Key History
Primary vs. secondary, duration, description (trouble falling asleep vs. multiple awakenings vs. early-morning awakening); daytime sleepiness; other medical problems keeping patient awake at night, such as arthritis (pain) or diabetes (polyuria); evidence of a common sleep disorder (eg, sleep apnea, restless leg syndrome); associated symptoms, including loud snoring, nightmares, and depression; caffeine, alcohol, medication, and recreational drug use; work or lifestyle (jet lag or shift work), stressors, sleep hygiene; presence of psychiatric symptoms (eg, grandiose delusions, irritability).
|
INSOMNIA (cant'd) |
||
|
Key Physical Exam Vital signs; mental status exam; thyroid exam. |
||
|
Presentation |
Differential |
Workup |
|
■ 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. |
Stress-induced insomnia Caffeine-induced insomnia Insomnia with circadian rhythm sleep disorder Insomnia related to major depressive disorder |
Polysomnography Mental status exam Urine toxicology CBC TSH |
|
■ 55 yo obese M presents with several months of poor sleep, daytime fatigue, and morning headaches. His wife reports that he snores loudly. |
Obstructive sleep apnea Daytime fatigue in primary hypersomnia Insomnia with circadian rhythm sleep disorder Insomnia related to major depressive disorder |
CBC TSH Polysomnography ECG |
|
■ 33 yo F c/o 3 weeks of fatigue and trouble sleeping. She states that she falls asleep easily but wakes up at 3 a.m. and cannot return to sleep. She also reports an unintentional weight loss of 8 lbs (3.6 kg) and an inability to enjoy the things she once liked to do. |
Insomnia related to major depressive disorder Primary hypersomnia Insomnia with circadian rhythm sleep disorder |
Mental status exam TSH CBC Polysomnography |
Key History
Duration, fever, other ENT symptoms (ear pain, nasal or sinus congestion), odynophagia, swollen glands, ± cough, rash; sick contacts, HIV risk factors.
Key Physical Exam
Vital signs; ENT exam, including oral thrush, tonsillar exudate, and lymphadenopathy; lung, abdominal (focusing on splenomegaly), and skin exams.
|
SORE THROAT (cant'd) |
||
|
Presentation |
Differential |
Workup |
|
■ 26 yo F presents with sore throat, fever, severe fatigue, and loss of appetite for the past week. She also reports epigastric and LUQ discomfort. She has cervical lymphadenopathy and a rash. Her boyfriend recently experienced similar symptoms. |
Infectious mononucleosis Hepatitis Viral or bacterial pharyngitis Acute HIV infection Secondary syphilis |
CBC with peripheral smear Monospot test Throat culture AST/ALT/bilirubin/ alkaline phosphatase HIV antibody and viral load Anti-EBV antibodies VDRL/RPR |
|
■ 26 yo M presents with sore throat, fever, rash, and weight loss. He has a history of IV drug abuse and sharing needles. |
HIV, acute retroviral syndrome Infectious mononucleosis Hepatitis Viral pharyngitis Streptococcal tonsillitis/ scarlet fever Secondary syphilis |
CBC with peripheral smear HIV antibody and viral load CD4 count Monospot test Throat culture VDRL/RPR AST/ALT/bilirubin/ alkaline phosphatase |
|
■ 46 yo F presents with fever and sore throat. |
Pharyngitis (bacterial or viral) Mycoplasma pneumonia Acute HIV infection Infectious mononucleosis |
Throat swab for culture and rapid streptococcal antigen Monospot test CBC Serologic test (cold agglutinin titer) for Mycoplasma HIV antibody and viral load |