Workups for Common Complaints

Question 1

Migraine

Answer 1

Hx: throbbing, temporal pain 2-3 hrs; flashes of light and weakness before onset; nausea and vomiting
Ddx: tension, cluster, pseudotumor, CNS vasculitis
Workup: CBC, ESR, CT, MRI, LP

Question 2

Cluster Headache

Answer 2

Hx: ipsilateral, rhinorrhea, eye tearing, redness, same time every night, last for 45 min
Ddx: migraine, tension, intracranial neoplasm
Workup: CBC, CT, MRI, LP, ESR

Question 3

Temporal Arteritis

Answer 3

Hx: intermittent, temporal, fever, blurred vision, pain in jaw
Ddx: migraine, cluster, tension, meningitis, carotid artery dissection, pseudotumor
Workup: ESR, CRP, CBC, Temporal artery biopsy, Doppler of carotids, MRI, LP

Question 4

Sinusitis

Answer 4

Hx: headache, fever, nasal discharge, pain on palpation of sinuses
Ddx: migraine, tension, meningitis, intracranial neoplasm
Workup: CBC, XR of sinuses, CT of sinuses, LP

Question 5

Tension Headache

Answer 5

Hx: bilateral squeezing, 3-4x/week, towards end of work day, associated stress, decreased caffeine
Ddx: migraine, depression, caffeine w/drawal, hypertension, cluster
Workup: CBC, lytes, ESR, CT, LP

Question 6

Subarachnoid hemorrhage

Answer 6

Hx: sudden onset of severe headache + vomiting, confusion, L hemiplegia, nuchal rigidity
Ddx: migraine, meninigitis, encephalitis, intracranial hemorrhage, vertebral artery dissection, venous thromobosis
Workup: non-con CT, LP, CBC, PT/PTT/INR, Urine toxicology

Question 7

Meningitis

Answer 7

Hx: high fever, confusion, photophobia, nuchal rigidity
Ddx: migraine, subarachnoid hemorrhage, sinusitis, abscess
Workup: CBC, CT, MRI, LP

Question 8

Pseudotumor

Answer 8

Hx: pulsatile, vomiting, blurred vision for 2-3 weeks, OCPs
Ddx: tension, migraine, cluster, meningitis, neoplasm
Workup: hCG, CBC, CT, LP for opening pressure

Question 9

Trigeminal neuralgia

Answer 9

Hx: daily pain in right cheek for month, stabbing, occurs while shaving, episodes last 2-4 minutes
Ddx: tension, migraine, cluster, TMJ, intracranial neoplasm
Workup: CBC, ESR, MRI

Question 10

Vascular Dementia

Answer 10

Hx: past several years, hx of HTN, diabetes, stroke history with worsening
Ddx: Alzheimers, NPH, chronic subdural, neoplasm, depression, B12
Workup: CBC, VDLR/RPR, Serum B12, TSH, MRI, CT, LP

Question 11

Alzheimer’s

Answer 11

Hx: forgetfullness (phone numbers, directions), difficulty performing daily activities (bathing, dressing, managing money, using phone), gradual
Ddx: Vascular, depression, hypothyroid, chronic subdural
Workup: CBC, VDRL/RPR, Serum B12, TSH, MRI, CT, LP

Question 12

Normal Pressure Hydrocephalus

Answer 12

Hx: gait disturbance, urinary incontinence
Ddx: Alzheimer’s, vascular demention, chronic subdural hematoma, depression
Workup: CT, MRI, LP opening pressure, Serum B12, VDRL/RPR, TSH

Question 13

Creutzfeldt-Jakob

Answer 13

Hx: rapidly progressive change and memory impairment in past 2 months, myoclonus, ataxia, startle response
Ddx: vascular, lewy body, wernicke’s, NPH
Workup: CBC, electrolytes, calcium, serum B12, VDLR/RPR, MRI, EEG, LP, Brain biopsy

Question 14

Hypoglycemia

Answer 14

Hx: insulin-dep diabetes, episodes of confusion, dizziness, palpitations, diaphoresis
Ddx: TIA, arrhythmia, delirium, angina
Workup: Glucose, CBC, lytes, CPK-MB, troponin, ECG, Echo, MRI, Doppler U/S

Question 15

Subdural Hematoma

Answer 15

Hx: gradual AMS, slipped two weeks ago and hit head and lost consciousness for 2 min
Ddx: SIADH –> hyponatremia, Creutzfeld-Jakob, intracranial neoplasm
Workup: CT, CBC, electrolytes, MRI, LP

Question 16

Retinal Artery Occlusion

Answer 16

Hx: sudden loss of vision, palpitations and SOB, hx of afib, no pain, discharge, no headache
Ddx: retinal vein occlusion, acute angle-closure glaucoma, retinal detatchment, temporal arteritis
Workup: fluoresceine angiogram, echo, doppler of carotids, intraocular tonometry, ESR, CBC

Question 17

Normal bereavement

Answer 17

Hx. 2 month hx of crying, excessive sleep, weight loss, poor hygiene, sees dead wife
Ddx: adjustment disorder, MDD, Schizoaffective
Workup: physical, TSH, CBC, Utox, Beck Depression Inventory

Question 18

MDD

Answer 18

Hx. month of excessive fatigue, insomnia, anhedonia, preoccupation with death, similar episodes, suicide attempts
Ddx: Substance-induced mood disorder, dysthymic disorder
Workup: physical, mental status, Beck’s inventory, Blood alcohol level, TSH, CBC, UTox

Question 19

Menieres

Answer 19

Hx: intermittent episodes of vertigo, tinnitus, hearing loss, nausea within past week
Ddx: vestibular neuronitis, labrinthitis, benign position vertigo, acoustic neuroma
Workup: CBC, VDRL/RPR, MRI, Dix Hallpike

Question 20

Orthostatic Hypotension

Answer 20

Hx. severe diarrhea, furosemide, dizziness for past day
Ddx: vestibular neuronitis, labyrinthitis, BPV, vertebrobasilar insufficiency
Workup: Orthostatics, CBC, Rectal exam with guaiac, stool electrolytes, lytes

Question 21

Benign Position Vertigo

Answer 21

Hx. dizziness with moving head to left; room spinning around head; tilt test with nystagmus and nausea
Ddx: vestibular neuronitis, labyrinthitis, Menieres
Workup: Dix-hallpike, MRI, audiogram

Question 22

Labyrinthitis

Answer 22

Hx. dizziness starting this morning and hx of not hearing well, n/v, URI two days ago
Ddx: vestibular neuronitis, Menieres, acoustic neuroma, vertebrobasilar insufficiency
Workup: audiogram, electronystagmography, MRI/MRA

Question 23

Arrhythmia (causing syncope)

Answer 23

Hx. No warning before passing out; recent palpitations
Ddx: severe aortic stenosis, syncope, seizure, PE
Workup: ECG, holter monitor, CBC, electrolytes (glucose), Echo, CT

Question 24

Stroke

Answer 24

Hx. slurred speech, right facial droop, right weakness, Babinsky, hx of htn, diabetes, heavy smoking
Ddx: TIA, seizure, intracranial neoplasm, subdural/epidural hematoma
Workup: CT, CBC, electrolytes, PT/PTT/INR, fasting lipid, MRI, Doppler, Echo, ECG

Question 25

GBS

Answer 25

Hx. ascending loss of strength over past two weeks, URI recently
Ddx. MS, polio, myasthenia, peripheral neuropathy, tumor of vertebral canal
Workup: CBC, electrolytes, CPK, LP, MRI, EMG, Nerve conduction, Tensilon (edrophonium test), B12

Question 26

MS

Answer 26

Hx. weakness, loss of sensation, tingling, eye pain, decreased vision, double vision, electric shocks with flexed spine
Ddx. stroke, conversion disorder, malingering, CNS tumor, neurosyphilis, syringomyelia, CNS vasculitis
Workup: CBC, ESR, VDRL/RPR, MRI, LP, retinal evoked potentials