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11 Cards in this Set
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PRESENTS: 21 y.o F with several episodes of throbbing left temporal pain that lasts for 2-3 hrs. Flashes of light in right visual field and she feels weak and numbness on the right side of her body for a few minutes. Headaches are often associted with N and V. She has a family history of migraine
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ASSESSMENT:
Migraine, tension H, Cluster H, pseudomotor cerebri, trigeminal neuralgia, CNS vasculitis, partial seizure, intracranial neoplasm |
PLAN:
CBC, ESR, CT, MRI, LP |
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26 y/o M presents with severe right temporal Headaches assoc with ipsilateral rhinorrhea, eye tearing, and redness. Episodes have occured at the same time every night for the past week and last 45 minutes
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Cluster H, Migraine, tension H, sinusitis, pseudomotor cerebri, trigeminal neuralgia, intracranial neoplasm
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CBC, CT, MRI, LP, ESR
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65 y/o F presents with severe intermittent right temporal H, F, blurred vision in he right eye, and pain in her jaw when chewing
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giant Cell Arteritis (Temporal arteritis), migraine, cluster H, tension H, meningitis, carotid artery dissection, pseudomotor cerebri, trigeminal neuralgia, intracranial neoplasm, temporomandibular joint disorder
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CBC, ESR, CRP, temporal artery biopsy, U/S, MRI LP
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Sore throat
PE: HEENT (nose, mouth, pharynx) Neck (supple, lymphadenopathy?) Lungs: breath sounds Heart: RRR, normal S1/S2? No murmurs, rubs, gallops? Abdomen: Soft, nondistended, + bowel sounds?, hepatosplenomegaly?, tenderness? Skin: rashes? |
Assessment:
Infectious mono HIV viral pharyngitis Bacterial Pharyngitis |
Plan:
CBC Peripheral smear Monospot Rapid strep antigen Throat culture Anti-EBV Abs HIV ab and viral load |
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Blood in Stool
CV Abdomen: bowel sounds, hepatosplenomegaly, soft/nondistended/nontender |
Assessment:
Colorectal cancer Hemorrhoids Diverticulosis Angiodysplasia Pseudomembraneous Colitis Other infectious colitis ulcerative colitis |
Plan:
Rectal exam Stool for occult blood Stool for C. dificile toxin Fecal Leukocyte CBC Anoscopy Flexible proctosigmoidoscopy Colonoscopy Double contrast CT |
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Chest Pain:
Neck: JVD, carotid auscultation CV: inspection, auscultation, palpation Pulmonary: Auscultation, palpation, percussion Abdominal: Auscultation, palpation, percussion Extremities: Peripheral pulses, BP in BOTH arms, Edema? Cyanosis? |
Assessment:
MI GERD Aortic dissection Pericarditis Pneumothorax Pulmonary Embolism Costochondritis |
Plan:
EKG Cardiac enzymes (CPK, CPK-MB, Troponin) X-ray Echocardiogram (transthoracic ad echocardiogram) Cardiac Catheterization CT Upper endoscopy Cholesterol panel |
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7 month old with fever:
Ears Throat Rashes? |
Assessment:
Viral URI Pneumonia Meningitis UTI Otitis media Gastroenteritis Occult Bacteremia |
Plan:
Pneumonia otoscopy Tympanometry CBC with differential Blood culture UA Urine Culture Lipid Panel CSF analysis X-ray Bronchoscopy Serum Ab titers US Voiding cystourethrogram |
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18 month old female with Fever for 2 days:
Ears Throat Rashes |
Assessment:
Otitis Media Meningococcal meningitis Scarlet Fever Fifth's disease or other viral exanthem Varicella |
Plan:
Otoscopy Tympanometry Lipid Panel CSF analysis Platelets PT/PTT D-Dimer Fibrin split products, fibrinogen CBC with differnetial, blood culture Urinalysis Urine culture Throat culture Parvovirus B19 IgM Ab Skin lesion scrapings Varicella Ab titer |
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26 y/o with cough:
Head and Neck - Examined mouth, throat, lymph nodes CV - Auscultation, Palpation Pulmonary - Auscultation, Palpation, Percussion Extremities - Inspect |
Assessment:
URI Bronchitis Pneumonia Pleuodynia Aspiration |
Plan:
X-ray CBC Sputum gram stain/culture Urine Legionella Antigen Serum mycoplasma PCR cold agglutinin measurement Bronchoscopy with bronchoalveolar levage Pulse ox or ABG |
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54 y/o female with cough x1 month:
Head and Neck- mouth, throat, lymph nodes CV Pulmonary Abdominal exam Extremities |
Assessment:
Pulmonary tuberculosis Lung cancer Lung Abcess Pneumonia COPD Wegener Granulomatosis |
Plan:
PPD CBC Blood cultures Sputum gram stain AFB smear mycobacterium sputum cultures X-ray CT c-ANCA Bronchoscopy Lung Biopsy |
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Female with yellow eyes and skin:
HEENT - inspect sclera, look under tongue CV Pulmonary Abdominal Exam Extremities - Asterixis? Edema? Skin - Looked for spider nevi, cutaneous telangiectasias, palmar erythema |
Assessment:
Biliary Obstruction -Pancreatic cancer -Choledocholithiasis -Cholangiocarcinoma -Carcinoma of the ampulla -Sphincter of Oddi Dysfunction Viral hepatitis Acetominophen liver toxicity Primary biliary cirrhosis |
Plan:
AST/ALT/bilirubin/alkaline phosphatase CBC PT/PTT Viral hepatits serologies Acetominophen level US CT MRCP/ERCP |
