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FIRST AID USMLE STEP 2 CS - MINI CASES WITH WELL
EXPLAINED ANSWERS
Presentation: 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)
- ANSWER-Differential: Generalized tonic-clonic seizure Convulsive syncope Substance abuse/overdose Malingering Hypoglycemia Workup: CBC Electrolytes, glucose Urine toxicology EEG MRI—brain CT—head LP—CSF analysis ECG Presentation: 34 yo F nurse presents with worsening cough of 6 weeks' duration accompanied by weight loss, fatigue, night sweats, and fever. She has a history of contact with tuberculosis patients at work. - ANSWER-Differential: Tuberculosis Pneumonia Lung abscess Vasculitis Lymphoma Metastatic cancer HIV/AIDS Sarcoidosis Workup: CBC PPD/QuantiFERON Gold Presentation: 55 yo F c/o dizziness for the past day. She feels faint and has severe diarrhea that started 2 days ago. She takes furosemide for hypertension. - ANSWER-Differential: Orthostatic hypotension due to dehydration (diarrhea, diuretic use)
Vestibular neuronitis Labyrinthitis Benign positional vertigo Vertebrobasilar insufficiency Workup: Orthostatic vital signs CBC Electrolytes Rectal exam, stool for occult blood Stool leukocytes Presentation: 65 yo M presents after falling and losing consciousness for a few seconds. He had no warning before passing out but recently had palpitations. His history includes a coronary artery bypass graft. - ANSWER-Differential: Cardiac arrhythmia (causing syncope) Severe aortic stenosis Syncope (other causes) Seizure Pulmonary embolism Workup: ECG Holter monitoring CBC Electrolytes, glucose Echocardiography CT—head Presentation: 1 - month-old F is brought in because she has been spitting up her milk for the last 10 days. The vomiting episodes have increased in frequency and forcefulness. Emesis is nonbloody and nonbilious. The episodes usually occur immediately after breastfeeding. She has stopped gaining weight. - ANSWER-Differential: Pyloric stenosis Partial duodenal atresia GERD Gastroenteritis Hepatitis UTI Otitis media Workup: Physical exam CBC
14 yo M presents with short stature and lack of sexual development. His birth weight and length were normal, but he is the shortest child in his class. His father and uncles had the same problem when they were young, but they are now of normal stature. - ANSWER-Differential: Constitutional short stature Growth hormone (GH) deficiency Hypothyroidism Chronic renal insufficiency Genetic causes Cystic fibrosis Workup: Physical exam CBC Electrolytes GH stimulation test IGF-1, IGFBP-3 levels TSH, FT XR—hand U/S—renal and cardiac Sweat chloride testing BUN/Cr Karyotype Presentation: 15 yo M presents with a 1-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- Differential: Substance abuse Conduct disorder Oppositional defiant disorder Adjustment disorder Workup: Urine toxicology Mental status exam Physical exam Presentation: 17 yo F presents with prolonged, excessive menstrual bleeding occurring irregularly within the past 6 months. - ANSWER-Differential: Dysfunctional uterine bleeding Coagulation disorder (eg, von Willebrand's disease, hemophilia) Cervical cancer Molar pregnancy
Hypothyroidism Diabetes mellitus Workup: Urine hCG Pelvic exam Cervical culture Pap smear CBC ESR Glucose PT/PTT LH/FSH, TSH, prolactin U/S—pelvis Presentation: 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-Differential: Malingering Lumbar muscle strain Disk herniation Knee or leg fracture Ankylosing spondylitis Workup: XR—L-spine/knee MRI—L-spine Presentation: 18 yo F presents with amenorrhea for the past 4 months. She is 5 feet, 6 inches (167. cm) and weighs 90 lbs (40.9 kg). She has a history of exercise and heat intolerance. - ANSWER-Differential: Anorexia nervosa Pregnancy Hyperthyroidism Workup: Urine hCG CBC TSH, FT LH/FSH Presentation:
18 yo obese F presents with a pulsatile headache, vomiting, and blurred vision for the past 2-3 weeks. She is taking OCPs. - ANSWER-Differential: Pseudotumor cerebri Tension headache Migraine Cluster headache Meningitis Intracranial venous thrombosis Intracranial neoplasm Workup: Urine hCG CBC CT—head LP—opening pressure and CSF analysis Presentation: 19 yo F presents with episodic palpitations, especially during presentations in front of her class. Episodes include heart pounding, facial blushing, and hand tremor. She also experiences excessive sweating and rapid breathing. She complains of intense worry and trouble sleeping for days or weeks before an upcoming social situation. Now she avoids all social events because she is afraid of humiliating herself. - ANSWER- Differential: Social phobia Avoidant personality disorder Agoraphobia/specific phobia Panic attack Generalized anxiety disorder Substance abuse/ dependence Hyperthyroidism Workup: CBC Electrolytes ECG Echocardiography TSH, FT Mental status exam Presentation: 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. 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." - ANSWER-Differential:
Schizophrenia Schizoid or schizotypal personality disorder Schizophreniform disorder Psychotic disorder due to a general medical condition Substance-induced psychosis Depression with psychotic features Workup: Mental status exam Urine toxicology TSH CBC Electrolytes Presentation: 2 - month-old M presents with persistent crying for 2 weeks. The episodes subside after passing flatus or eructation. There is no change in appetite, weight, or growth. There is no vomiting, constipation, or fever. - ANSWER-Differential: Colic Formula allergy GERD Lactose intolerance Strangulated hernia Testicular torsion Gastroenteritis Workup: Physical exam Rectal exam, stool for occult blood U/S—abdomen U/S—testicular Presentation: 20 yo African American F presents with acute onset of severe chest pain for a few hours. She has a history of sickle cell disease and multiple hospitalizations for pain and anemia management. - ANSWER-Differential: Sickle cell disease—acute chest syndrome Pulmonary embolism Pneumonia MI Pneumothorax Aortic dissection Workup: CBC with reticulocyte count and peripheral smear
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. - ANSWER-Differential: Acute appendicitis Gastroenteritis Diverticulitis Crohn's disease Nephrolithiasis Volvulus or other intestinal obstruction Perforation Acute cholecystitis Workup: CBC Electrolytes CT—abdomen AXR U/S—abdomen Blood culture Presentation: 20 - day-old M presents with fever, decreased breastfeeding, and lethargy. He was born at 36 weeks as a result of premature rupture of membranes. - ANSWER-Differential: Neonatal sepsis Meningitis Pneumonia Pyelonephritis Workup: Physical exam CBC Electrolytes Blood culture LP—CSF analysis CXR UA, urine culture Presentation: 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. She has been told that she had a cyst on her right ovary. - ANSWER-Differential: Ovarian torsion Appendicitis Nephrolithiasis
Ectopic pregnancy Ruptured ovarian cyst Pelvic inflammatory disease Bowel infarction or perforation Workup: Pelvic exam Urine hCG Doppler U/S—pelvis Rectal exam UA CBC CT—abdomen Laparoscopy Chlamydia and gonorrhea testing, VDRL/RPR Presentation: 21 yo F presents with several episodes of throbbing left temporal pain that last for 2- 3 hours. Before onset, she sees flashes of light in her right visual field and feels weakness and numbness on the right side of her body for a few minutes. Her headaches are often associated with nausea and vomiting. She has a family history of migraine. - ANSWER- Differentials: Migraine (complicated) Tension headache Cluster headache Pseudotumor cerebri CNS vasculitis Partial seizure Intracranial neoplasm Workup: CBC ESR CT—head MRI—brain LP—CSF analysis Presentation: 23 yo obese F presents with amenorrhea for 6 months, facial hair, and infertility for the past 3 years. - ANSWER-Differential: Polycystic ovary syndrome Thyroid disease Hyperprolactinemia Pregnancy Ovarian or adrenal malignancy Premature ovarian failure
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. - ANSWER-Differential: 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 Presentation: 25 yo M presents with hemiparesis after a tonic-clonic seizure that resolved within a few hours. - ANSWER-Differential: Todd's paralysis TIA Stroke Complicated migraine Malingering Workup: CBC Electrolytes EEG MRI—brain Doppler U/S—carotid Presentation: 25 yo M presents with high fever, severe headache, confusion, photophobia, and nuchal rigidity - ANSWER-Differential: Meningitis Migraine Subarachnoid hemorrhage Sinusitis/encephalitis Intracranial or epidural abscess Workup: CBC CT—head MRI—brain LP—CSF analysis (cell count, protein, glucose, Gram stain, PCR for specific pathogens, culture)
Presentation: 25 yo M presents with RUQ pain, fever, anorexia, nausea, and vomiting. He has dark urine and clay-colored stool. - ANSWER-Differential: Acute hepatitis Acute cholecystitis Ascending cholangitis Choledocholithiasis Pancreatitis Acute glomerulonephritis Workup: CBC Amylase, lipase AST/ALT/bilirubin/alkaline phosphatase Viral hepatitis serologies UA U/S—abdomen Presentation: 25 yo M presents with watery diarrhea and abdominal cramps. He was recently in Mexico. - ANSWER-Differential: Traveler's diarrhea Giardiasis Amebiasis Food poisoning Hepatitis A Workup: Rectal exam Stool leukocytes, culture, Giardia antigen, Entamoeba histolytica antigen CBC Electrolytes AST/ALT/bilirubin/alkaline phosphatase Viral hepatitis serologies Presentation: 26 yo F presents with a 6.5-lb (2.9-kg) weight loss in the past 2 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 6 months before her presentation. - ANSWER-Differential: Bipolar I disorder Bipolar II disorder Cyclothymic disorder Major depressive disorder
26 yo M presents with sore throat, fever, rash, and weight loss. He has a history of IV drug abuse and sharing needles. - ANSWER-Differential: HIV, acute retroviral syndrome Infectious mononucleosis Hepatitis Viral pharyngitis Streptococcal tonsillitis/scarlet fever Secondary syphilis Workup: CBC with peripheral smear HIV antibody and viral load CD4 count Monospot test Throat culture VDRL/RPR AST/ALT/bilirubin/alkaline phosphatase Presentation: 27 yo F presents with painful wrists and elbows, a swollen and hot knee joint that is painful on flexion, a rash on her limbs, and vaginal discharge. She is sexually active with multiple partners and occasionally uses condoms. - ANSWER-Differential: Disseminated gonorrhea Rheumatoid arthritis SLE Reiter's syndrome (reactive arthritis) Workup: Knee arthrocentesis and synovial fluid analysis (cell count, Gram stain, culture) ANA, anti-dsDNA, ESR, RF, CCP CBC Blood, cervical cultures XR—knee Presentation: 28 yo F c/o multiple facial and bodily injuries. She claims that she fell on the stairs. She was hospitalized for physical injuries 7 months ago. She presents with her husband. - ANSWER-Differential: Domestic violence Osteogenesis imperfecta Substance abuse Consensual violent sexual behavior Workup: XR—skeletal survey CT—maxillofacial
Urine toxicology CBC Presentation: 28 yo F c/o seeing bugs crawling on her bed for the past 2 days and hearing loud voices when she is alone in her room. She has never experienced anything similar in the past. She recently ingested an unknown substance. - ANSWER-Differential: Substance-induced psychosis Brief psychotic disorder Schizophreniform disorder Schizophrenia Psychotic disorder due to a general medical condition Workup: Urine toxicology Mental status exam TSH CBC Electrolytes, BUN/Cr AST/ALT Presentation: 28 yo F presents with a thin, grayish-white, foulsmelling vaginal discharge. - ANSWER- Differential: Bacterial vaginosis Vaginitis—candidal Vaginitis—trichomonal Cervicitis (chlamydia, gonorrhea) Workup: Pelvic exam Wet mount, KOH prep, "whiff test" pH of vaginal fluid Cervical cultures Presentation: 28 yo F presents with pain in the interphalangeal joints of her hands accompanied by hair loss and a rash on her face. - ANSWER-Differential: Systemic lupus erythematosus (SLE) Rheumatoid arthritis Psoriatic arthritis Parvovirus B19 infection Workup: ANA, anti-dsDNA, ESR, C3, C4, RF, CCP CBC
TSH
Electrolytes Urine toxicology Presentation: 29 yo F presents with amenorrhea for the past 6 months. She has a history of occasional palpitations and dizziness. She lost her fiancé in a car accident in which she was a passenger. - ANSWER-Differential: Anxiety-induced amenorrhea Posttraumatic stress disorder Depression Hyperthyroidism Workup: CBC TSH, FT Urine cortisol level Progesterone challenge test LH/FSH, estradiol levels Presentation: 3 yo F presents with a 3-day history of "pink eye." It began in the right eye but now involves both eyes. She has mucoid discharge, itching, and difficulty opening her eyes in the morning. Her mother had the flu last week. She has a history of asthma and atopic dermatitis. - ANSWER-Differential: Bacterial conjunctivitis Viral conjunctivitis Keratitis Seasonal allergies Uveitis Workup: Physical exam Ophthalmoscopic eye exam CBC Electrolytes Discharge cultures Slit lamp exam Presentation: 3 yo M presents with a 2-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-Differential: Acute otitis media URI Meningitis
Pyelonephritis Workup: Physical exam (including pneumatic otoscopy) CBC Blood culture Tympanocentesis culture LP—CSF analysis UA, urine culture Presentation: 3 yo M presents with constipation. The child has had 1 bowel movement per week since birth despite the use of stool softeners. At birth, he did not pass meconium for 48 hours. He has poor weight gain. There is a family history of this problem. - ANSWER- Differential: Hirschsprung's disease Low-fiber diet Anal stenosis Hypothyroidism Lead poisoning Workup: Physical exam Rectal exam Stool exam and culture Barium enema Suction rectal biopsy Anorectal manometry TSH, FT CBC Electrolytes Serum lead level Presentation: 30 yo F presents with a thick, white, cottage cheese- like, odorless vaginal discharge and vaginal itching. - ANSWER-Differential: Vaginitis—candidal Bacterial vaginosis Vaginitis—trichomonal Workup: Pelvic exam Wet mount, KOH prep, "whiff test" pH of vaginal fluid Cervical cultures
