First Aid for the USMLE Step 2 CS

Section 3. Minicases

Nausea/Vomiting

Key History

Acuity of onset, ± abdominal pain, relation to meals, sick contacts, possible food poisoning, possible pregnancy; neurologic symptoms (headache, stiff neck, vertigo, focal numbness or weakness); urinary symptoms; other associated symptoms (GI, chest pain); exacerbating and alleviating factors; medications; history of prior abdominal surgery.

Key Physical Exam

Vital signs; ENT; consider funduscopic exam (increased intracranial pressure); complete abdominal exam; consider heart, lung, and rectal exams.

Presentation

Differential

Workup

■ 39 yo F presents with a single 2-cm mass on the right side of her neck along with night sweats, fever, weight loss, loss of appetite, and early satiety. The mass is painless and movable and has not changed in size. She does not report heat intolerance, tremor, palpitations, hoarseness, cough, difficulty breathing, difficulty swallowing, or abdominal pain. Her husband was recently discharged from prison, and her mother has a history of gastric cancer.

Hodgkin’s/non-

Hodgkin’s lymphoma

Tuberculosis

Thyroid nodule

Gastric carcinoma

CBC with differential

Electrolytes

ESR, CRP

Lymph node biopsy

PPD

CXR

TSH

U/S—thyroid

Upper endoscopy

Presentation

Differential

Workup

■ 20 yo F presents with nausea, vomiting (especially in the morning), fatigue, and polyuria. Her last menstrual period was 6 weeks ago, and her breasts are full and tender. She is sexually active with her boyfriend, and they occasionally use condoms for contraception.

Pregnancy

Gastritis Hypercalcemia Diabetes mellitus UTI

Depression

Urine hCG

Pelvic exam

U/S—pelvis

CBC

Electrolytes, calcium, glucose

UA, urine culture HIV antibody

Abdominal Pain

Key History

Location, quality, intensity, duration, radiation, timing (relation to meals); associated symptoms (constitutional, GI, cardiac, pulmonary, renal, pelvic); exacerbating and alleviating factors; history of similar symptoms; history of abdominal surgeries, trauma, gallstones, renal stones, atherosclerotic vascular disease; medications (eg, NSAIDs, corticosteroids); alcohol and drug use; domestic violence, stress/anxiety, sexual history, pregnancy history.

Key Physical Exam

Vital signs; heart and lung exams; abdominal exam, including tenderness, guarding, rebound, Murphy’s sign, psoas and obturator signs, and CVA percussion; bowel sounds, aortic bruits; rectal exam; pelvic exam (women).

Presentation

Differential

Workup

■ 45 yo M presents with sudden onset of colicky rightsided flank pain that radiates to the testicles, accompanied by nausea, vomiting, hematuria, and CVA tenderness.

Nephrolithiasis

Renal cell carcinoma

Pyelonephritis

GI etiology (eg,

appendicitis)

UA, urine culture and sensitivity, urine cytology

BUN/Cr

CT—abdomen

U/S—renal

KUB

IVP

Blood culture

■ 60 yo M presents with dull epigastric pain that radiates to the back, accompanied by weight loss, dark urine, and clay-colored stool. He is a heavy drinker and smoker. He appears jaundiced on exam.

Pancreatic cancer

Cholangiocarcinoma

Acute viral hepatitis

Acute alcoholic hepatitis

Chronic pancreatitis

Cholecystitis/

choledocholithiasis

Abdominal aortic

aneurysm

Peptic ulcer disease

CBC

Electrolytes

Amylase, lipase

AST/ALT/bilirubin/

alkaline phosphatase

CT—abdomen

U/S—abdomen

■ 56 yo M presents with severe midepigastric abdominal pain that radiates to the back and improves when he leans forward. He also reports anorexia, nausea, and vomiting. He is an alcoholic and has spent the past 3 days binge drinking.

Acute pancreatitis

Peptic ulcer disease

Cholecystitis/ choledocholithiasis

Gastritis

Abdominal aortic

aneurysm

Mesenteric ischemia

Alcoholic hepatitis

Boerhaave syndrome

CBC

Electrolytes, BUN/Cr

Amylase, lipase AST/ALT/bilirubin/ alkaline phosphatase

U/S—abdomen

CT—abdomen

Upper endoscopy

ECG

ABDOMINAL PAIN (cont'd)

Presentation

Differential

Workup

■ 41 yo obese F presents with RUQ abdominal pain that radiates to the right scapula and is associated with nausea, vomiting, and a fever of 101.5°F. The pain started after she ate fatty food. She has had similar but less intense episodes that lasted a few hours. Exam reveals a positive Murphy’s sign.

Acute cholecystitis

Choledocholithiasis

Hepatitis

Ascending cholangitis

Peptic ulcer disease

Fitz-Hugh-Curtis syndrome

Acute subhepatic appendicitis

CBC

AST/ALT/bilirubin/ alkaline phosphatase

U/S—abdomen

CT—abdomen

Blood culture

■ 43 yo obese F presents with RUQ abdominal pain, fever, and jaundice. She was diagnosed with asymptomatic gallstones 1 year ago. She is found to be hypotensive on exam.

Ascending cholangitis

Acute gallstone cholangitis

Acute cholecystitis

Hepatitis

Sclerosing cholangitis

Fitz-Hugh-Curtis syndrome

CBC

AST/ALT/bilirubin/ alkaline phosphatase Blood culture

Viral hepatitis serologies U/S—abdomen MRCP ERCP

■ 25 yo M presents with RUQ pain, fever, anorexia, nausea, and vomiting. He has dark urine and clay- colored stool.

Acute hepatitis

Acute cholecystitis

Ascending cholangitis Choledocholithiasis

Pancreatitis

Acute glomerulonephritis

CBC

Amylase, lipase AST/ALT/bilirubin/ alkaline phosphatase

Viral hepatitis serologies UA

U/S—abdomen

■ 35 yo M presents with burning epigastric pain that starts 2-3 hours after meals. The pain is relieved by food and antacids.

Peptic ulcer disease

Gastritis

GERD

Cholecystitis

Chronic pancreatitis

Mesenteric ischemia

Rectal exam, stool for occult blood

Amylase, lipase, lactate AST/ALT/bilirubin/ alkaline phosphatase Upper endoscopy (including H pylori testing)

Upper GI series

ABDOMINAL PAIN (cont'd)

Presentation

Differential

Workup

■ 37 yo M presents with severe epigastric pain, nausea, vomiting, and mild fever. He appears toxic. He has a history of intermittent epigastric pain that is relieved by food and antacids. He also smokes heavily and takes aspirin on a daily basis.

Perforated peptic ulcer

Acute pancreatitis

Hepatitis

Cholecystitis

Gallstone cholangitis

Mesenteric ischemia

Rectal exam

CBC

Electrolytes

Amylase, lipase, lactate AST/ALT/bilirubin/ alkaline phosphatase CXR KUB

CT—abdomen

Upper endoscopy (including H pylori testing)

Blood culture

■ 18 yo M boxer presents with severe LUQ abdominal pain that radiates to the left scapula. He had infectious mononucleosis 3 weeks ago.

Splenic rupture

Kidney stone

Rib fracture

Pneumonia

Perforated peptic ulcer

Splenic infarct

CBC

Electrolytes

CXR

CT—abdomen U/S—abdomen (if hemodynamically unstable)

■ 40 yo M presents with crampy abdominal pain, vomiting, abdominal distention, and inability to pass flatus or stool. He has a history of multiple abdominal surgeries.

Intestinal obstruction

Small bowel or colon cancer

Volvulus

Gastroenteritis

Food poisoning

Ileus

Hernia

Rectal exam

CBC

Electrolytes

AXR

CT—abdomen/pelvis with contrast

Colonoscopy

■ 70 yo F presents with acute onset of severe, crampy abdominal pain. She recently vomited and had a massive dark bowel movement. She has a history of CHF and atrial fibrillation, for which she has received digitalis. Her pain is out of proportion to the exam.

Mesenteric ischemia/ infarction

Diverticulitis

Peptic ulcer disease

Gastroenteritis

Acute pancreatitis Cholecystitis

Rectal exam

CBC

Amylase, lipase, lactate

ECG

AXR

CT—abdomen

Mesenteric angiography

Barium enema

ABDOMINAL PAIN (cont'd)

Presentation

Differential

Workup

■ 21 yo F presents with acute onset of severe RLQ pain, nausea, and vomiting. She has no fever, urinary symptoms, or vaginal bleeding and has never taken OCPs. Her last menstrual period was regular, and she has no history of STDs. She has been told that she had a cyst on her right ovary.

Ovarian torsion

Appendicitis

Nephrolithiasis

Ectopic pregnancy

Ruptured ovarian cyst

Pelvic inflammatory disease

Bowel infarction or perforation

Pelvic exam

Urine hCG

Doppler U/S—pelvis

Rectal exam

UA

CBC

CT—abdomen

Laparoscopy

Chlamydia and gonorrhea testing, VDRL/RPR

■ 68 yo M presents with LLQ abdominal pain, fever, and chills for the past 3 days. He also reports recent onset of alternating diarrhea and constipation. He consumes a low-fiber, high-fat diet.

Diverticulitis

Crohn’s disease Ulcerative colitis Gastroenteritis Abscess

Rectal exam

CBC

Electrolytes

CXR

AXR

CT—abdomen

Blood culture

■ 20 yo M presents with severe RLQ abdominal pain, nausea, and vomiting. His discomfort started yesterday as a vague pain around the umbilicus. As the pain worsened, it became sharp and migrated to the RLQ. McBurney’s and psoas signs are positive.

Acute appendicitis

Gastroenteritis Diverticulitis Crohn’s disease Nephrolithiasis Volvulus or other

intestinal obstruction Perforation Acute cholecystitis

CBC

Electrolytes

CT—abdomen

AXR

U/S—abdomen

Blood culture

■ 30 yo F presents with periumbilical pain for 6 months. The pain never awakens her from sleep. It is relieved by defecation and worsens when she is upset. She has alternating constipation and diarrhea but no nausea, vomiting, weight loss, or anorexia.

Irritable bowel syndrome

Crohn’s disease Celiac disease Chronic pancreatitis GI parasitic infection (amebiasis, giardiasis) Endometriosis

Rectal exam, stool for occult blood

Pelvic exam

Urine hCG CBC

Electrolytes

Colonoscopy CT—abdomen/pelvis

Stool for ova andparasitology,

Entamoeba histolytica antigen

ABDOMINAL PAIN (cant'd)

Presentation

Differential

Workup

■ 24 yo F presents with bilateral lower abdominal pain that started with the first day of her menstrual period. The pain is associated with fever and a thick, greenish-yellow vaginal discharge. She has had unprotected sex with multiple sexual partners.

Pelvic inflammatory disease
Endometriosis
Dysmenorrhea
Vaginitis
Cystitis
Spontaneous abortion
Pyelonephritis

Pelvic exam
Urine hCG
Cervical cultures
CBC
ESR
UA, urine culture
U/S—pelvis



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