Differential diagnosis and mini-cases - LoC, Numbness and weakness, Fatigue/sleepiness, Night sweats, Insomnia Flashcards Preview

STEP 2 CS Hx Mnemonics > Differential diagnosis and mini-cases - LoC, Numbness and weakness, Fatigue/sleepiness, Night sweats, Insomnia > Flashcards

Flashcards in Differential diagnosis and mini-cases - LoC, Numbness and weakness, Fatigue/sleepiness, Night sweats, Insomnia Deck (33):
1

Loss of consciousness - key history ?

  1. Presence or absence of preceding symptoms (nausea, diaphoresis, palpitations, pallor, lightheadedness, pain) ?
  2. Context (exertional, postural, traumatic; stressful, painful, claustrophobic experience; dehydration) ?
  3. Associated tongue biting or incontinence, tonic-clonic movements, prolonged confusion;
  4. Asssociated : dyspnea, pulmonary embolism risk factors ?
  5. History of heart disease, arrhythmia, hypertension, or diabetes; alcohol and drug use ?

2

Loss of consciousness - key physical findings ?

  1. Vital signs, including orthostatics;

  2. Complete neurologic exam;

  3. Carotid and cardiac exam;

  4. Lung exam;

  5. Exam of the lower extremities. 

3

What is your differential diagnosis and workup ?

"26 yo M presents after falling and losing consciousness at work. He had rhythmic movements of the limbs, bit his tongue, and lost control of his bladder. He was subsequently confused after regaining consciousness (as witnessed by his colleagues)"

  • Differential diagnosis :
    • Seizures - generalized tonic clonic seizure 
    • Convulsive syncope 
    • Substance abuse/overdose 
    • Malingering
    • Hypoglycemia  
  • Workup :
    • CB, Electrolytes, glucose
    • Urine toxicology
    • EEG
    • MRI—brain, CT—head
    • LP—CSF analysis
    • ECG 

4

What is your differential diagnosis and workup ?

"55 yo M c/o falling after feeling dizzy and unsteady. He experienced transient loss of consciousness. His past medical history is significant for hypertension and diabetes mellitus"

  • Differential diagnosis :
    1. Drug-induced orthostatic hypotension
    2. Hypoglycemia
    3. Hyperosmolar, hyperglycemic state 
    4. Cardiac arrythmia
    5. Vadovagal syncope
    6. Seizure
    7. TIA, Stroke
    8. MI, PE
    9. Hypoxia
  • Workup :
    • CBC with differential
    • ECG, echocardiography
    • Blood gasometry, glucose, electrolytes
    • CT head, MRI brain, angiography
    • CXR 
    • D-dimers

5

What is your differential diagnosis and workup plan ?

"65 yo M presents after falling and losing conscious- ness for a few seconds. He had no warning before passing out but recently had palpitations. His history includes a coronary artery bypass graft"

  • Differential diagnosis :
    • Cardiac arrythmia
    • Severe aortic stenosis
    • AMI
    • Hypoxia - heart failure
    • Vasovagal syncope
    • Seizure
    • Pulmonary embolism
  • Workup :

    • ECG
    • Holter monitoring
    • CBC
    • Electrolytes, glucose
    • Echocardiography
    • CT—head 

6

What is the key history for : numbness / weakness ?

  1. Distribution (unilateral, bilateral, proximal, distal),
  2. Duration, ± progression,
  3. Pain (especially headache, neck or back pain);
  4. Constitutional symptoms,
  5. Other neurologic symptoms;
  6. History of diabetes, alcoholism, atherosclerotic vascular disease. 

7

What are the key physical exam manouvers in case of weakness/numbness ?

  1. Vital signs;
  2. Neurologic and musculoskeletal exams;
  3. Relevant vascular exam. 

8

What is your differential diagnosis and workup ?

"68 yo M presents following a 20-minute episode of slurred speech, right facial drooping and numbness, and right hand weakness. His symptoms had totally resolved by the time he got to the emergency de- partment. He has a history of hypertension, diabetes mellitus, and heavy smoking"

Differential diagnosis 

  • TIA
  • Seizure
  • Stroke
  • Hypoxia
  • Hypoglycemia
  • Facial nerve palsy

Workup

  • CT-brain, angiography
  • CBC with differential
  • Echocardiography
  • EEG
  • ECG
  • Blood gasometry
  • Fasting lipid panel
  • Glucose, electrolytes, BUN, Creatinine
  • Nerve conduction studies - facial nerve
  • Doppler - U/S - carotid

9

What is your differential diagnosis and workup ?

"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 his- tory of hypertension, diabetes mellitus, and heavy smoking"

Differential diagnosis 

  • Stroke 
  • TIA
  • Seizure
  • Intracranial neoplasm
  • Subdural or epidural hematoma

Workup

  • CT—head
  • CBC
  • Electrolytes PT/PTT/INR
  • Fasting lipid panel
  • MRI—brain
  • Doppler U/S—carotid
  • Echocardiography
  • ECG 

10

What is your differential diagnosis and workup ?

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

Differential diagnosis 

  1. Guillain-Barre syndrome
  2. Polymiositis
  3. Mulitiple sclerosis
  4. Myasthenia gravis
  5. Peripheral neuropathy
  6. Tumor in the vertebral canal
  7. Transverse myelitis

Workup

  1. CBC, electrolytes, AST/ALT 
  2. Nerve conduction studies 
  3. Needle electromyography
  4. LP - OP, CSF exam - glucose, proteins, cellularity
  5. Creatinine Kinase (CPK), Aldolase
  6. Anti-Jo1 antibody screen
  7. CRP, ESR
  8. Edrophonium test
  9. TSH, T4, serum B12
  10. MRI-spine

11

What is your differential diagnosis and workup ?

"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 vi- sion, and double vision. She reports feeling “electric shocks” down her spine upon flexing her head"

Differential diagnosis 

  • Multiple sclerosis
  • Myasthenia gravis
  • Stroke
  • Conversion disorder
  • Malingering
  • Intracranial mass
  • Neurosyphilis
  • Syringomyelia
  • Transverse myelitis
  • CNS vasculitis

Workup

  1. CBC, ESR
  2. VDRL/RPR
  3. MRI—brain
  4. spine LP—CSF analysis
  5. Retinal evoked potentials 

12

What is your differential diagnosis and workup ?

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

Differential diagnosis 

  1. Peripheral neuropathy - DM2
  2. Peripheral neuropathy - B12 defficiency 
  3. Alcoholic peripheral neuropathy
  4. Peripheral neuropathy - uremic
  5. Hypocalcemia
  6. Hyperventilation
  7. Paraproteinemia/myeloma

Workup

  1. HbA1c
  2. ESR
  3. Calcium
  4. Serum B12
  5. UA
  6. Serum and urine protein electrophoresis 

13

What is your differential diagnosis and workup ?

"40 yo F presents with occasional double vision and droopy eyelids at night with normalization by morning"

Differential diagnosis 

  1. Myasthenia gravis
  2. Lambert-Eaton syndrome
  3. Horner's syndrome
  4. IIIrd nerve palsy
  5. Multiple sclerosis
  6. ALS

Workup

  1. Tensilon (edrophonium) test
  2. Serum ACh receptor antibodies
  3. CXR
  4. CT—chest
  5. MRI—brain
  6. EMG 

14

What is your differential diagnosis and workup ?

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

Differential diagnosis 

  1. Todd’s paralysis
  2. TIA
  3. Stroke
  4. Complicated migraine
  5. Malingering 

Workup

  1. CBC
  2. Electrolytes
  3. EEG
  4. MRI—brain
  5. Doppler U/S—carotid 

15

What is your differential diagnosis and workup ?

"56 yo obese F c/o tingling and numbness of her thumb, index finger, and middle finger for the past 5 months. Her symptoms are constant, have pro- gressively worsened, and are relieved with rest. She works as a secretary. She has a history of fatigue and a 20-lb (9-kg) weight gain over the same period"

Differential diagnosis :

  1. Carpal tunnel syndrome secondary to hypothyroidism
  2. Overuse injury of median nerve
  3. Medial epicondylitis 

Workup

  1. Phalen’s maneuver and Tinel’s sign
  2. Nerve conduction studies
  3. TSH
  4. CBC 

16

Key history - fatigue and sleepiness ?

  1. Duration;
  2. Sleep hygiene, snoring, waking up choking/gasping, witnessed apnea;
  3. Overexertion;
  4. Stress, depression, emotional problems;
  5. Lifestyle changes, shift changes at work;
  6. Diet, weight changes;
  7. Other constitutional symptoms;
  8. Symptoms of thyroid disease;
  9. History of bleeding or anemia;
  10. Medications;
  11. Alcohol, caffeine, and drug use. 

17

Fatigue and sleepiness - key physical exam ?

18

What is your differential diagnosis and workup plan ?

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

  • Differential diagnosis :
    • Major depressive disorder
    • Adjustment disorder
    • Hypothyroidism
    • Anemia
    • Cushing's
    • Intracranial neoplasm - frontal lobes
  • Workup :
    • CBC 
    • TSH
    • HIV/STD testing
    • Beck Depression Inventory

19

What is your differential diagnosis and workup plan ?

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

  • Differential diagnosis :
    • PTSD 
    • Depression
    • Generalized anxiety disorder
    • Psychotic/delusional disorder
    • Hypothyroidism
    • Parasomnias
  • Workup :
    • CBC
    • TSH
    • Urine toxicology
    • Beck Depression Inventory

20

What is your differential diagnosis and workup plan ?

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

  • Differential diagnosis :
    • Colorectal carcinoma
    • Hypothyroidism
    • Renal failure
    • Other neoplastic disorder 
    • Depression
    • Hypercalcemia
    • Heart failure
    • Dehydration 
  • Workup :
    •  

21

What is your differential diagnosis and workup plan ?

"40 yo F presents with fatigue, weight gain, sleepiness, cold intolerance, constipation, dry skin"

  • Differential diagnosis :
    • Hypothyroidism
    • Premature menopause
    • Premature ovarian insufficiency
    • Depression
    • Anemia
  • Workup :
    •  

22

What is your differential diagnosis and workup plan ?

"50 yo obese F presents with fatigue and daytime sleepiness. She snores heavily and naps 3–4 times per day but never feels refreshed. She also has hypertension"

  • Differential diagnosis :
    • OSA - Obstructive sleep apnea
    • Hypothyroidism
    • Chronic fatigue syndrome 
    • Narcolepsy
    • Left heart failure 
    • Pulmonary hypertension
  • Workup :
    •  

23

What is your differential diagnosis and workup plan ?

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

  • Differential diagnosis :
    • Diabetes mellitus
    • Diabetes insipitus
    • Atypical depression
    • Primary polydypsia
    • Dyselectronemia - Hypercalcemia, Hypernatriemia 
  • Workup :
    • Glucose tolerance test, HbA1c
    • UA, CBC
    • Electrolytes, BUN/Cr, glucose 

24

What is your differential diagnosis and workup plan ?

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

  • Differential diagnosis :
    • Shift work sleep disorder
    • Sleep apnea
    • Depression
    • Anemia
  • Workup :
    • CBC
    • Nocturnal pulse oximetry
    • Polysomnography

25

Night sweats - key history

  1. Onset, duration, severity, frequency, timing, patterns (escalating, waxing, waning)
  2. Precipitants (eg, food, medications);
  3. Associated diseases and symptoms (fever, recent URIs, associated cough, hemoptysis, pleuritic chest pain);
  4. Lymphadenopathy, rash, malaise, weight loss, itching, diarrhea, nausea/vomiting, early satiety, anorexia;
  5. Presence of significant risk factors (eg, traveling to areas with endemic infections, IV drug use);
  6. Alcohol history, sexual exposure, sick contacts, exposure to high-risk populations such as prisoners or homeless people;
  7. Menstrual history, menopausal status, travel history;

26

Night sweats - key physical exam ?

  • Vital signs;
  • HEENT exam, including inspection of the throat and other areas for lymphadenopathy;
  • Heart and lung exam;
  • Abdominal exam for hepatosplenomegaly;
  • Skin exam;
  • Musculoskeletal exam for joint pain. 

27

What is your differential diagnosis and workup plan ?

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

  • Differential diagnosis :
    • Tuberculosis
    • Acute HIV infection
    • Lymphoma
    • Leukemia
    • Hyperthyroidism
  • Workup :
    • PPD/QuantiFERON Gold
    • CBC
    • CXR
    • Sputum
    • Gram stain, acid-fast stain, and culture HIV antibody
    • TSH, FT4

28

What is your differential diagnosis and workup plan ?

"45 yo F presents with excessive sweating, unintentional weight loss, palpitations, diarrhea, and shortness of breath"

  • Differential diagnosis :
    • Hyperthyroidism
    • Pheochromocytoma
    • Carcinoid syndrome
    • Tuberculosis
  • Workup :
    • TSH, FT4
    • 24-hour urinary catecholamines
    • 5-HIAA
    • CBC
    • PPD 

29

Insomnia - key history 

  1. Primary vs. secondary ? 
  2. Duration ? 
  3. Description (trouble falling asleep vs. multiple awakenings vs. early-morning awakening) ?
  4. Daytime sleepiness ?
  5. Other medical problems keeping patient awake at night, such as arthritis (pain) or diabetes (polyuria);
  6. Evidence of a common sleep disorder (eg, sleep apnea, restless leg syndrome) ?
  7. Associated symptoms, including loud snoring, nightmares, and depression;
  8. Caffeine, alcohol, medication, recreational drug use;
  9. Work or lifestyle (jet lag or shift work), stressors, sleep hygiene;
  10. Presence of psychiatric symptoms (eg, grandiose delusions, irritability);

30

What questions will you ask during an "insomnia" encounter ?

  • Problems in initiating or maintaining sleep ?
  • Sleep latency ?
  • Initial or terminal insomnia ?
  • Quality and quantity of sleep ?
  • Daytime symptoms ?
  • Triggers ?
  • Comorbid conditions ?
  1. How long have you had insomnia ?
  2. Do you have problems falling asleep or staying asleep ?
  3. How often do you have troubles sleeping ?
  4. How long does it take to fall asleep ?
  5. How much sleep do you get during a typical night ?
  6. Do you feel tired in the morning when you wake up ? 
  7. Do you feel tired during the day ? 
  8. How does your lack of sleep affect your daily routines ? daily functioning ?
  9. Have you taken any medications to help you fall asleep ?
  10. Do you notice any additional symptoms when you lie down ?
  11. How much caffeine do you consume daily ? Do you drink coffee/coke in the evenings ?
  12. Do you watch television in bed ? Do you use electronics in bed - phone, an ipad, laptop etc. ?
  13. Do you wake up at night to urinate ? to use the toilet ?
  14. Have you beed under more stress lately ?
  15. How is your mood ?
  16. Have anyone noticed that you move during the sleep ? like your legs ?
  17. Has anyone noticed that : you snore loudly ? you stop breathing for some time during sleeping ?
  18. Have you been diagnosed with any other medical conditions ?
  19. Do you have any conditions that cause chronic pain ? 
  20. Medications : what medications do you take ? Do you take stimulants ? psychoative meds ? gcs ? weight loss meds ? hormones ? OTC energy suplements ?
  21. SH : tobacco products ? alcohol ? recreational drugs ?
  22. SLEEP DIARY ! 

31

What is your differential diagnosis and workup plan ?

"25 yo F presents with a 3-week history of difficulty falling asleep. She sleeps 7 hours per night without nightmares or snoring. She recently began college and is having trouble with her boyfriend. She drinks 3–4 cups of coffee a day"

  • Differential diagnosis :
    • Stress-induced insomnia
    • Caffeine-induced insomnia
    • Insomnia with circadian rhythm sleep disorder
    • Insomnia related to major depressive disorder
  • Workup :
    • Polysomnography
    • Mental status exam
    • Urine toxicology
    • CBC
    • TSH

32

What is your differential diagnosis and workup plan ?

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

  • Differential diagnosis :
    • Obstructive sleep apnea
    • Daytime fatigue in primary hypersomnia
    • Insomnia with circadian rhythm sleep disorder
    • Insomnia related to major depressive disorder
  • Workup :
    • CBC, TSH
    • Polysomnography
    • ECG

33

What is your differential diagnosis and workup plan ?

"33 yo F c/o 3 weeks of fatigue and trouble sleeping. She states that she falls asleep easily but wakes up at 3 A.M. and cannot return to sleep. She also reports an unintentional weight loss of 8 lbs (3.6 kg) and an inability to enjoy the things she once liked to do"

  • Differential diagnosis :
    • Insomnia related to major depressive disorder
    • Primary hypersomnia
    • Insomnia with circadian rhythm sleep disorder
  • Workup :
    • Mental status exam
    • TSH, CBC
    • Polysomnography