Key History
Positive symptoms (delusions, hallucinations, disorganized thoughts, disorganized or catatonic behavior), negative symptoms (blunted affect, social withdrawal, decreased motivation, decreased speech/thought), cognitive symptoms (disorganized speech or thought patterns, paranoia); age at first symptoms and/or hospitalization; previous psychiatric medications; alcohol and substance use.
Key Physical Exam
Vital signs; mental status exam; during physical exam, pay particular attention to general appearance (eg, poor grooming, odd or poorly fitting clothing).
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Presentation |
Differential |
Workup |
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■ 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.” |
Schizophrenia Schizoid or schizotypal personality disorder Schizophreniform disorder Psychotic disorder due to a general medical condition Substance-induced psychosis Depression with psychotic features |
Mental status exam Urine toxicology TSH CBC Electrolytes |
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■ 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. |
Substance-induced psychosis Brief psychotic disorder Schizophreniform disorder Schizophrenia Psychotic disorder due to a general medical condition |
Urine toxicology Mental status exam TSH CBC Electrolytes, BUN/Cr AST/ALT |
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■ 48 yo F presents with a 1-week history of auditory hallucinations that state, “I am worthless” and “I should kill myself.” She also reports a 2-week history of weight loss, early-morning awakening, decreased motivation, and overwhelming feelings of guilt. |
Schizoaffective disorder Mood disorder with psychotic features Schizophrenia Schizophreniform disorder Psychotic disorder due to a general medical condition |
Mental status exam Beck Depression Inventory TSH CBC Electrolytes |
Key History
Lightheadedness vs. vertigo, ± auditory symptoms (hearing loss, tinnitus), duration of episodes, context (occurs with positioning, following head trauma); other associated symptoms (visual disturbance, URI, nausea); neck pain or injury; medications; history of atherosclerotic vascular disease.
Key Physical Exam
Vital signs; complete neurologic exam, including Romberg test, nystagmus, tilt test (eg, Dix-Hallpike maneuver), gait, hearing, and Weber and Rinne tests; ENT exam; cardiovascular exam.
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■ 35 yo F presents with intermittent episodes of vertigo, tinnitus, nausea, and hearing loss within the past week. |
Ménière’s disease Vestibular neuronitis Labyrinthitis Benign positional vertigo Acoustic neuroma |
CBC VDRL/RPR (syphilis is a cause of Ménière’s disease) MRI—brain Dix-Hallpike maneuver |
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■ 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. |
Orthostatic hypotension due to dehydration (diarrhea, diuretic use) Vestibular neuronitis Labyrinthitis Benign positional vertigo Vertebrobasilar insufficiency |
Orthostatic vital signs CBC Electrolytes Rectal exam, stool for occult blood Stool leukocytes |
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■ 65 yo M presents with postural dizziness and unsteadiness. He has hypertension and was started on hydrochlorothiazide 2 days ago. |
Drug-induced orthostatic hypotension Vestibular neuronitis Labyrinthitis Benign positional vertigo Brain stem or cerebellar tumor Acute renal failure |
Orthostatic vital signs CBC Electrolytes Echocardiography MRI—brain |
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■ 44 yo F c/o dizziness on moving her head to the left. She feels that the room is spinning around her head. A tilt test results in nystagmus and nausea. |
Benign positional vertigo Vestibular neuronitis Labyrinthitis Ménière’s disease |
Dix-Hallpike maneuver MRI—brain Audiogram |
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DIZZINESS (cant'd) |
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Presentation |
Differential |
Workup |
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■ 55 yo F c/o dizziness that started this morning. She is nauseated and has vomited once in the past day. She had a URI 2 days ago and has experienced no hearing loss. |
Vestibular neuronitis Labyrinthitis Ménière’s disease Benign positional vertigo Vertigo associated with cervical spine disease or injury Vertebrobasilar insufficiency |
CBC Electrolytes Electronystagmography MRI/MRA—brain |
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■ 55 yo F c/o dizziness that started this morning and of “not hearing well.” She feels nauseated and has vomited once in the past day. She had a URI 2 days ago. |
Labyrinthitis Vestibular neuronitis Ménière’s disease Acoustic neuroma Vertebrobasilar insufficiency |
Audiogram Electronystagmography MRI/MRA—brain |