Clinical Cases Flashcards
(43 cards)
CC: 25 y/o F comes into ED after being assaulted- physical assault, R CP, pain exacerbated by movement and deep breaths, sexual assault by 2 men, no condom use, unprotected vaginal intercourse with possible ejaculation, no OCP use, LMP 3 weeks ago
PE?
DDx and Workup?
Head and neck exam: inspection, palpation
Mouth: Inspection
CV: Auscultation
Pulmonary: Inspection, Auscultation, palpation, percussion
Abd: Inspection, auscultation, palpation
Neurologic: Mental status, cranial nerves, gross motor
MSK: Inspect, palpate
DD1: Rib fracture- physical assault, right CP, Pain exacerbated by movement and deep breaths; PE- tenderness on palpation of right chest wall
DD2: STD- sexual assault by 2 men, no condom use
DD3: unprotected vaginal intercourse with possible ejaculation, no OCP use, LMP 3 weeks ago
Workup: Pelvic exam, XR-skeletal survey, CBC, Urine hCG, Wet mount, KOH Prep, cervical culture, gonorrhea and chlamydia tests, HIV ab, VDRL, HBV antigen
CC: chest pain- pain midchest, pressure like substernal, radiates to LA, upper back, and neck, awakens pt, cocaine use, prev relieved with antacids and occurred after meals
PE?
DDx and workup?
Neck: JVD, carotid auscultation CV: inspect, ausc, palpate Pulm: ausc, palp; percuss Abd: ausc, palp, percuss Extermities: peripheral pulses, check BP in both arms, edema and cyanosis
DD1: MI or Ischemia- pressure like substernal pain, radiate to LA, upper back and neck, awakens pt
DD2: Cocaine induced MI- hx of cocaine use, last use yesterday, pressure like substernal pain
DD3: GERD- mischest pain, relief with antacid prev and prev occur after meals
Workup: EKG, cardiac enzymes (CPK, CKMB, trops), TTE, upper endoscopy, Urine tox, cardiac Cath, TEE, CXR, CT chest with IV, cholesterol panel
CC: Bloody urine- hematuria, straining on urination, weak stream and dribbling, works as painter (exposure to industrial solvents), Hx of smoking 1PPD x30 yrs, polyuria and nocturia
PE?
DDx and Workup
CV: Ausc
Pulm: Ausc
Abd: Ausc, palpate percuss, CVA tenderness
Ext: inspect
DD1: Bladder cancer- hematuria, straining on urination, weak stream and dribble, works as painting, hx of smoking
DD2: Urolithiasis- hematuria, straining on urination, CVA tender
DD3: BPH- polyuria, nocturia, weak stream and dribbling, straining on urination
Workup: Genital exam, rectal exam, cystoscopy, U/S renal, UA, CT Abd/Pelvis, PSA, Urine Cx, Urine cytology, Bun/Cr, IVP
CC: Back pain- low back pain, pain started after lifting heavy object, pain radiates to L thigh and foot, pain worse with movement, better when lying down, lying still or sitting, hx of intermittent back pain and leg pain with ambulation, difficulty urinating, incomplete emptying of bladder
PE?
DDx and workup?
Back: Inspect, palp, ROM
Extremities: Inspect, palp (peripheral pulses), hip exam
Neuro: motor, DTR, Babinski, Gait (toe and heel walking), passive straight leg raising, sensory exam
DD1: Disc Herniation- Back pain- low back pain, pain started after lifting heavy object, pain radiates to L thigh and foot, pain worse with movement, better when lying down, lying still or sitting
DD2: Lumbar spinal stenosis- hx of intermittent back pain and leg pain with ambulation, pain with ambulation better with rest
DD3: Prostate ca (mets)- difficulty urinating, incomplete emptying of bladder, low back pain
CC: Trouble breathing and pain after MVA- LS chest pain after MVA, pain worse by movement and deep breaths, dyspnea, cough, u/l CP, productive cough, low grade fever
PE?
DDx and workup?
Head and neck: Inspect
CV: Ausc
Pulm: Inspect, Ausc, palp, Percuss
Abd: Inspect, Ausc, palp, percuss
Neuro: Mental status exam, CN, gross motor
Skin: inspect for abrasion, laceration, bruise
DD1: Pneumothorax- LS chest pain after MVA, pain worse by movement and deep breaths, dyspnea; PE decreased breath sounds over L lung, Increased respiration
DD2: Hemothorax- cough, LS chest pain after MVA, pain worse by movement and deep breaths, dyspnea; PE decreased breath sounds over L lung, Increased respiration
DD3: Pneumonia- u/l CP, productive cough, low grade fever
Workup: CXR, Sputum and blood gram stain and cx, urine tox and blood alcohol level, XR/CT And, Pulse Ox
CC: + preg test- Amenorrhea, + preg test, b/l breast engorgement, nausea and weight gain
PE:
DDx and Workup?
HEENT: Inspect and palpate thyroid CV: Ausc Pulm: Ausc Abd: Inspect, ausc, palpate Skin: Inspect pigmentation or pallor
DD1: normal pregnancy- Amenorrhea, + preg test, b/l breast engorgement, nausea and weight gain
DD2: Ectopic preg- Amenorrhea and + preg test
DD3: Molar preg- + preg test and nausea
Workup: Urine hCG, U/S pelvis, breast and pelvic exam, Blood type, Rh, Ab screen, CBC, TSH, RPR, rubella, HBsAg, HIV ab, Pap smear, cervical cx, G/C DNA test, UA, urine culture
CC: Mother concerned about daughter with diabetes- Polyuria, polydipsia, recent weight loss, hyperglycemia, obesity
PE?
DDx ad Workup?
None.
DD1: DM 1- polyuria/polydipsia, recent weight loss, hyperglycemia
DD2: DM2- polyuria/ polydipsia, obesity, hyperglycemia
DD3: secondary cause of DM (Cushing syndrome)- obesity
Workup: insulin and c peptide, islet cell ab, HbA1c, electrolytes, glucose, UA, urine micro albumin, 24 hr urine free cortisol
CC: Pain in right arm- fall on outstretched arm, pain with movement, advanced age
PE?
DDx and Workup?
Head and neck: bruises, neck movement
CV: Ausc
Pulm: Ausc
Ext: strength, ROM shoulder, elbow, wrist, joint stability, sensation, DTR, and pulses
DD1: humeral fracture- pain after fall on outstretched arm, pain increases with arm movement; tender over upper and middle RA, restricted ROM
DD2: shoulder dislocation- pain after fall on outstretched arm, pain increases with arm movement; RA external rotated and slightly abducted, pain and restricted ROM on shoulder exam
DD3: Osteoporosis- Advanced age
Workup: XR shoulder and arm, MRI shoulder, Bone density scan (DEXA)
CC: Diabetes f/u- episodes of palpitation and diaphoresis that resolve with drinking orange juice, tight glycemic control, hx of DM, constant numbness and tingling in feet, loss of erection for 2 years with absence of early morning erection, hx of alcohol, taking lovastatin and atenolol
PE?
DDx and Workup?
Eye: Fundoscopic Neck: Carotid auscultation CV: Palp, ausc Pulm: Ausc Abd: ausc, palp, percuss Ext: Inspect feet and peripheral pulses Neuro: DTR, Babinski, sens and strength in LE
DD1: Insulin induced hypoglycemia- episodes of palpitation and diaphoresis that resolve with drinking orange juice, tight glycemic control
DD2: Diabetic peripheral neuropathy- hx of DM, constant numbness and tingling in feet, absent ankle jerk
DD3: Organic erectile dysfunction- loss of erection for 2 years with absence of early morning erection, hx of DM, hx of alcohol, taking lovastatin and atenolol
Workup: Genital exam, serum glucose, HbA1c, UA, Urine microalbumin, BUN/Cr, Doppler US penis, Nerve conduction studies, CBC, serum Ca, ESR, serum protein electrophoresis
CC: Pain in right calf- recent 15 hr flight, weight gain of 50lbs over past 3 years, taking OCPs for 2 years, father with DVT, cuts to right leg secondary to fall, low grade fever, spasmodic pain in right calf
PE?
DDx and Workup?
PE:
CV/Pulm: Inspect, ausc, palp; compared pulses (femoral, popliteal, dorsalis pedis) on both sides
Joint exam: inspect, palp, ROM (hip, knee, ankle) both sides
Ext: inspect, palp, Homans sign
Neuro: sensory and motor reflexes (knee, ankle)
DD1: DVT- recent 15 hr flight, weight gain of 50lbs over past 3 years, taking OCPs for 2 years, father with DVT; Homans sign, pitting edema, swollen, tender, red, warm right calf
DD2: Cellulitis- cuts to right leg secondary to fall, low grade fever; swollen, tender, red, warm right calf, T 99.9
DD3: Rupture of Bakers cyst- spasmodic pain in right calf; swollen tender, red, warm right calf
Workup: Dopper U/S legs, D-dimer, Hypercoagulability testing, CBC with diff, wound and blood cx
CC: Hoarsness- cervical lymphadenopathy, worsening hoarseness over past three months, weight loss, decreased appetite, and low grade fever, hx of cig smoking and alcohol use, advanced age, hx of flu 4 weeks ago, low grade fever, GERD, Hx of smoking, vocal overuse from teaching 20 yrs
PE?
DDx and workup?
HEENT: inspect conjunctivae, mouth, throat, lymph nodes, examine thyroid gland CV: ausc Pulm: ausc Abd: ausc, palp, percuss Ext: Inspect, DTRs
DD1: Laryngeal Ca- cervical lymphadenopathy, worsening hoarseness over past three months, weight loss, decreased appetite, and low grade fever, hx of cig smoking and alcohol use, advanced age; T 99.9
DD2: Laryngitis- hx of flu 4 weeks ago, low grade fever, GERD, Hx of smoking; T 99.9
DD3: Vocal cord polyp/nodule-vocal overuse from teaching 20 yrs
Workup: Larngoscopy, ESR, CT chest and neck, US neck
CC: Neck pain- neck pain that increases with movement, radiculopathy (LA numbness), rapid rotation of neck preceded pain, Osteopenia on last DEXA
PE?
DDx and workup?
Neck: inspect, palp, stiffness, ROM
Ext: inspect, palp peripheral pulses, ROM
Neuro: motor, DTRs, sensory, Kernig and Brudzinski
DD1: Disc herniation- neck pain that increases with movement, radiculopathy (LA numbness); loss of pin prick sensation noted on dorsum of left hand and posterior left arm and forearm
DD2: Cervical fracture-rapid rotation of neck preceded pain, pain increases with movement; Osteopenia on last DEXA
DD3: Neck muscle strain- rapid rotation of neck preceded pain
Workup: XR C spine, MRI C spine, Nerve conduction studies, CBC, calcium, BUN/Cr, serum and urine protein electrophoresis
CC: Abdominal pain- pain exacerbated by heavy, fatty foods, associated with N/V, Female, 40s, Hx of NSAID use, epigastric pain 2-3 hrs after meals, pain exacerbated by hunger and fatty foods and relieved by antacids
PE?
DDx and workup?
CV: Ausc
Pulm: Ausc
Abd: inspect, auscultation, palp (murphy sign), percuss
DD1: Cholecystitis- pain exacerbated by heavy, fatty foods, associated with N/V, Female, 40s; epigastric tenderness, + Murphy sign
DD2: Peptic ulcer dz- Hx of NSAID use, epigastric pain 2-3 hrs after meals, pain exacerbated by hunger and fatty foods and relieved by antacids; epigastric tenderness
DD3: Gastritis- Hx of NSAID use, epigastric pain associated with food, N/V; Epigastric tenderness
Workup: Rectal exam, FOBT, US abd, Upper endoscopy, H pylori Ab testing, AST/ALT/bilirubin/Alk Phos/lipase, HIDA scan
CC: Headache- u/l sharp headache, N/V, Photophobia, hx chronic headaches, association with stress at work, improve with sleep, fam hx of brain tumor
PE?
DDx and workup?
HEENT: palp (head, sinus, TMJ), fundoycopic exam, inspect nose mouth teeth and throat
Neck: inspect, palp
CV: auscultation
Pulm: auscultation
Neuro: cranial nerves, muscle strength, DTRs
DD1: Migranes- u/l sharp headache, N/V, Photophobia; severe pain with lack of neurologic finding
DD2: Tension HA- hx chronic headaches, association with stress at work, improve with sleep; severe pain with lack of neurologic findings
DD3: intracranial mass lesion: Headaches associated with N/V, fam hx of brain tumor
Workup: CBC, CT head, MRI brain, LP, CT sinus
CC: No period in three months- changes in mens cycle, regular sexual activity, previous successful pregnancy, galactorrhea, oliomenorrhea, weight gain, hirsutism
PE?
DDx and workup?
Neck: examine thyroid CV: Ausc Pulm: Ausc Ext: inspect Neuro: visual fields, EOM, DTRs
DD1: Pregnancy- changes in mens cycle, regular sexual activity, previous successful pregnancy,
DD2: Hyperprolactinemia- galactorrhea, oligomenorrhea
DD3: PCOS- weight gain, hirsutism, oligomenorrhea
Workup: urine hCG, Pelvic and breast exams, Prolactin, TSH, LH/FSH
CC: Pain during sex- white vag d/c, fishy odor of d/c, vaginal puritis, dyspareunia, sexual activity without barrier contraception, Dsymenorrhea
PE?
Ddx and workup?
CV- Ausc
Pulm: Ausc
Abd: Ausc, palp, percuss
DD1: Vulvovaginitis- white vag d/c, fishy odor of d/c, vaginal puritis
DD2: Cervicitis- white vag d/c, dyspareunia, sexual activity w/o barrier contraception
DD3: Endometriosis- Dsymenorrhea, Dyspareunia
Workup: Pelvic exam, wet mount, KOH prep, whiff test, cervical cultures (g/c), laparoscopy, u/s pelvis
CC: hearing loss- b/l progressive hearing loss, advanced age, HTN, prior exposure to loud noise
PE?
Ddx and Workup?
HEENT: Tested hearing by speaking with back turned, inspected sinuses, nose, mouth, throat; fundoscopic and otoscopic exam, assessed hearing with Rinne and Weber tests and whisper test
CV/Pulm: Ausc
Neuro: CN, sensation, motor, reflexes, cerebellar- finger to nose, heel to shin
DD1: Presbycusis- b/l progressive hearing loss, advanced age, HTN; + Rinne test, lack of lateralization on Weber test
DD2: Cochlear nerve damage- prior exposure to loud noise, b/l hearing loss; + Rinne, lack of lateralization on Weber test
DD3: Otosclerosis- b/l progressive hearing loss, advanced age; lack of lateralization on weber test
Workup: Audiometry, Tympanography, Brain stem auditory evoked potentials, CT head, VDRL/RPR
CC: mom comes to office complaining of child having yellow skin and eyes- infant in first week of life, no changes in feeding, urination or bowel movements, mother and father with diff ABO types, Hx of maternal infection
PE?
Ddx and Workup?
None.
DD1: Physiologic Jaundice- infant in first week of life, no changes in feeding, urination or bowel movements
DD2: ABO or Rh incompatibility- infant in first week of life, mother and father with diff ABO types
DD3: Neonatal sepsis- hx of maternal infection
Workup: Total and indirect Bilirubin, blood typing, direct Coombs test, CRP, CBC, Serology for CMV, toxoplasmosis, and rubella, RPR for syphillis, urine cx for CMV
CC: mom comes to office complaining of child having a fever- fever 101F, Rhinorrhea, Sibling with URI, Day care attendance, increased RR, Irritability
PE?
Ddx and workup?
None.
DD1: Viral URI- fever 101F, Rhinorrhea, Sibling with URI, Day care attendance, increased RR
DD2: Pneumonia- fever 101F, Sibling with URI, Day care attendance, increased RR
DD3: Otitis media- fever 101F, Day care attendance, Irritability
Workup: CBC with diff, blood cx, UA and urine cx, CXR, respiratory viral panel, pneumatic otoscopy
CC: cough- persistent cough, low grade fever, recent URI, white sputum production
PE?
Ddx and workup?
Head and neck: inspect mouth, throat, lymph nodes
CV: Ausc, palp
Pulm: ausc, palp, percuss
Ext: inspect
DD1: Pneumonia- persistent cough, low grade fever, recent URI; increased tactile fremitus, decreased breath sounds on the right, T 99.9
DD2: URI- associated cough (post infectious cough)- Recent URI, low grade fever, persistent cough; increased tactile fremitus; T 99.9
DD3: Acute bronchitis- low grade fever, persistent cough, white sputum production; increased tactile fremitus, T 99
Workup: CXR, CBC with differential, Sputum gram stain and culture
CC: 50 yr old female with yellow eyes and skin- light stool, dark urine, pruritus, father with pancreatic ca, hx of blood transfusion, recent travel to Mexico, freq acetaminophen use, concomitant alcohol use
PE?
Ddx and workup?
HEENT: Inspect sclerae, under tongue
CV: ausc
Pulm: ausc
Abd: inspect, auscultation, palp (include murphy), percuss, measure liver span, palp and percuss for splenomegaly, fluid wave for shifting dullness
Ext: asterisks, edema
Skin: spider nevi, cutaneous telangectasias, palmar erythema
DD1: Extrahepatic biliary obstruction- light stool, dark urine, pruritus, father with pancreatic ca; jaundice, scleral icterus, RUQ tenderness
DD2: Viral hepatitis: hx of blood transfusion, recent travel to Mexico; jaundice, scleral icterus, RUQ tender
DD3: Acetaminophen toxicity: freq acetaminophen use, concomitant alcohol use; jaundice, scleral icterus, RUQ tender
Workup: AST/ALT/Bilirubin/Alk phos, US RUQ abdomen, Viral hepatitis serologies, CBC, PT/PTT, Acetaminophen level, CT abdomen, MRCP/ERCP
CC: dizziness- sensation of room spinning, LS hearing loss, onset with positional changes, duration of 20-30 mins, hx of diarrhea, taking antiHTN meds
DDx and workup?
DD1: Meniere’s disease: sensation of room spinning, LS hearing loss; Decreased hearing acuity on left, + Rinne
DD2: BPPV: sensation of room spinning, onset with positional changes, duration of 20-30 mins
DD3: Orthostatic hypotension due to dehydration: hx of diarrhea, taking antiHTN meds
Workup: Dix Hallpike, Audiometry, MRI brain, VDRL/RPR
CC: Knee pain- monoarticular joint pain and tenderness, history of swollen toe, occasional alcohol use, morning joint stiffness, family hx of RA, systemic symptoms (anorexia, weight loss, fatigue, fever), hx of multiple oral ulcers, hx of 2 spontaneous abortions, Raynauds phenomenon
Ddx and workup?
DD1: Gout- monoarticular joint pain and tenderness, history of swollen toe, occasional alcohol use; joint tenderness and stiffness, swelling at left knee
DD2: RA- morning joint stiffness, family hx of RA, systemic symptoms (anorexia, weight loss, fatigue, fever); joint tenderness and stiffness, T99.9
DD3: SLE- systemic symptoms (anorexia, weight loss, fatigue, fever), hx of multiple oral ulcers, hx of 2 spontaneous abortions, Raynauds phenomenon; Joint tenderness and stiffness
Workup: CBC with diff, Immunologic testing (ANA titer, anti dsDNA, RF, anti-CCP), Knee aspiration with gram stain, cx and inspection for crystals, XR left knee and both hands
CC: Heel pain- training for marathon, pain gradual, pain worsens with few steps in morning and after prolonged sitting, diffused pain over heel, refractory to conservative management
Ddx and workup?
DD1: Plantar fasciitis- training for a marathon, pain gradual, pain worsen with few steps in morning and after prolonged sitting; tenderness over medial calcanea tuberosity, pain with toe dorsiflexion
DD2: Calcaneal stress fracture- training for a marathon, diffuse heel pain, refractory to conservative management; tenderness over plantar heel and arch
DD3: Achilles tendinitis-training for marathon; pain with toe dorsiflexion
Workup: XR right ankle and foot, bone scan, MRI right a ankle and foot
