Key History
Gradual vs. acute onset/offset, context (exertion, caffeine, anxiety); associated symptoms (lightheadedness, loss of consciousness, chest pain, dyspnea, fever, sweating, pale skin, flushing, diarrhea); hyperthyroid symptoms; history of bleeding or anemia; history of heart disease, hypertension, or diabetes.
Key Physical Exam
Vital signs; endocrine/thyroid exam, including exophthalmos, lid retraction, lid lag, gland size, bruit, and tremor; complete cardiovascular exam.
|
Presentation |
Differential |
Workup |
|
■ 70 yo diabetic M presents with episodes of palpitations and diaphoresis. He is on insulin. |
Hypoglycemia Cardiac arrhythmia Angina Hyperthyroidism Hyperventilation episodes Panic attack Pheochromocytoma Carcinoid syndrome |
Glucose CBC Electrolytes TSH ECG Holter monitor 24-hour urinary catecholamines 5-HIAA |
|
PALPITATIONS (cant'd) |
||
|
Presentation |
Differential |
Workup |
|
■ 35 yo M presents with several episodes of palpitations, sweating, and rapid breathing. Episodes occur unexpectedly, and he does not recall any triggers. He has had 4-5 episodes per month for several months. Each episode lasts 2-3 minutes. He does not have any history of psychiatric illness except for separation anxiety as a child. |
Panic attack Generalized anxiety disorder Acute stress disorder Specific phobia Hyperthyroidism Agoraphobia Substance abuse/ dependence Mitral valve prolapse Pheochromocytoma |
CBC Electrolytes TSH, ft4 ECG Echocardiography Urine toxicology 24-hour urinary catecholamines |
|
■ 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. |
Social phobia Avoidant personality disorder Agoraphobia/specific phobia Panic attack Generalized anxiety disorder Substance abuse/ dependence Hyperthyroidism |
CBC Electrolytes ECG Echocardiography TSH, ft4 Mental status exam |
|
■ 34 yo F presents with episodic palpitations accompanied by lightheadedness and sharp, atypical chest pain. |
Mitral valve prolapse Cardiac arrhythmia Panic attack Pheochromocytoma |
ECG Echocardiography Holter monitor 24-hour urinary catecholamines |
Key History
Amount, duration, ± intention; diet and exercise history; body image, anxiety or depression; other constitutional symptoms; hyperthyroid symptoms (palpitations, tremor, diarrhea); family history of thyroid disease; HIV risk factors; tobacco, alcohol, and drug use; medications; history of cancer; blood in urine or stool.
WEIGHT LOSS (cant'd)
Key Physical Exam
Vital signs; complete physical.
|
Presentation |
Differential Workup |
|
■ 42 yo F presents with a 15.5-lb (7-kg) weight loss within the past 2 months. She has a fine tremor, and her pulse is 112. |
Hyperthyroidism TSH, FT4 Cancer CBC HIV infection Electrolytes Dieting/diet drugs HIV antibody Anorexia nervosa Urine toxicology Malabsorption |
WEIGHT GAIN
Key History
Amount, duration, timing (relation to medication changes, smoking cessation, depression); diet history; hypothyroid symptoms (fatigue, constipation, skin/hair/nail changes); menstrual irregularity, hirsutism; medical history; alcohol and drug use.
Key Physical Exam
Vital signs; complete exam, including signs of Cushing’s syndrome (hypertension, central obesity, moon face, buffalo hump, supraclavicular fat pads, purple abdominal striae); edema resulting from water retention in renal disease.
|
Presentation |
Differential |
Workup |
|
■ 44 yo F presents with a weight gain of > 25 lbs (11.3 kg) within the past 2 months. She quit smoking 3 months ago and is on amitriptyline for depression. She also reports cold intolerance and constipation. |
Smoking cessation Drug side effect Hypothyroidism Cushing’s syndrome Polycystic ovary syndrome Diabetes mellitus Atypical depression |
CBC Electrolytes, glucose TSH 24-hour urine free cortisol Dexamethasone suppression test |
|
■ 30 yo F presents with weight gain over the past 3 months. She also reports tremor, palpitations, anxiety, and hunger that is relieved by eating. She exhibits proximal muscle weakness and easy bruising. |
Insulinoma Reactive postprandial hypoglycemia Cushing’s syndrome |
Blood glucose and plasma insulin Glucose tolerance test 24-hour urine free cortisol |