First Aid for the USMLE Step 2 CS

Section 3. Minicases

Fatigue And Sleepiness

Key History

Duration; sleep hygiene, snoring, waking up choking/gasping, witnessed apnea; overexertion; stress, depression, or other emotional problems; lifestyle changes, shift changes at work; diet, weight changes; other constitutional symptoms; symptoms of thyroid disease; history of bleeding or anemia; medications; alcohol, caffeine, and drug use.

Key Physical Exam

Vital signs; ENT exam (conjunctival pallor, oropharynx/palate, lymphadenopathy, thyroid exam); heart, lung, abdominal, neurologic, and extremity (pallor, coolness at distal extremities) exams; consider rectal exam and occult blood testing.

Presentation

Differential

Workup

■ 40 yo F c/o feeling tired, hopeless, and worthless and of having suicidal thoughts. She lost her job and has been having fights with her husband about money.

Depression

Adjustment disorder Hypothyroidism Anemia

CBC

TSH

HIV/STD testing

Beck Depression

Inventory

FATIGUE AND SLEEPINESS (cont'd)

Presentation

Differential

Workup

■ 44 yo M presents with fatigue, insomnia, and nightmares about a murder that he witnessed in a mall 1 year ago. Since then, he has avoided the mall and has not gone out at night.

Posttraumatic stress disorder

Depression

Generalized anxiety disorder

Psychotic or delusional disorder

Hypothyroidism

CBC

TSH

Urine toxicology Beck Depression Inventory

■ 55 yo M presents with fatigue, weight loss, and constipation. He has a family history of colon cancer.

Colon cancer

Hypothyroidism Renal failure Hypercalcemia Depression

Rectal exam, stool for occult blood CBC

Electrolytes, BUN/Cr, calcium AST/ALT TSH

Colonoscopy Barium enema CT—abdomen/pelvis

■ 40 yo F presents with fatigue, weight gain, sleepiness, cold intolerance, constipation, and dry skin.

Hypothyroidism

Depression

Diabetes

Anemia

TSH, FT3, FTCBC

Fasting glucose HbA

1c

■ 50 yo obese F presents with fatigue and daytime sleepiness. She snores heavily and naps 3-4 times per day but never feels refreshed. She also has hypertension.

Obstructive sleep apnea

Hypothyroidism Chronic fatigue syndrome Narcolepsy

CBC

TSH

Nocturnal pulse oximetry Polysomnography

ECG

■ 20 yo M presents with fatigue, thirst, increased appetite, and polyuria.

Diabetes mellitus

Atypical depression Primary polydipsia Diabetes insipidus

Glucose tolerance test HbA,

1c

UA

CBC

Electrolytes, BUN/Cr, glucose

■ 35 yo M policeman c/o feeling tired and sleepy during the day. He changed to the night shift last week.

Shift work sleep disorder

Sleep apnea

Depression

Anemia

CBC

Nocturnal pulse oximetry Polysomnography

 

Night Sweats

Key History

Onset, duration, severity, frequency, timing, patterns (escalating, waxing, waning), precipitants (eg, food, medications); associated diseases and symptoms (fever, recent URIs, associated cough, hemoptysis, pleuritic chest pain); lymphadenopathy, rash, malaise, weight loss, itching, diarrhea, nausea/vomiting, early satiety, anorexia; presence of significant risk factors (eg, traveling to areas with endemic infections, IV drug use); alcohol history, sexual exposure, sick contacts, exposure to high-risk populations such as prisoners or homeless people; menstrual history, menopausal status, travel history.

Key Physical Exam

Vital signs; HEENT exam, including inspection of the throat and other areas for lymphadenopathy; heart and lung exam; abdominal exam for hepatosplenomegaly; skin exam; musculoskeletal exam for joint pain.

Presentation

Differential

Workup

■ 30 yo M presents with night sweats, cough, and swollen glands of 1 month’s duration. He recently emigrated from the African subcontinent.

Tuberculosis

Acute HIV infection

Lymphoma

Leukemia

Hyperthyroidism

PPD/QuantiFERON

Gold

CBC

CXR

Sputum Gram stain, acidfast stain, and culture

HIV antibody

TSH, ft4

■ 45 yo F presents with excessive sweating, unintentional weight loss, palpitations, diarrhea, and shortness of breath.

Hyperthyroidism

Pheochromocytoma

Carcinoid syndrome Tuberculosis

TSH, FT24-hour urinary catecholamines

5-HIAA

CBC

PPD

 


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