First Aid for the USMLE Step 2 CS

Section 3. Minicases

Confusion/Memory Loss

Key History

Must include history from family members/caregivers when available. Detailed time course of cognitive deficits (acute vs. chronic/gradual onset); associated symptoms (constitutional, incontinence, ataxia, hypothyroid symptoms, depression); screen for delirium (waxing/waning level of alertness); falls, medications (and recent medication changes); history of stroke or other atherosclerotic vascular disease, syphilis, HIV risk factors, alcohol use, or vitamin B12 deficiency; family history of Alzheimer’s disease or other neurologic disorders.

Key Physical Exam

Vital signs; complete neurologic exam, including mini-mental status exam and gait; general physical exam, including ENT, heart, lungs, abdomen, and extremities.

   

Presentation

Differential

Workup

 

■ 81 yo M presents with progressive confusion for the past several years accompanied by forgetfulness and clumsiness. He has a history of hypertension, diabetes mellitus, and 2 strokes with residual left hemiparesis. His mental status has worsened after each stroke (stepwise decline in cognitive function).

Vascular (“multiinfarct”) dementia

Alzheimer’s disease

Normal pressure hydrocephalus

Chronic subdural hematoma

Intracranial neoplasm

Depression

B12 deficiency

Neurosyphilis

Hypothyroidism

CBC

VDRL/RPR

Serum B12

TSH

MRI—brain

CT—head

LP—CSF analysis

 

CONFUSION/MEMORY LOSS (cant'd)

 

Presentation

Differential

Workup

 

■ 84 yo F brought by her son c/o forgetfulness (eg, forgets phone numbers, loses her way back home) and difficulty performing some of her daily activities (eg, bathing, dressing, managing money, using the phone). The problem has progressed gradually over the past few years.

Alzheimer’s disease

Vascular dementia

Depression

Hypothyroidism

Chronic subdural

hematoma

Normal pressure

hydrocephalus

Intracranial neoplasm

B deficiency

Neurosyphilis

CBC

VDRL/RPR

Serum B12

TSH

MRI—brain (preferred)

CT—head

LP—CSF analysis

 
 
 
 
 
 
 

■ 72 yo M presents with memory loss, gait disturbance, and urinary incontinence for the past 6 months.

Normal pressure hydrocephalus

Alzheimer’s disease

Vascular dementia

Chronic subdural

hematoma

Intracranial neoplasm

Depression

B12 deficiency

Neurosyphilis

Hypothyroidism

CT—head

MRI—brain

LP—opening pressure and

CSF analysis

Serum B

VDRL/RPR

TSH

 
 
 
 
 
 
 

■ 55 yo M presents with a rapidly progressive change in mental status, inability to concentrate, and memory impairment for the past 2 months. His symptoms are associated with myoclonus, ataxia, and a startle response.

Creutzfeldt-Jakob disease

Vascular dementia

Lewy body dementia

Wernicke’s

encephalopathy

Normal pressure

hydrocephalus

Chronic subdural

hematoma

Intracranial neoplasm

Depression

Delirium

B12 deficiency

Neurosyphilis

CBC

Electrolytes, calcium

Serum B12

VDRL/RPR

MRI—brain (preferred)

CT—head

EEG

LP—CSF analysis

Brain biopsy

 
 
 
 
 
 
 
 
 

CONFUSION/MEMORY LOSS (cant'd)

 

Presentation

Differential

Workup

 

■ 70 yo insulin-dependent diabetic M presents with episodes of confusion, dizziness, palpitations, diaphoresis, and weakness.

Hypoglycemia

Transient ischemic attack

Arrhythmia

Delirium

Angina

Glucose

CBC

Electrolytes

CPK-MB, troponin

Echocardiography

ECG

MRI—brain

Doppler U/S—carotid

 

■ 55 yo F presents with gradual altered mental status and headache. Two weeks ago she slipped, hit her head on the ground, and lost consciousness for 2 minutes.

Subdural hematoma

SIADH (causing

hyponatremia)

Creutzfeldt-Jakob disease

Intracranial neoplasm

CT—head

CBC

Electrolytes

MRI—brain

LP—CSF analysis

 



Loss Of Vision

Key History

Acute vs. chronic, progression, ability to see light; associated symptoms (eye pain, discharge, itching, tearing, photophobia, redness, headache, weakness, numbness, floaters, sparks); history of cardiac, rheumatic, thrombotic, autoimmune, or neurologic disorders; jaw claudication, medications, trauma.

Key Physical Exam

Vital signs; cardiovascular, HEENT, funduscopic, and neurologic exams.

Presentation

Differential

Workup

■ 73 yo M presents with acute loss of vision in his left eye, palpitations, and shortness of breath. He has a history of atrial fibrillation and cataracts in his right eye. He has no eye pain, discharge, redness, or photophobia. He has not experienced headache, weakness, or numbness.

Retinal artery occlusion

Retinal vein occlusion

Acute angle-closure

glaucoma

Retinal detachment

Temporal arteritis (giant cell arteritis)

Fluorescein angiogram Echocardiography

Doppler U/S—carotid

Intraocular tonometry ESR

Temporal artery biopsy CBC



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