Key History
Presence or absence of preceding symptoms (nausea, diaphoresis, palpitations, pallor, lightheadedness), context (exertional, postural, traumatic; stressful, painful, or claustrophobic experience; dehydration); associated tongue biting or incontinence, tonic-clonic movements, prolonged confusion; dyspnea or pulmonary embolism risk factors; history of heart disease, arrhythmia, hypertension, or diabetes; alcohol and drug use.
Key Physical Exam
Vital signs, including orthostatics; complete neurologic exam; carotid and cardiac exam; lung exam; exam of the lower extremities.
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■ 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). |
Generalized tonic-clonic seizure Convulsive syncope Substance abuse/overdose Malingering Hypoglycemia |
CBC Electrolytes, glucose Urine toxicology EEG MRI—brain CT—head LP—CSF analysis ECG |
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LOSS OF CONSCIOUSNESS (cant'd) |
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■ 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. |
Drug-induced orthostatic hypotension (causing syncope) Hypoglycemia Cardiac arrhythmia Syncope (vasovagal, other causes) Stroke MI Pulmonary embolism |
Orthostatic vital signs CBC Electrolytes, glucose Echocardiography CT—head ECG V/Q scan CTA—chest with IV contrast D-dimer |
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■ 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. |
Cardiac arrhythmia (causing syncope) Severe aortic stenosis Syncope (other causes) Seizure Pulmonary embolism |
ECG Holter monitoring CBC Electrolytes, glucose Echocardiography CT—head |
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Key History
Distribution (unilateral, bilateral, proximal, distal), duration, ± progression, pain (especially headache, neck or back pain); constitutional symptoms, other neurologic symptoms; history of diabetes, alcoholism, atherosclerotic vascular disease.
Key Physical Exam
Vital signs; neurologic and musculoskeletal exams; relevant vascular exam.
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■ 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 department. He has a history of hypertension, diabetes mellitus, and heavy smoking. |
Transient ischemic attack (TIA) Hypoglycemia Seizure Stroke Facial nerve palsy |
CT—head CBC Electrolytes, glucose Fasting lipid panel ECG MRI—brain Doppler U/S—carotid Echocardiography EEG |
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NUMBNESS/WEAKNESS (cont'd) |
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■ 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 history of hypertension, diabetes mellitus, and heavy smoking. |
Stroke TIA Seizure Intracranial neoplasm Subdural or epidural hematoma |
CT—head CBC Electrolytes PT/PTT/INR Fasting lipid panel MRI—brain Doppler U/S—carotid Echocardiography ECG |
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■ 33 yo F presents with ascending loss of strength in her lower legs over the past 2 weeks. She had a recent URI. |
Guillain-Barré syndrome Multiple sclerosis Polymyositis Myasthenia gravis Peripheral neuropathy Tumor in the vertebral canal |
CBC Electrolytes CPK LP—CSF analysis MRI—spine EMG Nerve conduction studies Tensilon (edrophonium) test Serum B12 |
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■ 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 vision, and double vision. She reports feeling “electric shocks” down her spine upon flexing her head. |
Multiple sclerosis Stroke Conversion disorder Malingering CNS tumor Neurosyphilis Syringomyelia CNS vasculitis |
CBC ESR VDRL/RPR MRI—brain, spine LP—CSF analysis Retinal evoked potentials |
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■ 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. |
Diabetic peripheral neuropathy Alcoholic peripheral neuropathy B12 deficiency Hypocalcemia Hyperventilation Paraproteinemia/myeloma |
HbA, 1c ESR Calcium Serum B12 UA Serum and urine protein electrophoresis |
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NUMBNESS/WEAKNESS (cant'd) |
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■ 40 yo F presents with occasional double vision and droopy eyelids at night with normalization by morning. |
Myasthenia gravis Horner’s syndrome Multiple sclerosis Intracranial neoplasm compressing CN III, IV, or VI Amyotrophic lateral sclerosis |
Tensilon (edrophonium) test Serum ACh receptor antibodies CXR CT—chest MRI—brain EMG |
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■ 25 yo M presents with hemiparesis after a tonic- clonic seizure that resolved within a few hours. |
Todd’s paralysis TIA Stroke Complicated migraine Malingering |
CBC Electrolytes EEG MRI—brain Doppler U/S—carotid |
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■ 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 progressively 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. |
Carpal tunnel syndrome secondary to hypothyroidism Overuse injury of median nerve Medial epicondylitis |
Phalen’s maneuver and Tinel’s sign Nerve conduction studies TSH CBC |
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