USMLE Step 2 CS Minicases – Flashcards
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21 yo F presents with several episodes of throbbing left temporal pain that lasts for 2-3 hours. Prior to its onset, she sees fl ashes of light in her right visual fi eld and feels weakness and numbness on the right side of her body for a few minutes. Headaches are often associated with nausea and vomiting. She has a family history of migraine.
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Migraine (complicated) Tension headache Cluster headache Pseudotumor cerebri Trigeminal neuralgia CNS vasculitis Partial seizure Intracranial neoplasm CBC ESR CT—head MRI—brain LP
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26 yo M presents with severe right temporal headaches associated with ipsilateral rhinorrhea, eye tearing, and redness. Episodes have occurred at the same time every night for the past week and last for 45 minutes.
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Cluster headache Migraine Tension headache Sinusitis Pseudotumor cerebri Trigeminal neuralgia Intracranial neoplasm CBC ESR CT—head MRI—brain LP
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65 yo F presents with severe, intermittent right temporal headache, fever, blurred vision in her right eye, and pain in her jaw when chewing.
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Temporal arteritis (giant cell arteritis) Migraine Cluster headache Tension headache Meningitis Carotid artery dissection Pseudotumor cerebri Trigeminal neuralgia Intracranial neoplasm CBC ESR CRP Temporal artery biopsy Doppler U/S—carotid MRI—brain
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30 yo F presents with frontal headache, fever, and nasal discharge. There is pain on palpation of the frontal and maxillary sinuses. She has a history of sinusitis.
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Sinusitis Migraine Tension headache Meningitis Intracranial neoplasm CBC XR—sinus CT—sinus LP
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50 yo F presents with recurrent episodes of bilateral squeezing headaches that occur 3-4 times a week, typically toward the end of her work day. She is experiencing signifi cant stress in her life.
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Tension headache Migraine Depression Caffeine or analgesic withdrawal Hypertension Cluster headache Pseudotumor cerebri Intracranial neoplasm CBC Electrolytes ESR CT—head LP
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35 yo M presents with sudden severe headache, vomiting, confusion, left hemiplegia, and nuchal rigidity.
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DDX: 1 - Subarachnoid hemorrhage 2 - Migraine 3 - Meningitis/encephalitis 4 - Intracranial hemorrhage 5 - Intracranial neoplasm, vertebral a. dissection, intracranial venous thrombosis, acute htn W/U: 1 - CBC, PT/PTT, CT head w/o contrast, MRI/MRA brain 3 - LP
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25 yo M presents with high fever, severe headache, confusion, photophobia, and nuchal rigidity. Kernig's and Brudzinski's signs are positive.
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Meningitis Migraine Subarachnoid hemorrhage Sinusitis/encephalitis Intracranial or epidural abscess W/U: CBC CT—head MRI—brain LP—CSF analysis (cell count, protein, glucose, Gram stain, PCR for antigens, culture)
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18 yo obese F presents with a pulsatile headache, vomiting, and blurred vision for the past 2-3 weeks. She is taking OCPs.
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Pseudotumor cerebri Tension headache Migraine Cluster headache Meningitis Intracranial venous thrombosis Intracranial neoplasm W/U: Urine hCG CBC CT—head LP—opening pressure and CSF analysis
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57 yo M c/o daily pain in the right cheek over the past month. The pain is electric and stabbing in character and occurs while he is shaving. Each episode lasts 2-4 minutes.
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Trigeminal neuralgia Tension headache Migraine Cluster headache TMJ dysfunction Intracranial neoplasm W/U: CBC ESR MRI—brain
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81 yo M presents with progressive confusion over the past several years together with forgetfulness and clumsiness. He has a history of hypertension, diabetes mellitus, and two strokes with residual left hemiparesis. His mental status has clearly worsened after each stroke (stepwise decline in cognitive function).
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Vascular ("multi-infarct") dementia Alzheimer's disease Normal pressure hydrocephalus Chronic subdural hematoma Intracranial tumor Depression B12 defi ciency Neurosyphilis Hypothyroidism W/U: CBC VDRL/RPR Serum B12 TSH MRI—brain CT—head LP—CSF analysis (rare)
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84 yo F brought by her son c/o forgetfulness (e.g., forgets phone numbers, loses her way back home) along with diffi culty performing some of her daily activities (e.g., bathing, dressing, managing money, using the phone). The problem has gradually progressed over the past few years.
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Alzheimer's disease Vascular dementia Depression Hypothyroidism Chronic subdural hematoma Normal pressure hydrocephalus Intracranial neoplasm B12 defi ciency Neurosyphilis W/U: CBC VDRL/RPR Serum B12 TSH MRI—brain (preferred) CT—head LP—CSF analysis (rare)
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72 yo M presents with memory loss, gait disturbance, and urinary incontinence for the past six months.
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Normal pressure hydrocephalus Alzheimer's disease Vascular dementia Chronic subdural hematoma Intracranial neoplasm Depression B12 defi ciency Neurosyphilis Hypothyroidism W/U: CT—head LP—opening pressure and CSF analysis Serum B12 VDRL/RPR TSH
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55 yo M presents with a rapidly progressive change in mental status, inability to concentrate, and memory impairment for the past two months. His symptoms are associated with myoclonus and ataxia.
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Creutzfeldt-Jakob disease Vascular dementia Lewy body dementia Wernicke's encephalopathy Normal pressure hydrocephalus Chronic subdural hematoma Intracranial neoplasm Depression Delirium B12 defi ciency Neurosyphilis W/U: CBC, electrolytes, calcium Serum B12 VDRL/RPR MRI—brain (preferred) CT—head EEG LP—CSF analysis Brain biopsy
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70 yo insulin-dependent diabetic M presents with episodes of confusion, dizziness, palpitation, diaphoresis, and weakness.
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Hypoglycemia Transient ischemic attack Arrhythmia Delirium Angina W/U: Glucose CBC, electrolytes Echocardiography ECG MRI—brain Doppler U/S—carotid
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55 yo F presents with gradual altered mental status and headache. Two weeks ago she slipped, hit her head on the ground, and lost consciousness for two minutes.
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Subdural hematoma SIADH (causing hyponatremia) Creutzfeldt-Jakob disease Intracranial neoplasm W/U: Electrolytes CT—head MRI—brain LP
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68 yo M presents with a two-month history of crying spells, excessive sleep, poor hygiene, and a 7-kg weight loss, all following his wife's death. He cannot enjoy time with his grandchildren and reluctantly admits to thinking he has seen his dead wife in line at the supermarket or standing in the kitchen making dinner.
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Normal bereavement Adjustment disorder with depressed mood Major depressive disorder with psychotic features Schizoaffective disorder Depressive disorder not otherwise specifi ed (NOS) W/U: Physical exam Mental status exam TSH CBC Urine toxicology
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42 yo F presents with a four-week history of excessive fatigue, insomnia, and anhedonia. She states that she thinks constantly about death. She has suffered fi ve similar episodes in the past, the fi rst in her 20s, and has made two previous suicide attempts. She further admits to increased alcohol use in the past month.
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Major depressive disorder Substance-induced mood disorder Dysthymic disorder W/U: Physical exam Mental status exam Blood alcohol level TSH CBC Urine toxicology
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26 yo F presents with a 3-kg weight loss over the past two months, accompanied by early-morning awakening, excessive guilt, and psychomotor retardation. She does not identify a trigger for the depressive episode but reports several weeks of increased energy, sexual promiscuity, irresponsible spending, and racing thoughts approximately six months before her presentation.
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Bipolar I disorder Bipolar II disorder Cyclothymic disorder Major depressive disorder Schizoaffective disorder W/U: Physical exam Mental status exam Urine toxicology
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19 yo M c/o receiving messages from his television set. He reports that he did not have many friends in high school. In college, he started to suspect his roommate of bugging the phone. In the same time frame, he stopped going to classes because he felt that his professors were saying horrible things about him that no one else noticed. He rarely showered or left his room and has recently been hearing a voice from his television set telling him to "guard against the evil empire."
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Schizophrenia Schizoid or schizotypal personality disorder Schizophreniform disorder Psychotic disorder due to a general medical condition Substance-induced psychosis Depression with psychotic features W/U: Mental status exam Urine toxicology TSH CBC Electrolytes
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28 yo F c/o seeing bugs crawling on her bed over the past two days and reports hearing loud voices when she is alone in her room. She has never experienced symptoms such as these in the past. She recently ingested an unknown substance.
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Substance-induced psychosis Brief psychotic disorder Schizophreniform disorder Schizophrenia Psychotic disorder due to a general medical condition W/U: Urine toxicology Mental status exam TSH CBC Electrolytes, BUN/Cr, AST/ ALT
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48 yo F presents with a one-week history of auditory hallucinations, stating, "I am worthless" and "I should kill myself." She also reports a two-week history of weight loss, early-morning awakening, decreased motivation, and overwhelming feelings of guilt.
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Schizoaffective disorder Mood disorder with psychotic features Schizophrenia Schizophreniform disorder Psychotic disorder due to a general medical condition W/U: Mental status exam Beck Depression Inventory TSH CBC Electrolytes
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35 yo F presents with intermittent episodes of vertigo, tinnitus, nausea, and hearing loss over the past week.
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Ménière's disease Vestibular neuronitis Labyrinthitis Benign positional vertigo Acoustic neuroma W/U: CBC VDRL/RPR (syphilis is a cause of Ménière's disease) MRI—brain
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55 yo F c/o dizziness for the past day. She feels faint and has severe diarrhea that started two days ago. She takes furosemide for her hypertension.
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Orthostatic hypotension due to dehydration (diarrhea, diuretic use) Vestibular neuronitis Labyrinthitis Benign positional vertigo Vertebrobasilar insuffi ciency W/U: Orthostatic vital signs CBC Electrolytes Stool exam (occult blood, fecal leukocytes
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65 yo M presents with postural dizziness and unsteadiness. He has hypertension and was started on hydrochlorothiazide two days ago.
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Drug-induced orthostatic hypotension Vestibular neuronitis Labyrinthitis Benign positional vertigo Brain stem or cerebellar tumor Acute renal failure W/U: Orthostatic vital signs CBC Electrolytes BUN/Cr MRI—brain
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44 yo F c/o dizziness on moving her head to the left. She feels that the room is spinning around her head. Tilt test results in nystagmus and nausea.
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Benign positional vertigo Vestibular neuronitis Labyrinthitis Ménière's disease W/U: MRI—brain Audiogram
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55 yo F c/o dizziness that started this morning. She is nauseated and has vomited once in the past day. She had a URI two days ago and has experienced no hearing loss.
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Vestibular neuronitis Labyrinthitis Ménière's disease Benign positional vertigo Vertigo associated with cervical spine disease/injury Vertebrobasilar insufficiency W/U: CBC Electrolytes Electronystagmography MRI/MRA—brain
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55 yo F c/o dizziness that started this morning and of "not hearing well." She feels nauseated and has vomited once in the past day. She had a URI two days ago.
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Labyrinthitis Vestibular neuronitis Ménière's disease Acoustic neuroma Vertebrobasilar insuffi ciency W/U: Audiogram Electronystagmography MRI/MRA—brain
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26 yo M presents after falling and losing consciousness at work. He had rhythmic movements of the limbs, bit his tongue, and lost control of his bladder. He was subsequently confused (as witnessed by his colleagues).
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Seizure, grand mal (now called complex tonic-clonic seizure) Convulsive syncope Substance abuse/overdose Malingering Hypoglycemia W/U: CBC, electrolytes, glucose Urine toxicology EEG MRI—brain CT—head LP—CSF analysis ECG
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55 yo M c/o falling after feeling dizzy and unsteady. He experienced transient LOC. He has hypertension and is on numerous antihypertensive drugs.
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Drug-induced orthostatic hypotension (causing syncope) Cardiac arrhythmia Syncope (vasovagal, other causes) Stroke MI Pulmonary embolism W/U: Orthostatic vital signs CBC Electrolytes CT—head ECG V/Q scan CT—chest with IV contrast
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65 yo M presents after falling and losing consciousness for a few seconds. He had no warning prior to passing out but recently had palpitations. His past history includes coronary artery bypass grafting (CABG).
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Cardiac arrhythmia (causing syncope) Severe aortic stenosis Syncope (other causes) Seizure Pulmonary embolism W/U: ECG Holter monitoring CBC, electrolytes Glucose Echocardiography CT—head
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68 yo M presents following a 20-minute episode of slurred speech, right facial drooping and numbness, and right hand weakness. His symptoms had totally resolved by the time he got to the ER. He has a history of hypertension, diabetes mellitus, and heavy smoking.
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Transient ischemic attack (TIA) Hypoglycemia Seizure Stroke Facial nerve palsy W/U: CBC Glucose Electrolytes ECG CT—head MRI—brain Doppler U/S—carotid Echocardiography EEG
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68 yo M presents with slurred speech, right facial drooping and numbness, and right hand weakness. Babinski's sign is present on the right. He has a history of hypertension, diabetes mellitus, and heavy smoking.
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Stroke TIA Seizure Intracranial neoplasm Subdural or epidural hematoma W/U: CBC, electrolytes PT/PTT CT—head MRI—brain (preferred) Doppler U/S—carotid Echocardiography
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33 yo F presents with ascending loss of strength in her lower legs over the past two weeks. She had a recent URI.
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Guillain-Barré syndrome Multiple sclerosis Polymyositis Myasthenia gravis Peripheral neuropathy Tumor in the vertebral canal W/U: CBC, electrolytes CPK LP—CSF analysis MRI—spine EMG/nerve conduction study Tensilon test Serum B12
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30 yo F presents with weakness, loss of sensation, and tingling in her left leg that started this morning. She is also experiencing right eye pain, decreased vision, and double vision. She reports feeling "electric shocks" down her spine upon fl exing her head.
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Multiple sclerosis Stroke Conversion disorder Malingering CNS tumor Neurosyphilis Syringomyelia CNS vasculitis W/U: CBC, ESR VDRL/RPR MRI—brain LP—CSF analysis Retinal evoked potentials
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55 yo M presents with tingling and numbness in the hands and feet (gloveand- stocking distribution) over the past two months. He has a history of diabetes mellitus, hypertension, and alcoholism. There is decreased soft touch, vibratory, and position sense in the feet.
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Diabetic peripheral neuropathy Alcoholic peripheral neuropathy B12 defi ciency Hypocalcemia Hyperventilation Paraproteinemia/myeloma W/U: HbA1c ESR Calcium Serum B12 Serum and urine protein electrophoresis
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40 yo F presents with occasional double vision and droopy eyelids at night with normalization by morning.
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Myasthenia gravis Horner's syndrome Multiple sclerosis Intracranial tumor compressing CN III, IV, or VI Amyotrophic lateral sclerosis W/U: Tensilon test ACh receptor antibodies (in serum) CXR CT—chest MRI—brain EMG
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25 yo M presents with hemiparesis (after a tonic-clonic seizure) that resolves over a few hours.
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Todd's paralysis TIA Stroke Complicated migraine Malingering W/U: CBC, electrolytes EEG MRI—brain Doppler U/S—carotid
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40 yo F c/o feeling tired, hopeless, and worthless and of having suicidal thoughts. She recently discovered that her husband is homosexual.
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Depression Adjustment disorder Hypothyroidism Anemia W/U: CBC TSH HIV/STD testing (given husband's possible risk factors)
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44 yo M presents with fatigue, insomnia, and nightmares about a murder that he witnessed in a mall one year ago. Since then, he has avoided that mall and has not gone out at night.
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Post-traumatic stress disorder (PTSD) Depression Generalized anxiety disorder Psychotic or delusional disorder Hypothyroidism W/U: CBC TSH Calcium Urine toxicology
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55 yo M presents with fatigue, weight loss, and constipation. He has a family history of colon cancer.
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Colon cancer Hypothyroidism Renal failure Hypercalcemia Depression W/U: Rectal exam, stool for occult blood CBC, electrolytes, calcium, BUN/Cr, AST/ALT, TSH Colonoscopy Barium enema
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40 yo F presents with fatigue, weight gain, sleepiness, cold intolerance, constipation, and dry skin.
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Hypothyroidism Depression Diabetes Anemia W/U: TSH, FT3, FT4 CBC Glucose, HbA1c
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50 yo obese F presents with fatigue and daytime sleepiness. She snores heavily and naps 3-4 times per day but never feels refreshed. She also has hypertension.
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Obstructive sleep apnea Hypothyroidism Chronic fatigue syndrome Narcolepsy W/U: CBC TSH Nocturnal pulse oximetry Polysomnography ECG
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20 yo M presents with fatigue, thirst, increased appetite, and polyuria.
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Diabetes mellitus Atypical depression Primary polydipsia Diabetes insipidus W/U: Glucose tolerance test, HbA1c UA CBC, electrolytes, glucose BUN/Cr
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35 yo M policeman c/o feeling tired and sleepy during the day. He changed to the night shift last week.
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Sleep deprivation Sleep apnea Depression Anemia W/U: CBC Nocturnal pulse oximetry Polysomnography
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30 yo M presents with night sweats, cough, and swollen glands of one month's duration.
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Tuberculosis Acute HIV infection Lymphoma Leukemia Hyperthyroidism W/U: PPD CBC CXR Sputum Gram stain, acid-fast stain, and culture HIV antibody TSH, FT4
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25 yo F presents with a three-week history of diffi culty falling asleep. She sleeps seven hours per night without nightmares or snoring. She recently began college and is having trouble with her boyfriend. She drinks 3-4 cups of coffee a day.
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Stress-induced insomnia Caffeine-induced insomnia Insomnia with circadian rhythm sleep disorder Insomnia related to major depressive disorder W/U: Polysomnography Mental status exam Urine toxicology CBC TSH
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55 yo obese M presents with several months of poor sleep and daytime fatigue. His wife reports that he snores loudly.
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Obstructive sleep apnea Daytime fatigue in primary hypersomnia Insomnia with circadian rhythm sleep disorder Insomnia related to major depressive disorder W/U: CBC TSH Polysomnography ECG
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33 yo F c/o three weeks of fatigue and trouble sleeping. She states that she falls asleep easily but wakes up at 3 A.M. and cannot return to sleep. She also reports an unintentional weight loss of 3.5 kg along with an inability to enjoy the things she once liked to do.
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Insomnia related to major depressive disorder Primary hypersomnia Insomnia with circadian rhythm sleep disorder W/U: Mental status exam TSH CBC Polysomnography
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26 yo F presents with sore throat, fever, severe fatigue, and loss of appetite for the past week. She also reports epigastric and LUQ discomfort. She has cervical lymphadenopathy and a rash. Her boyfriend recently experienced similar symptoms.
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Infectious mononucleosis Hepatitis Viral or bacterial pharyngitis Acute HIV infection Secondary syphilis W/U: CBC, peripheral smear Monospot test Throat culture AST/ALT/bilirubin/alkaline phosphatase HIV antibody and viral load Anti-EBV antibodies VDRL/RPR
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26 yo M presents with sore throat, fever, rash, and weight loss. He has a history of IV drug abuse and sharing needles.
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HIV, acute retroviral syndrome Infectious mononucleosis Hepatitis Viral pharyngitis Streptococcal tonsillitis/ scarlet fever Secondary syphilis W/U: CBC Peripheral smear HIV antibody and viral load CD4 count Monospot test Throat culture VDRL/RPR AST/ALT/bilirubin/alkaline phosphatas
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46 yo F presents with fever and sore throat.
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Pharyngitis (bacterial or viral) Mycoplasma pneumonia Acute HIV infection Infectious mononucleosis W/U: Throat swab for culture and rapid streptococcal antigen Monospot test CBC HIV antibody and viral load
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30 yo M presents with shortness of breath, cough, and wheezing that worsen in cold air. He has had several such episodes over the past four months.
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Asthma GERD Bronchitis Pneumonitis Foreign body W/U: CBC CXR Peak fl ow measurement PFTs Methacholine challenge test
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56 yo F presents with shortness of breath as well as with a productive cough that has occurred over the past two years for at least three months each year. She is a heavy smoker.
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COPD—chronic bronchitis Bronchiectasis Lung cancer Tuberculosis W/U: CBC Sputum Gram stain and culture CXR PFTs CT—chest PPD
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58 yo M presents with pleuritic chest pain, fever, chills, and cough with purulent yellow sputum. He is a heavy smoker with COPD.
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Pneumonia Bronchitis Lung abscess Lung cancer Tuberculosis Pericarditis W/U: CBC Sputum Gram stain and culture CXR CT—chest ECG PPD
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25 yo F presents with two weeks of a nonproductive cough. Three weeks ago she had a sore throat and a runny nose.
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Atypical pneumonia Reactive airway disease URI-associated ("postinfectious") Postnasal drip GERD W/U: CBC Induced sputum Gram stain and culture CXR IgM detection for Mycoplasma pneumoniae Urine Legionella antigen
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65 yo M presents with worsening cough over the past six months together with hemoptysis, dyspnea, weakness, and weight loss. He is a heavy smoker.
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Lung cancer Tuberculosis Lung abscess COPD Vasculitis (i.e., Wegener's) Interstitial lung disease CHF W/U: CBC Sputum Gram stain, culture, and cytology CXR CT—chest PPD Bronchoscopy
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55 yo M presents with increased dyspnea and sputum production over the past three days. He has COPD and stopped using his inhalers last week. He also stopped smoking two days ago.
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COPD exacerbation (bronchitis) Lung cancer Pneumonia URI CHF W/U: CBC CXR PFTs Sputum Gram stain and culture CT—chest
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34 yo F nurse presents with worsening cough of six weeks' duration together with weight loss, fatigue, night sweats, and fever. She has a history of contact with tuberculosis patients at work.
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Tuberculosis Pneumonia Lung abscess Vasculitis Lymphoma Metastatic cancer HIV/AIDS Sarcoidosis W/U: CBC PPD Sputum Gram stain, acid-fast stain, and culture CXR CT—chest Bronchoscopy HIV antibody
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35 yo M presents with shortness of breath and cough. He has had unprotected sex with multiple sexual partners and was recently exposed to a patient with active tuberculosis.
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Tuberculosis Pneumonia (including Pneumocystis jiroveci) Bronchitis CHF (cardiomyopathy) Asthma Acute HIV infection W/U: CBC PPD Sputum Gram stain, acid-fast stain, silver stain, and culture CXR HIV antibody
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50 yo M presents with a cough that is exacerbated by lying down at night and improved by propping up on three pillows. He also reports exertional dyspnea.
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CHF Cardiac valvular disease GERD Pulmonary fi brosis COPD Postnasal drip W/U: CBC CXR ECG Echocardiography PFTs BNP
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60 yo M presents with sudden onset of substernal heavy chest pain that has lasted for 30 minutes and radiates to the left arm. The pain is accompanied by dyspnea, diaphoresis, and nausea. He has a history of hypertension, hyperlipidemia, and smoking.
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Myocardial infarction (MI) GERD Angina Costochondritis Aortic dissection Pericarditis Pulmonary embolism Pneumothorax W/U: ECG CPK-MB, troponin CXR CBC, electrolytes Echocardiography Cardiac catheterization
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20 yo African-American F presents with acute onset of severe chest pain. She has a history of sickle cell disease and multiple previous hospitalizations for pain and anemia management.
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Sickle cell disease—pulmonary infarction Pneumonia Pulmonary embolism MI Pneumothorax Aortic dissection W/U: CBC, reticulocyte count, LDH, peripheral smear ABG CXR CPK-MB, troponin ECG CT—chest with IV contrast
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45 yo F presents with a retrosternal burning sensation that occurs after heavy meals and when lying down. Her symptoms are relieved by antacids.
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GERD Esophagitis Peptic ulcer disease Esophageal spasm MI Angina W/U: ECG Barium swallow Upper endoscopy Esophageal pH monitoring
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55 yo M presents with retrosternal squeezing pain that lasts for two minutes and occurs with exercise. It is relieved by rest and is not related to food intake.
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Angina Esophageal spasm Esophagitis W/U: ECG CPK-MB, troponin CXR CBC, electrolytes Exercise stress test Upper endoscopy/pH monitor Cardiac catheterization
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34 yo F presents with retrosternal stabbing chest pain that improves when she leans forward and worsens with deep inspiration. She had a URI one week ago.
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Pericarditis Aortic dissection MI Costochondritis GERD Esophageal rupture W/U: ECG CPK-MB, troponin CXR Echocardiography CBC Upper endoscopy
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34 yo F presents with stabbing chest pain that worsens with deep inspiration and is relieved by aspirin. She had a URI one week ago. Chest wall tenderness is noted.
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Costochondritis Pneumonia MI Pulmonary embolism Pericarditis Muscle strain W/U: ECG CPK-MB, troponin CXR CBC
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70 yo F presents with acute onset of shortness of breath at rest and pleuritic chest pain. She also presents with tachycardia, hypotension, tachypnea, and mild fever. She is recovering from hip replacement surgery.
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Pulmonary embolism Pneumonia Costochondritis MI CHF Aortic dissection W/U: ECG CXR ABG CPK-MB, troponin CBC, electrolytes CT—chest with IV contrast Doppler U/S—legs D-dimer
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55 yo M presents with sudden onset of severe chest pain that radiates to the back. He has a history of uncontrolled hypertension.
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Aortic dissection MI Pericarditis Esophageal rupture Esophageal spasm GERD Pancreatitis Fat embolism W/U: ECG, CPK-MB, troponin CXR CBC, amylase, lipase Transesophageal echocardiography (TEE), MRI/MRA—aorta Aortic angiography Upper endoscopy
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70 yo diabetic M presents with episodes of palpitations and diaphoresis. He is on insulin.
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Hypoglycemia Cardiac arrhythmias Angina Hyperthyroidism Hyperventilation episodes Panic attacks Pheochromocytoma Carcinoid W/U: Glucose CBC, electrolytes TSH BUN/Cr ECG Holter monitor
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42 yo F presents with a 7-kg weight loss over the past two months. She has a fi ne tremor, and her pulse is 112.
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Hyperthyroidism Cancer HIV infection Dieting/diet drugs Anorexia nervosa Malabsorption W/U: TSH, FT4 CBC, electrolytes HIV antibody Urine toxicology
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44 yo F presents with a weight gain of > 11 kg over the past two months. She quit smoking three months ago and is on amitriptyline for depression. She also reports cold intolerance and constipation.
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Smoking cessation Drug side effect Hypothyroidism Cushing's syndrome Polycystic ovary syndrome Diabetes mellitus Atypical depression W/U: CBC, electrolytes, glucose TSH 24-hour urine free cortisol Dexamethasone suppression test
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75 yo M presents with dysphagia that started with solids and progressed to liquids. He is an alcoholic and a heavy smoker. He has had an unintentional weight loss of 7 kg over the past four months.
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Esophageal cancer Achalasia Esophagitis Systemic sclerosis Esophageal stricture Amyotrophic lateral sclerosis W/U: CBC CXR Endoscopy with biopsy Barium swallow CT—chest
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45 yo F presents with dysphagia for two weeks together with fatigue and a craving for ice and clay.
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Plummer-Vinson syndrome Esophageal cancer Esophagitis Achalasia Systemic sclerosis Mitral valve stenosis W/U: CBC Serum iron, ferritin, TIBC Barium swallow Endoscopy
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48 yo F presents with dysphagia for both solid and liquid foods that has slowly progressed in severity over the past year. It is associated with regurgitation of undigested food, especially at night.
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Achalasia Plummer-Vinson syndrome Esophageal cancer Esophagitis Systemic sclerosis Mitral valve stenosis Esophageal stricture Zenker's diverticulum W/U: CXR Endoscopy Barium swallow Esophageal manometry
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38 yo M presents with dysphagia and pain on swallowing solids more than liquids. Exam reveals oral thrush.
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Esophagitis (CMV, HSV, pillinduced) Systemic sclerosis GERD Esophageal stricture Zenker's diverticulum W/U: CBC Endoscopy Barium swallow HIV antibody CD4 count
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20 yo F presents with nausea, vomiting (especially in the morning), fatigue, and polyuria. Her last menstrual period was six weeks ago, and her breasts are full and tender. She is sexually active with her boyfriend, and they use condoms for contraception.
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Pregnancy Gastritis Hypercalcemia Diabetes mellitus UTI Depression W/U: Urine hCG Pelvic exam U/S—pelvis CBC, electrolytes, calcium, glucose UA, urine culture Baseline Pap smear, cervical cultures, rubella antibody, HIV antibody, hepatitis B surface antigen, and VDRL/ RPR
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45 yo M presents with sudden onset of colicky right-sided fl ank pain that radiates to the testicles, accompanied by nausea, vomiting, hematuria, and CVA tenderness.
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Nephrolithiasis Renal cell carcinoma Pyelonephritis GI etiology (e.g., appendicitis) W/U: Rectal exam UA Urine culture and sensitivity BUN/Cr CT—abdomen U/S—renal IVP
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60 yo M presents with dull epigastric pain that radiates to the back, together with weight loss, dark urine, and clay-colored stool. He is a heavy drinker and smoker.
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Pancreatic cancer Acute viral hepatitis Chronic pancreatitis Cholecystitis/choledocholithiasis Abdominal aortic aneurysm Peptic ulcer disease W/U: Rectal exam CBC, electrolytes Amylase and lipase AST/ALT/bilirubin/alkaline phosphatase U/S—abdomen CT—abdomen
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56 yo M presents with severe midepigastric abdominal pain that radiates to the back and improves when he leans forward. He also reports anorexia, nausea, and vomiting. He is an alcoholic and has spent the past three days binge drinking.
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Acute pancreatitis Peptic ulcer disease Cholecystitis/choledocholithiasis Gastritis Abdominal aortic aneurysm Mesenteric ischemia Alcoholic hepatitis Mallory-Weiss tear W/U: Rectal exam CBC, electrolytes, BUN/Cr, amylase, lipase, AST/ALT/ bilirubin/alkaline phosphatase U/S—abdomen CT—abdomen Upper endoscopy ECG
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41 yo obese F presents with RUQ abdominal pain that radiates to the right scapula and is associated with nausea, vomiting, and a fever of 101.5°F. The pain started after she had eaten fatty food. She has had similar but less intense episodes that lasted a few hours. Exam reveals positive Murphy's sign.
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Acute cholecystitis Hepatitis Choledocholithiasis Ascending cholangitis Peptic ulcer disease Fitz-Hugh-Curtis syndrome W/U: Rectal exam CBC AST/ALT/bilirubin/alkaline phosphatase U/S—abdomen HIDA scan
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43 yo obese F presents with RUQ abdominal pain, fever, and jaundice. She was diagnosed with asymptomatic gallstones one year ago.
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Ascending cholangitis Acute cholecystitis Hepatitis Choledocholithiasis Sclerosing cholangitis Fitz-Hugh-Curtis syndrome W/U: Rectal exam CBC AST/ALT/bilirubin/alkaline phosphatase Viral hepatitis serologies U/S—abdomen MRCP ERCP
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25 yo M presents with RUQ pain, fever, anorexia, nausea, and vomiting. He has dark urine and clay-colored stool.
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Acute hepatitis Acute cholecystitis Ascending cholangitis Choledocholithiasis Pancreatitis Acute glomerulonephritis W/U: Rectal exam CBC, amylase, lipase AST/ALT/bilirubin/alkaline phosphatase UA Viral hepatitis serologies U/S—abdomen
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35 yo M presents with burning epigastric pain that starts 2-3 hours after meals. The pain is relieved by food and antacids.
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Peptic ulcer disease Gastritis GERD Cholecystitis Chronic pancreatitis Mesenteric ischemia W/U: Rectal exam Amylase, lipase, lactate AST/ALT/bilirubin/alkaline phosphatase Endoscopy (including H. pylori testing) Upper GI series
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37 yo M presents with severe epigastric pain, nausea, vomiting, and mild fever. He appears toxic. He has a history of intermittent epigastric pain that is relieved by food and antacids. He also smokes heavily and takes aspirin on a regular basis.
answer
Peptic ulcer perforation Acute pancreatitis Hepatitis Cholecystitis Choledocholithiasis Mesenteric ischemia W/U: Rectal exam CBC, electrolytes, amylase, lipase, lactate AST/ALT/bilirubin/alkaline phosphatase AXR Upright CXR Endoscopy (including H. pylori testing)
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18 yo M boxer presents with severe LUQ abdominal pain that radiates to the left scapula. He had infectious mononucleosis three weeks ago.
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Splenic rupture Kidney stone Rib fracture Pneumonia Perforated peptic ulcer Splenic infarct W/U: Rectal exam CBC, electrolytes CXR CT—abdomen U/S—abdomen
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40 yo M presents with crampy abdominal pain, vomiting, abdominal distention, and inability to pass fl atus or stool. He has a history of multiple abdominal surgeries.
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Intestinal obstruction Small bowel or colon cancer Volvulus of the bowel Gastroenteritis Food poisoning Ileus Hernia W/U: Rectal exam CBC, electrolytes AXR CT—abdomen/pelvis CXR
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70 yo F presents with acute onset of severe, crampy abdominal pain. She recently vomited and had a massive dark bowel movement. She has a history of CHF and atrial fi brillation, for which she has received digitalis. Her pain is out of proportion to the exam.
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Mesenteric ischemia/infarction Diverticulitis Peptic ulcer disease Gastroenteritis Acute pancreatitis Cholecystitis/choledocholithiasis MI W/U: Rectal exam CBC, amylase, lipase, lactate ECG, CPK-MB, troponin AXR CT—abdomen Mesenteric angiography Barium enema
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21 yo F presents with acute onset of severe RLQ pain, nausea, and vomiting. She has no fever, urinary symptoms, or vaginal bleeding and has never taken OCPs. Her last menstrual period was regular, and she has no history of STDs.
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Ovarian torsion Appendicitis Nephrolithiasis Ectopic pregnancy Ruptured ovarian cyst PID Bowel infarction or perforation W/U: Pelvic exam Rectal exam Urine hCG UA CBC Doppler U/S—pelvis CT—abdomen Laparoscopy
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68 yo M presents with LLQ abdominal pain, fever, and chills for the past three days. He also reports recent onset of alternating diarrhea and constipation. He consumes a low-fi ber, high-fat diet.
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Diverticulitis Crohn's disease Ulcerative colitis Gastroenteritis Abscess W/U: Rectal exam CBC, electrolytes CXR AXR CT—abdomen
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20 yo M presents with severe RLQ abdominal pain, nausea, and vomiting. His discomfort started yesterday as a vague pain around the umbilicus. As the pain worsened, it became sharp and migrated to the RLQ. McBurney's and psoas signs are positive.
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Acute appendicitis Gastroenteritis Diverticulitis Crohn's disease Nephrolithiasis Volvulus or other intestinal obstruction/perforation W/U: Rectal exam CBC, electrolytes AXR CT—abdomen U/S—abdomen
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30 yo F presents with periumbilical pain for six months. The pain never awakens her from sleep. It is relieved by defecation and worsens when she is upset. She has alternating constipation and diarrhea but no nausea, vomiting, weight loss, or anorexia.
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Irritable bowel syndrome Crohn's disease Celiac disease Chronic pancreatitis GI parasitic infection (amebiasis, giardiasis) Endometriosis W/U: Rectal exam, stool for occult blood Pelvic exam Urine hCG CBC Electrolytes CT—abdomen/pelvis Stool for ova and parasitology, Entamoeba histolytica antigen
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24 yo F presents with bilateral lower abdominal pain that started with the fi rst day of her menstrual period. The pain is associated with fever and a thick, greenish-yellow vaginal discharge. She has had unprotected sex with multiple sexual partners.
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PID Endometriosis Dysmenorrhea Vaginitis Cystitis Spontaneous abortion Pyelonephritis W/U: Pelvic exam Rectal exam Urine hCG Cervical cultures CBC/ESR UA, urine culture U/S—pelvis
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67 yo M presents with alternating diarrhea and constipation, decreased stool caliber, and blood in the stool for the past eight months. He also reports unintentional weight loss. He is on a low-fi ber diet and has a family history of colon cancer.
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Colorectal cancer Irritable bowel syndrome Diverticulosis GI parasitic infection (ascariasis, giardiasis) Infl ammatory bowel disease Angiodysplasia W/U: Rectal exam CBC AST/ALT/bilirubin/alkaline phosphatase Colonoscopy Barium enema CT—abdomen/pelvis
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28 yo M presents with constipation (very hard stool) for the last three weeks. Since his mother died two months ago, he and his father have eaten only junk food.
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Low-fi ber diet Irritable bowel syndrome Substance abuse (e.g., heroin) Depression Hypothyroidism W/U: Rectal exam TSH Electrolytes Urine toxicology
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30 yo F presents with alternating constipation and diarrhea and abdominal pain that is relieved by defecation. She has no nausea, vomiting, weight loss, or blood in her stool.
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Irritable bowel syndrome Infl ammatory bowel disease Celiac disease Chronic pancreatitis GI parasitic infection (ascariasis, giardiasis) Lactose intolerance W/U: Rectal exam, stool for occult blood CBC Electrolytes Stool for ova and parasitology AXR CT—abdomen/pelvis
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33 yo M presents with watery diarrhea, vomiting, and diffuse abdominal pain that began yesterday. He also reports feeling hot. Several of his coworkers are also ill.
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Infectious diarrhea (gastroenteritis)—bacterial, viral, parasitic, protozoal Food poisoning Infl ammatory bowel disease W/U: Rectal exam, stool for occult blood Stool leukocytes and culture CBC Electrolytes CT—abdomen/pelvis
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40 yo F presents with watery diarrhea and abdominal cramps. Last week she was on antibiotics for a UTI.
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Pseudomembranous (Clostridium diffi cile) colitis Gastroenteritis Cryptosporidiosis Food poisoning Inflammatory bowel disease W/U: Rectal exam Stool leukocytes, culture, occult blood C. diffi cile toxin in stool Electrolytes
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25 yo M presents with watery diarrhea and abdominal cramps. He was recently in Mexico.
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Traveler's diarrhea Giardiasis Amebiasis Food poisoning Hepatitis A W/U: Rectal exam Stool leukocytes, culture, Giardia antigen, Entamoeba histolytica antigen Electrolytes AST/ALT/bilirubin/alkaline phosphatase Viral hepatitis serology
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30 yo F presents with watery diarrhea and abdominal cramping and bloating. Her symptoms are aggravated by milk ingestion and are relieved by fasting.
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Lactose intolerance Gastroenteritis Infl ammatory bowel disease Irritable bowel syndrome Hyperthyroidism W/U: Rectal exam Stool exam Hydrogen breath test TSH
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33 yo M presents with watery diarrhea, diffuse abdominal pain, and weight loss over the past three weeks. He has not responded to antibiotics.
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Crohn's disease Gastroenteritis Ulcerative colitis Celiac disease Pseudomembranous colitis Hyperthyroidism Small bowel lymphoma Carcinoid W/U: Rectal exam Stool exam and culture CBC, electrolytes TSH CT—abdomen Colonoscopy Small bowel series Urinary 5-HIAA
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45 yo F presents with coffee-ground emesis for the last three days. Her stool is dark and tarry. She has a history of intermittent epigastric pain that is relieved by food and antacids.
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Bleeding peptic ulcer Gastritis Gastric cancer Esophageal varices W/U: Rectal exam CBC, electrolytes AST/ALT/bilirubin/alkaline phosphatase Endoscopy (including H. pylori testing if ulcer is confi rmed)
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40 yo F presents with epigastric pain and coffee-ground emesis. She has a history of rheumatoid arthritis that has been treated with aspirin. She is an alcoholic.
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Gastritis Bleeding peptic ulcer Gastric cancer Esophageal varices Mallory-Weiss tear W/U: Rectal exam CBC, electrolytes AST/ALT/bilirubin/alkaline phosphatase Barium swallow Endoscopy
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67 yo M presents with blood in his stool, weight loss, and constipation. He has a family history of colon cancer.
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Colorectal cancer Anal fi ssure Hemorrhoids Diverticulosis Ischemic bowel disease Angiodysplasia Upper GI bleeding Inflammatory bowel disease W/U: Rectal exam CBC, PT/PTT AST/ALT/bilirubin/alkaline phosphatase CEA Colonoscopy CT—abdomen/pelvis Barium enema
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33 yo F presents with rectal bleeding and diarrhea for the past week. She has had lower abdominal pain and tenesmus for several months.
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Ulcerative colitis Crohn's disease Proctitis Anal fi ssure Hemorrhoids Diverticulosis Dysentery W/U: Rectal exam CBC, PT/PTT AXR Colonoscopy CT—abdomen/pelvis Barium enema
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58 yo M presents with bright red blood per rectum and chronic constipation. He consumes a low-fi ber diet.
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Diverticulosis Anal fi ssure Hemorrhoids Angiodysplasia Colorectal cancer W/U: Rectal exam CBC, PT/PTT Electrolytes Colonoscopy CT—abdomen/pelvis
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65 yo M presents with painless hematuria. He is a heavy smoker and works as a painter.
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Bladder cancer Renal cell carcinoma Nephrolithiasis Acute glomerulonephritis Prostate cancer Coagulation disorder (i.e., factor VIII antibodies) Polycystic kidney disease Genitourinary exam W/U: UA, urine cytology BUN/Cr, PSA, CBC, PT/PTT Cystoscopy U/S—renal/bladder CT—abdomen/pelvis IVP
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35 yo M presents with painless hematuria. He has a family history of kidney problems.
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Polycystic kidney disease Nephrolithiasis Acute glomerulonephritis (e.g., IgA nephropathy) UTI Coagulation disorder Bladder cancer W/U: Genitourinary exam UA BUN/Cr, PSA, CBC, PT/PTT U/S—renal CT—abdomen/pelvis IVP
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55 yo M presents with fl ank pain and blood in his urine without dysuria. He has experienced weight loss and fever over the past two months.
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Renal cell carcinoma Bladder cancer Nephrolithiasis Acute glomerulonephritis Pyelonephritis Prostate cancer Genitourinary, rectal exam W/U: UA, urine cytology, BUN/Cr, PSA, CBC, PT/PTT U/S—renal CT—abdomen/pelvis IVP
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60 yo M presents with nocturia, urgency, weak stream, and terminal dribbling. He denies any weight loss, fatigue, or bone pain. He has had two episodes of urinary retention that required catheterization.
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Benign prostatic hyperplasia (BPH) Prostate cancer UTI Bladder stones W/U: Rectal exam UA CBC, BUN/Cr, PSA U/S—prostate (transrectal)
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71 yo M presents with nocturia, urgency, weak stream, terminal dribbling, hematuria, and lower back pain over the past four months. He has also experienced weight loss and fatigue.
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Prostate cancer BPH Renal cell carcinoma UTI Bladder stones W/U: Rectal exam UA CBC, BUN/Cr, PSA U/S—prostate (transrectal) CT—pelvis IVP
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18 yo M presents with a burning sensation during urination and urethral discharge. He recently had unprotected sex with a new partner.
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Urethritis Cystitis Prostatitis W/U: Genital ± rectal exam UA Urine culture Gram stain and culture of urethral discharge Chlamydia and gonorrhea PCR
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45 yo diabetic F presents with dysuria, urinary frequency, fever, chills, and nausea over the past three days. There is left CVA tenderness on exam.
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Acute pyelonephritis Nephrolithiasis Renal cell carcinoma Lower UTI (cystitis, urethritis) W/U: UA Urine culture and sensitivity CBC, BUN/Cr U/S—renal CT—abdomen
question
47 yo M presents with impotence that started three months ago. He has hypertension and was started on atenolol four months ago. He also has diabetes and is on insulin.
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Drug-related ED ED caused by hypertension ED caused by diabetes mellitus Psychogenic ED Peyronie's disease W/U: Genital exam Rectal exam Glucose CBC
question
40 yo F presents with amenorrhea, morning nausea and vomiting, fatigue, and polyuria. Her last menstrual period was six weeks ago, and her breasts are full and tender. She uses the rhythm method for contraception.
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Pregnancy Anovulatory cycle Hyperprolactinemia UTI Thyroid disease W/U: Pelvic exam Urine hCG U/S—pelvis CBC, electrolytes UA, urine culture Prolactin, TSH Baseline Pap smear, cervical cultures, rubella antibody, HIV antibody, hepatitis B surface antigen, and VDRL/ RPR
question
23 yo obese F presents with amenorrhea for six months, facial hair, and infertility for the past three years.
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Polycystic ovary syndrome Thyroid disease Hyperprolactinemia Pregnancy Ovarian or adrenal malignancy Premature ovarian failure W/U: Pelvic exam Urine hCG U/S—pelvis LH/FSH, TSH, prolactin Testosterone, DHEAS
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35 yo F presents with amenorrhea, galactorrhea, visual fi eld defects, and headaches for the past six months.
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Amenorrhea secondary to prolactinoma Pregnancy Thyroid disease Premature ovarian failure Pituitary tumor W/U: Pelvic and breast exam Urine hCG Prolactin LH/FSH, TSH MRI—brain
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48 yo F presents with amenorrhea for the past six months accompanied by hot fl ashes, night sweats, emotional lability, and dyspareunia.
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Menopause Pregnancy Pituitary tumor Thyroid disease W/U: Pelvic exam Urine hCG LH/FSH, TSH, prolactin, testosterone, DHEAS CBC MRI—brain
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35 yo F presents with amenorrhea, cold intolerance, coarse hair, weight loss, and fatigue. She has a history of abruptio placentae followed by hypovolemic shock and failure of lactation two years ago.
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Sheehan's syndrome Premature ovarian failure Pituitary tumor Thyroid disease Asherman's syndrome W/U: Pelvic exam Urine hCG CBC LH/FSH, prolactin TSH, FT4 ACTH MRI—brain Hysteroscopy
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18 yo F presents with amenorrhea for the past four months. She has lost 95 pounds and has a history of vigorous exercise and cold intolerance.
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Anorexia nervosa W/U: CBC TSH FT4 ACTH FSH LH
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29 yo F presents with amenorrhea for the past six months. She has a history of occasional palpitations and dizziness. She lost her fi ancé in a car accident.
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Anxiety-induced amenorrhea W/U: CBC TSH FT4 ACTH Urine cortisol level Progesterone challenge test FSH/LH/estradiol levels
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17 yo F presents with prolonged, excessive menstrual bleeding occurring irregularly over the past six months.
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Dysfunctional uterine bleeding Coagulation disorders (e.g., von Willebrand's disease, hemophilia) Cervical cancer Molar pregnancy Hypothyroidism Diabetes mellitus W/U: Pelvic exam Urine hCG Cervical cultures, Pap smear CBC, ESR, glucose PT/PTT Prolactin, LH/FSH TSH U/S—pelvis
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61 yo obese F presents with profuse vaginal bleeding over the past month. Her last menstrual period was 10 years ago. She has a history of hypertension and diabetes mellitus. She is nulliparous.
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Endometrial cancer Cervical cancer Atrophic endometrium Endometrial hyperplasia Endometrial polyps Atrophic vaginitis W/U: Pelvic exam Pap smear Endometrial biopsy U/S—pelvis Endometrial curettage Colposcopy Hysteroscopy
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45 yo G5P5 F presents with postcoital bleeding. She is a cigarette smoker and takes OCPs.
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Cervical cancer Cervical polyp Cervicitis Trauma (e.g., cervical laceration) W/U: Pelvic exam Pap smear Colposcopy and biopsy
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28 yo F who is eight weeks pregnant presents with lower abdominal pain and vaginal bleeding.
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Spontaneous abortion Ectopic pregnancy Molar pregnancy W/U: Pelvic exam Urine hCG U/S—pelvis CBC, PT/PTT Quantitative serum hCG
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32 yo F presents with sudden onset of left lower abdominal pain that radiates to the scapula and back and is associated with vaginal bleeding. Her last menstrual period was fi ve weeks ago. She has a history of PID and unprotected intercourse.
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Ectopic pregnancy Ruptured ovarian cyst Ovarian torsion PID W/U: Pelvic exam Urine hCG Cervical cultures U/S—pelvis Quantitative serum hCG
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28 yo F presents with a thin, grayish white, foul-smelling vaginal discharge.
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Bacterial vaginosis Vaginitis—candidal Vaginitis—trichomonal Cervicitis (chlamydia, gonorrhea) W/U: Pelvic exam Wet mount Cervical cultures KOH prep ("whiff test") pH of vaginal fl uid
question
30 yo F presents with a thick, white, cottage cheese-like, odorless Vaginal discharge and vaginal itching.
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Vaginitis—candidal Bacterial vaginosis Vaginitis—trichomonal W/U: Pelvic exam KOH prep ("whiff test") Wet mount Cervical cultures pH of vaginal fl uid
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35 yo F presents with a malodorous, profuse, frothy, greenish vaginal discharge with intense vaginal itching and discomfort.
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Vaginitis—trichomonal Vaginitis—candidal Bacterial vaginosis Cervicitis (chlamydia, gonorrhea) W/U: Pelvic exam Wet mount Cervical cultures pH of the vaginal fl uid KOH prep ("whiff test")
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54 yo F c/o painful intercourse. Her last menstrual period was nine months ago. She has hot fl ashes.
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Atrophic vaginitis Endometriosis Cervicitis Depression Domestic abuse W/U: Pelvic exam Wet mount, KOH prep, cervical cultures U/S—pelvis
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37 yo F presents with dyspareunia, inability to conceive, and dysmenorrhea.
answer
Endometriosis Cervicitis Vaginismus Vulvodynia PID Depression Domestic violence W/U: Pelvic exam Wet mount, KOH prep, cervical cultures U/S—pelvis Laparoscopy
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28 yo F c/o multiple facial and bodily injuries. She claims that she fell on the stairs. She was hospitalized for some physical injuries seven months ago. She presents with her husband.
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Domestic violence Osteogenesis imperfecta Substance abuse Consensual violent sexual behavior W/U: XR—skeletal survey CT—maxillofacial Urine toxicology CBC
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30 yo F presents with multiple facial and physical injuries. She was attacked and raped by two men.
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Rape W/U: Pelvic exam Urine hCG Wet mount, KOH prep, cervical cultures XR—skeletal survey CBC HIV antibody Viral hepatitis serologies
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30 yo F presents with wrist pain and a black eye after tripping, falling, and hitting her head on the edge of a table. She looks anxious and gives an inconsistent story.
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Domestic violence Factitious disorder Substance abuse W/U: XR—wrist CT—head Urine toxicology
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30 yo F secretary presents with wrist pain and a sensation of numbness and burning in her palm and the fi rst, second, and third 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 fi ngers. Exam reveals a positive Tinel's sign.
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Carpal tunnel syndrome Median nerve compression in forearm or arm Radiculopathy of nerve roots C6 and C7 in cervical spine W/U: Nerve conduction study EMG
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28 yo F presents with pain in the interphalangeal joints of her hands together with hair loss and a butterfly rash on her face.
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Systemic lupus erythematosus (SLE) Rheumatoid arthritis Psoriatic arthritis Parvovirus B19 infection W/U: ANA, anti-dsDNA, ESR, C3, C4, rheumatoid factor (RF), CBC XR—hands UA
question
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.
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Rheumatoid arthritis SLE Disseminated gonorrhea Arthritis associated with infl ammatory bowel disease Osteoarthritis W/U: ANA, anti-dsDNA, ESR, RF, CBC XR—hands, left knee Cervical culture Arthrocentesis and synovial fl uid analysis
question
18 yo M presents with pain in the interphalangeal joints of both hands. He also has scaly, salmon-pink lesions on the extensor surface of his elbows and knees.
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Psoriatic arthritis Rheumatoid arthritis SLE W/U: RF, ANA, ESR CBC XR—hands XR—pelvis/sacroiliac joints Uric acid
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65 yo F presents with inability to use her left leg and bear weight on it after tripping on a carpet. Onset of menopause was 20 years ago, and she did not receive HRT or calcium supplements. Her left leg is externally rotated, shortened, and adducted, and there is tenderness in her left groin.
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Hip fracture Hip dislocation Pelvic fracture W/U: XR—hip/pelvis CT or MRI—hip CBC Serum calcium and vitamin D Bone density scan (DEXA)
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40 yo M presents with pain in the right groin after a motor vehicle accident. His right leg is fl exed at the hip, adducted, and internally rotated.
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Hip dislocation—traumatic Hip fracture W/U: XR—hip CT or MRI—hip CBC PT/PTT Blood type and cross-match Urine toxicologyand blood alcohol level
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56 yo obese F presents with right knee stiffness and pain that increases with movement. Her symptoms have gradually worsened over the past 10 years. She noticed swelling and deformity of the joint and is having diffi culty walking.
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Osteoarthritis Pseudogout Gout Meniscal or ligament damage W/U: XR—knee CBC ESR Knee arthrocentesis and synovial fl uid analysis (cell count, Gram stain, culture, crystals) MRI—knee
question
45 yo M presents with right knee pain with swelling and redness.
answer
Septic arthritis Gout Pseudogout Lyme arthritis Trauma Reiter's arthritis W/U: CBC Knee arthrocentesis and synovial fl uid analysis (see above) Blood, urethral cultures XR—knee Uric acid Lyme antibody
question
65 yo M presents with right foot pain. He has been training for a marathon.
answer
Stress fracture Plantar fasciitis Foot sprain or strain W/U: XR—foot Bone scan—foot MRI—foot
question
65 yo M presents with pain in the heel of the right foot that is most notable with his first few steps and then improves as he continues walking. He has no known trauma.
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Plantar fasciitis Heel fracture Splinter/foreign body W/U: XR—heel Bone scan
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55 yo M presents with pain in the elbow when he plays tennis. His grip is impaired as a result of the pain. There is tenderness over the lateral epicondyle as well as pain on resisted wrist dorsiflexion (Cozen's test) with the elbow in extension.
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Tennis elbow (lateral epicondylitis) Stress fracture W/U: XR—arm Bone scan MRI—elbow
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27 yo F presents with painful wrists and elbows, a swollen and hot knee joint that is painful on fl exion, a rash on her limbs, and vaginal discharge. She is sexually active with multiple partners and occasionally uses condoms.
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Disseminated gonorrhea Rheumatoid arthritis SLE Psoriatic arthritis Reiter's arthritis W/U: Knee arthrocentesis and synovial fluid analysis (cell count, Gram stain, culture) ANA, anti-dsDNA, ESR, RF, CBC Blood, cervical cultures XR—knee
question
60 yo F presents with pain in both legs that is induced by walking and is relieved by rest. She had cardiac bypass surgery six months ago and continues to smoke heavily.
answer
Peripheral vascular disease (intermittent claudication) Leriche's syndrome (aortoiliac occlusive disease) Lumbar spinal stenosis (pseudoclaudication) Osteoarthritis W/U: Ankle-brachial index Doppler U/S—lower extremity Angiography MRI—lumbar spine
question
45 yo F presents with right calf pain. Her calf is tender, warm, red, and swollen compared to the left side. She was started on OCPs two months ago for dysfunctional uterine bleeding.
answer
DVT Baker's cyst rupture Myositis Cellulitis Superfi cial venous thrombosis W/U: Doppler U/S—right leg CBC CPK D-dimer PT, aPTT, fi brinogen XR—right leg
question
60 yo F c/o left arm pain that started while she was swimming and was relieved by rest.
answer
Angina/MI Tendonitis Osteoarthritis Shoulder dislocation W/U: CPK-MB, troponin, ECG CBC ESR XR—shoulder CXR Echocardiography Stress test
question
50 yo M presents with right shoulder pain after falling onto his outstretched hand while skiing. He noticed deformity of his shoulder and had to hold his right arm.
answer
Shoulder dislocation Fracture of the humerus Rotator cuff injury W/U: XR—shoulder XR—arm MRI—shoulder
question
55 yo M presents with crampy bilateral thigh and calf pain, fatigue, and dark urine. He is on simvastatin and clofibrate for hyperlipidemia.
answer
Rhabdomyolysis due to simvastatin or clofi brate Polymyositis Inclusion body myositis Thyroid disease W/U: CBC CPK Aldolase UA Urine myoglobin TSH
question
45 yo F presents with low back pain that radiates to the lateral aspect of her left foot. Straight leg raising is positive. Thepatient is unable to tiptoe.
answer
Disk herniation Lumbar muscle strain Tumor in the vertebral canal W/U: XR—L-spine MRI—L-spine
question
45 yo F presents with low back pain that started after she cleaned her house. The pain does not radiate, and there is no sensory deficit or weakness in her legs. Paraspinal muscle tenderness and spasm are also noted.
answer
Lumbar muscle strain Disk herniation Abdominal aortic aneurysm Vertebral compression fracture W/U: XR—L-spine
question
45 yo M presents with pain in the lower back and legs during prolonged standing and walking. The pain is relieved by sitting and leaning forward (e.g., pushing a grocery cart).
answer
Lumbar spinal stenosis Lumbar muscle strain Tumor in the vertebral canal Peripheral vascular disease W/U: XR—L-spine MRI—L-spine (preferred) CT—L-spine Ankle-brachial index
question
17 yo M presents with low back pain that radiates to the left leg and began after he fell on his knee during gym class. He also describes areas of loss of sensation in his left foot. The pain and sensory loss do not match any known distribution. He insists on requesting a week off from school because of his injury.
answer
Malingering Lumbar muscle strain Disk herniation Knee or leg fracture Ankylosing spondylitis W/U: XR—L-spine/knee MRI—L-spine
question
20-day-old M presents with fever, decreased breast-feeding, and lethargy. He was born at 36 weeks as a result of premature rupture of membranes.
answer
Neonatal sepsis Meningitis Pneumonia UTI W/U: Physical exam CBC, electrolytes UA Urine culture Blood culture CXR LP—CSF analysis
question
3 yo M presents with a two-day history of fever and pulling on his right ear. He is otherwise healthy, and his immunizations are up to date. His older sister recently had a cold. The child attends a day care center.
answer
Acute otitis media URI Meningitis UTI W/U: Physical exam (including pneumatic otoscopy) CBC UA
question
12-month-old M presents with fever for the last two days accompanied by a maculopapular rash on his face and body. He has not yet received the MMR vaccine.
answer
Measles (or other viral exanthem) Rubella Roseola Fifth disease Varicella Scarlet fever Meningitis W/U: Physical exam CBC Viral antibodies/titers Throat swab for culture LP
question
4 yo M presents with diarrhea, vomiting, lethargy, weakness, and fever. The child attends a day care center where several children have had similar symptoms.
answer
Gastroenteritis (viral, bacterial, parasitic) Food poisoning UTI URI Volvulus Intussusception W/U: Physical exam Stool exam and culture CBC Electrolytes UA, urine culture AXR
question
9 yo M presents with a two-year history of angry outbursts both in school and at home. His mother complains that he runs around "as if driven by a motor." His teacher reports that he cannot sit still in class, regularly interrupts his classmates, and has trouble making friends.
answer
Attention-defi cit hyperactivity disorder (ADHD) Oppositional defi ant disorder Manic episode Conduct disorder W/U: Physical exam Mental status exam
question
12 yo F presents with a two-month history of fi ghting in school, truancy, and breaking curfew. Her parents recently divorced, and she just started school in a new district. Before her parents divorced, she was an average student with no behavioral problems.
answer
Adjustment disorder Substance intoxication/abuse/ dependence Manic episode Oppositional defi ant disorder Conduct disorder W/U: Physical exam Mental status exam Urine toxicology
question
15 yo M presents with a one-year history of failing grades, school absenteeism, and legal problems, including shoplifting. His parents report that he spends most of his time alone in his room, adding that when he does go out, it is with a new set of friends.
answer
Substance abuse Conduct disorder Oppositional defi ant disorder Adjustment disorder W/U: Urine toxicology Mental status exam
question
5 yo M presents with a six-month history of temper tantrums that last 5-10 minutes and immediately follow a disappointment or a discipline. He has no trouble sleeping, has had no change in appetite, and does not display thesebehaviors when he is at day care.
answer
Age-appropriate behavior ADHD Oppositional defiant disorder W/U: Physical exam Mental status exam
