First Aid for the USMLE Step 2 CS

Section 3. Minicases

In this section, we will attempt to cover most of the clinical cases that you are likely to encounter on the Step 2 CS. The main title of each case represents a chief complaint that you may see on the doorway information sheet before you enter the examination room or a complaint that you may have to elicit from the standardized patient. After each chief complaint, key points pertinent to the history and physical exam are reviewed. Each clinical case consists of three components:

 Presentation: A brief clinical vignette with some pertinent positives and negatives.

 Differential: An appropriate differential diagnosis; the most likely diagnosis appears in boldface. The supporting history and physical findings for each diagnosis are not provided.

 Workup: The main diagnostic tests that should be considered for each disease. Note that the diagnostic tests in the third column are generally listed in rough order of priority. In clinical practice, many tests may be performed at the same time or not at all.

The sum of the Differential column will give you a wide differential diagnosis for the chief complaint, whereas the sum of the Workup column will give you a pool of tests from which to choose in the exam.

If you are studying by yourself, we suggest that you read the vignette and then try to figure out the diagnosis and workup. Think through the supporting history and physical findings for each diagnosis. If you are studying with a partner or in a group, we suggest that you take turns reading the vignette aloud and allow each other to figure out the differential diagnosis and workup.

Headache

Key History

Onset (acute vs. chronic), location (unilateral vs. bilateral), quality (dull vs. stabbing), intensity (is it the “worst headache of their life”?), duration, timing (does it disturb sleep?), presence of associated neurologic symptoms (paresthesias, visual stigmata, weakness, numbness, ataxia, photophobia, dizziness, auras, neck stiffness); nausea/vomit- ing, jaw claudication, recent trauma, dental surgery, sinusitis symptoms; exacerbating factors (stress, fatigue, menses, exercise, certain foods) and alleviating factors (rest, medications); patient and family history of headache; history of trauma.

Key Physical Exam

Vital signs; inspection and palpation of entire head; ENT inspection; complete neurologic exam, including funduscopic exam.

Presentation

Differential

Workup

■ 21 yo F presents with several episodes of throbbing left temporal pain that last for 2-3 hours. Before onset, she sees flashes of light in her right visual field and feels weakness and numbness on the right side of her body for a few minutes. Her headaches are often associated with nausea and vomiting. She has a family history of migraine.

Migraine (complicated)

Tension headache Cluster headache Pseudotumor cerebri CNS vasculitis Partial seizure Intracranial neoplasm

CBC

ESR

CT—head MRI—brain LP—CSF analysis

■ 26 yo M presents with severe right temporal headaches associated with ipsilateral rhinorrhea, eye tearing, and redness. Episodes have occurred at the same time every night for the past week and last for 45 minutes.

Cluster headache

Migraine

Tension headache Intracranial neoplasm Pseudotumor cerebri

CBC

CT—head MRI—brain LP—CSF analysis ESR

■ 65 yo F presents with severe, intermittent right temporal headache, fever, blurred vision in her right eye, and pain in her jaw when chewing.

Temporal arteritis (giant cell arteritis)

Migraine Cluster headache Tension headache Meningitis

Carotid artery dissection Pseudotumor cerebri Trigeminal neuralgia Intracranial neoplasm Temporomandibular joint (TMJ) disorder

ESR

CBC

CRP

Temporal artery biopsy Doppler U/S—carotid MRI—brain LP—CSF analysis

HEADACHE (cant'd)

Presentation

Differential

Workup

■ 30 yo F presents with frontal headache, fever, and nasal discharge. There is pain on palpation of the frontal and maxillary sinuses. She has a history of allergies.

Sinusitis

Migraine

Tension headache

Meningitis

Intracranial neoplasm

CBC

XR—sinus

CT—sinus

LP—CSF analysis

■ 50 yo F presents with recurrent episodes of bilateral squeezing headaches that occur 3-4 times a week, typically toward the end of her work day. She is experiencing significant stress in her life and recently decreased her intake of caffeine.

Tension headache

Migraine

Depression

Caffeine or analgesic withdrawal

Hypertension

Cluster headache

Pseudotumor cerebri

Intracranial neoplasm

CBC

Electrolytes

ESR

CT—head

LP—CSF analysis

■ 35 yo M presents with sudden severe headache, vomiting, confusion, left hemiplegia, and nuchal rigidity.

Subarachnoid hemorrhage

Migraine

Meningitis/encephalitis

Intracranial hemorrhage Vertebral artery dissection Intracranial venous thrombosis

Acute hypertension Intracranial neoplasm

Noncontrast CT—head

LP—CSF analysis

CBC

PT/PTT/INR

Urine toxicology

■ 25 yo M presents with high fever, severe headache, confusion, photophobia, and nuchal rigidity.

Meningitis

Migraine

Subarachnoid hemorrhage

Sinusitis/encephalitis

Intracranial or epidural abscess

CBC

CT—head

MRI—brain

LP—CSF analysis (cell count, protein, glucose, Gram stain, PCR for specific pathogens, culture)

■ 18 yo obese F presents with a pulsatile headache, vomiting, and blurred vision for the past 2-3 weeks. She is taking OCPs.

Pseudotumor cerebri

Tension headache

Migraine

Cluster headache

Meningitis

Intracranial venous

thrombosis

Intracranial neoplasm

Urine hCG

CBC

CT—head

LP—opening pressure and

CSF analysis

HEADACHE (cant'd)

Presentation

Differential

Workup

■ 57 yo M c/o daily pain in the right cheek for the past month. The pain is electric and stabbing in character and occurs while he is shaving. Each episode lasts 2-4 minutes.

Trigeminal neuralgia

Tension headache

Migraine

Cluster headache

TMJ disorder

Intracranial neoplasm

CBC

ESR

MRI—brain



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