First Aid for the USMLE Step 2 CS

Section 3. Minicases

Palpitations

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

 

Weight Loss

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



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