- Pain centered over eye
- First episode
Physical Exam
- Red Eye
- Decreased visual acuity
- Dilated upi
25. Confusion/Memory Loss DDX - Alzheimer's
- Vascular Dementia (Vascular Multi Infarct
Dementia)
- Normal Pressure Hydrocephalus (NPH)
- Creutzfeld-Jakob
- Subdural Hematoma (SDH)
- Hypoglycemia
- Depression with Pseudo Dementia
- Hypothyroidism
- Vit B12 deficiency
26. Confusion/Memory • VS: State (or WNL or WNL except...)
Loss Physical Exam • General: Patient is in no acute distress
• Eye Exam: Inspect pupils, fundus
=> Normocephalic/Atraumatic, PERLA (PEERLA), No funduscopic abnormalities
• Neck Exam: Carotid auscultation
=> Supple, No carotid bruits
• Heart Exam: Auscultation (orthostatic vital signs)
=> RRR, S1, S2 wnl, No murmurs, rubs, or gallops heard
• Chest Exam: Auscultation
=> Clear breath sounds bilaterally/Clear breath sounds bilaterally
• Abd Exam: Palpation
=> Soft, non-distended, non-tender, no hepatosplenomegaly
• Neuro Exam: Mini-mental status exam, Cranial nerves, Motor exam, DTRs, gait, Romberg sign, sensory exam
=> Mental Status: Alert and oriented x 3, spells backward, recalls 3 objects; CN 2-12 intact grossly; Motor:
Strength 5/5 in all muscle groups; DTRs, upper and lower extremities 2+ intact bilaterally, negative babinski
bilaterally; Cerebellar: (-) Romberg; Gait: Normal; Sensation: Intact to pinprick and soft touch
27. Confusion/Memory - CBC, VDRL/RPR, Serum B12, TSH
Loss Work-up - MRI—brain
- CT—head
- LP
- Glucose (hypo)
- Electrolytes
- (Orthostatic vital signs)
28. Dementia vs
Delirium quick
compare
29. Dementia vs
Delirium
30. Dementia Types

31. Delirium
1. Disturbance of CONSCIOUSNESS (can't focus or

shift attention)
2. Change in COGNITION (memory, language)
3. Develops over SHORT period of time and
FLUCTUATES
4. Caused by a general MEDICAL condition
32. 81 yo M presents with progressive confusion over the past several years CONFUSION/MEMORY LOSS DDX
together with forgetfulness and clumsiness. He has a history of - Vascular ("multi-infarct") dementia*
hypertension, diabetes mellitus, and two - Alzheimer's disease
strokes with residual left hemiparesis. His mental status has clearly worsened - Normal pressure hydrocephalus
after each stroke (stepwise decline in cognitive function). - Chronic subdural hematoma
- Depression
- Vitamin B12 deficiency
- Neurosyphilis
- Hypothyroidism
CONFUSION/MEMORY LOSS WORK-UP

- CBC with diff, VDRL/RPR, Serum B12, TSH
- MRI—brain
- CT—head
- LP—CSF analysis (rare)
33. Vascular ("multi-infarct") dementia (Confusion/Memory Loss DDX)
- Often coexists with Alzheimer's Disease

- Look at history of atherosclerotic vascular disease
(i.e. stroke, MI)
- Classically more step-wise deterioration in
vascular dementia compared to steady cognitive
decline seen in Alzheimer
- May be earlier loss of executive function and
personality changes in vascular dementia
34. 84 yo F brought by her son c/o CONFUSION/MEMORY LOSS DDX
forgetfulness (e.g., forgets phone - Alzheimer's disease*
numbers, loses her way back home) along - Vascular ("multi-infarct") dementia
with diffi culty performing some of her - Depression
daily activities (e.g., bathing, dressing, - Hypothyroidism
managing money, using the phone). The - Chronic subdural hematoma
problem has gradually progressed over - Normal pressure hydrocephalus
the past few years. - Intracranial neoplasm
- Neurosyphilis

- CBC with diff, VDRL/RPR, Serum B12, TSH
- MRI—brain
- CT—head
- LP—CSF analysis (rare)
35. Alzheimer's Disease (Confusion/Memory Loss DDX)
- Most common cause of dementia

- Insidious onset with steady, progressive decline in cognitive function over
years
- Earliest findings are impairment in memory and visuospatial abilities
- Clinical Diagnosis
36. Alzheimer's Disease 5A's (Confusion/Memory Loss
DDX)
37. 72 yo M presents with memory loss, gait disturbance, and urinary incontinence for the CONFUSION/MEMORY LOSS DDX
past six months - Normal pressure hydrocephalus*
- Alzheimer's disease
- Vascular ("multi-infarct") dementia
- Chronic subdural hematoma
- Depression
- Neurosyphilis
- Hypothyroidism

- CT—head
- LP— Opening Pressure and CSF analysis
- CBC with diff, VDRL/RPR, Serum B12,
TSH
38. Normal Pressure Hydrocephalus (NPH) (Confusion/Memory Loss DDX)
- Adams/Hakim Triad ("wet, wobbly and

wacky"):
1. Wet = Incontinence
2. Wobbly = Gait ataxia (Wide-based)
3. Wacky = Dementia
39. 55 yo M presents with a rapidly progressive change in mental status, inability to CONFUSION/MEMORY LOSS DDX
concentrate, and memory impairment for the past two months. His symptoms are - Creutzfeldt-Jakob Disease*
associated with myoclonus and ataxia. - Vascular ("multi-infarct") dementia
- Lewy Body Dementia
- Wernicke Encephalopathy
- Normal pressure hydrocephalus
- Chronic subdural hematoma
- Depression
- Delirium
- Neurosyphilis

- CBC with diff, Electrolytes, Calcium, Serum
B12, VDRL/RPR,
- MRI—brain (preferred)
- CT—head
- EEG
- LP— CSF analysis
- Brian biopsy
40. Creutzfeldt-Jakob Disease (CJD) (Confusion/Memory Loss DDX)
- Dementia, mood, anxiety, movement

disorders
- Rapidly progressive dementia; usually
sporadic but can be rarely familial. Occurs in
7th decade, fatal in 7 months.
- Caused by prions (small proteinaceous
particle's that cause spongiform changes in
the brain)
41. 70 yo insulin-dependent diabetic M presents with episodes of confusion, CONFUSION/MEMORY LOSS DDX
dizziness, palpitation, diaphoresis, and weakness. - Hypoglycemia*
- Transient Ischemic Attack
- Arrhythmia
- Delirium
- Angina

- Glucose, Electrolytes, CBC with diff
- ECG
- Echocardiography
- MRI—brain
- Doppler U/S - Carotid
42. Hypoglycemia (Confusion/Memory Loss DDX)
Hypoglycemia Mnemonic
T - Tachycardia
I - Irritability
R - Restless
E - Excessive Hunger
D - Diaphoresis/Depression
Hypoglycemia Symptoms
- Autonomic: Anxiety, Palpitations, Sweating,
Tingling, Trembling
- Neuroglycopenia: Irritability, drowsiness, dizziness,
blurred vision, difficulty with speech, confusion,
feeling faint
43. 55 yo F presents with gradual altered mental status and headache. Two CONFUSION/MEMORY LOSS DDX
weeks ago she slipped, hit her head on the ground, and lost consciousness - Subdural Hematoma*
for two minutes. - SIADH (causing hyponatremia)
- Creutzfeldt-Jakob Disease

- Electrolytes,
- CT—head
- MRI—brain
- LP
44. Subdural Hematoma (Headache and Confusion/Memory Loss DDX)
Symptoms
- History of Trauma
- On warfarin
- Headache
Physical Exam
- Mental status changes
- Ataxia
- Focal weakness
- Visual Changes
45. Depression with - Patient often tends to emphasize disability related to memory loss much more than patients
Pseudodementia experiencing true dementia
- Appears to have dementia
- Unable to remember correctly,
- Cannot calculate well
- Complains, bitterly, of lost cognitive abilities or skills
- High risk of progressing to dementia
- Depression or mild depressive symptoms can be comorbid
Clues:
- Recent weight loss
- Worsening sleep
- Frequent crying spells
- Self-deprecating comments,
- Recent-onset behavior changes (social withdrawal, psychomotor agitation, extreme negativism)
46. Vitamin B12 Deficiency
Symptoms
- Lower Energy/Fatigue
- Depression/Anxiety
- Muscle pain
- Irritability
- Hearing and Vision problems
- Mood disorders
- Memory loss
- Sexual problems/infertility
47. Depressed Mood DDX - Major Depressive Disorder
- Bereavement Disorder
- Bipolar I and II Disorders
48. Depressed Mood Physical • VS: State (or WNL or WNL except...)
Exam • General: No acute distress, Looks ___ (tired) with ___ (flat) affect, speaks and moves ___ (slowly)
• HEENT: Inspect conjunctivae, mouth, and throat, lymph nodes, examine thyroid gland
=> No conjuctival pallor, mouth and pharynx wnl
• Neck Exam: No lymphadenopathy, thyroid normal
• Abd Exam: Auscultation, Palpation, Percussion
=> Soft, non-distended, non-tender, +BS, no hepatosplenomegaly
• Extremities: Inspection, checked DTRs
=> No edema, normal DTRs in lower extremities
49. Depressed Mood Work-Up - Physical Exam (PE)
- Mental Status Exam (MSE)
- Blood alcohol
- TSH
- CBC
- Urine Toxicology (Urine Tox)
50. 68 yo M presents with a two-month history of crying spells, excessive sleep, DEPRESSED MOOD DDX
poor hygiene, and a 7-kg weight loss, all following his wife's death. He cannot - Normal bereavement*
enjoy time with his grandchildren and reluctantly admits to thinking he has seen - Adjustment disorder with depressed mood
his dead wife in line at the supermarket or standing in the kitchen making dinner. - Major depressive disorder with psychotic
features
- Schizoaffective disorder
- Depressive disorder not otherwise specified
(NOS)
DEPRESSED MOOD WORK-UP

- Physical Exam
- Mental Status Exam
- CBC with diff, TSH
- Urine Toxicology
51. Normal Bereavement (Depressed Mood DDX) - 6 months - 18 months (normal)
- Reaction to death of a loved one
- Regards "depressed mood" as normal
- May seek relief of insomnia or anorexia
- Follows Major loss/event → normal → Patient
relates sadness to loss → Intense sadness, pain
- No significant loss of self-esteem
---
DSM - V
- "Symptoms lasting less than 2 months since
death of loved one" has been eliminated
- Bereavement becomes Depression if suffering,
feelings of worthlessness, suicidal ideation,
poorer somatic health, worse interpersonal and
work functioning
- Examples: Isolation of self from others,
Work/marital/familial issues, patient planning to
"meet" with dead loved one (suicide), severe
weight loss (ex. 25 lbs in 1 month not by medical
condition)
52. 42 yo F presents with a four-week history of excessive fatigue, insomnia, and DEPRESSED MOOD DDX
anhedonia. She states that she thinks constantly about death. She has suffered - Major Depressive Disorder (MDD)*
five similar episodes in the past, the first in her 20s, and has made two previous - Substance-Induced Modd Disorder
suicide attempts. She further admits to increased alcohol use in the past month. - Dysthymic Disorder

- Physical Exam
- Blood Alcohol Levels
- Urine Toxicology
53. Major Depressive Disorder (MDD) (Depressed
Mood DDX)
Last ≥ 2 weeks with ≥ 5 symptoms and MUST Include Depressed Mood or

Anhedonia (loss of interest)
SIGECAPS
- Sleep disturbance (↑ or ↓)
- Interest Loss → MUST Include (or depressed mood)
- Guilt → Feeling worthless or inappropriately guilty
- Energy Loss → Fatigue
- Concentration Loss → impaired concentration or indecisiveness
- Appetite (weight) changes (↑ or ↓)
- Psychomotor Changes (agitation or retardation)
- Suicidal ideation → thoughts of death
54. Dysthmic Disorder (Depressed Mood DDX) Milder form of depression lasting at least 2 years → Not as severe or disabling
HE'S 2 SAD
1. Hopelessness
2. Energy loss or fatigue
3. Self-esteem is low
4. 2 years minimum of depressed mood most of day, for more days than not
5. Sleep disorder (↑ or ↓)
6. Appetite change (↑ or ↓)
7. Decision-making or concentration impaired
55. 26 yo F presents with a 3-kg weight loss over the past two months, accompanied by
early-morning awakening, excessive guilt, and psychomotor retardation. She does not
identify a trigger for the depressive episode but reports several weeks of increased
energy, sexual promiscuity, irresponsible spending, and racing thoughts approximately
six months before her presentation.
DEPRESSED MOOD DDX

- Bipolar I Disorder*
- Bipolar II Disorder
- Cyclothymic disorder
- Major Depressive Disorder (MDD)
- Schizoaffective Disorder

- Physical Exam
- Urine Toxicology
56. Bipolar Disorder
(Depressed Mood DDX)
Presence of at least 1 manic episode for at least 1 week (↑ Mood → cheerful, enthusiastic, Expansive or
Irritable + ≥ 3 or 4 (if irritable) of 7 of DIGFAST)
• Manic = DIG FAST → ≥3 symptoms

1. Distractibility
2. Impaired judgment/ Indiscretion
3. Grandiosity
4. Flight of ideas
5. Activity ↑
6. Sleep deficit
7. Talkativeness
• Hypomania = TAD HIGH

1. Talkative
2. Attention deficit
3. Decreased need for sleep
4. High self-esteem/ grandiosity
5. Ideas that race
6. Goal-directed activity increased
7. High-risk activity
57. Cyclothymic Disorder 2 years (1-year in Children and Adolescents) of hypomania + mild depressive symptoms (not MDE)
(Depressed Mood DDX)
- Mildly depressed mood and Mild mania (cycles)
- No symptom-free period > 2 months
- Dysthymia and Hypomania → milder form of bipolar disorder lasting at least 2 years
- At least 2 years of hypomanic symptoms that DO NOT meet criteria for Manic Episode and numerous
periods of depressive symptoms that DO NOT meet the criteria for MDE
58. Psychosis DDX - Schizophrenia
- Substance induced
- Schizoaffective
- Brief Psychotic Disorder
- Psychosis sec. medical
- Narcolepsy
- Seizure
59. Psychosis Physical Exam • VS: State (or WNL or WNL except...)
• Eye Exam: Inspect pupils, checked for
reactivity
=> Pupils reactive to light, PEERLA
• Heart Exam: Auscultation, vital signs
=> RRR, S1, S2 wnl, No murmurs, rubs, or
gallops heard
=> Clear breath sounds bilaterally/Clear
breath sounds bilaterally
• Abd Exam: Palpation
=> Soft, non-distended, non-tender, no
hepatosplenomegaly
• Neuro Exam: Mini-mental status exam,
Cranial nerves, Motor exam, DTRs, gait,
sensory exam
=> Mental Status: Alert and oriented x 3,
spells backward, recalls 3 objects; CN 2-12
intact grossly; Motor: Strength 5/5 in all
muscle groups; DTRs, symmetric, upper and
lower extremities 2+ intact bilaterally, Gait:
Normal; Sensation: Intact to pinprick and
soft touch
60. Psychosis Work-up - Mental Status Exam (MSE)
- Urine Toxicology
- TSH
- CBC with diff
- Electrolytes
61. 19 yo M c/o receiving messages from his television set. He reports that he did not PSYCHOSIS DDX
have many friends in high school. In college, he started to suspect his roommate of - Schizophrenia*
bugging the phone. In the same time frame, he stopped going to classes because he - Schizoid or schizotypal personality
felt that his professors were saying horrible things about him that no one else disorder
noticed. He rarely showered or left his room and has recently been hearing a voice - Schizophreniform disorder
from his television set telling him to "guard against the evil empire." - Psychotic disorder due to a general
medical condition
- Substance-induced psychosis
- Depression with psychotic features
PSYCHOSIS WORK-UP
- Mental status exam
- Urine toxicology
- CBC with diff, TSH, Electrolytes
62. Schizophrenia (Psychosis DDX)
DSM-IV-TR Criteria → Period of psychosis > 6 months

• Criterion A: active-phase symptoms x 1 month
> 2 symptoms => Bizarre delusions or commenting/conversing
hallucinations (1 only)
• Criterion B: Social or Occupational Dysfunction
• Criterion C: Duration of at least 6 Months
• Criterion D: Schizoaffective and Mood Disorder Exclusion
•Criterion E: Substance or General Medical Exclusion
• Criterion F: Relationship to a PDD
• Schizophrenia prototype is a patient who has psychotic symptoms

and disturbed behavior lasting are present for > 6 months → 2 of 5
symptoms →1. Delusions; 2. Hallucinations; 3. Disorganized behavior;
4. Disorganized speech; and/or 5. Negative symptoms (flat affect,
amotivation, etc.)
---
DSM-V Changes
- Two Criterion A symptoms now required for diagnosis
- One of criterion A symptoms must be one of three symptoms:
Delusions, Hallucinations, or Disorganized Speech
- Subtypes of Schizophrenia (Paranoid, Disorganized, etc.) are
eliminated
63. 28 yo F c/o seeing bugs crawling on her bed over the past PSYCHOSIS DDX
two days and reports hearing loud voices when she is - Substance-induced psychosis*
alone in her room. She has never experienced symptoms - Brief psychotic disorder
such as these in the past. She recently ingested an - Schizophreniform disorder
unknown substance. - Schizophrenia
- Schizoid or schizotypal personality disorder
- Psychotic disorder due to a general medical condition
PSYCHOSIS WORK-UP
- Urine toxicology
- CBC with diff, TSH, Electrolytes, BUN/Cr, AST/ALT (LFTs)
64. Substance-induced psychosis (Psychosis DDX) Psychosis resulting from ingestion of medications, alcohol, illicit drugs,
or may stem from the withdrawal of alcohol or sedative drugs such as
benzodiazepines
- Should be able to detect in work-up
65. 48 yo F presents with a one-week history of auditory hallucinations, stating, "I PSYCHOSIS DDX
am worthless" and "I should kill myself." She also reports a two-week history - Schizoaffective Disorder*
of weight loss, early-morning awakening, decreased motivation, and - Mood disorder with psychotic features
overwhelming feelings of guilt. - Schizophrenia
- Schizophreniform disorder
- Psychotic disorder due to a general medical
condition
PSYCHOSIS WORK-UP
- Beck Depression Inventory
- CBC with diff, TSH, Electrolytes
66. Schizoaffective Disorder (Psychosis DDX) - Schizoaffective Disorder prototype has a mood
disorder and also unrelated psychotic symptoms,
which are seen at times when the patient is
between mood episodes
- Mood episode and active phase symptoms of
Schizophrenia occur together
- Proceeded and or followed by ≥ 2 weeks of
delusions or hallucinations WITHOUT prominent
mood symptoms
- Psychosis occurs concurrently with a mood
episode
- Psychosis occurs without mood symptoms
present
- Mood symptoms present for a substantial
portion of the total duration of the illness (30%
per some experts)
- Hallucinations or delusions present for ≥ 2
weeksin absence of prominent mood symptoms
- Types: (1) Bipolar Type (if mania → current or
previous manic episode) or (2) Depressive Type (if
only depression)
---
DSM-V changes
Mood disorder must be present for more than the
period of time the two Criterion A symptoms of
Schizophrenia has been found
67. Schizophreniform Disorder (Psychosis DDX) • > 1 month but < 6 months → symptoms last
between 1 - 6 months
• Provisional diagnosis in patients who recovered
• Bizarre behavior, hallucination, paranoid, and
delusion are present. However,
• Symptoms of schizophrenia i.e., usually 2
psychotic symptoms
68. Brief Psychotic Disorder (Psychosis DDX) - Brief psychotic disturbance that's episode lasts
→ > 1 day but < 1 month with full remission
- Often precipitated by psychosocial factors
- Sudden onset of at least 1 positive symptom of
schizophrenia
- Bizarre behavior, hallucination, paranoid,
delusion do occur and symptoms present for <1
month
69. Dizziness DDX - Meniere's disease
- Orthostatic hypotension
- Drugs vs fluids
- Benign Positional Vertigo
- Vestibular Neuronitis
- Labyrinthitis
70. Dizziness Physical Exam
• VS: State (or WNL or WNL except...)

• HEENT: Inspect for nystagmus, funduscopic exam, otoscopy, assessed hearing, Rinne and
Weber tests, inspected mouth and throat
=> NC/AT, PERRLA, EOMI without nystagmus, no papilledema, no cerumen, TMs normal,
mouth and oropharynx normal
• Neuro Exam: Cranial nerves, Motor exam, DTRs, Gait, Romberg sign, tilt test (eg. Dix-Hallpike
maneuver)
=> CN 2-12 intact grossly, (except for ___), (+) rinne test (Air conduction > bone conduction),
weber no lateralization, (-) tilt test. Motor: Strength 5/5 in all muscle groups; DTRs, 2+ intact
symmetric, (-) babinski bilaterally; Cerebellar: (-) Romberg, finer to nose normal, Gait: Normal
71. Dizziness Work-up - Orthostatic Vital Signs
- Diz-Hallpike maneuver - used to diagnose BPPV
- CBC with diff
- VDRL/RPR
- MRI—brain
- Electrolytes
- Audiogram
72. 35 yo F presents with intermittent DIZZINESS DDX
episodes of vertigo, tinnitus, nausea, - Ménière's disease*
and hearing loss over the past week - Vestibular neuronitis
- Labyrinthitis
- Benign positional vertigo
- Acoustic neuroma
DIZZINESS WORK-UP
- CBC with diff
- VDRL/RPR (syphilis is a cause of Ménière's disease)
- MRI—brain
73. Ménière's Disease (Dizziness DDX) - Classically presents with episodic vertigo (usually lasting 1-8 hours) and low-frequency
hearing loss
- Tinnitus and a sensation of aural fullness
-Symptoms result from distension of the endolymphatic compartment of the inner ear
- Syphilis and heard trauma are two known causes
74. 55 yo F c/o dizziness for the past day. She feels faint and has severe diarrhea that DIZZINESS DDX
started two days ago. She takes furosemide for her hypertension. - Orthostatic hypotension due to
dehydration (diarrhea, diuretic use)*
- Vestibular neuronitis
- Labyrinthitis
- Vertebrobasilar insufficiency
DIZZINESS WORK-UP
- Orthostatic vital signs
- CBC with diff, Electrolytes
- Stool exam (occult blood, fecal
leukocytes)
75. Orthostatic hypotension due to dehydration (diarrhea, diuretic use) (Dizziness DDX) - Risk factors = diuretics and diarrhea
76. 65 yo M presents with postural dizziness and unsteadiness. He has hypertension and DIZZINESS DDX
was started on hydrochlorothiazide two days ago. - Drug-induced orthostatic hypotension*
- Labyrinthitis
- Brain stem or cerebellar tumor
- Acute renal failure
DIZZINESS WORK-UP
- Orthostatic vital signs
- CBC with diff, Electrolytes, BUN/Cr
- MRI—brain
77. 44 yo F c/o dizziness on moving her head to the left. She feels that the room is DIZZINESS DDX
spinning around her head. Tilt test results in nystagmus and nausea - Benign positional vertigo*
- Labyrinthitis
- Ménière's Disease
DIZZINESS WORK-UP
- MRI—brain
- Audiogram
- Dix-Hallpike Test
78. Benign Paroxysmal Positional Vertigo (BPPV) (Dizziness DDX) Transient vertigo following changes in head
position but is not associated with hearing
loss
79. 55 yo F c/o dizziness that started this morning. She is nauseated and has vomited DIZZINESS DDX
once in the past day. She had a URI two days ago and has experienced no hearing - Vestibular neuronitis*
loss. - Labyrinthitis
- Ménière's disease
- Vertigo associated with cervical spine
disease/injury
DIZZINESS WORK-UP
- Electronystagmography
- MRI/MRA—brain
80. Vestibular Neuronitis (Dizziness DDX) - Can be a paroxysmal, single attack of vertigo, a series of
attacks, or a persistent condition which diminishes over two
weeks.
- Associated with nausea, vomiting, and previous upper
respiratory tract infections
- NO Hearing Loss - Generally has no auditory symptoms, unlike
labyrinthitis.
- May also be associated with eye nystagmus.
- Due to inflammation of the vestibular nerve, the nerve that
connects the inner ear to the brain.
81. 55 yo F c/o dizziness that started this morning and of "not DIZZINESS DDX
hearing well." She feels nauseated and has vomited once in the - Labyrinthitis*
past day. She had a URI two days ago. - Vestibular neuronitis
- Ménière's disease
- Acoustic Neuroma
DIZZINESS WORK-UP
- Audiogram
- Electronystagmography
- MRI/MRA—brain
82. Labyrinthitis (Dizziness DDX) - Frequently follows viral infection (usually URI) and is
accompanied by hearing loss and tinnitus,, but vertigo is usually
continuous and lasts several days to a week
- HEARING LOSS
83. Acoustic Neuroma (Dizziness DDX) - More commonly causes continuous dysequilibrium rather than
episodic vertigo
- Central lesions are unlikely in patients with vertigo, hearing loss
and an otherwise normal neurological exam
- Must r/o intracranial mass lesion in any patient with unilateral
hearing loss
84. Perilymphatic Fistula (Dizziness DDX) - Rare cause of vertigo and sensorineural hearing loss
- Usually resulting from head trauma or extensive barotrauma
- Episodes of vertigo are fleeting, generally lasting seconds
85. Loss of Consciousness (LOC) DDX - Seizure, grand mal
- Vasovagal
- Cardiac arrhythmia
- Drug/orthostatic
- Convulsive syncope
- Aortic stenosis
86. Loss of Consciousness (LOC) Physical Exam • VS: State (or WNL or WNL except...) (no orthostatic changes)
• HEENT: Inspect head, mouth, carotid auscultation and palpation,
thyroid exam
=> NC/AT, PERRLA, EOMI without nystagmus, no papilledema, no
cerumen, TMs normal, mouth and oropharynx normal
=> Supple, No carotid bruits, 2+ carotid pulses with good upstroke
bilaterally, thyroid normal
• Heart Exam: Palpation, Auscultation (orthostatic vital signs)
=> Apical impulse not displaced, RRR, S1, S2 wnl, No murmurs, rubs,
or gallops heard
• Extremities: Palpated peripheral Pulses
=> Symmetric 2_ brachial, radial, and dorsalis pedis pulses bilaterally
• Neuro Exam: Cranial nerves (including fundoscopic exam), Motor
exam, DTRs, cerebellar, Romberg sign, gait, sensory exam
=> CN 2-12 intact grossly; Motor: Strength 5/5 in all muscle groups;
Sensation: Intact to pinprick and soft touch; DTRs, symmetric 2+ in
upper and lower extremities, (-) babinski bilaterally; Cerebellar: (-)
Romberg, finger to nose normal; Gait: Normal;
87. Loss of Consciousness (LOC) Work-Up - CBC with diff
- Electrolytes
- Glucose
- EEG
- MRI
- CT
- ECG
88. 26 yo M presents after falling and losing consciousness at LOSS OF CONSCIOUSNESS DDX
work. He had rhythmic movements of the limbs, bit his - Seizure, grand mal (now called complex tonic-clonic seizure)
tongue, and lost control of his bladder. He was subsequently - Convulsive syncope
confused (as witnessed by his colleagues). - Substance abuse/overdose
- Malingering
- Hypoglycemia
LOSS OF CONSCIOUSNESS WORK-UP

- CBC with diff, Electrolytes, Glucose
- Urine Toxicology
- EEG
- MRI—brain
- CT—head
- LP—CSF analysis
- ECG
89. Seizure Summary
(Syncope/LOC DDX)
- Seizures usually occur unpredictably in a manner unrelated to posture or exertion

- May stem from a variety of causes, including metabolic factors, trauma, vascular factors, and brain tumors
- Tonic -clonic seizures are often accompanied by tongue biting, incontinence, and prolonged confusion or
drowsiness postictally
90. Seizure Types
(Syncope/LOC DDX)
Partial Seizures (Produced by a small area of the brain)

1. Simple (awareness is retained)
1a. Simple Motor = Jerking, muscle rigidity, spasms, head-turning
1b. Simple Sensory = Unusual sensations affecting either the vision, hearing, smell taste, or touch
1c. Simple Psychological = Memory or emotional disturbances
2. Complex (Impairment of awareness) = Automatisms such as lip smacking, chewing, fidgeting, walking and
other repetitive, involuntary but coordinated movements
3. Partial seizure with secondary generalization = Symptoms that are initially associated with a preservation
of consciousness that then evolves into a loss of consciousness and convulsions.
Generalized Seizures (Produced by the entire brain) - 6 Types

1. "Grand Mal" or Generalized tonic-clonic = Unconsciousness, convulsions, muscle rigidity
2. Absence = Brief loss of consciousness
3. Myoclonic = Sporadic (isolated), jerking movements
4. Clonic = Repetitive, jerking movements
5. Tonic = Muscle stiffness, rigidity
6. Atonic = Loss of muscle tone
91. Convulsive Syncope - Seizure-like activity often occurs after syncope and is due to global cerebral hypoperfusion
- There is no EEG correlate and seizure w/u is not required
92. 55 yo M c/o falling after feeling dizzy and unsteady. He experienced LOSS OF CONSCIOUSNESS DDX
transient LOC. He has hypertension and is on numerous - Drug-induced orthostatic hypotension (causing
antihypertensive drugs. syncope)*
- Cardiac arrhythmia
- Syncope (vasovagal, other causes)
- Stroke
- MI
- Pulmonary embolism

- Orthostatic Vital Signs
- CT—head
- ECG
- V/Q Scan
- CTA—Chest with IV contrast
93. Drug-Induced Orthostatic Hypotension (Syncope/LOC DDX) - Anti-hypertensive meds, diuretics, etc.. can cause
orthostatic hypotesnion and syncope
- However, lightheadedness and syncope in this condition is
usually postural (i.e., occurs when getting up from a lying or
seated position), and this patient's orthosttic vital signs were
normal
94. Orthostatic Hypotension (Syncope/LOC DDX) History
- Alcohol ingestion
- Medication as cause
- Dehydration
Physical
- Tachycardia
- Hypotension when standing
- Advanced age
95. Vasovagal Syncope (Syncope/LOC DDX) History
- Emotional, Stressful situation/Pain ( may be due to
excessive vagal tone with resulting hypotension)
- Quick recovery in minutes
- No seizure activity
- Syncope is often heralded by nausea, sweating,

tachycardia, pallor, and feeling "faint" (same mechanism as
posmicturation syncope)
Physical
- Normal vital signs (when recovered)
96. 65 yo M presents after falling and losing consciousness for a few LOSS OF CONSCIOUSNESS DDX
seconds. He had no warning prior to passing out but recently had - Cardiac Arrhythmia (causing syncope)*
palpitations. His past history includes coronary artery bypass - Severe aortic stenosis
grafting (CABG). - Syncope (other causes)
- Seizure

- ECG
- Holter monitoring
- CBC with diff, Electrolytes, Glucose
- Echocardiography
- CT—head
97. Cardiac Arrhythmia (Syncope/LOC - Cardiac syncope typically occurs w/o warning, although a history of palpitations may
DDX) indicate the presence of underlying arrhythmias
- MI/Stroke = Increased risk for developing ventricular tachycardia
- Beta-blockers can contribute to bradyarrhythmia
History
- Palpitations
- Chest discomfort
- Shortness of breath
- Medication history
Physical
- Abnormal heart rate
- Irregular heartbear
98. Aortic Stenosis (Syncope/LOC DDX) - Commonly exertional or postecertional and occur w/o warning
History
- Anginal chest discomfort
- Family history of same
Physical
- Age 60 and up
- Narrow pulse pressure
- Displaced PMI
99. Hypertrophic Cardiomyopathy - Commonly exertional or postecertional and occur w/o warning
(Syncope/LOC DDX) History
- Palpitations
- Dizziness
- Younger athlete
- Family history
- Occurs with exercise
Physical Exam
- Heart Murmur
100. Numbness/Weakness DDX - TIA
- Stroke
- Guillain Barre
- MS
- DM peripheral
- Myasthenia Gravis
- Todds Paralysis
101. Numbness/Weakness Physical Exam - VSS
- Neuro
- MSS
- Relevant vascular exam
• VS: State (or WNL or WNL except...) (no orthostatic changes)

• HEENT: Inspect head, mouth, carotid auscultation and palpation, thyroid exam
=> NC/AT, Conjunctivae normal, PERRLA, (EOMI without nystagmus,) Fundoscopic exam
normal, red reflex intact, no papilledema;
• Heart Exam: Auscultation, Palpate pulses
=> RRR, S1, S2 wnl, No murmurs, rubs, or gallops heard, Carotid upstroke NL, no bruit. Radial,
Posterior tibial, dorsalis pedis pulse intact 2+ b/l, feet warm
• Neuro Exam: Mental Status Exam, Cranial nerves (including fundoscopic exam), Motor
exam, DTRs, Gait, sensory exam
=> Alert and Oriented x 3, CN 2-12 intact grossly (except ...); Motor: Strength 5/5 in all
muscle groups; Sensation: Intact to pinprick and soft touch; DTRs, symmetric 2+ in upper and
lower extremities, (-) babinski bilaterally; Gait: Normal
102. Numbess/Weakness Work-up - CBC with diff
- Electrolytes
- Glucose
- ECG
- CT (CT—head)
- MRI (MRI—brain)
- Doppler U/S—Carotids
- Echo
- PT/PTT
- EMG/Nerve Conduction Study
- Serum B12
- Tensilon test (MG) - ACH receptor antibodies
103. • What is the lesion?
- TIA → biggest indicator of stroke →
most happen within 2 weeks of TIA
- Stroke - ischemic vs. hemorrhagic
TIA/stroke mimic - seizure, tumor,
subdural, migraine, hypoglycemia
• TIA: sudden, focal neurologic

deficit that resolves in <24 hrs
(WHO); majority <10 - 15 minutes
• Stroke: sudden onset of neurologic

deficit caused by interrupting blood
supply to brain
• What are you going to do? => MRI

104. • Where is the lesion?
- Hemisphere or brainstem
- Symptoms based on vascular territory affected
105. 68 yo M presents following a 20-minute episode of slurred speech, right facial NUMBNESS/WEAKNESS DDX
drooping and numbness, and right hand weakness. His symptoms had totally resolved - Transient Ischemic Attack (TIA)*
by the time he got to the ER. He has a history of hypertension, diabetes mellitus, and - Hypoglycemia
heavy smoking. - Seizure
- Stroke
- Facial nerve palsy
NUMBNESS/WEAKNESS WORK-UP
- CBC with diff, Glucose, Electrolytes
- ECG
- CT—head
- MRI—brain, spine
- Echocardiography
- EEG
106. 68 yo M presents with slurred speech, right facial drooping and numbness, and right
hand weakness. Babinski's sign is present on the right. He has a history of hypertension,
diabetes mellitus, and heavy smoking.
NUMBNESS/WEAKNESS DDX
- Stroke*
- Transient Ischemic Attack (TIA)
- Seizure
- Subdural or epidural hematoma
- CBC with diff, Electrolytes, PT/PTT/INR
- CT—head
- MRI—brain (preferred)
- Echocardiography
107. Signs and Symptoms of Stoke
(Numbness/Weakness DDX)
Five Warning Signs:

1. Sudden Severe Headache → no apparent reason
2. Sudden weakness → Numbness and/or tingling in face, arm, or leg
3. Sudden dizziness → unsteadiness or sudden falls, especially with any of the other warning
signs
4. Sudden vision trouble → sudden loss of vision (sight), particularly in one eye, or double
vision
5. Sudden Speech trouble → Temporary loss of speech or trouble understanding speech
108. 33 yo F presents with ascending NUMBNESS/WEAKNESS DDX
loss of strength in her lower legs - Guillain-Barré Syndrome (GBS)*
over the past two weeks. She had a - Multiple Sclerosis (MS)
recent URI. - Polymyositis
- Myasthenia Gravis (MG)
- Peripheral Neuropathy
- Tumor in the vertebral canal
- CBC with diff, Electrolytes, CPK, Serum B12
- LP—CSF analysis
- MRI— spine
- Tensilon Test
109. Guillain-Barré Syndrome (GBS)
(Numbness/Weakness DDX)
- Acute, autoimmune, polyradiculoneuropathy affecting the peripheral nervous system, usually

triggered by an acute infectious process.
- Several types of GBS, but unless otherwise stated, GBS refers to the most common form,
acute inflammatory demyelinating polyneuropathy (AIDP). - Severe and usually ascending
paralysis starting with lower limb (legs) weakness that ascends to upper limbs and face along
with complete loss of DTRs.
- Tx = plasmapheresis followed by immunoglobulins and supportive care (ventilator b/c death
may occur if severe pulmonary complications and dysautonomia are present)
110. 30 yo F presents with weakness, loss of sensation, and tingling in her left leg that
started this morning. She is also experiencing right eye pain, decreased vision, and
double vision. She reports feeling "electric shocks" down her spine upon flexing her
head.
NUMBNESS/WEAKNESS DDX
- Multiple Sclerosis (MS)*
- Stroke
- Conversion Disorder
- Malingering
- CNS Tumor
- Neurosyphillis
- Syringomyelia
- CNS Vasculitis
- CBC with diff, EST, VDRL/RPR
- MRI— brain
- LP—CSF analysis
- Retinal evoked potentials
111. Multiple Sclerosis (MS) (Numbness/Weakness DDX)
- Nervous system disease that affects

brain and spinal
cord
- Damages the myelin sheath, the
material that surrounds and protects
your nerve cells
- Damage slows down or blocks
messages between your brain and your
body, leading to the symptoms of MS
112. 55 yo M presents with tingling and numbness in the hands and NUMBNESS/WEAKNESS DDX
feet (glove and-stocking distribution) over the past two months. - Diabetic Peripheral Neuropathy*
He has a history of diabetes mellitus, hypertension, and - Alcoholic Peripheral Neuropathy
alcoholism. There is decreased soft touch, vibratory, and position - Vitamin B12 deficiency
sense in the feet. - Hypocalcemia
- Hyperventilation
- Paraproteinemia/Myeloma
- CBC with diff, HbA1c, ESR, Calcium, Serum B12
- Urinary Analysis
- Serum and urine protein electrophoresis
113. Diabetic Peripheral Neuropathy (Numbness/Weakness DDX)
- Sumptoms = burning foot paresthesias, that are worse at night

and loss of ankle reflexes
- Neuropathic disorders associated with diabetes mellitus.
- Presumed to be as a result from diabetic microvascular injury
involving small blood vessels that supply nerves (vasa
nervorum)
- Relatively common conditions which may be associated with
diabetic neuropathy include third nerve palsy;
mononeuropathy; mononeuropathy multiplex; diabetic
amyotrophy; a painful polyneuropathy; autonomic neuropathy;
and thoracoabdominal neuropathy.
114. 40 yo F presents with occasional double vision and droopy NUMBNESS/WEAKNESS DDX
eyelids at night with normalization by morning. - Myasthenia Sravis (MG)*
- Horner's Syndrome
- Multiple Sclerosis (MS)
- Intracranial Tumor Compressing CN III, IV, or VI
- Amyotrophic Lateral Sclerosis (ALS) or Lou Gehrig's Disease
- Tensilon test
- ACh Receptor Antibodies (in serum)
- CXR
- CT—chest
- MRI—brain
- EMG
115. Myasthenia Gravis (MG) (Numbness/Weakness
DDX)
- Neuromuscular disease leading to fluctuating muscle weakness and

fatiguability
- Autoimmune disorder → weakness d/t circulating antibodies that block AChR
at post-synaptic neuromuscular junction → inhibit ACh NT stim effect
- Treated medically with cholinesterase inhibitors or immunosuppressants, and,
in selected cases, thymectomy
116. 25 yo M presents with hemiparesis (after a tonic- NUMBNESS/WEAKNESS DDX
clonic seizure) that resolves over a few hours. - Todd's paralysis
- TIA
- Stroke
- Complicated Migraine
- Malingering
- EEG
- MRI—brain
- Doppler U/S—Carotid
117. Todd's Paralysis (Numbness/Weakness DDX) - Focal weakness in a part of body after a seizure.
- Weakness typically affects appendages and is localized to either the left or
right side of the body.
- Usually subsides completely within 48 hours
- Todd's paresis may also affect speech, eye position (gaze) or vision.
118. Peripheral Neuropathies
119. Neuromuscular Junction Disorders

120. Fatigue/Sleepiness DDX - Depression
- Post-Traumatic Stress Disorder(PTSD)
- Colon Cancer
- Hypothyroid
- Obstructive Sleep Apnea (OSA)
- Diabetes Mellitus (DM)
- Sleep deprivation
121. Fatigue/Sleepiness Physical Exam - VS
- ENT exam (conjunctival pallor, oropharynx/palate,
lymphadenopathy, thyroid exam)
- Heart
- Chest
- Abdominal
- Neurological
- Extremity (pallor, coolness at distal extremities) exams
- Consider rectal exam and occult blood testing

• HEENT exam (conjunctival pallor, oropharynx/palate,
lymphadenopathy, thyroid exam): => No Conjunctival pallor,
mouth and pharynx wnl
• Neck: No lymphadenopathy, thyroid normal
=> Clear breath sounds bilaterally/Clear breath sounds
bilaterally
• Heart Exam: Auscultation
Abdomen Exam: Auscultation, Palpation, Percussion
=> Soft, nondistended, nontender, +BS, no hepatosplenomegaly
Extremities Exam: No edema, normal DTRs in lower extremities
122. Fatigue/Sleepiness Work-up - CBC with diff
- TSH/Free T4 (FT4)
- HIV/STD
- Glucose/HbA1c
- Urine Analysis
123. 40 yo F c/o feeling tired, hopeless, and worthless and of having FATIGUE AND SLEEPINESS DDX
suicidal thoughts. She recently discovered that her husband is - Depression (Major Depressive Disorder (MDD))*
homosexual - Adjustment disorder
- Hypothyroidism
- Anemia
FATIGUE AND SLEEPINESS WORK-UP

- HIV/STD testing (given husband's possible risk factors)
124. 44 yo M presents with fatigue, insomnia, and nightmares about a murder that FATIGUE AND SLEEPINESS
he witnessed in a mall one year ago. Since then, he has avoided that mall and - Post-Traumatic Stress Disorder (PTSD)*
has not gone out at night. - Depression (Major Depressive Disorder (MDD))
- Generalized Anxiety Disorder (GAD)
- Psychotic or delusional disorder
- Hypothyroidism

- CBC with diff, TSH, Calcium
- Urine Toxicology
125. Post-Traumatic Stress Disorder (PTSD) (Fatigue/Sleepiness DDX)
TRAUMA
T - Traumatic event exposure
R - Re-experience (1+)
A - Avoidance (3+)
U - Unable to function
M - Month or more of symptoms
A - Arousal increased (2+)
126. Generalized Anxiety Disorder (GAD) (Fatigue/Sleepiness DDX)
Worry WARTS
- Wound up
- Worn-out
- Absent minded
- Restless
- Touchy
- Sleepless
127. Adjustment Disorder (Fatigue/Sleepiness DDX) - Stress-related, short-term, nonpsychotic
disturbance
- Disproportionately overwhelmed or overly
intense in their responses to given stimuli (divorce,
new baby, move etc...)
- Begins w/in 3 months of stressor and symptoms
lessen within 6 months upon stressor removal or
new adaptation occurs
128. 55 yo M presents with fatigue, weight loss, and constipation. FATIGUE AND SLEEPINESS DDX
He has a family history of colon cancer - Colon cancer*
- Hypothyroidism
- Renal failure
- Hypercalcemia
- Depression (Major Depressive Disorder (MDD))

- Rectal exam, stool for occult blood
- CBC with diff, Electrolytes, Calcium, BUN/Cr, LFTs-AST/ALT, TSH
- Colonoscopy
- Barium enema
129. Hypercalcemia (Fatigue/Sleepiness DDX)
- Hypercalcemia is a disorder that most commonly results from

malignancy or primary hyperparathyroidism.
- Other causes of ↑ calcium are less common and not considered
until malignancy and PTH disease are r/o
130. 40 yo F presents with fatigue, weight gain, sleepiness, cold FATIGUE AND SLEEPINESS DDX
intolerance, constipation, and dry skin. - Hypothyroidism*
- Depression (Major Depressive Disorder (MDD))
- Diabetes
- Anemia

- TSH, FT3, FT4
- CBC with diff
- Fasting Glucose, HbA1c
131. Hypothyroidism (Fatigue/Sleepiness DDX)
- Usually primary hypothyroidism - ↓ Thyroid hormone

(TH) but secondary = ↓ TSH secreation or tertiary = ↓
TRH secretion
- In USA MCC - Autoimmune thyroid disease =
Hashimoto thyroiditis
• Symptoms/Sings → AABBCDDEEFG H
- Arthralgia and Weakness/ Paresthesias/ Muscle
Cramps → Peripheral Neuropathy and Carpal Tunnel
Syndrome
- Anorexia → Decreased Appetite
- Bowel → Constipation
- Bradycardia → Slow Heart Rate
- Cold Intolerance → Dressed Inappropriately for
Ambient Temperature
- Depressed → Mental Clouding and Impaired
Memory
- Delayed DTRs
- Energy → No Energy/Fatigue (Drowsiness)/
Lethargy→ Somnolence →Uninterested, Immobile
- Eyebrows → Loss /thinning of lateral ⅓
- Facial →Periorbital puffiness
- Gain → Weight Gain
- Hair → Coarse/brittle hair, hair falling out
- Voice Hoarseness
- Swelling of face, hands, and legs
132. 50 yo obese F presents with fatigue and daytime sleepiness. She snores FATIGUE AND SLEEPINESS DDX
heavily and naps 3-4 times per day but never feels refreshed. She also - Obstructive Sleep Apnea (OSA)*
has hypertension. - Hypothyroidism
- Chronic fatigue syndrome
- Narcolepsy

- Nocturnal pulse oximetry
- Polysomnography
- ECG
133. Obstructive Sleep Apnea (OSA)
(Fatigue/Sleepiness DDX)
- Sleep apnea is a common disorder in which you have one or more pauses in breathing or
shallow breaths while you sleep.
- Breathing pauses can last from a few seconds to minutes. They may occur 30 times or more
an hour. Typically, normal breathing then starts again, sometimes with a loud snort or choking
sound.
• Cessation for >10 seconds → ↓ O2 saturation → Episodes of breathing cessation for 10
seconds during sleep, 10 - 15 events per hour with ↓ O2 saturation
o Associated signs → Snoring, gasping, GI reflux (GERD), nocturia, excessive moving, night
sweats, morning headaches, daytime sleepiness, sleep attacks
o Psychological: Slow thought process, memory impairment, inattention
134. 20 yo M presents with fatigue, FATIGUE AND SLEEPINESS DDX
thirst, increased appetite, and - Diabetes Mellitus*
polyuria - Atypical depression
- Primary polydipsia
- Diabetes Insipidus

- Glucose tolerance test, HbA1c
- Urinary Analysis
- CBC with diff, Electrolytes, Glucose, BUN/Cr
135. Diabetes Mellitus
(Fatigue/Sleepiness DDX)
- Polyuria, Polydipsia, Polyphagia** (either DM or DI → DM = glucose in urine, high specific

gravity, DI → dilute urine)
- Metabolic diseases → ↑ blood sugar levels over a prolonged period
- ↑ Blood sugar symptoms = frequent urination, ↑ thirst, and ↑ hunger
- Untreated, diabetes can cause many complications.
- Acute complications include diabetic ketoacidosis and nonketotic hyperosmolar coma.
- Serious long-term complications include heart disease, stroke, kidney failure, foot ulcers and
damage to the eyes.[3]
136. Diabetes Insipidus (DI) (Fatigue/Sleepiness - Excretion of large amounts of severely diluted urine, which cannot be reduced
DDX) when fluid intake is reduced.
- Denotes inability of the kidney to concentrate urine.
- DI is caused by a deficiency of antidiuretic hormone (ADH), aka vasopressin, or by
an insensitivity of the kidneys to that hormone
- It can also be induced iatrogenically by the diuretic conivaptan
137. 35 yo M policeman c/o feeling tired and FATIGUE AND SLEEPINESS DDX
sleepy during the day. He changed to the - Sleep deprivation*
night shift last week. - Sleep apnea
- Depression
- Anemia

- CBC with diff
- Nocturnal pulse oximetry
- Polysomnography
138. Sleep Deprivation (Fatigue/Sleepiness DDX)
Sleep deprivation is a general lack of the necessary amount of sleep. This may occur
as a result of sleep disorders, active choice or deliberate inducement such as in
interrogation or for torture.
139. Night Sweats DDX - Tuberculosis (TB)
- Acute HIV infection
- Lymphoma
- Leukemia
- Hyperthyroid
140. Night Sweats Physical Exam - History of TB exposure

• HEENT: HEENT exam including throat inspection for lymphadenopathy
=> Mouth and pharynx WNL
• Neck Exam: No JVD, no lympadenopathy
=> Clear breath sounds bilaterally/Clear breath sounds bilaterally, no rhonchi, rales,
or wheezing; tactile fremitus normal
• Heart Exam: Palpation, Auscultation
=> Apical impulse not displaced, RRR, S1, S2 wnl, No murmurs, rubs, or gallops heard
• Abd Exam: Palpation, Auscultation
=> Soft, non-distended, non-tender, (+) BS, no hepatosplenomegaly
• Extremities: Inspect
=> No clubbing, cyanosis, or edema
141. Night Sweats Work-Up - PPD
- Chest X-ray (CXR)
- CBC with diff
- Sputum Gram Stain and Acid Fast Stain
- (Bronchoalveolar lavage (BAL))
142. 30 yo M presents with night sweats, cough, NIGHT SWEATS DDX
and swollen glands of one month's duration. - Tuberculosis (TB)*
- Lymphoma
- Leukemia
- Hyperthyroidism
NIGHT SWEATS WORK-UP

- PPD
- CBC with diff, TSH, FT4
- HIV antibody
- Sputum gram stain, acid-fast stain, and culture
143. Tuberculosis (TB) (Night Sweats DDX)
- History: Chronic cough, Hemoptysis, Weight loss, Exposure to TB, Night Sweats
- Physical Exam: Fever, lung findings, low weight
144. Acute HIV Infection (Night Sweats DDX)
• Primary/Acute HIV infection occurs 2 - 4 weeks after infection with the human
immunodeficiency virus (HIV).
• Virus is spread by:
- Breastfeeding (rarely)
- Contaminated blood transfusions and blood products
- Intravenous (IV) drug use with contaminated needles and syringes
- Passing through the placenta from the mother to the fetus
- Sexual contact
• HIV seroconversion (converting from HIV negative to HIV positive [HIV Abs
detected in blood]), occurs w/in 3 months of exposure (can be up to 1 year)
• Following the acute infection, there may be no further evidence of illness for the
next 10 years.
145. Insomnia DDX - Stress
- Caffeine
- Major Depressive
Disorder (MDD)
- Obstructive Sleep
Apnea
146. Insomnia Physical Exam - VS
147. Insomnia Work-Up - Polysomnography
(MSE)
- Urine Toxicology (Urine
Tox)
- CBC with diff
- TSH
148. 25 yo F presents with a three-week history INSOMNIA DDX
of difficulty falling asleep. She sleeps 7 hours per night without nightmares or snoring. She recently - Stress-induced
began college and is having trouble with her boyfriend. She drinks 3-4 cups of coffee a day. Insomnia*
- Caffeine-induced
Insomnia
- Insomnia with Circadian
Rhythm Sleep Disorder
- Insomnia related to
Major Depressive
Disorder*
INSOMNIA WORK-UP
- Polysomnography
- Urine toxicology
149. 55 yo obese M presents with several months of poor sleep and daytime fatigue. His wife reports that INSOMNIA DDX
he snores loudly. - Obstructive Sleep
Apnea (OSA)*
- Daytime fatigue in
Primary Hypersomnia
- Insomnia with Circadian
Rhythm Sleep Disorder
- Insomnia related to
Major Depressive
Disorder*
INSOMNIA WORK-UP
- Polysomnography
- ECG
150. 33 yo F c/o three weeks of fatigue and trouble sleeping. She states that INSOMNIA DDX
she falls asleep easily but wakes up at 3 AM and cannot return to sleep. - Insomnia related to Major Depressive Disorder*
She also reports an unintentional weight loss of 3.5 kg along with an - Primary Hypersomnia
inability to enjoy the things she once liked to do. - Insomnia with Circadian Rhythm Sleep Disorder
INSOMNIA WORK-UP
- Polysomnography
151. Insomnia
• State of hyperarousal
• CC = Dissatisfaction with sleep quantity or quality,
associated with ≥1 following symptoms:
- Difficulty initiating sleep. (In children, this may manifest
as difficulty initiating sleep without caregiver
intervention.)
- Difficulty maintaining sleep, characterized by frequent
awakenings or problems returning to sleep after
awakenings. (In children, this may manifest as difficulty
returning to sleep without caregiver intervention.)
- Early-morning awakening with inability to return to
sleep.
- ≥ 3 nights per a week for ≥ 3 months with adequate
opportunity to sleep
- Caffeine0induced insomina = MC pharm cause of
insomnia
- People w/ OSA, >50% complain of insomnia sx
152. Sore Throat DDX - Infectious mononucleosis
- Pharyngitis (bacterial (strep) or viral)
- Streptococcal tonsillitis/scarlet fever
- Atypical Pneumonia (Mycoplasma pneumonia)
153. Sore Throat Physical Exam • VS: State (or WNL or WNL except...)
• HEENT exam → examine nose, mouth, throat,
lymphnodes, check for sinus tenderness →
oral thrush, tonsillar exuddate and
lymphadenopathy
=> Nose, mouth, and pharynx wnl
• Neck: Supple, No lymphadenopathy
• Chest Exam: Auscultation => Clear breath
sounds bilaterally/Clear breath sounds
bilaterally
• Heart Exam: Auscultation => RRR, S1, S2 wnl,
No murmurs, rubs, or gallops heard
Abdomen Exam: Auscultation, Palpation,
Percussion => Soft, nondistended, nontender,
+BS, no hepatosplenomegaly
Skin/Lymph Node Exam: Inspect for rashes,
lesions, lymphadenopathy => No rash or
lymphadenopathy
154. 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
155. 26 yo F presents with sore throat, fever, severe fatigue, and loss of appetite for SORE THROAT DDX
the past week. She also reports epigastric and LUQ discomfort. She has cervical - Infectious Mononucleosis*
lymphadenopathy and a rash. Her boyfriend recently experienced similar - Hepatitis
symptoms. - Viral or Bacterial Pharyngitis
- Acute HIV Infection
- Secondary Syphilis
SORE THROAT WORK-UP

- CBC, peripheral smear
- Monospot test
- Throat culture
- AST/ALT/bilirubin/alkaline phosphatase
- HIV antibody and viral load
- Anti-EBV antibodies
VDRL/RPR
156. Infectious Mononucleosis (Sore Throat DDX)
- MC in adolescents and young adults

- Sx = Teen w/ fever, sore throat, muscle soreness, malaise, and fatigue.
→ Central sx = Fatigue, Malaise, Appetite loss, Headache
→ Visual sx = Photophobia
→ Tonsils sx = Erythema, Swelling, White patches
→ Throat sx = Erythema and Soreness
→ Lymph nodes sx = Swelling
→ Respiratory sx = Cough
→ Spleen sx = Enlargement, LUQ Abdominal pain
→ Gastric sx = Nausea
→ Systemic sx = Chills, Fever, and Aches
- ~90% of people will acquire EBV no symptoms

- Mononucleosis is usually caused by the Epstein-Barr virus (EBV), which infects B
cells (B-lymphocytes), producing a reactive lymphocytosis and atypical T cells (T-
lymphocytes) known as Downey bodies.
157. 26 yo M presents with sore throat, fever, rash, SORE THROAT DDX
and weight loss. He has a history of IV drug - HIV, Acute Retroviral Syndrome*
abuse and sharing needles. - Infectious Mononucleosis
- Hepatitis
- Viral Pharyngitis
- Streptococcal Tonsillitis/ Scarlet Fever
- Secondary syphilis
SORE THROAT WORK-UP

- CBC, peripheral smear
- HIV antibody and viral load, CD4 count
- Monospot test
- Throat culture
- Anti-EBV antibodies
- VDRL/RPR
158. Strep Tonsillitis/ Scarlet
Fever (Sore Throat DDX)
• Caused by an exotoxin released by Streptococcus pyogenes Group A

• Presentation = sore throat, fever, a 'strawberry' tongue, and a fine sandpaper rash over upper (or
entire) body
- Day 1 = Abrupt onset → Sore throat, reddened fauces, Punctate, bright red rash on hard palate =
Coated "strawberry tongue"
- Day 2 = Polymorphonuclear leukocytosis. Eosionphiles increased
- Day 3 = Flushed cheeks, Punctate blush over neck and chest spreading to entire body. Rash is fine,
red, w/ rough-textures, blanches; Pastia lines in armpits and goin, appear (can last after rash gone)
- Day 4 = Desquamation (peeling) begins
• Scarlet Fever ≠ Rheumatic Fever, but may progress into RF.

• Treat with Penicillin G or Clindamycin to prevent RF (will not prevent post-streptococcal
glomerulonephritis)
159. 46 yo F presents with fever SORE THROAT DDX
and sore throat. - Pharyngitis (bacterial or viral)*
- Atypical Pneumonia/Mycoplasma Pneumonia
- Infectious Mononucleosis
SORE THROAT WORK-UP

- Throat swab for culture and rapid streptococcal antigen
- Monospot test
- CBC with diff
- HIV antibody and viral load, CD4 count
160. Pharyngitis (bacterial
(strep) or viral) (Sore Throat
DDX)
- Painful inflammation of pharynx, and is colloquially referred to as a sore throat.

- Infection of the tonsils (tonsillitis) and/or larynx (laryngitis) may occur simultaneously.
- ~90% of cases are caused by viral infection, with the rest d/t bacterial infection and, in rare cases,
oral thrush (fungal candidiasis e.g. in babies).
- Some cases of pharyngitis are caused by irritation from elements such as pollutants or chemical
substances.
161. 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
162. Cough/Shortness of Breath (SOB) Physical Exam • VS: State (or WNL or WNL except...)
• 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
• Extremities: Inspect
=> No cyanosis, or edema
163. 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
164. 30 yo M presents with shortness of breath, cough, COUGH/SHORTNESS OF BREATH DDX
and wheezing that worsen in cold air. He has had - Asthma*
several such episodes over the past 4 months. - GERD
- Bronchitis
- Pneumonitis
- Foreign body
COUGH/SHORTNESS OF BREATH WORK-UP

- CBC with diff
- Chest X-ray (CXR)
- PFT's
- Methacholine Challenge Test
165. Asthma (Cough/SOB DDX)
• Chronic inﬂammatory disease of the airways

characterized by hyper-responsiveness, mucosal edema,
and mucus production.
• Recurrent episodes sx = cough, chest tightness,
wheezing, and dyspnea
• History: Recurrent attachs of dyspnea, cough,
wheezing, Hx or FH of asthma
• Physical: Wheezing (Expiratory high-pitched whistling
sound made during breathing)
166. Exercise Induced Asthma (Cough/SOB DDX) • During normal breathing via nose → warms and
moistens air
• When exercise breathe via mouth → inhale colder and
drier air
• Exercise-induced asthma, muscle bands around airways
sensitive to these changes in temperature and humidity
→ contract → airway narrows
• Sx begin 5 - 20 min after exercise started and stop 5 -
10 min after exercise stopped → Sx =
- Coughing with asthma
- Tightening of the chest
- Wheezing
- Unusual fatigue while exercising
- SOB when exercising
167. 56 yo F presents with shortness of breath as well as with a productive COUGH/SHORTNESS OF BREATH DDX
cough that has occurred over the past two years for at least three - COPD—chronic bronchitis*
months each year. She is a heavy smoker. - Bronchiectasis
- Lung cancer/neoplasm
- Tuberculosis (TB)

- CBC with diff
- Sputum Gram stain and culture
- Chest X-ray (CXR)
- PFT's
- CT—chest
- PPD
168. 55 yo M presents with increased dyspnea and sputum COUGH/SHORTNESS OF BREATH DDX
production over the past 3 days. He has COPD and - COPD exacerbation (bronchitis)*
stopped using his inhalers last week. He also stopped - Lung cancer/neoplasm
smoking two days ago. - Pneumonia
- Upper Respiratory Infection (URI)
- CHF

- CBC with diff
- Chest X-ray (CXR)
- PFT's
- CT—chest
169. Chronic Obstructive Pulmonary Disease (COPD) -
Chronic Bronchitis (Cough/SOB DDX)
- Common preventable and treatable disease → characterized by

persistent airflow, limitation that is usually progressive and associated
with an enhanced chronic inflammatory response in the airways and the
lung to noxious particles or gases.
- History: Dyspnea, Cough, Weight loss, Pursed lip breathing, Chronic

condition, Smoking history
- Physical: Rales in lungs, Gallop heart rhythm, Distended neck vein,
Distended liver
- COPD exacerbation have ↑ sputum production and cough

170. 58 yo M presents with pleuritic chest pain, fever, chills, COUGH/SHORTNESS OF BREATH DDX
and cough with purulent yellow sputum. He is a heavy - Pneumonia*
smoker with COPD. - Bronchitis
- Lung abscess
- Lung cancer
- Tuberculosis
- Pericarditis

- CBC with diff
- Chest X-ray (CXR)
- CT—chest
- ECG
- PPD
171. Pneumonia (Cough/SOB DDX)
- Classical bacterial pneumonia begins with abrupt onset of fever,

chills, pleuritic chest pain and productive cough (sputum production)
- Pleuritic pain may signal lower respiratory tract infection (diagnosis
confirmed via chest exam)
- Physical Exam: Fever, dullness to percussion, abnormal breath
sounds, ↑ tactile fremitus
- Signs of pulmonary consolidation on physical exam are absent 2/3s
of time
172. 25 yo F presents with two weeks of a nonproductive cough. COUGH/SHORTNESS OF BREATH
Three weeks ago she had a sore throat and a runny nose. - Atypical pneumonia*
- Reactive airway disease
- URI-associated ("postinfectious")
- Postnasal drip
- GERD

- CBC with diff
- Induced Sputum Gram stain and culture
- IgM detection for Mycoplasma pneumoniae
- Urine Legionella antigen
173. Atypical Pneumonia (Sore Throat • Anyone at any age can get walking pneumonia.
or Cough/SOB DDX) • Caused by Mycoplasma pneumoniae, Chlamydia pneumoniae, Legionella species
• M. pneumoniae is a common cause of mild pneumonia that usually affects people younger
than 40
• People who live and work in crowded places, i.e. schools, homeless shelters, prisons →
↑ risk contracting it
• Spread via resp. droplets → sx appear 15 - 25d after exposure to mycoplasma and develop
slowly over 2 - 4 days
• Symptoms include:
- Non-Productive Cough → may come in violent spasms but produce very little mucus
- Fever, Malaise Headache, Myalgia → Mild flu-like symptoms such as fever and chills
- Sore throat/Hoarseness
- Headache
- Tiredness
- Chest pain
- Lingering weakness may persist after other sx gone
- Sputum may be blood-streaked

- GI sx prominent in Legionella infection
- Severe ear pain d/t bullous myringitis may complicate up to 5% of Mycoplasma infections
174. URI-Associated Cough - Acute cough frequently follows URI ("postinfectious") and can commonly persist for 1-2 weeks
(Cough/SOB DDX) (or up to 6-8 weeks in patients with underlying asthma)
- Causes range form rhinosinusitis to acute bronchitis
175. Pleurodynia (Cough/SOB DDX) - Uncommon acute illness usually caused by one of the coxsackieviruses
- Occurs in summer and early fall and presents with acute severe paroxysmal pain of thorax or
abdomen that worsens with cough or breathing
- Most patients recover within 3 days to 1 week
176. Bronchiectasis (Cough/SOB DDX) - Localized, irreversible dilatation of part of bronchial tree
- Involved bronchi are dilated, inflamed, and easily collapsible, resulting in airflow obstruction
and impaired clearance of secretions
- Associated with a wide range of disorders, usually from necrotizing bacterial infections, i,e,
Staph, Klebsiella sp., or Bordetella pertussis
177. 65 yo M presents with worsening cough over the past 6 months together COUGH/SHORTNESS OF BREATH DDX
with hemoptysis, dyspnea, weakness, and weight loss. He is a heavy - Lung cancer/neoplasm*
smoker. - Tuberculosis
- Lung abscess
- COPD
- Vasculitis (i.e., Wegener's)
- Interstitial lung disease
- CHF

- CBC with diff
- Chest X-ray (CXR)
- CT—chest
- PPD
- Bronchoscopy
178. Lung Cancer/Neoplasm (Cough/SOB DDX)
History: Hx of smoking, Cough, Chest pain, shortness

of breath, hemoptysis
Physical exam: Weight loss, wheezing
179. Lung Abscess (Cough/SOB DDX) - D/t anaerobic bacteria
- Usually associated with gradual onset of fatigue,
fever, night sweats, cough producing a foul-smelling
expectoration, and weight loss
- Evolves over weeks to months
180. 34 yo F nurse presents with worsening cough of 6 weeks' duration together COUGH/SHORTNESS OF BREATH DDX
with weight loss, fatigue, night sweats, and fever. She has a history of - Tuberculosis(
contact with tuberculosis patients at work. - Pneumonia
- Lung abscess
- Vasculitis
- Lymphoma
- Metastatic cancer
- HIV/AIDS
- Sarcoidosis

- CBC with diff
- PPD
- Sputum Grain Stain, Acid-fast stain, and Culture
- Chest X-ray (CXR)
- CT—chest
- Bronchoscopy (Bronchoalveolar lavage (BAL))
- HIV antibody
181. 35 yo M presents with shortness of breath and cough. He has had unprotected COUGH/SHORTNESS OF BREATH DDX
sex with multiple sexual partners and was recently exposed to a patient with - Tuberculosis*
active tuberculosis. - Pneumonia (including Pneumocystis jiroveci)
- Bronchitis
- CHF (cardiomyopathy)
- Asthma

- CBC with diff
- PPD
- Sputum Grain Stain, Acid-fast stain, silver stain
and Culture
- Chest X-ray (CXR)
- HIV antibody
182. 50 yo M presents with a cough that is exacerbated by lying down at night and COUGH/SHORTNESS OF BREATH DDX
improved by propping up on three pillows. He also reports exertional dyspnea. - Congestive Heart Failure (CHF)*
- Cardiac valvular disease
- GERD
- Pulmonary fibrosis
- COPD
- Postnasal drip

- CBC with diff
- Chest X-ray (CXR)
- ECG
- Echocardiography
- PFTs
- BNP
183. Congestive Heart Failure (CHF) (Cough/SOB DDX)
- Heart's function as a pump to deliver oxygen

rich blood to the body is inadequate to meet the
body's needs.
- Congestive heart failure can be caused by
diseases that:
1) Weaken the heart muscle
2 Cause stiffening of the hear muscles
3) ↑ Oxygen demand by body tissue beyond
heart's capability to deliver.
- History: Dyspnea on exertion, pedal edema,

orthopnea, hx of HTN, smoking, coronary
disease
- Physical: Rales in lungs, gallop heart rhythm,
distended neck vein, distended liver
184. Allergic Rhinitis (Chronic Cough DDX) - History: Runny Nose, Itchy watery eyes, recurrent with season
- Physical Exam: Rhinorrhea, Watery eyes, Allergic shiners
185. ACE Inhibitor Use (Chronic Cough DDX) - History: Taking ACE Inhibitor, Dry and non-productive cough
- Physical Exam: No fever, normal lung exam
186. Anemia (SOB DDX)
History: Fatigue, Generalized Weakness

Physical Exam: Pallor
187. Airway Obstruction (SOB DDX) - History: Sudden onset, change to voice, choked on food or denture
Physical Exam: Stridor, Cyanosis
188. Anaphylaxis (SOB DDX)
- History: Acute SOB, Wheezing, Hx of exposure to allergen

- Physical Exam: Hives, Hypotension, Tachypnea, Tachycardia
189. Chest Pain DDX - Myocardial Infarct (MI)
- Sickle Cell Disease - Pulmonary Infract
- Gastroesophageal Reflux Disorder (GERD)
- Angina
- Pericarditis
- Costochodritis
- Pulmonary Embolism (PE)
- Aortic dissection
- Cocaine induced
190. Chest Pain Physical History
Exam - Location, Quality, Severity, Radiation, Duration, Context (exertional, postprandial, positional, coacaine use,
trauma)
- Associated sx (sweating, Nausea, Dyspnea, Palpitations, Sense of doom)
- Exacerbating and alleviating factors (esp meds)
- H/o similar sx, known heart or lung disease, h/o diagnostic testing
- Cardiac risk factors (HTN, DYSL, Smoking, FH of early MI)
- Pulmonary embolism risk factors ( H/o DVT, coagulopathy, malignancy, recent immobilization)
• VS: State (or WNL or WNL except...) +/- BP in both arms

• Neck Exam: JVD, Carotid Auscultation = > No JVD, No bruits
• Chest Exam: Palpation (Chest wall tenderness), Percussion, Auscultation
=> No tenderness, Tactile fremitus normal, Clear breath sounds bilaterally/Clear breath sounds bilaterally, no
rhonchi, rales, or wheezing;
• Heart Exam: Palpation, Auscultation → PMI, heart sounds,
=> Apical impulse not displaced, RRR, S1, S2 wnl, No murmurs, rubs, or gallops heard
=> Soft, non-distended, non-tendere, (+) BS, no hepatosplenomegaly
• Extremities: Inspect, Peripheral pulses, BP in both arms pulses, edema
=> No cyanosis, or edema, peripheral pulses 2+ and symmetric
191. Chest Pain Work-up - ECG
- CPK-MB, Troponin
- Chest X-ray (CXR)
- CBC with diff
- Electrolytes
- Echo
- Barium Swallow
- Upper Endoscopy
192. 60 yo M presents with sudden onset of substernal heavy chest pain that has lasted for CHEST PAIN DDX
30 minutes and radiates to the left arm. The pain is accompanied by dyspnea, - Myocardial infarction (MI)*
diaphoresis, and nausea. He has a history of hypertension, hyperlipidemia, and - GERD
smoking. - Angina
- Costochondritis
- Aortic dissection
- Pericarditis
- Pneumothorax
CHEST PAIN WORK-UP

- ECG
- CPK-MB, troponin
- Chest X-ray (CXR)
- Echocardiography
- Cardiac catherization
193. Myocardial Infarction (MI) (Chest Pain DDX)
History: Substernal chest pain, dyspnea,

nausea, hx of smoking, HTN
Physical Exam: Diaphoresis (list any
abnormal vital signs)
194. Pneumothorax (Chest Pain DDX)
History: Pleuritic unilateral chest pain,

Sudden onset, SOB
Physical Exam: ↑ HR, ↑ RR, ↓ unilateral
breath sounds, ↓ tactile fremitus
195. 20 yo African-American F presents with CHEST PAIN DDX
acute onset of severe chest pain. She has a - Sickle cell disease—pulmonary infarction*
history of sickle cell disease and multiple - Pneumonia
previous hospitalizations for pain and - Pulmonary embolism
anemia management. - MI
- Pneumothorax
- Aortic dissection
CHEST PAIN WORK-UP

- CBC peripheral smear, reticulocyte (retic) count, LDH
- Arterial Blood Gas (ABG)
- Chest X-ray (CXR)
- CPK-MB, Troponin
- ECG
- CT—chest with IV contrast
196. Sickle Cell Pulmonary Infarct (Chest Pain - In sickle cell disease, an initial trigger (often infection) exacerbated by dehydration
DDX) (i.e., d/t fever, tachypnea, or ↓intake) leads to sickling of RBCs within small blood
vessels of lung → precipitates a cycle of relative deoxygenation that further
exacerbates the sickling tendency, leading to small vessel occlusion and, ultimately,
infarction of areas of the pulmonary parenchyma.
- Allied to this sequence is the tendency of many patients with sickle cell disease to
have a component of reactive airways disease, which further decreases oxygenation.
197. Acute Coronary Syndrome (Chest Pain - History: Heavy substernal pressure feeling, shortness of breath, Nausea, Diaphoresis,
DDX) Lasts minutes to starting coupe hours ago
- Physical Exam: Diaphoretic, Abnormal vital signs, No high fever
198. 45 yo F presents with a retrosternal CHEST PAIN DDX
burning sensation that occurs after heavy - GERD*
meals and when lying down. Her - Esophagitis
symptoms are relieved by antacids. - Peptic ulcer disease
- Esophageal spasm
- MI
- Angina
CHEST PAIN WORK-UP

- ECG
- Barium swallow
- Upper endoscopy
- Esophageal pH monitoring
199. Gastroesophageal Reflux Disease (GERD)
(Chest Pain DDX)
History: Heartburn, Sour taste coming up to mouth, Pregnant, Better with Antacids
Physical Exam: No fever, No pleuritic pain, No abdominal pain
Severe chest pain is atypical presentation but not uncommon for GERD and may
worsen with recumbency overnight. Other atypical symptoms may include chronic
cough, wheezing, or dysphagia
- Classic sx of GERD is heartburn, which may be exacerbated by meals
200. 55 yo M presents with retrosternal squeezing CHEST PAIN DDX
pain that lasts for 2 minutes and occurs with - Angina*
exercise. It is relieved by - Esophageal spasm
rest and is not related to food intake. - Esophagitis
CHEST PAIN WORK-UP

- ECG
- CPK-MB, troponin
- Chest X-ray (CXR)
- Exercise stress test
- Upper endoscopy/pH monitor
- Cardiac catheterization
201. Angina (Chest Pain DDX) • Angina pectoris, chest pain d/t ischemia (lack of blood, hence O2 supply) of
heart muscle
- One common form of Angina is chest pain or discomfort that occurs when your
heart isn't getting enough oxygen because of reduced blood flow to heart. It is
usually a symptom of coronary heart disease.
• Abdominal angina, postprandial abdominal pain that occurs in individuals with

insufficient blood flow to meet visceral demands
• Ludwig's angina, a serious, potentially life-threatening infection of the tissues of

floor of mouth
• Prinzmetal's angina, a syndrome typically consisting of cardiac chest pain at rest

that occurs in cycles
• Vincent's angina, trench mouth, infection of the gums leading to inflammation,

bleeding, deep ulceration and necrotic gum tissue
• Angina tonsillaris, an inflammation of the tonsils
• "Angina" (song) is also the name of a single by the Gothic metal band Tristania
202. 34 yo F presents with retrosternal CHEST PAIN DDX
stabbing chest pain that improves when - Pericarditis*
she leans forward and worsens with deep - Aortic dissection
inspiration. She had a URI one week ago. - MI
- Costochondritis
- GERD
- Esophageal rupture
CHEST PAIN WORK-UP

- ECG
- CPK-MB, troponin
- Chest X-ray (CXR)
- Echocardiography
- CBC with diff
- Upper endoscopy
203. Pericarditis (Chest Pain DDX) - Inflammation (-itis) of the pericardium (the fibrous sac
surrounding the heart).
- Pericarditis is further classified according to the
composition of the inflammatory exudate: serous,
purulent, fibrinous, and hemorrhagic types are
distinguished.
- Acute pericarditis is more common than chronic
pericarditis, and can occur as a complication of
infections, immunologic conditions, or heart attack
- History: Pain better sitting up and leaning foward,

Pleuritic pain, Started after viral URI
- Physical Exam: Cardiac rub, Fever
204. 34 yo F presents with stabbing chest pain that worsens with deep CHEST PAIN DDX
inspiration and is relieved by aspirin. She had a URI one week ago. - Costochondritis*
Chest wall tenderness is noted. - Pneumonia
- MI
- Pericarditis
- Muscle strain
CHEST PAIN WORK-UP

- ECG
- CPK-MB, troponin
- Chest X-ray (CXR)
- CBC with diff
- CT—chest with IV contrast
- Doppler U/S—legs
- D-dimer
205. Costochondritis (Chest Pain DDX) - History: Sharp pain, Hurts with movement and twisting
- Physical Exam: Point tenderness causing the pain
206. Herpes Zoster (Chest Pain DDX) - History: Unilateral, paresthesia of skin unilateral
dermatone
- Physical Exam: Unilateral blistering rash on a
dermatome fever
207. 70 yo F presents with acute onset of SOB at rest and pleuritic chest CHEST PAIN DDX
pain. She also presents with tachycardia, hypotension, tachypnea, and - Pulmonary Embolism (PE)*
mild fever. She is recovering from hip replacement surgery. - Pneumonia
- Costochondritis
- MI
- CHF
- Aortic Dissection
CHEST PAIN WORK-UP

- ECG
- Chest X-ray (CXR)
- CPK-MB, troponin
208. Pulmonary Embolism (Chest Pain DDX) - History: Pleuritic Chest pain, SOB, Unilateral swollen
lower left, Hx of DVT in past, Not on warfarin
- Physical Exam: Tachycardia, Tachypnea, No pain to
palpation of chest wall, unilateral swollen leg
209. 55 yo M presents with sudden onset of severe chest pain that CHEST PAIN DDX
radiates to the back. He has a history of uncontrolled - Aortic Dissection*
hypertension. - MI
- Pericarditis
- Esophageal rupture
- Esophageal spasm
- GERD
- Pancreatitis
- Fat embolism
CHEST PAIN DDX

- ECG, CPK-MB, troponin
- Chest X-ray (CXR)
- CBC with diff, amylase, lipase
- Transesophageal echocardiography (TEE),
- MRI/MRA—aorta
- Aortic angiography
- Upper endoscopy
210. Aortic Dissection (Chest Pain DDX) History: Ripping Chest Pain, Sudden onset, Pain may migrate to
neck or back
Physical Exam: Blood pressure difference between arms, Heart
murmur (if aortic insufficiency), pulse differences between sides
211. Acute Cardiovascular Illness (Mycoardial infarction, pulmonary - History: Vomiting, Chest pain, Back pain, SOB
embolism, aortic dissection) - Physical Exam: ↑ RR, Heart murmur, unequal pulse
212. Palpitation DDX - Hypoglycemia
- Cardiac Arrhythmias
- Hyperthyroidism
- Panic Attacks
- Pheochromocytoma
- Carcinoid Syndrome
- Angina
- Hyperventilation Episodes
- Generalized Anxiety Disorder
- Agoraphobia/Social Phobia
- Substance Abuse/Dependence
213. Palpitation Physical Exam • VS: state or WNL (WNL except ___)
• General: No Acute Distress
• Endocrine/Thyroid Exam, including exophtalmos, lid
retraction, lid lag, gland size, bruit, and tremor
• HEENT: => NC/AT, PERRLA, EOMI without nystagmus, no
papilledema, mouth and oropharynx normal
=> Supple, No carotid bruits, 2+ carotid pulses with good
upstroke bilaterally, thyroid normal
• Chest: Auscultation
=> Clear breath sounds bilaterally/Clear breath sounds
bilaterally
• Heart: Auscultations, Palpation
=> Apical impulse not displaced, RRR, S1, S2 wnl, No murmurs,
rubs, or gallops heard
214. Palpitation Work-Up - Glucose
- CBC with diff
- Electrolytes
- TSH
- BUN/Cr
- ECG
215. 70 yo diabetic M presents with episodes of palpitations and diaphoresis. He is on PALPITATIONS DDX
insulin. - Hypoglycemia*
- Cardiac arrhythmias
- Angina
- Hyperthyroidism
- Hyperventilation episodes
- Panic attacks
- Pheochromocytoma
- Carcinoid Syndrome
PALPITATIONS DDX
- Glucose, CBC with diff, Electrolytes, TSH,
BUN/Cr
- ECG
- Holter monitor
216. Hyperthyroidism (Palpitations DDX)
- Hyperthyroidism is a condition caused by an overactive thyroid gland.

- The gland makes too much T4 and T3 hormones.
- Hormones are substances that affect and control many important functions in the body.
• Symptoms
- Heat Intolerance → Excessive sweating and heat intolerance
- Weight Loss → despite ↑ Appetite
- Diarrhea → Frequent bowel movements
- Nervousness
- Emotional Labiality
- Poor Concentration
- Palpitations
- Swelling of Eyes
- Double of Vision
- Weakness and Fatigability
• Signs
- Dressed Inappropriately for Ambient Temperature
- Weight Loss
- Hyperactive
- Fidgety, Restless
- Tremors of hand
- Tachycardia/Afib
- Periorbital Edema
- Opthalmoplegia → Diplopia
- Exopthalmos/Proptosis
- Lid Retraction, Lid Lag
- With Graves' disease, eye signs such as stare, lid lag, and exophthalmos
- Proximal Muscle Weakness
217. 35 yo M presents with several episodes of palpitations, sweating, and rapid breathing. PALPITATIONS DDX
Episodes occur unexpectedly and he does not recall any triggers. He has had 4 - 5 - Panic Attack*
episodes per month for several months. Each episode lasts 2 - 3 minutes. He does not - Generalized Anxiety Disorder
have any history of psychiatric illness except for separation anxiety as a child. - Acute Stress Disorder
- Specific Phobia
- Hyperthyroidism
- Agoraphobia
- Mitral Valve Prolapse
- Pheochromocytoma
PALPITATIONS DDX
- CBC with diff, Electrolytes, TSH, FT4
- ECG
- Echocardiography
- Urine toxicology
218. Panic Attacks (Palpitations DDX)
• PANIC DISORDER with or without

agoraphobia
- Recurrent unexpected panic attacks
- ≥ 1 of the attacks has been followed by
≥ 1 month of ≥ 1 of the following:
(*Anticipatory anxiety)
1. Persistent concern about additional
attacks*
2. Worries about implications of attack
or its consequences*
3. Significant change in behavior related
to the attacks (avoidance)
• Panic Disorder without Agoraphobia

- Recurrent, unexpected panic attacks
- Persistent worry/concern about
additional attacks or their
consequences
• Panic Disorder with Agoraphobia

- Meets criteria for panic disorder
Fear/avoidance of situations where
panic attacks might occur
219. Pheohromocytoma (Palpitations DDX) - Rare catecholamine-secreting
tumor derived from chromaffin
cells.
- Tumors arise outside the adrenal
gland are termed extra-adrenal
pheochromocytomas or
paragangliomas b/c of excessive
catecholamine secretion
- May precipitate life-threatening
hypertension or cardiac
arrhythmias.
- Check Urine catecholamines
220. Carcinoid Syndrome - Serotonin overproduction
- Tumor of serotonin producing
cells in GIT → APUD (Amine
Precursor Uptake Decarboxylase)
Cells
- Slow-growing but often malignant
type of neuroendocrine tumor,
originating in cells of
neuroendocrine system
- Most commonly found in the
foregut (35.6% cases) with lung,
bronchus and trachea constituting
27.9% cases from where they rarely
metastasize (except in case of
pancreas).
- Sx = Cutaneous flushing
accompanied by sweating, GI
hypermotility → causing diarrhea,
Bronchospasm
- Increased 5-HIAA excretion of in
urine
221. 19 yo F presents with episodic palpitations especially during presentations in front of her PALPITATIONS DDX
class. Episodes include heart pounding, facial blushing, and hand shaking. She also states - Specific Phobia*
she experiences excessive sweating and rapid breathing. She complains of intense worry - Avoidant Personality Disorder
and trouble sleeping for days or weeks before upcoming social situation. Now she avoids - Agoraphobia/Specific Phobia
all social events because she is always afraid of humiliating herself. - Panic Attack
- Generalized Anxiety Disorder
-- Hyperthyroidism
PALPITATIONS DDX
- CBC with diff, Electrolytes, TSH,
FT4
- ECG
- Echocardiography
222. Social Phobia (Palpitations DDX) • Marked fear/avoidance of social
situations due to the possibility of
embarrassment or humiliation
223. Weight Loss DDX - Hyperthyroid
- Cancer
- HIV
- Diet
- Drugs
- Anorexia
- Malabsorption
224. Weight Loss Physical Exam • VS: State (or WNL or WNL except...)
• General: No acute distress, Looks ___ (anxious and restless) with ___ (hand
tremors and fidgety)
• HEENT: Inspect eyes, Inspection, palpation, auscultation of thyroid for
lymphadenopathy
=> No conjuctival pallor, No periorbital edema
• Neck Exam: No lymphadenopathy, no thyroid masses
• Heart Exam: Auscultation
• Abd Exam: Inspect, Auscultation, Palpation
=> Soft, non-distended, non-tender, +BS, no hepatosplenomegaly, no
guarding
• Extremities: Inspection → Check for tremor on outstretched fingertips,
look for edema
=> No edema, (No) Tremor on outstretched fingertips
• Skin: Inspection
=> No rashes, palms moist
• Neuro Exam: Look for brisk reflex
=> 2+ reflex b/l (or brist reflec)
225. Weight Loss Work-Up - TSH/Free T4 (FT4)
- CBC with diff
- Electrolytes
- HIV antibody
226. 42 yo F presents with a 7-kg weight loss WEIGHT LOSS DDX
over the past two months. She has a fi ne tremor, and - Hyperthyroidism
her pulse is 112. - Cancer
- HIV infection
- Dieting/diet drugs
- Anorexia nervosa
- Malabsorption
WEIGHT LOSS WORK-UP

- TSH, FT4
- HIV antibody
- Urine toxicology
227. Weight Gain DDX - Smoking cessation
- Drugs (Lithium)
- Hypothyroid
- Cushings Syndrome/Disease/Syndrome
- PCOS
- DM
- Atypical depression
- Familial
- Pregnancy
228. Weight Gain Physical Exam - Vital Signs
- Complete Exam including sings of Cushing syndrome
(hypertension, central obesity, moon face, buffalo hump,
supraclavicular fat pads, purple abdominal striae)
229. Weight Gain Work-Up - CBC with diff
- Electrolytes
- Glucose
- TSH
- 24 hour Free Cortisol
- Dexmatheasone Suppresion Test
230. 44 yo F presents with a weight gain of > 11 kg over the past two months. WEIGHT GAIN DDX
She quit smoking three months ago and is on amitriptyline for - Smoking cessation
depression. She also reports cold intolerance and constipation. - Drug side effect
- Hypothyroidism
- Cushing's syndrome
- Polycystic ovary syndrome
- Diabetes mellitus
- Atypical depression
WEIGHT GAIN WORK-UP

- CBC with diff, electrolytes, glucose, TSH
- 24-hour urine free cortisol
- Dexamethasone suppression test
231. Dysphagia DDX - Esophageal cancer
- Plummer-Vinson
- Achalasia
- Esophagitis
232. Dysphagia DDX Flowchart 1
233. Dysphagia DDX Flowchart 2
234. Dysphagia Physical Exam - Vital Sings

- Head and neck exam
- Lung Exam
- Abdominal Exams
- Skin Exams - for signs of scleroderma/CREST
235. Dysphagia Work-Up - CBC with diff
- Chest X-ray (CXR)
- (Upper) Endoscopy
- Barium Swallow
- CT
236. 75 yo M presents with dysphagia that started with solids and progressed to DYSPHAGIA DDX
liquids. He is an alcoholic and a heavy smoker. He has had an unintentional - Esophageal cancer
weight loss of 7 kg over the past four months. - Achalasia
- Esophagitis
- Systemic sclerosis
- Esophageal stricture
- Amyotrophic Lateral Sclerosis (ALS)
DYSPHAGIA DDX
- CBC with diff
- Chest X-Ray (CXR)
- Endoscopy with biopsy
- Barium swallow
- CT—chest
237. Esophageal Cancer (Dysphagia DDX) • Squamous Cell Carcinoma (SCC).
- More common worldwide → d/t slow passage of
food through esophagus
- Men >50, Asians. Upper 2/3 of esophagus → D/t:
=> Diet (Nitrosamines, ↓Vit. A, riboflavin): ↑ exposure
to carcinogens (tobacco/alcohol)
=> Lifestyle (smoking, etOH),
=> Genetic (celiac, tylosis). p53 mutation (no
KRAS/APC mutations)
=> Esophageal disease (Plummer-Vinson/Patterson
Brown Kelly, achalasia).
- Sx: Dysphagia to solid foods, wt. loss, chest pain,
cough.
- Spreads via LN. Exophytic, infiltrative, excavated
• Adenocarcinoma (ADC).
- More common in US. Median age 50. More
common in whites. Lower 1/3 of esophagus
- All ADC due to Barret's esophagus Assoc'd with
lifestyle (obesity + alcohol)
- Sx: Dysphagia to solid foods, wt. loss, chest pain,
cough.
- Most = mucin producing. Poor prognosis.
- Surveillance in Barrett's esophagus = mandatory
238. 45 yo F presents with dysphagia for two weeks together with fatigue and a DYSPHAGIA
craving for ice and clay - Plummer-Vinson syndrome
- Esophageal cancer
- Esophagitis
- Achalasia
- Mitral valve stenosis
DYSPHAGIA DDX
- CBC with diff
- Serum iron, ferritin, TIBC
- Barium swallow
- Endoscopy
- CT—chest
239. Plummer-Vinson Syndrome (Dysphagia DDX) - Can occurs in people with long-term (chronic)
iron deficiency anemia
- Condition have problems swallowing due to
small, thin growths of tissue that partially block
the upper food pipe (esophagus)
- Difficulty swallowing
- Weakness
- Has been linked to esophageal cancer
240. 48 yo F presents with dysphagia for both solid and liquid foods that has DYSPHAGIA DDX
slowly progressed in severity over the past year. It is associated with - Achalasia
regurgitation of undigested food, especially at night. - Plummer-Vinson syndrome
- Esophageal cancer
- Esophagitis
- Mitral valve stenosis
- Zenker's diverticulum
DYSPHAGIA DDX
- Chest X-Ray (CXR)
- Endoscopy
- Barium swallow
- Esophageal Monometry
241. Achalasia/Cardiospasm (Dysphagia DDX) - Incomplete relax of LES in response to
swallowing → Esophagus dilates above LES
1° - Myenteric plexus (Auerbach) ganglion cells
absent in esophagus → ↓ LES relaxation
2° - Chagas disease: T. cruzi (can also cause acq'd
megacolon) → ↑ LES Tone
CREST syndrome/scleroderma ("E" in CREST =

Esoph. dysmotility)
5% risk of SCC
242. 38 yo M presents with dysphagia and pain on swallowing DYSPHAGIA DDX
solids more than liquids. Exam reveals oral thrush. - Esophagitis (CMV, HSV, pillinduced)
- GERD
- Zenker's diverticulum
DYSPHAGIA DDX
- CBC with diff
- Endoscopy
- Barium swallow
- HIV antibody
- CD4 count
243. Esophagitis (Dysphagia DDX) • Irritation or inflammation of the esophagus
• Can be painful and can make it hard to swallow
• Common symptoms of esophagitis include:
- Heartburn
- Pain when you swallow
- Trouble swallowing food or liquids
- Chest pain (may be similar to the pain of a heart attack)
- A cough.
• Sometimes it also causes:
- Nausea or vomiting
- Fever
- Belly pain
244. Scleroderma/CREST (Dysphagia DDX)
245. Hiatal Hernia (Dysphagia DDX) Herniation of stomach through enlarged esophageal hiatus in
diaphragm.
- 95% Axial/Sliding: Incompetent LES → bell-shaped dilation →
gastric reflux epigastric pain, heart burn, respiratory distress
- 5% Non-axial/Paraesophageal: Greater curvature of stomach
246. Mallory Weiss Syndrome (Dysphagia DDX) - Mucosa: longitudinal Lesions: tears @ esophageal-gastric junction.
Acute.
- Due to severe retching in alcoholics/bulemics.
- Inadequate relaxation of LES during vomiting → stretching/tearing
@ esoph-gastric junction
- PAIN + Hematesis
247. Nausea/Vomiting DDX - Pregnancy
- Gastritis
- Hypercalcemia
- DM
- UTI
- Infection - Gatroenteroritis
- Bowel Obstruction (Large or Small)
248. Nausea/Vomiting Physical Exam - VSS
- ENT, consider fundoscopic exam
(increased intracranial pressure)
- Complete Abdomen exam
- Consider heart, lung, and rectal exam
• VS: State (or WNL or WNL except...) (no

orthostatic changes)
• HEENT: Inspect eyes, carotid auscultation
and palpation, thyroid exam
=> EOMI without diplopia or lid lag; visual
fields full to conffrontation. Fundoscopic
exam normal, red reflex intact, no
papilledema;
• Neck Exam: No thyromegaly
=> Clear breath sounds bilaterally/Clear
breath sounds bilaterally
• Heart Exam: Auscultation, Palpate pulses
=> RRR, S1, S2 wnl, No murmurs, rubs, or
gallops heard
• Abd Exam: Auscultation, Palpate, Percuss
=> Sorft, non-tender, non-distended, + BS,
no hepatosplenomegaly
• Extremities Exam: Inspect
=> No edema, no tremor
• Neuro Exam: Normal DTRs in lower
extremities bilaterally
249. Nausea/Vomiting Work-Up - Urine B-HCG (r/o pregnancy in females)
- CBC with diff
- Electrolytes
- Calcium
- Glucose
- Urine Analysis/Urine Culture
250. 20 yo F presents with nausea, vomiting (especially in the morning), fatigue, and NAUSEA/VOMITING DDX
polyuria. Her last menstrual period was six weeks ago, and her breasts are full and - Pregnancy*
tender. She is sexually active with her boyfriend, and they use condoms for - Gastritis
contraception. - Hypercalcemia
- Diabetes mellitus
- UTI
- Depression
NAUSEA/VOMITING WORK-UP
- Urine hCG
- Pelvic exam
- U/S—pelvis
- CBC with diff, Electrolytes, Calcium,
Glucose
- UA, urine culture
- Baseline Pap smear, cervical cultures,
rubella antibody, HIV antibody, hepatitis B
surface antigen, and VDRL/RPR
251. Abdominal Pain DDX - 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
252. Abdominal Pain Physical - VS
Exam - General
- Chest
- Heart
- Abdomen Complete - including guarding, rebound, Murphy signs, psoas, and obturator signs, and
CVA palpation; rectal exam; pelvic exam (women)
253. Abdominal Pain Work-Up - Rectal Exam
- BUN/Cr
- CBC with diff
- Electrolytes
- Amylase, Lipase
- Ultrasound (U/S) Abdomen
- CT Abdomen
- Viral Hepatitis Serologies
254. Abdominal Pain DDX
Location Quadrants
255. Abdominal Pain DDX Location 3x3
256. Perotinitis
257. 45 yo M presents with sudden onset of colicky right-sided flank pain that radiates to ABDOMINAL PAIN DDX
the testicles, accompanied by nausea, vomiting, hematuria, and CVA tenderness. - Nephrolithiasis
- Renal cell carcinoma
- Pyelonephritis
- GI etiology (e.g., appendicitis)
ABDOMINAL PAIN WORK-UP

- Rectal Exam
- Urinary Analysis
- Urine Culture and sensitivity
- CBC with diff, BUN/Cr
- CT—abdomen
- U/S—renal
- IVP
258. Abdominal Pain DDX by Location Table
259. Common Causes of Common GI Symptoms

260. Nephrolithiasis (Abd Pain DDX) - Sudden onset, very severe and colicky (intermittent), not
improved by changes in position, radiating from the back,
down the flank, and into the groin.
- Severe colicky pain, can't get comfortable
- Pain may be felt in the belly area or side of the back.
- Pain may move to groin area (groin pain) or testicles
(testicle pain).
- Other symptoms can include:
--> Abnormal urine color
--> Blood in the urine
--> Chills
--> Fever
--> Nausea
--> Vomiting
Pyelonephritis = ascending UTI that reached kidney's pyelum

(pelvis) --> severe infection = urosepsis
--> form of nephritis. It can also be called pyelitis
261. 60 yo M presents with dull epigastric pain that radiates to the ABDOMINAL PAIN DDX
back, together with weight loss, dark urine, and clay-colored stool. - Acute pancreatitis*
He is a heavy drinker and smoker. - Peptic ulcer disease
- Cholecystitis/choledocholithiasis
- Gastritis
- Abdominal aortic aneurysm
- Mesenteric ischemia
- Alcoholic hepatitis
- Mallory-Weiss tear

- Rectal exam
- CBC with diff, electrolytes, BUN/Cr,
- Amylase, lipase, AST/ALT/bilirubin/ alkaline phosphatase
- U/S—abdomen
- CT—abdomen
262. Pancreatic Cancer (Ab Pain DDX)
- Upper abdominal pain that may radiate to your back

- Bloating. Some people with pancreatic cancer have a sense
of early fullness with meals (satiety) or an uncomfortable
swelling in the abdomen.
- Nausea
- Diarrhea
- Pale-colored stools. If the duct draining bile into the
intestine is blocked by pancreatic cancer, the stools may lose
their brown color and become pale or clay-colored. Urine
may become darker.
- Yellowing of your skin and the whites of your eyes

( jaundice)
- Itching => blockage of bile ducts response
- Loss of appetite
- Weight loss
- Depression
- Blood clots
- Elevated blood sugars. Some people with pancreatic cancer
develop diabetes since cancer impairs the pancreas' ability to
produce insulin (not all new onset of diabetes = pancreatic
cancer)
263. 56 yo M presents with severe ABDOMINAL PAIN DDX
midepigastric abdominal pain that radiates to the back and - Acute pancreatitis* (Epigastric and RUQ pain & tenderness,
improves when he leans forward. He also reports anorexia, hx of alcoholism, hx of gallstones)
nausea, and vomiting. He is an alcoholic and has spent the past - Peptic ulcer disease
three days binge drinking. - Cholecystitis/choledocholithiasis
- Gastritis
- Alcoholic hepatitis

- Rectal exam
- CBC with diff, electrolytes, BUN/Cr,
- Amylase, lipase, AST/ALT/bilirubin/ alkaline phosphatase
- U/S—abdomen
- CT—abdomen
- Upper endoscopy
- ECG
264. Acute Pancreatitis (Ab Pain DDX) - Severe epigastric pain (upper left side
or middle abdomen pain) radiating to the
back
→ May be worse few minutes w/in
eating/drinking esp. high fat content
→ May radiate to back and below left
shoulder
- Nausea /Vomiting
- Loss of appetite
- Fever/- Chills (shivering)
- Clay colored stools
- Gaseous abdominal fullness
- Hiccups/- Indigestion
- Mild yellowing of the skin and whites of
the eyes ( jaundice)
- Swollen abdomen/- Peritonitis
- Grey-Turner's sign (hemorrhagic
discoloration of the flanks)
- Cullen's sign (hemorrhagic discoloration
of the umbilicus)
265. 41 yo obese F presents with RUQ abdominal pain that radiates to the right scapula
and is associated with nausea,
vomiting, and a fever of 101.5°F. The pain started after she had eaten fatty food. She
has had similar but less intense episodes that lasted a few hours. Exam reveals
positive Murphy's sign.
ABDOMINAL PAIN
- Acute cholecystitis* (RUQ pain radiates
to R Scapula, fever, (+) Murphy's Sign,
tender RUQ)
- Biliary Colic (Intermittent RUQ pain, last
several hours, s/p fatty meal, no fever,
tender RUQ)
- Hepatitis
- Choledocholithiasis
- Ascending cholangitis
- Peptic ulcer disease
- Fitz-Hugh-Curtis syndrome

- Rectal Exam
- CBC
- AST/ALT/bilirubin/alkaline
phosphatase
- U/S—abdomen
- HIDA scan
266. 43 yo obese F presents with RUQ abdominal pain, fever, and
jaundice. She was diagnosed with asymptomatic
gallstones one year ago.
ABDOMINAL PAIN DDX

- Ascending cholangitis*
- Acute cholecystitis
- Hepatitis
- Choledocholithiasis (stones within the hepatic or common bile
duct - jaundice and liver damage )
- Sclerosing cholangitis
- Fitz-Hugh-Curtis syndrome

- Rectal exam
- CBC with diff
phosphatase
- Viral hepatitis serologies
- U/S—abdomen
- MRCP
- ERCP
267. 25 yo M presents with RUQ pain, fever, anorexia, nausea, and
vomiting. He has dark urine and clay-colored stool.
ABDOMINAL PAIN DDX

- Acute hepatitis* (Fever, Jaundice, RUQ pain, tender enlated liver,
(-) Murphy's Sign, Fever, Hep virus exposure behavior)
- Acute cholecystitis
- Ascending cholangitis
- Pancreatitis
- Acute glomerulonephritis

- Rectal exam
- CBC with diff, amylase, lipase
AST/ALT/bilirubin/alkaline
phosphatase
- Urinary Analysis
- U/S—abdomen
268. 35 yo M presents with burning epigastric pain that starts 2-3 hours after meals.
The pain is relieved by food and antacids.
ABDOMINAL PAIN DDX

- Peptic ulcer disease* (Epigastric RUQ pain,
taking aspiring/NSAIDs, blood in stool, pain
may radiate to back)
- Gastritis
- GERD
- Cholecystitis
- Chronic pancreatitis

- Rectal exam
- Amylase, lipase, lactate
phosphatase
- Endoscopy (including H. pylori
testing)
- Upper GI series
269. 37 yo M presents with severe epigastric pain, nausea, vomiting, and mild fever. ABDOMINAL PAIN DDX
He appears toxic. He has a history of intermittent epigastric pain that is relieved - Peptic ulcer perforation*
by food and antacids. He also smokes heavily and takes aspirin on a - Acute pancreatitis
regular basis. - Hepatitis
- Cholecystitis

- Rectal exam
- CBC with diff, electrolytes, amylase, lipase,
lactate
phosphatase
- AXR
- Upright CXR
- Endoscopy (including H. pylori testing)
270. Peptic Ulcer Perforation (Ab Pain DDX) - First sign is often sudden intense abdominal
pain
- Perforation at anterior surface of stomach
leads to acute peritonitis, → initially chemical
and later bacterial peritonitis
- Posterior wall perforation leads to bleeding
due to involvement of gastroduodenal artery
that lies posterior to 1st part of duodenum.
271. 18 yo M boxer presents with severe LUQ abdominal ABDOMINAL PAIN DDX
pain that radiates to the left scapula. He had - Splenic rupture* (LUQ pain/tendereness radiative to L shoulder, Internal
infectious mononucleosis three weeks ago. bleeding → signs of shock, including restlessness, anxiety, nausea, and
paleness, blurred vision, confusion, light-headedness, fainting)
- Kidney stone
- Rib fracture
- Pneumonia
- Perforated peptic ulcer
- Splenic infarct

- Rectal exam
- CXR
- CT—abdomen
- U/S—abdomen
272. 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.
ABDOMINAL PAIN DDX

- Intestinal obstruction*
- Small bowel or colon cancer
- Volvulus of the bowel
- Gastroenteritis
- Food poisoning
- Ileus
- Hernia

- Rectal exam
- AXR
- CT—abdomen/pelvis
- CXR
273. 70 yo F presents with acute onset of severe, crampy abdominal pain. She recently vomited and ABDOMINAL PAIN DDX
had a massive dark bowel movement. She has a history of CHF and atrial fibrillation, for which - Mesenteric
she has received digitalis. Her pain is out of proportion to the exam. ischemia/infarction* (Pain out of
proportion to exam!!)
- Diverticulitis
- Peptic ulcer disease
- Gastroenteritis
- Acute pancreatitis
-
Cholecystitis/choledocholithiasis
- MI
- Rectal exam
- CBC with diff, amylase, lipase,
lactate
- ECG
- CPK-MB, troponin
- AXR
- CT—abdomen
- Mesenteric angiography
- Barium enema
274. 68 yo M presents with LLQ abdominal pain, fever, and chills for the past three days. He also ABDOMINAL PAIN DDX
reports recent onset of - Diverticulitis* (LLQ pain &
alternating diarrhea and constipation. He consumes a low-fiber, high-fat diet tendereness, fever, diarrhea
often, vomiting)
- Crohn's disease
- Ulcerative colitis
- Gastroenteritis
- Abscess
- Rectal exam
- CXR
- AXR
- CT—abdomen
275. 20 yo M presents with severe RLQ abdominal pain, nausea, and vomiting. His
discomfort started yesterday as a vague pain around the umbilicus. As the pain
worsened, it became sharp and migrated to the RLQ. McBurney's and psoas
signs are positive.
ABDOMINAL PAIN DDX

- Acute appendicitis* (Midabdominal pain
migrating to RLQ, RLQ tendereness, Anorexia,
Feverish (fever), Acute Onset, RLQ (+) Obturator
sign, (+) Psoas sign)
- Gastroenteritis
- Diverticulitis
- Crohn's disease
- Nephrolithiasis
- Volvulus or other intestinal
obstruction/perforation

- Rectal exam
- AXR
- CT—abdomen
- U/S—abdomen
276. 30 yo F presents with periumbilical pain for six months. The
pain never awakens her from sleep. It is relieved by
defecation and worsens when she is upset. She has alternating
constipation and diarrhea but no nausea, vomiting, weight
loss, or anorexia.
ABDOMINAL PAIN DDX

- Irritable bowel syndrome*
- Crohn's disease
- Celiac disease
- Chronic pancreatitis
- GI parasitic infection (amebiasis, giardiasis)
- Endometriosis

- Pelvic exam
- Urine hCG
- Stool for ova and parasitology,
- Entamoeba histolytica antigen
277. 21 yo F presents with acute onset of severe RLQ pain, nausea, ABDOMINAL PAIN DDX
and vomiting. She has no fever, urinary symptoms, or vaginal - Ovarian (Adnexal) Torsion* (nonspecific with few distinctive
bleeding and has never taken OCPs. Her last menstrual period physical findings, commonly resulting in delay in diagnosis and
was regular, and she has no history of STDs. surgical management- sudden onset, unilateral lower pain,
nausea, vomiting, can start with exercise, lower and tenderness)
- Appendicitis
- Nephrolithiasis
- Ectopic pregnancy (Lower abd pain and tenderness, may radiant
to top of shoulder, later period or known pregnant)
- Ruptured ovarian cyst
- Pelvic Inflammatory Disease (PID)
- Bowel infarction or perforation

- Pelvic exam
- Rectal exam
- Urine hCG
- Urine Analysis
- CBC with diff
- Doppler U/S—pelvis
- CT—abdomen
- Laparoscopy
278. 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
ABDOMINAL PAIN DDX
unprotected sex with multiple
- Pelvic Inflammatory Disease (PID)* (Lower Ab pain, Fever, unusual vaginal d/c w/ bad order,
sexual partners.
pain and/or bleeding w/ sex, dysuria, Painful intercourse (dyspareunia), or bleeding with
intercourse, bleeding between periods) (fever, lower abd pain and tenderness, vaginal discharge,
sexually active, +pain w/ cervical motion tenderness, shuffling gait)
- Endometriosis
- Dysmenorrhea
- Vaginitis
- Cystitis
- Spontaneous abortion
- Pyelonephritis

- Pelvic exam
- Rectal exam
- Urine hCG
- Cervical cultures
- CBC with diff/ESR
- UA, urine culture
- U/S—pelvis
279. Ruptured Ovarian Cyst (Ab Pain - Ovarian cyst = any collection of fluid, surrounded by a very thin wall, within an ovary.
DDX) - Any ovarian follicle that is > ~2cm = ovarian cyst (Ovarian cyst can be as small as a pea, or as
large as a cantaloupe.)
- Most ovarian cysts are functional in nature, and harmless (benign)
- In the US ovarian cysts are found in nearly all premenopausal women, and in up to 14.8% of
postmenopausal women.
- Incidence of ovarian carcinoma is approximately 15 cases per 100,000 women per year
- Ovarian cysts affect women of all ages.
- Most often, however, during a woman's childbearing years.
- Some ovarian cysts cause problems, such as bleeding and pain, may need surgical removal
280. Fitz-Hugh-Curtis syndrome (Ab - Rare complication of PID
Pain DDX) - Usually caused by gonorrhoea (acute gonococcal perihepatitis) or chlamydia bacteria, which
cause a thinning of cervical mucous and allow bacteria from the vagina into the uterus and
oviducts, causing infection and inflammation.
- Occasionally, inflammation can affect Glisson's capsule, a thin layer of connective tissue
surrounding the liver.
- Signs are acute onset, RUQ Ab pain and tendereness aggravated by breathing, coughing or
movement, and referred to the right shoulder following an episode of PID
- Laparoscopy may reveal "violin string" adhesions.
- Treatment involves diagnosing and treating the underlying cause correctly. The adhesions can
be cut laparoscopically
281. Constipation/Diarrhea DDX - Colorectal Cancer
- Low-Fiber Diet
- IBS
- Infectious Diarrhea
- C Diff colitis
- Travelers Diarrhea
- Lactose intolerance
- Crohn's Disease
- UC
282. Constipation/Diarrhea Physical Exam - Vital Signs
- Relevant Thyroid/endocrine
exam
- Abdominal/Rectal exams
- +/- Female Pelvic Exam
283. Constipation/Diarrhea Work-Up - Rectal Exam
- CBC with diff
- Colonoscopy
- TSH
- Electrolytes
- Stool for Occult Blood
- CT Abdomen/Pelvis
284. 67 yo M presents with alternating diarrhea and constipation, decreased stool caliber, and
blood in the stool for the past eight months. He also reports unintentional weight loss. He is
on a low-fiber diet and has a family history of colon cancer.
CONSTIPATION/DIARRHEA DDX
- Colorectal cancer*
- Irritable bowel syndrome
- Diverticulosis
- GI parasitic infection (ascariasis,
giardiasis)
- Inflammatory bowel disease
- Angiodysplasia
CONSTIPATION/DIARRHEA
WORK-UP
- Rectal exam
- CBC with diff
phosphatase
- Colonoscopy
- Barium enema
285. Colon Cancer (Constipation/Diarrhea, • Microcytic Anemia lab → seen in Adult male or post-menopausal women = Colon
Blood in Stool DDX) Cancer until otherwise proven
• Left Sided → Insidious
- No Gross blood in stools
- Fatigue
- Anorexia
- Weight loss
- Abd discomfort
- Constipation
- (don't see constipation b/c R side = unformed (loose stools))
• Right Sided → Gross blood
- Change in bowl habit
- Pencil thin stools
- Diarrhea
- Sensation of incomplete emptying

- Sensation of Fullness
286. 28 yo M presents with constipation (very CONSTIPATION/DIARRHEA DDX
hard stool) for the last three weeks. Since - Low-fiber diet*
his mother died two months ago, he and - Irritable bowel syndrome
his father have eaten only junk food. - Substance abuse (e.g., heroin)
- Depression
- Hypothyroidism
CONSTIPATION/DIARRHEA WORK-UP
- Rectal exam
- TSH
- Electrolytes
- Urine toxicology
287. 30 yo F presents with alternating CONSTIPATION/DIARRHEA DDX
constipation and diarrhea and abdominal - Irritable bowel syndrome*
pain that is relieved by defecation. She - Inflammatory bowel disease
has no nausea, vomiting, weight loss, or - Celiac disease
blood in her stool. - Chronic pancreatitis
- GI parasitic infection (ascariasis,
giardiasis)
- Lactose intolerance
- CBC with diff
- Electrolytes
- Stool for ova and parasitology
- AXR
288. 33 yo M presents with watery diarrhea, vomiting, and CONSTIPATION/DIARRHEA DDX
diffuse abdominal pain that began yesterday. He also - Infectious diarrhea (gastroenteritis)—bacterial, viral, parasitic,
reports feeling hot. Several of his coworkers are also ill. protozoal* (Diarrhea prominent, +/- bloody stool, +/- vomiting, others
with same illness, acute onset, fever, diffuse abdominal tenderness, no
rebound)
- Food poisoning (vomiting predomin.)
- Stool leukocytes and culture
- CBC with diff
- Electrolytes
289. 40 yo F presents with watery diarrhea and abdominal CONSTIPATION/DIARRHEA DDX
cramps. Last week she was on antibiotics for a UTI. - Pseudomembranous (Clostridium diffi cile) colitis
- Gastroenteritis
- Cryptosporidiosis
- Food poisoning
- Rectal exam
- Stool leukocytes, culture, occult blood
- C. difficile toxin in stool
- Electrolytes
290. 25 yo M presents with watery diarrhea CONSTIPATION/DIARRHEA DDX
and abdominal cramps. He was recently - Traveler's diarrhea
in Mexico - Giardiasis
- Amebiasis
- Food poisoning
- Hepatitis A
- Rectal exam
- Stool leukocytes, culture, Giardia antigen, Entamoeba histolytica
antigen
- Electrolytes
- Viral hepatitis serology
291. 30 yo F presents with watery diarrhea and abdominal CONSTIPATION/DIARRHEA DDX
cramping and bloating. Her symptoms are aggravated - Lactose intolerance
by milk ingestion and are relieved by fasting. - Gastroenteritis
- Irritable bowel syndrome
- Hyperthyroidism
- Rectal exam
- Stool exam
- Hydrogen breath test
- TSH
292. 33 yo M presents with watery diarrhea, diffuse abdominal pain, and weight loss over
the past three weeks. He has not responded to antibiotics.
CONSTIPATION/DIARRHEA DDX
- Crohn's disease*
- Gastroenteritis
- Ulcerative colitis
- Celiac disease
- Pseudomembranous colitis
- Hyperthyroidism
- Small bowel lymphoma
- Carcinoid
- Rectal exam
- Stool exam and culture
- CBC with diff, electrolytes, TSH
- CT—abdomen
- Colonoscopy
- Small bowel series
- Urinary 5-HIAA
293. Upper GI (UGI) Bleeding DDX - Peptic Ulcer Disease
- Gastritis
- Varices
- Mallory Weiss
- Cancer
294. Upper GI (UGI) Bleeding Physical Exam - VS
- General
- ENT
- Chest
- Heart
- Abdomen
- Rectal
295. Upper GI (UGI) Bleeding Work-Up - Rectal Exam
- CBC with diff
- Electrolytes
- (Upper) Endoscopy
- H. Pylori
296. 45 yo F presents with coffee-ground emesis for the last three days. Her stool is dark and
tarry. She has a history of intermittent epigastric pain that is relieved by food and
antacids.
UPPER GI BLEEDING DDX

- Bleeding peptic ulcer
- Gastritis
- Gastric cancer
- Esophageal varices
UPPER GI BLEEDING WORK-UP

- Rectal exam
- CBC with diff, electrolytes
- Bleeding peptic ulcer*
testing if ulcer is confirmed)
- Gastritis
- Gastric cancer

- Rectal exam
phosphatase
testing if ulcer is confirmed)
297. 40 yo F presents with epigastric pain and coffee-ground emesis. She has a history of
rheumatoid arthritis that has been treated with aspirin. She is an alcoholic

- Gastritis*
- Bleeding peptic ulcer
- Gastric cancer

- Rectal exam
phosphatase
- Barium swallow
- Endoscopy
298. Blood in Stool DDX - Colon Cancer
- Ulcerative Colitis
- Diverticulosis
- Hemorrhoids
- Crohns Disease
- Angiodysplasia
- Ischemic Colitis
- Dysentery
299. Blood in Stool Physical Exam - VS
- General
- Heart
- Chest
- Complete Abdomen
- Rectal Exam
300. Blood in Stool Work-Up - Rectal Exam
- CBC with diff
- PT/PTT
- Abdominal X-ray (AXR)
- Colonoscopy
- Barium Enema
- CT Abdomen/Pelvis
301. 67 yo M presents with blood in his stool, weight loss, and
constipation. He has a family history of colon cancer.
BLOOD IN STOOL DDX

- Colorectal cancer*
- Anal fissure (Pain with defecation, bright red blood with
straining at stool, no fever, no abdominal tenderness)
- Hemorrhoids
- Diverticulosis
- Ischemic bowel disease
- Angiodysplasia
- Upper GI bleeding
BLOOD IN STOOL WORK-UP

- Rectal exam
- CBC with diff, PT/PTT
- CEA
- Colonoscopy
- Barium enema
302. 33 yo F presents with rectal bleeding and diarrhea for the
past week. She has had lower abdominal pain and tenesmus
for several months
BLOOD IN STOOL DDX

- Ulcerative colitis* (Inflammatory bowel disease = Fever, diarrhea,
chronic onset, (+) FH, diffuse abdominal tenderness)
- Crohn's disease
- Proctitis
- Anal fissure
- Hemorrhoids (Bright red blood, streaks usually on stool or toilet
paper, h/o patient able to palpate hemorrhoid, no abdominal
tenderness, no fever)
- Diverticulosis
- Dysentery

- Rectal exam
- AXR
- Colonoscopy
- Barium enema
303. 58 yo M presents with bright red blood per rectum and BLOOD IN STOOL DDX
chronic constipation. He consumes a low-fiber diet. - Diverticulosis* (Abdominal cramps, blood mixed with stool, may
be recurrent, age > 40, pallor)
- Anal fissure
- Hemorrhoids
- Angiodysplasia
- Colorectal cancer

- Rectal exam
- Electrolytes
- Colonoscopy
304. Hematuria DDX - Bladder Cancer
- PKD
- Nephrolithiasis
- Glomerulonephritis
- UTI
- Coagulation disorder
305. Hematuria Physical Exam - VS
- General
- Lymph nodes
- Abdominal exam
- Genitourinary and rectal exams
- Extremities
306. 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
307. 65 yo M presents with painless hematuria. He is a heavy smoker and works as a HEMATURIA DDX
painter. - Bladder cancer*
- Nephrolithiasis
- Prostate cancer
- Coagulation disorder (i.e., factor VIII
antibodies)
- Polycystic kidney disease
HEMATURIA WORK-UP
- Genitourinary exam
- Urinary Analysis, urine cytology
- BUN/Cr, PSA, CBC with diff, PT/PTT
- Cystoscopy
- U/S—renal/bladder
- IVP
308. 35 yo M presents with painless HEMATURIA DDX
hematuria. He has a family history of - Polycystic kidney disease*
kidney problems. - Nephrolithiasis
- Acute glomerulonephritis (e.g., IgA
nephropathy)
- UTI
- Coagulation disorder
- Bladder cancer
HEMATURIA WORK-UP
- Genitourinary exam
- Urinary Analysis
- BUN/Cr, PSA, CBC with diff, PT/PTT
- U/S—renal
- IVP
309. 55 yo M presents with fl ank pain and HEMATURIA DDX
blood in his urine without dysuria. He - Renal cell carcinoma
has experienced weight loss and fever - Bladder cancer
over the past two months. - Nephrolithiasis
- Pyelonephritis
- Prostate cancer
HEMATURIA WORK-UP
- Genitourinary, rectal exam
- Urinary Analysis, urine cytology,
BUN/Cr,
- PSA, CBC with diff, PT/PTT
- U/S—renal
- IVP
310. Other Urinary Symptoms DDX - Benign Prostatic Hyperplasia (BPH)
- Prostate Cancer
- Urethritis
- Urinary Tract Infection (UTI)
- Acute Pyelonephritis
- Bladder stone
311. 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
312. 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
313. 60 yo M presents with nocturia, urgency, weak stream, and terminal dribbling. He denies URINARY SYMPTOMS DDX
any weight loss, fatigue, or bone pain. He has had two episodes of urinary retention that - Benign prostatic hyperplasia
required catheterization. (BPH)*
- Prostate cancer
- Urinary Tract Infection (UTI)
- Bladder stones
URINARY SYMPTOMS WORK-UP

- Rectal exam
- Urinary Analysis
- CBC with diff, BUN/Cr, PSA
- U/S—prostate (transrectal)
314. 71 yo M presents with nocturia, urgency, weak stream, terminal dribbling, hematuria, URINARY SYMPTOMS
and lower back pain over the - Prostate cancer*
past four months. He has also - BPH
experienced weight loss and fatigue. - Renal cell carcinoma
- UTI
- Bladder stones

- Rectal exam
- Urinary Analysis
- CBC with diff, BUN/Cr, PSA
- U/S—prostate (transrectal)
- CT—pelvis
- IVP
315. 18 yo M presents with a burning sensation during urination and urethral discharge. He URINARY SYMPTOMS DDX
recently had unprotected sex with a new partner. - Urethritis*
- Cystitis
- Prostatitis
- Genital ± Rectal exam

- Urinary Analysis
- Urine culture
- Gram stain and culture of
urethral discharge
- Chlamydia and gonorrhea - PCR
316. 45 yo diabetic F presents with dysuria, urinary frequency, fever, chills, and nausea over
the past 3 days. There is left CVA tenderness on exam.
URINARY SYMPTOMS DDX

- Acute pyelonephritis*
- Nephrolithiasis
- Lower UTI (cystitis, urethritis)

- Urinary Analysis
- Urine culture and sensitivity
- CBC with diff, BUN/Cr
- U/S—renal
- CT—abdomen
317. 55 yo F presents with urinary leakage after exercise. She loses a small amount of
urine when she coughs, laughs, or sneezes. She also complains of vague low back
pain. She has a history of multiple C-section and her other had the same problem
after the onset of menopause
URINARY SYMPTOMS DDX

- Stress Incontinence
- Mixed Incontinence
- Urge Incontinence
- Overflow Incontinence
- Functional Incontinence
- UTI
- Diabetes Mellitus

- CBC with diff, Electrolytes, BUN/Cr,
Glucose
- Urinary Analysis, Urine Culture
- Urodynamic testing
IVP
Cystiurethroscopy
318. 33 yo F presents with urinary leakage. She is unable to suppress the urge to URINARY SYMPTOMS DDX
urinate. She loses large amounts of urine w/o warning. She has a history of UTI's - Urge Incontinence
and a family history of diabetes mellitus. She drinks 8 cups of coffee per daa. She - Mixed Incontinence
has been under a lot of stress since her sister died a few months ago. - Stress Incontinence
- Overflow Incontinence
- Functional Incontinence
- UTI
- Diabetes Mellitus

- CBC with diff, Electrolytes, BUN/Cr,
Glucose
- Urinary Analysis, Urine Culture
- Urodynamic testing
IVP
Cystiurethroscopy
319. Erectile Dysfunction (ED) DDX - Drugs
- Hypertension
- Diabetes Mellitus
- Psychogenic
- Peyronie's disease (induratio penis plastica
(IPP) or chronic inflammation of the tunica
albuginea (CITA)) - connective tissue
disorder involving the growth of fibrous
plaques
320. Erectile Dysfunction (ED) Physical Exam - VS
- General
- Heart
- Lungs
- Genital and Rectal Exams
321. Erectile Dysfunction (ED) Work-Up - Rectal Exam
- Genitourinary Exam
- Glucose
- CBC with diff
322. 47 yo M presents with impotence that started three months ago. He has hypertension and ERECTILE DYSFUNCTION (ED)
was started on atenolol DDX
four months ago. He also has diabetes and is on insulin. - Drug-related ED
- ED caused by hypertension
- ED caused by diabetes mellitus
- Psychogenic ED
- Peyronie's disease
ERECTILE DYSFUNCTION (ED)

WORK-UP
- Genital Exam
- Rectal Exam
- CBC with diff, Glucose
323. Amenorrhea DDX - Pregnancy
- PCOS
- Prolactinoma
- Menopause
- Sheehan's
- Anorexia
- Anxiety
- Asherman's
- Hypothyroid
324. Amenorrhea Physical Exam - VS
- General
- Heart
- Lungs
- Breast exam
- Complete pelvic exam
325. Amenorrhea Work-Up - Pelvic Exam
- Urine B-HCG
- Ultrasound (U/S) Pelvis
- CBC with diff
- Electrolytes
- LH/FSH/TSH/Prolactin
- MRI Brain
326. 40 yo F presents with amenorrhea, morning nausea and vomiting, fatigue, and polyuria. AMENORRHEA DDX
Her last menstrual period was six weeks ago, and her breasts are full and tender. She - Pregnancy*
uses the rhythm method for contraception. - Anovulatory cycle
- Hyperprolactinemia
- UTI
- Thyroid disease
AMENORRHEA WORK-UP
- Pelvic exam
- Urine hCG
- U/S—pelvis
- Urinary Analysis, urine culture
- Prolactin, TSH
- Baseline Pap smear, cervical cultures,
rubella antibody,
- HIV antibody, hepatitis B surface
antigen, and VDRL/RPR
327. 23 yo obese F presents with amenorrhea for 6 months, facial hair, and infertility for the
past 3 years.
AMENORRHEA DDX
- Polycystic ovary syndrome*
- Thyroid disease
- Hyperprolactinemia
- Pregnancy
- Ovarian or adrenal malignancy
- Premature ovarian failure
AMENORRHEA WORK-UP
- Pelvic exam
- Urine hCG
- U/S—pelvis
- LH/FSH, TSH, prolactin
- Testosterone, DHEAS
328. 35 yo F presents with amenorrhea, AMENORRHEA DDX
galactorrhea, visual fi eld defects, and - Amenorrhea secondary to prolactinoma*
headaches for the past six months - Pregnancy
- Thyroid disease
- Premature ovarian failure
- Pituitary tumor
AMENORRHEA WORK-UP
- Pelvic and breast exam
- Urine hCG
- Prolactin
- LH/FSH, TSH
- MRI—brain
329. 48 yo F presents with amenorrhea for the
past six months accompanied by hot
fl ashes, night sweats, emotional lability,
and dyspareunia.
AMENORRHEA
- Menopause
- Pregnancy
- Pituitary tumor
- Thyroid disease
AMENORRHEA WORK-UP
- Pelvic exam
- Urine hCG
- LH/FSH, TSH, prolactin, testosterone, DHEAS
- CBC with diff
- MRI—brain
330. 35 yo F presents with amenorrhea, cold intolerance, coarse hair, weight loss, and AMENORRHEA DDX
fatigue. She has a history of abruptio placentae followed by hypovolemic shock and - Sheehan's syndrome
failure of lactation two years ago. - Premature ovarian failure
- Pituitary tumor
- Thyroid disease
- Asherman's syndrome
AMENORRHEA WORK-UP
- Pelvic exam
- Urine hCG
- CBC with diff
- LH/FSH, prolactin
- TSH, FT4
- ACTH
- MRI—brain
- Hysteroscopy
331. 18 yo F presents with amenorrhea for the past 4 months. She has lost 95 pounds
and has a history of vigorous exercise and
cold intolerance.
AMENORRHEA DDX
- Anorexia nervosa
AMENORRHEA WORK-UP
- CBC with diff, TSH, FT4
- ACTH, FSH, LH
332. 29 yo F presents with amenorrhea for the AMENORRHEA DDX
past six months. She has a history of - Anxiety-induced amenorrhea
occasional palpitations and dizziness. She
lost her fiancé in a car accident. AMENORRHEA WORK-UP
- CBC with diff
- TSH, FT4
- ACTH
- Urine cortisol level
- Progesterone challenge test
- FSH/LH/estradiol levels
333. Menopause Work-Up
- DDX = Pregnancy, Pituitary tumor, Thyroid, Amenorrhea

- SX = Hot Flash, Night Sweats, Emotional Lability (mood swings), Dyspareunia (painful
intercourse)
- Pelvic Exam
- Urine B-HCG - r/o Pregnancy
- LH/FSH/TSH/Prolactin
- CBC with diff
334. 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
335. Vaginal Bleeding Physical - VS
Exam - General
- Abdominal exam
336. Vaginal Bleeding Work-Up - Pelvic Exam
- Urine B-HCG - r/o Pregnancy
- Cervical Cultures
- PAP Smear
- CBC with diff
- ESR
- Glucose
- Colposcoy (Cervical Cancer)
- Endometrial Biopsy
337. 17 yo F presents with prolonged, excessive menstrual VAGINAL BLEEDING DDX
bleeding occurring irregularly over the past six months. - Dysfunctional uterine bleeding* (Bleeding or spotting from the
vagina between periods, excessive body hair growth (male
pattern) = hirsutism, hot flashes, mood swings, tenderness and
dryness of vagina, anemia)
- Coagulation disorders (e.g., von Willebrand's disease, hemophilia)
- Cervical cancer
- Molar pregnancy
- Hypothyroidism
- Diabetes mellitus
VAGINAL BLEEDING WORK-UP

- Pelvic exam
- Urine hCG
- Cervical cultures, Pap smear
- CBC with diff, ESR, glucose, PT/PTT
- Prolactin, LH/FSH, TSH
- U/S—pelvis
338. 61 yo obese F presents with profuse vaginal bleeding over VAGINAL BLEEDING DDX
the past month. Her last menstrual period was 10 years ago. - Endometrial cancer* (Unopposed Estrogen → Triad; 1. Obese →
She has a history of hypertension and diabetes mellitus. She ↑ Estrogen ; 2. HTN; 3. DM)
is nulliparous. - Cervical cancer
- Atrophic endometrium
- Endometrial hyperplasia
- Endometrial polyps
- Atrophic vaginitis

- Pelvic exam
- Pap smear
- Endometrial biopsy
- U/S—pelvis
- Endometrial curettage
- Colposcopy
- Hysteroscopy
339. 45 yo G5P5 F presents with postcoital bleeding. She is a VAGINAL BLEEDING DDX
cigarette smoker and takes OCPs. - Cervical cancer*
- Cervical polyp
- Cervicitis
- Trauma (e.g., cervical laceration)

- Pelvic exam
- Pap smear
- Colposcopy and biopsy
340. 28 yo F who is eight weeks pregnant presents with lower abdominal pain and VAGINAL BLEEDING DDX
vaginal bleeding. - Spontaneous abortion*
- Ectopic pregnancy
- Molar pregnancy

- Pelvic exam
- Urine hCG
- U/S—pelvis
- CBC, PT/PTT
- Quantitative serum hCG
341. 32 yo F presents with sudden onset of left VAGINAL BLEEDING DDX
lower abdominal pain that radiates to the scapula and back and is associated - Ectopic pregnancy*
with vaginal bleeding. Her last menstrual period was five weeks ago. She has a - Ruptured ovarian cyst
history of PID and unprotected intercourse. - Ovarian torsion
- Pelvic inflammatory disease (PID) (General
term for infection in the upper genital tract
(uterus, fallopian tubes and ovaries))

- Pelvic exam
- Urine hCG
- Cervical cultures
- U/S—pelvis
Quantitative serum hCG
342. Gynecologic Cancer Symptoms
343. Vaginal Discharge DDX - Bacterial Vaginosis

- Vaginitis (trich vs candida)
- Cervicitis
344. Vaginal Discharge Physical Exam - VS
- General
- Abdominal Exam
345. Vaginal Discharge Work-Up - Pelvic Exam
- Wet Mount
- KOH prep
- Cervical Cultures
- pH Vaginal Fluid
346. 28 yo F presents with a thin, grayish white, VAGINAL DISCHARGE DDX
foul-smelling vaginal discharge. - Bacterial vaginosis* (Vaginal discharge = grey/white, fishy vaginal
ordor, 'clue' cells on microscopy)
- Vaginitis—candidal
- Vaginitis—trichomonal
- Cervicitis (chlamydia, gonorrhea)
VAGINAL DISCHARGE WORK-UP

- Pelvic exam
- Wet mount
- Cervical cultures
- KOH prep ("whiff test")
- pH of vaginal fluid
347. 30 yo F presents with a thick, white, cottage cheese-like, VAGINAL DISCHARGE DDX
odorless vaginal discharge and vaginal itching. - Vaginitis—candida* (Vulval itching, soreness and erythema;
Dyspareunia; Dysuria; Vaginal Discharge - thick, white curdy
discharge "cottage cheese")
- Bacterial vaginosis
- Vaginitis—trichomonal

- Pelvic exam
- Wet mount
- Cervical cultures
- pH of vaginal fluid
348. 35 yo F presents with a malodorous, profuse, frothy, VAGINAL DISCHARGE DDX
greenish vaginal discharge with intense vaginal itching - Vaginitis—trichomonal*
and discomfort. - Vaginitis—candidal
- Bacterial vaginosis
- Cervicitis (chlamydia, gonorrhea)

- Pelvic exam
- Wet mount
- Cervical cultures
- pH of the vaginal fluid
349. Chlamydia/Gonorrhea Discharge (Vaginal Discharge DDX) Chlamydia Trachomatis
- Asymptomatic (50% of men, 80% of women)
- Urethritis and proctitis in men
- Vaginal discharge, dysuria, dyspareunia, lower abdominal pain, IMB
or PCB in women.
Neisseria Gonorrhea
- Asymptomatic
- Urethritis (dysuria)
- Discharge (purulent)
- In men only: fever, sweating, proctitis, pharyngitis.
350. Dyspareunia (Painful Intercourse) DDX - Atrophic vaginitis
- Endometriosis
- Cervicitis
- Depression
- Domestic Abuse
- Vaginismus
- PID
- Abuse
- Depression
- Vulvo vaginitis
- Vulvodynia
351. Dyspareunia (Painful Intercourse) Physical Exam - VS
- General
- Abdominal Exam
352. Dyspareunia (Painful Intercourse) Work-Up - Pelvic Exam
- Wet Mount
- KOH prep
- Cervical Cultures
353. 54 yo F c/o painful intercourse. Her last menstrual period was nine months ago. She
has hot flashes.
DYSPAREUNIA DDX
- Atrophic vaginitis*
- Endometriosis
- Cervicitis
- Depression
- Domestic abuse
DYSPAREUNIA WORK-UP
- Pelvic exam
- Wet mount, KOH prep, cervical
cultures
- U/S—pelvis
354. 37 yo F presents with dyspareunia, inability to conceive, and dysmenorrhea.
DYSPAREUNIA DDX
- Endometriosis*
- Cervicitis
- Vaginismus
- Vulvodynia
- PID
- Depression
- Domestic violence
DYSPAREUNIA WORK-UP
- Pelvic exam
- Wet mount, KOH prep, cervical
cultures
- U/S—pelvis
- Laparoscopy
355. Abuse DDX - Domestic Violence
- Osteogenesis Imperfecta
- Substance abuse
- Rape
- Consensual violent sex
356. Abuse Physical Exam - Complete Exam +/- Pelvic Exam
357. Abuse Work-Up - X-Ray Skeletal Survey
- CT Maxillofacial
- CBC with Diff
- Pelvic Exam
- Urine- B-HCG (females)
358. 28 yo F c/o multiple facial and bodily injuries. She claims that she fell on the stairs. She ABUSE DDX
was hospitalized for some physical injuries seven months ago. She presents with her - Domestic violence*
husband. - Osteogenesis imperfecta
- Substance abuse
- Consensual violent sexual behavior
ABUSE WORK-UP
- XR—skeletal survey
- CT—maxillofacial
- Urine toxicology
- CBC with diff
359. 30 yo F presents with multiple facial and physical injuries. She was attacked ABUSE DDX
and raped by two men. - Rape*
ABUSE WORK-UP
- Pelvic exam
- Urine hCG
- Wet mount, KOH prep, cervical cultures
- XR—skeletal survey
- CBC with diff
- HIV antibody
360. 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
361. Joint/Limb Pain Physical Exam - VS
- General
- HEENT
- Musculoskeletal exams
- Relevant neurovascular exam
362. Joint/Limb Pain Work-Up - X-Ray (and/or CT) of Affected Area
- Rheum Blood Test - ANA, Anti-dsDNA, C3, C4,
RF
- ESR
- CBC with Diff
- Arthrocentesis ( joint aspiration) and Synovial
Fluid Analysis
- DEXA Scan (Bone Densitometry)
- Lyme Antibody
363. 30 yo F presents with wrist pain and a black eye after tripping, falling, and hitting her JOINT/ LIMB PAIN DDX
head on the edge of a table. She looks anxious and gives an inconsistent story. - Domestic violence
- Factitious disorder
- Substance abuse
JOINT/ LIMB PAIN WORK-UP

- XR—wrist
- CT—head
- Urine toxicology
364. 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.
JOINT/ LIMB PAIN DDX

- Carpal tunnel syndrome*
- Median nerve compression in forearm
or arm
- Radiculopathy of nerve roots C6 and
C7 in cervical spine

- Nerve conduction study
- EMG
365. 28 yo F presents with pain in the interphalangeal joints of her hands together with hair
loss and a butterfly rash on her face.

- Systemic lupus erythematosus (SLE)*
- Rheumatoid arthritis (RA)
- Psoriatic arthritis
- Parvovirus B19 infection

- ANA, anti-dsDNA, ESR, C3, C4,
Rheumatoid factor (RF), CBC with diff
- XR—hands
- Urinary Analysis
366. 28 yo F presents with pain in the metacarpophalangeal joints of both hands. Her left
knee is also painful and red. She has morning joint stiffness that lasts for an hour. Her
mother had rheumatoid arthritis.

- Rheumatoid arthritis (RA)
- Systemic lupus erythematosus (SLE)
- Disseminated gonorrhea
- Arthritis associated with Inflammatory
bowel disease
- Osteoarthritis (OA)

- ANA, anti-dsDNA, CCP, ESR, RF, CBC
with diff
- XR—hands, left knee
- Cervical culture
- Arthrocentesis and synovial fluid
analysis
367. 56 yo obese F presents with right knee stiffness and pain that increases with
movement. Her symptoms have gradually worsened over the past 10 years. She noticed
swelling and deformity of the joint and is having difficulty walking

- Osteoarthritis*
- Pseudogout
- Gout
- Meniscal or ligament damage

- XR—knee
- Knee arthrocentesis and synovial fluid
analysis (cell count, Gram stain, culture,
crystals)
- MRI—knee
368. Differing presentation of RA vs. OA
RA - morning stiffness > 30 min (worst in the

AM)
OA - short morning stiffness but usually gets

worse THROUGHOUT THE DAY
RA joints - hands, wrists, elbows, shoulders,

ankles, hips, knees, CERVICAL spine
OA joints - DIP, PIP, weight bearing joints

(hip, knee), ANY SPINE
MAJOR DISTINCTIONS:
RA - only cervical spine; no DIP; PIP
OA - lumbar or cervical spine; DIP; PIP
369. 18 yo M presents with pain in the interphalangeal joints of both hands. He also has JOINT/ LIMB PAIN DDX
scaly, salmon-pink lesions on the extensor surface of his elbows and knees. - Psoriatic arthritis*
- Rheumatoid arthritis
- SLE

- RF, ANA, ESR, CBC with diff
- XR—hands
- XR—pelvis/sacroiliac joints
- Uric acid
370. 45 yo M presents with right knee pain with swelling and redness. JOINT/ LIMB PAIN DDX
- Septic arthritis*
- Gout
- Pseudogout
- Lyme arthritis
- Trauma
- Reiter's arthritis

- CBC with diff
- Knee arthrocentesis and synovial fluid
analysis (cell count, Gram stain, culture,
crystals)
- Blood, urethral cultures
- XR—knee
- Uric acid
- Lyme antibody
371. 65 yo F presents with inability to use her left leg and bear weight on it after tripping on
a carpet. Onset of menopause was 20 years ago, and she did not receive HRT or
calcium supplements. Her left leg is externally rotated, shortened, and adducted, and
there is tenderness in her left groin.

- Hip fracture* (Externally rotated,
adducted, and shortened)
- Hip dislocation
- Pelvic fracture

- XR—hip/pelvis
- CT or MRI—hip
- CBC with diff, Serum calcium and
vitamin D
- Bone density scan (DEXA)
372. 40 yo M presents with pain in the right groin after a motor vehicle accident. His right
leg is flexed at the hip, adducted, and internally rotated.

- Hip dislocation—traumatic* (Internally
rotated, flexed, and adducted)
- Hip fracture

- XR—hip
- CT or MRI—hip
- Blood type and cross-match
- Urine toxicology and blood alcohol
level
373. 65 yo M presents with right foot
pain. He
has been training for a marathon.

- Stress fracture* (Worsens with time, tenderness at originating spot, decreases during rest)
- Plantar fasciitis
- Foot sprain or strain

- XR—foot
- Bone scan—foot
- MRI—foot
374. 65 yo M presents with pain in the JOINT/ LIMB PAIN DDX
heel - Plantar fasciitis* (Acute form of inflammation of band of tissues running across plantar foot,
of the right foot that is most may lead to heal spur)
notable with - Heel fracture
his fi rst few steps and then - Splinter/foreign body
improves as
he continues walking. He has no JOINT/ LIMB PAIN WORK-UP
known - XR—heel
trauma. - Bone scan
375. 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 extension [dorsiflexion](Cozen's test) with the elbow in extension.

- Tennis elbow (lateral epicondylitis)*
- Stress fracture

- XR—arm
- Bone scan
- MRI—elbow
376. 27 yo F presents with painful wrists and JOINT/ LIMB PAIN DDX
elbows, a swollen and hot knee joint that - Disseminated gonorrhea*
is painful on fl exion, a rash on her limbs, - Rheumatoid arthritis
and vaginal discharge. She is sexually - SLE
active with multiple partners and - Psoriatic arthritis
occasionally uses condoms. - Reiter's arthritis

- Knee arthrocentesis and synovial fl uid
analysis (cell count, Gram stain, culture)
- ANA, anti-dsDNA, ESR, RF, CBC with
diff
- Blood, cervical cultures
- XR—knee
377. 60 yo F presents with pain in both legs that is induced by walking and is relieved by JOINT/ LIMB PAIN DDX
rest. She had cardiac bypass surgery six months ago and continues to smoke heavily. - Peripheral vascular disease
(intermittent claudication)*
- Leriche's syndrome (aortoiliac
occlusive disease)
- Lumbar spinal stenosis
(pseudoclaudication)
- Osteoarthritis

- Ankle-brachial index
- Doppler U/S—lower extremity
- Angiography
- MRI—lumbar spine
378. 5 yo F presents with right calf pain. Her calf is tender, warm, red,
and swollen compared to the left side. She was started on OCPs
two months ago for dysfunctional uterine bleeding.
JOINT/ LIMB PAIN DDX → UNILATERAL LEG SWELLING DDX

- Deep Vein Thrombosis (DVT)* (Unilateral Pain and swelling
recently in leg, risk factor for hypercoagulable state,
immobility; P/E → lower leg red, warm, swollen, tender)
- Baker's cyst rupture (Previous arthritis of knee, red, swollen,
tender calf; P/E → swelling and fullness behind knee)
- Myositis
- Cellulitis (Red, swollen, tender, calf, distal break in skin of
leg; P/E → fever, inguinal adenopathy)
- Superficial venous thrombosis
[- Lymphathic Obstruction (Chronic leg swelling, chronic skin
changes, not red or tender; P/E → No fever, inguinal
adenopathy, lower abdominal mass]

- Doppler U/S—right leg
- CBC with diff, CPK, D-dimer, PT, aPTT, fi brinogen
- XR—right leg
379. 60 yo F c/o left arm pain that started while she was swimming and JOINT/ LIMB PAIN DDX
was relieved by rest. - Angina/MI*
- Tendonitis
- Osteoarthritis
- Shoulder dislocation

- CPK-MB, troponin, CBC with diff, ESR
- ECG
- XR—shoulder
- CXR
- Echocardiography
Stress test
380. 50 yo M presents with right shoulder pain after falling onto his JOINT/ LIMB PAIN DDX
outstretched hand while skiing. He noticed deformity of his - Shoulder dislocation*
shoulder and had to hold his right arm. - Fracture of the humerus
- Rotator cuff injury

- XR—shoulder
- XR—arm
- MRI—shoulder
381. Shoulder Exam
• Look at:
- Muscles, Clavicular position, scapular location
- Note swellings, masses, or changes/scars
• Palpate
- Sternoclavicular joint form notch across clavicle to
Acromioclavicular joint → feel for coracoid process
- Feel posterior spine of scapula, anterior scapula
- Humerus
• Movement → Flexion and Extension, Abduction and
Adduction, Internal and External Rotation, Circumduction
• Impinged
- Bring arm across chest
- Arms at right angle - externally rotate
- Looping movement up and arm
• Rotator Cuff test
- Hold arms out, point thumbs down, push hands up
against
- Drop arm test - examiner holds their hand out with pat
arms out and then removes - if arm falls = rotator cuff
injury
382. 55 yo M presents with crampy bilateral thigh and calf pain, fatigue, JOINT/ LIMB PAIN DDX
and dark urine. He is on simvastatin and clofibrate for hyperlipidemia - Rhabdomyolysis due to simvastatin or clofibrate
- Polymyositis
- Inclusion body myositis
- Thyroid disease

- CBC with diff, CPK, Aldolase
- Urinary Analysis
- Urine myoglobin
- TSH
383. Low Back Pain DDX - Disk herniation
- Lumbar muscle strain
- Lumbar spinal stenosis
- Malingering
- Ankylosing Spondylitis
- Cancer
- AAA
384. Low Back Pain Physical Exam
- VS
- General
- Neuro exam - esp L4-S1 nerev roots
- Back palpation and range of motion (although rarely of
diagnostic utility)
- Hip exam (referred pain to back)
- Consider rectal exam
385. Low Back Pain Work-Up - X-Ray of Lumbar Spine
- CT of Lumbar Spine
- MRI of Lumbar Spine
386. 45 yo F presents with low back pain that radiates to the lateral LOW BACK PAIN DDX
aspect of her left foot. Straight leg raising is positive. The patient is - Disk herniation* (Low Back Pain radiating down butt and
unable to tiptoe. below knee; nerve roots check Knee-jerk reflex (L4), great
toe dorsiflexion (L5), ankle-jerk (S1); Ipsilateral straight leg
test (leg raised < 60))
LOW BACK PAIN WORK-UP

- XR—L-spine
- MRI—L-spine
387. 45 yo F presents with low back pain that started after she cleaned LOW BACK PAIN DDX
her house. The pain does not radiate, and there is no sensory deficit - Lumbar muscle strain* (Often follows strenuous or unusual
or weakness in her legs. Paraspinal muscle tenderness and spasm exertion, but pain usually does not radiate to extremities,
are also noted. paraspinal muscle tenderness present)
- Disk herniation
- Vertebral compression fracture

- XR—L-spine
388. 45 yo M presents with pain in the lower back and legs during LOW BACK PAIN DDX
prolonged standing and walking. The pain is relieved by - Lumbar spinal stenosis* (Mostly seen in ≥ 60 yo, gradual onset of
sitting and leaning forward (e.g., pushing a grocery cart). back pain that radiate to butt and legs w/ or w/o leg numbness
and weakness; pain occurs w/ walking or prolonged standing,
subsides by sitting or leaning forward)
- Peripheral vascular disease

- XR—L-spine
- MRI—L-spine (preferred)
- CT—L-spine
- Ankle-brachial index
389. 17 yo M presents with low back pain that radiates to the left LOW BACK PAIN DDX
leg and began after he fell on his knee during gym class. He - Malingering*
also describes areas of loss of sensation in his left foot. The - Lumbar muscle strain
pain and sensory loss do not - Disk herniation
match any known distribution. He insists on requesting a - Knee or leg fracture
week off from school because of his injury. - Ankylosing spondylitis

- XR—L-spine/knee
- MRI—L-spine
390. Child with Fever DDX - Sepsis
- Meningitis
- Pneumonia
- UTI
- Otitis Media
- URI
- Viral exanthem
- Gastroenteritis
- Volvulus
- Intussueption
- Food poisoning
391. Child with Fever Physical Exam - VS
- General
- HEENT
- Neck
- Heart
- Lung
- Abdominal
- Skin
392. Child with Fever Work-Up - Physical Exam
- CBC with Diff
- Electrolytes
- Blood Culture
- Viral Antibodies
- Throat Swab for Culture
- Stool Exam/Culture
393. 20-day-old M presents with fever, CHILD WITH FEVER
decreased breast-feeding, and lethargy. DDX
He was born at 36 weeks as a result of - Neonatal sepsis*
premature rupture of membranes. - Meningitis
- Pneumonia
- UTI
CHILD WITH FEVER

WORK-UP
- Physical exam
- CBC with diff,
electrolytes
- Urinary Analysis,
Urine culture
- Blood culture
- CXR
LP—CSF analysis
394. 3 yo M presents with a two-day history of fever and pulling on his right ear. He is otherwise healthy, and CHILD WITH FEVER
his immunizations are up to date. His older sister recently had a cold. The child attends a day care center DDX
- Acute otitis media*
- URI
- Meningitis
- UTI
CHILD WITH FEVER

WORK-UP
- Physical exam
(including pneumatic
otoscopy)
- CBC with diff
- Urinary Analysis
395. 12-month-old M presents with fever for the last two days accompanied by a maculopapular rash on his CHILD WITH FEVER
face and body. He has not yet received the MMR vaccine. DDX
- Measles (or other
viral exanthem)*
- Rubella
- Roseola
- Fifth disease
- Varicella
- Scarlet fever
- Meningitis
CHILD WITH FEVER

WORK-UP
- Physical exam
- CBC with diff
- Viral antibodies/titers
- Throat swab for
culture
- LP
396. 4 yo M presents with diarrhea, vomiting, lethargy, weakness, and fever. The child attends a day CHILD WITH FEVER DDX
care center where several children have had similar symptoms. - Gastroenteritis (viral,
bacterial, parasitic)*
- Food poisoning
- UTI
- URI
- Volvulus
- Intussusception
CHILD WITH FEVER WORK-UP

- Physical exam
- Stool exam and culture
- Urinary Analysis, urine culture
- AXR
397. Behavioral Problems DDX - ADHD
- Adjustment disorder
- ODD
- Childhood BPD
- Substance abuse
- Age appropriate behavior
398. Behavioral Problems Physical Exam - VS
- General
- Neuro Exam
399. Behavioral Problems Work-Up - Physical Exam
- Mental Status Exam (MSE)
400. 9 yo M presents with a two-year history BEHAVIORAL PROBLEMS I N
of angry outbursts both in school and at home. His mother complains that he runs around "as if CHILDHOOD DDX
driven by a motor." His teacher reports that he cannot sit still in class, regularly interrupts his - Attention-deficit hyperactivity
classmates, and has trouble making friends. disorder (ADHD)
- Oppositional defiant disorder
- Manic episode
- Conduct disorder
BEHAVIORAL PROBLEMS I N
CHILDHOOD WORK-UP
- Physical exam
401. 12 yo F presents with a two-month history of fighting in school, truancy, and breaking curfew. BEHAVIORAL PROBLEMS I N
Her parents recently divorced, and she just started school in a new district. Before her parents CHILDHOOD DDX
divorced, she was an average student with no behavioral problems. - Adjustment disorder
- Substance
intoxication/abuse/dependence
- Manic episode
- Oppositional defiant disorder
- Conduct disorder
BEHAVIORAL PROBLEMS I N
CHILDHOOD WORK-UP
- Physical exam
- Urine toxicology
402. 15 yo M presents with a one-year history BEHAVIORAL
of failing grades, school absenteeism, and PROBLEMS I N
legal problems, including shoplifting. His parents report that he spends most of his time alone in his room, CHILDHOOD DDX
adding that when he does go out, it is with a new set of friends. - Substance abuse
- Conduct disorder
- Oppositional
defiant disorder
- Adjustment
disorder
BEHAVIORAL
PROBLEMS I N
CHILDHOOD
WORK-UP
- Urine toxicology
- Physical Exam
403. 5 yo M presents with a six-month history of temper tantrums that last 5-10 minutes and immediately follow BEHAVIORAL
a disappointment or a discipline. He has no trouble sleeping, has had no change in appetite, and does not PROBLEMS I N
display these behaviors when he is at day care. CHILDHOOD DDX
- Age-appropriate
behavior
- ADHD
- Oppositional
defiant disorder
BEHAVIORAL
PROBLEMS I N
CHILDHOOD
WORK-UP
- Physical exam

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Step 2 CS - Cases, Differentials, Diagnoses

Study online at quizlet.com/_4e8r71

• VS - state or say wnl (wnl except...)

HEADACHE PHYSICAL EXAM (in general)

HEADACHE WORK-UP (in general)

• Diagnosis with CPH: ≥ 20 attacks filling the following criteria:

• Headache needs to take place w/ 1 of the following:

• Attacks can be prevented completely by therapeutic doses of

• Symptoms not due to another disorder and neuropathy of the

30. Dementia Types

1. Disturbance of CONSCIOUSNESS (can't focus or

CONFUSION/MEMORY LOSS WORK-UP

- Often coexists with Alzheimer's Disease

CONFUSION/MEMORY LOSS WORK-UP

- Most common cause of dementia

CONFUSION/MEMORY LOSS WORK-UP

- Adams/Hakim Triad ("wet, wobbly and

CONFUSION/MEMORY LOSS WORK-UP

- Dementia, mood, anxiety, movement

CONFUSION/MEMORY LOSS WORK-UP

CONFUSION/MEMORY LOSS WORK-UP

DEPRESSED MOOD WORK-UP

DEPRESSED MOOD WORK-UP

Last ≥ 2 weeks with ≥ 5 symptoms and MUST Include Depressed Mood or

DEPRESSED MOOD DDX

DEPRESSED MOOD WORK-UP

• Manic = DIG FAST → ≥3 symptoms

• Hypomania = TAD HIGH

DSM-IV-TR Criteria → Period of psychosis > 6 months

• Schizophrenia prototype is a patient who has psychotic symptoms

• VS: State (or WNL or WNL except...)

LOSS OF CONSCIOUSNESS WORK-UP

- Seizures usually occur unpredictably in a manner unrelated to posture or exertion

Partial Seizures (Produced by a small area of the brain)

Generalized Seizures (Produced by the entire brain) - 6 Types

LOSS OF CONSCIOUSNESS WORK-UP

- Syncope is often heralded by nausea, sweating,

LOSS OF CONSCIOUSNESS WORK-UP

• VS: State (or WNL or WNL except...) (no orthostatic changes)

• TIA: sudden, focal neurologic

• Stroke: sudden onset of neurologic

• What are you going to do? => MRI

Five Warning Signs:

- Acute, autoimmune, polyradiculoneuropathy affecting the peripheral nervous system, usually

- Nervous system disease that affects

- Sumptoms = burning foot paresthesias, that are worse at night

- Neuromuscular disease leading to fluctuating muscle weakness and

119. Neuromuscular Junction Disorders

• VS: State (or WNL or WNL except...)

FATIGUE AND SLEEPINESS WORK-UP

FATIGUE AND SLEEPINESS WORK-UP

FATIGUE AND SLEEPINESS WORK-UP

- Hypercalcemia is a disorder that most commonly results from

FATIGUE AND SLEEPINESS WORK-UP

- Usually primary hypothyroidism - ↓ Thyroid hormone

FATIGUE AND SLEEPINESS WORK-UP

FATIGUE AND SLEEPINESS WORK-UP

- Polyuria, Polydipsia, Polyphagia** (either DM or DI → DM = glucose in urine, high specific

FATIGUE AND SLEEPINESS WORK-UP

• VS: State (or WNL or WNL except...)

NIGHT SWEATS WORK-UP

SORE THROAT WORK-UP

- MC in adolescents and young adults