Source: First Aid for the USMLE STEP 2 CS

Chest Pain
HPI: location, quality, severity, radiation, duration, context (exertion, postprandial, positional, cocaine use, trauma)
- assoc sx: sweating, nausea, dyspnea, palpitation)
- modifying factors: medication, exertion, position
- Hx of similar sx, known heart or lung disease, diagnostic testing
cardiac risk: HTN, hyperlipid, smoking, FHx)
PE risk: DVT, coagulopathy, malignancy, recent immobolization

PEx: Cardiovascular (JVP, PMI, chest wall tenderness, heart sounds, pulses, edema) + Lung + Abd exam

Typical Presentations DDx Workup
Sudden onset
Substernal heavy CP
Radiates to L arm
dyspnea, diaphoresis, nausea
MI
GERD
Angina
Costochondritis
Aortic dissection
Pericarditis
PE
ECG
CXR
CK-MB, troponin
CBC, electrolytes
Echocardiography
Cardiac catheterization
Retrosternal burning sensation
After heavy meals and when lying down
Sx relieved by antacids
GERD
Esophagitis
Peptic ulcer
Esophageal spasm
ECG
Barium swallow
Upper endoscopy

Retrosternal squeezing pain
Lasts for 2 min
Occurs w/ exercise
Relieved by rest and not related to food intake
Angina
Esophageal spasm
Esophagitis
ECG
CXR
CK-MB, troponin
CBC, electrolytes
Exercise stress test
Upper endoscopy
Retrosternal stabbing pain
Improves when leaning forward
Worsens w/ deep inspiration
Had URI 1 wk ago
Pericarditis
Aortic dissection
MI
Costochondritis
GERD
Esophagreal rupture
ECG
CXR, Chest CT
CK-MB, troponin
Echocardiography
CBC
Upper endoscopy
Stabbing pain
Worsens w/ deep inspiration
Relieved by aspirin
Had URI 1 wk ago
+ chest wall tenderness
Costochondritis
Pneumonia
MI
PE
Pericarditis
Muscle strain
ECG
CXR
CK-MB, tropnin
CBC
Acute onset of SOB at rest
Pleuritis CP
tachycardia, hypotension, tachypnea, mild fever
Long-term immobilization

PE
Pneumonia
Costochondritis
MI
CHF
Aortic dissection
ECG
CXR
ABG
Sudden onset of severe CP
Radiates to the back
Hx of uncontrolled HTN
Aortic dissection
MI
Pericarditis
Esophageal rupture
Pancreatitis
ECG
CK-MB, troponin
CXR, MRI
CBC, amylase, lipase
TEE (transesophagreal echocardiography)


Source: First Aid for the USMLE STEP 2 CS
SOB/Cough
HPI: Acute v.s. chronic, +/- sputum, timing
- assoc sx: constitutional, URI, postnasal drip, dyspnea, wheezing, CP, heartburn
- modifying factors: medication, exertion, position
- Hx of exposure, smoking, lung disease, allergies, medication (ACE inhibitors)

PEx: Nasal mucosa, oropharynx, heart, lungs, lymph nodes, extremities (clubbing, cyanosis, edema)

Typical Presentations DDx Workup
SOB/cough worsens by lying down
Improved by propping up on pillows
Exertional dyspnea
CHF
Cardiac valvular disease
GERD
COPD
CBC
CXR
ECG
Echocardiography
PFT (pulmonary function test)
SOB, cough, wheezing
Worsen in cold air
Several episodes in past few months
Asthma
GERD
Bronchitis
CBC
CXR
Peak flow meter
PFT
SOB, productive cough
Over past 2 yrs for at least 3 months each yr
Heavy smoker
COPD chronic bronchitis
Bronchiectasis
Lung cancer
TB
CBC
Sputum gram stain + culture, PPD skin test
CXR, CT
PFT
Productive cough (yellow sputum) w/ pleuritic CP
Fever, chills

Pneumonia
Bronchitis
Lung abscess
Lung cancer
TB
Pericarditis
CBC
Sputum gram stain + culture, PPD skin test
CXR, CT
ECG

Worsening cough over past 6 months
Hemoptysis, dyspnea, weakness, wt loss
Heavy smoker
Lung cancer
TB
Lung abscess
COPD
Vasculitis (Wegneners)
CBC
Sputum gram stain + culture, PPD skin test
CXR, CT
bronchoscopy
Increased dyspnea and cough w/ sputum
Hx of COPD and stopped using his inhalers

COPD exacerbation
Lung cancer
Pneumonia
URI
CHF
CBC
CXR, CT
PFTs
Sputum gram stain + culture
Worsening cough of 6 wk
Wt loss, fatigue, fever, night sweats
Hx of contact
TB
Pneumonia
Lung abscess
Vasculitis
Lymphoma
Metastatic cancer
HIV/AIDS
Sarcoidosis
CBC
Sputum gram stain + culture, acid-fast stain
PPD skin test
CXR, CT
Bronchoscopy
HIV Ab
Nonproductive cough for 2 wks
Hx of sore throat and runny nose 3 wks ago
Atypical pneumonia
Reactive airway disease
URI-associated
CBC
Sputum gram stain + culture
CXR
IgM detection for Mycoplasma pneumonia
Urine Legionella Ag


Source: First Aid for the USMLE STEP 2 CS
Headache (H/A)
HPI: location (unilat/bilat), quality, intensity, duration, timing
- assoc sx: neurologic (paresthesia, visual stigmata, weakness, numbness, ataxia, photophobia, dizziness, auras, neck stiffness),
nausea/vomiting, jaw claudication, recent trausma, dental surgery, sinusitis, sx
- modifying factors: stress, fatigue, menses, exercise, certain foods, rest, medications
- Hx of H/A, FHx of migraine

PEx: Head exam (inspection and palpation), ENT inspection, neurologic exam (including funduscopic exam)

Typical Presentations DDx Workup
Episodes of throbbing unilat temporal pain
Lasts 2-3 hrs
Sees flashes of lights and feels weakness and
numbness prior to H/A onset
Often w/ nausea and vomiting
FHx of migraine
Migraine
Tension H/A
Cluster H/A
Trigeminal Neuralgia
CNS vasculitis
CBC
ESR
CT head, MRI brain

Severe unilat temporal H/A
Ipsilateral rhinorrhea, eye tearing and redness
Occur same time every night and last for 45 min
Cluster H/A
Migraine
Tension H/A
Sinusitis
CBC
ESR
CT head, MRI brain
LP
Recurrent bilat squeezing H/A
3-4x/wk typically at the end of the work day
Experiencing significant stress
Tension H/A
Migraine
Depression
Caffeine withdrawal
Analgesic withdrawal
CBC, electrolytes
ESR
CT head
LP
Severe, intermittent unilat temporal H/A
Fever, blurred ipsilat vision
Pain in jaw when chewing
Temporal arteritis
Migraine
Cluster H/A
Tension H/A
Meningitis
CBC
ESR
CRP
Temporal artery biopsy
MRI brain
Frontal H/A
Fever, nasal discharge
Pain on palpitation of frontal & maxillary sinuses
Hx of sinusitis
Sinusitis
Migraine
Tension H/A
Meningitis
Intracranial neoplasm
CBC
XR sinus, CT sinus
LP
Daily pain (electric and stabbing) in unilat cheek
Pain when shaving/touching
Lasts 2-4 mins
Trigeminal Neuralgia
Tension H/A
Migraine
Cluster H/A
TMJ dysfunction
CBC
ESR
MRI brain
Severe H/A, confusion, photophobia, nuchal
rigidity, high fever
Meningitis
Migraine
Subarachnoid hemorrhage
Sinusitis/encephalitis
CBC
CT head, MRI brain
LP CSF analysis
Sudden severe H/A
Vomiting, confusion, hemiplegia, nuchal rigidity
Subarachnoid hemorrhage
Migraine
Meningitis/encephalitis
Intracranial hemorrhage
CT head w/o contrast, MRI brain
LP
CBC
PT/PTT


Source: First Aid for the USMLE STEP 2 CS
Abdominal Pain
HPI: location, quality, intensity, duration, radiation, timing (meals)
- assoc sx: constitutional, GI, cardiac, pulmonary, renal, pelvic, other
- modifying factors: w/ food, medication
- Hx of abd surgeries, gallstones, renal stones, atherosclerotic vascular disease, medication, alcohol, trauma/injury

PEx: Cardio, lung, abd (inspection, auscultation, percussion, palpation guarding, rebound, signs, CVA palpation), rectal, pelvic

Typical Presentations DDx Workup
Sudden onset of colicky unilat flank pain
Radiates to the pelvic region
Nausea, vomiting, hematuria
CVA tenderness
Nephrolithiasis
Renal cell carcinoma
Pyelonephritis
Other GI stuff (ex. appendicitis...)
UA
Urine culture and sensitivity
BUN/Cr
CT abd, US renal
Dull epigastric pain radiating to the back
Wt loss, dark urine, clay-colored stool
Heavy drinker and smoker
Pancreatic cancer
Acute viral hepatitis
Chronic pancreatitis
Cholecystitis/Choledocholithiasis
CBC, electrolytes, amylase, lipase,
AST/ALT/bilirubin/alkaline phosphatase
US abd, CT abd
Severe midepigastric abd pain
Radiates to the back
Improves when leaning forward
Anorexia, nausea, vomiting
Alcoholic
Acute pancreatitis
Peptic ulcer
Cholecystitis/Choledocholithiasis
Gastritis
Abd aortic aneurysm
CBC, electrolytes, BUN/Cr, amylase, lipase,
AST/ALT/bilirubin/alk phos
US abd, CT abd
Upper endoscopy
ECG
RUQ abd pain radiating to R scapula
Nausea, vomiting, mild fever
Pain starts after eating fatty food
+ Murphys sign
Acute cholecystitis
Hepatitis
Choledocholithiasis
Ascending Cholangitis
Peptic ulcer
CBC, AST/ALT/bilirubin/alk phos
US abd, HIDA scan
RUQ abd pain, fever, anorexia, nausea,
vomiting, dark urine, clay-colored stool
Acute hepatitis
Acute cholecystitis
Ascending cholangitis
Choledocholithiasis
Pancreatitis
CBC, amylast, lipase,
AST/ALT/bilirubin/alk phos
UA
Viral hepatitis serologies
US abd
Burning epigastric pain 2-3 hr after meals
Pain relieved by food and antacids
Peptic ulcer disease
Gastritis
GERD
Cholecystitis
Chronic pancreatitis
CBC, electrolytes, amylase, lipase, lactate,
AST/ALT/bilirubin/alk phos
XR abd, upright CXR
Endoscopy, H. pylori testing
Severe epigastric pain and appears toxic
Nausea, vomiting, mild fever
Hx of intermittent epigastric pain relieved
by food and antacids
Heavy smoking, takes NSAIDS regularly
Peptic ulcer perforation
Acute pancreatitis
Hepatitis
Cholecystitis
Cholecocholithiasis
CBC, electrolytes, amylase, lipase, lactate,
AST/ALT/bilirubin/alk phos
XR abd, upright CXR
Endoscopy, H. pylori testing
Crampy abd pain, vomiting, abd distention,
inability to pass flatus, or stool
Hx of multiple abd surgeries
Intestinal obstruction
SB or colon cancer
Vulvulus of the bowel
Gastroenteritis
CBC, electrolytes
XR abd, CT abd/pelvis, CXR
Acute onset of severe, crampy abd pain
Vomiting, massive dark bowel movement
Hx of CHF and A-fib (taking digitalis)
Pain is out of proportion to the exam!
Mesenteric ischemia/infarction
Diverticulitis
Peptic ulcer disease
Gastroenteritis
CBC, electrolytes, amylase, lipase, lactate
ECG, CK-MB, troponin
XR abd, CT abd
Mesenteric angiography, barium enema
LLQ abd pain, fever, chills for past 3 days
Recent alternating diarrhea & constipation
Low-fiver, high-fat diet
Diverticulitis
Crohns disease
Ulcerative colitis
Gastroenteritis
CBC, electrolytes
XR abd, CT abd

Source: First Aid for the USMLE STEP 2 CS
Severe sharp RLQ pain, nausea, vomiting
Started as vague periumbilical pain
McBurneys and psoas signs positive
Acute appendicitis
Gastroenteritis
Diverticulitis
Crohns disease
Nephrolithiasis
Intestinal obstruction
CBC, electrolytes
XR abd, CT abd, US abd
Periumbilical pain for months
Relieved by defecation worse when upset
Alternating constipation and diarrhea
NO nausea, vomiting, wt loss or anorexia
IBS (Irritable bowel syndrome)
Crohns disease
Celiac disease
Chronic pancreatitis
GI infection
Endometriosis
Stool exam and culture
Pelvic exam, urine hCG (for female)
CBC, electrolytes
CT abd/pelvis

Diffuse abd pain, watery diarrhea, wt loss
Has not responded to abx
Crohns disease
Gastroenteritis
Ulcerative colitis
Celiac disease
Hyperthyroidism
Stool exam and culture
CBC, electrolytes
TSH
CT abd, colonoscopy
SB series
Female w/ bilat lower abd pain that started
w/ the 1
st
day of menstrual period
Fever, thick green-yellow vaginal discharge.
Had unprotected sex w/ multiple partners
PID
Endometriosis
Dysmenorrheal
Vaginitis
Pelvic exam, cervical cultures
Urine hCG, UA/urine culture
CBC/ESR
US pelvis
Numbness/Weakness
HPI: distribution (unilat, bilat, proximal, distal), duration, +/- progressive, pain (H/A, neck, back pain)
- assoc sx: constitutional, neurologic sx
- modifying factors: improves/worsens w/ exertion
- Hx of DM, alcoholism, atherosclerotic vascular disease

PEx: Neurologic, musculoskeletal exams + relevant vascular exam

Typical Presentations DDx Workup
Sudden onset of slurred speech, unilat facial
drooping and numbness, unilat weakness
Sx resolve in <24 hrs
Hx of HTN, DM, heavy smoking
TIA
Hypoglycemia
Seizure
Stroke
Facial n. palsy
CBC, electrolytes, glucose,
ECG
CT head, MRI brain, Doppler US carotid
Echocardiography
EEG
Slurred speech, unilat facial drooping and
numbness, unilat weakness
+ Babinskis sign ipsilat
Hx of HTN, DM, heavy smoking
Stroke
TIA
Seizure
Intracranial neoplasm
Subdural, epidural hematoma
CBC, electrolytes
PT/PTT
CT head, MRI brain, Doppler US carotid
Echocardiography
Ascending loss of strength in lower legs
Recent URI
Guillain-Barre syndrome
MS
Polymyositis
Peripheral neuropathy
CBC, electrolytes, CK
LP-CSF analysis
MRI spine
EMG/nerve conduction study
Weakness, loss of sensation, tingling in unilat
leg, unilat eye pain, decr vision, double vision
Feeling electric shocks down the spine upon
flexing her head
MS
Stroke
CNS tumor
Neurosyphilis
CNS vasculitis
CBC, ESR
VDRL/RPR
MRI brain
LP-CSF analysis
Tingling and numbness in hands and feet
(glove-stoking distribution)
Hx of DM, HTN, alcoholism
Decr soft touch, vibratory, position sense
Diabetic peripheral neuropathy
B12 deficiency
Hypocalcemia
Hyperventilation
HbA1c, ESR, Calcium, Serum B12
Occasional double vision, droopy eyelids at
night w/ normalization by morning
Incr weakness w/ exertion
Myasthenia gravis
Horners syndrome
MS
Intracranial tumor
ALS
Tensilon test, EMG
Ach receptor Ab
CXR, CT chest, MRI brain


Source: First Aid for the USMLE STEP 2 CS
Joint/Limb Pain
HPI: Location, quality, intensity, duration, pattern (small v.s. large, number, swelling, redness, warmth)
- assoc sx: constitutional, red eye, oral or genital ulceration, diarrhea, dysuria, rash, focal numbness/weakness
- modifying factors: better/worse in the morning, improves/worsens w/ movement
- Hx of trauma, vigorous exercise, medication, alcohol/drug use, FHx of rheumatic disease

PEx: HEENT, musculoskeletal exams, relevant neurovascular exam

Typical Presentations DDx Workup
Pain in metacarpophalangreal joints of bilat
hands, painful and swollen knee joint
Morning joint stiffness that lasts for ~ 1 hr
Mother had rheumatoid arthritis
Rheumatoid arthritis
SLE
Disseminated gonorrhea
Osteoarthritis
ANA, anti-DNA, ESR, RF, CBC
XR hands
Cervical culture
Arthrocentesis synoivial fluid analysis
Pain in the interphalangreal joints of bilat
hands, hair loss, butterfly rash on face
SLE
Rheumatoid arthritis
Psoriatic arthritis
Parvovirus B19 infection
ANA, anti-dsDNA, ESR, RF, CBC
XR hands
UA
Knee stiffness and pain (incr w/ movement)
Sx gradually worsened over past few yrs
Now w/ swelling and deformity of the joint
and is having difficulty walking
Osteoarthritis
Pseudogout
Gout
Meniscal or ligament damage
XR knee
CBC, ESR
Arthrocentesis synovial fluid analysis
MRI knee
Knee/other joint pain w/ swelling & redness Septic arthritis
Gout
Pseudogout
Lyme arthritis
Trauma
Reiters arthritis
CBC
Arthrocentesis synovial fluid analysis
Blood, urethral cultures
XR knee
Uric acid
Lyme Ab
Painful wrists and elbows, swollen and hot
knee joint that is painful on flexion, rash on
limbs, vaginal discharge
Sexually active w/ multiple partners
Disseminated gonorrhea
Rheumatoid arthritis
SLE
Psoriatic arthritis
Reiters arthritis
Arthrocentesis synovial fluid analysis
ANA, anti-dsDNA, ESR, RF, CBC
Blood, cervical cultures
XR knee
Crampy bilateral thigh and calf pain, fatigue,
dark urine (cola-colored)
Taking simvastatin and clofibrate
Rhabdomyolysis (due to meds)
Polymyositis
Inclusion body myositis
Thyroid disease
CBC, CK, Aldolase
UA, urine myoglobin
TSH

Dizziness
HPI: Lightheadedness v.s. vertigo, +/- auditory sx (hearing loss, tinnitus), duration of episodes, context (position, after trauma)
- assoc sx: visual disturbance, URI, nausea, neck pain
- modifying factors: position, improves/worsens w/ movement
- Hx of trauma, medication, atherosclerotic vascular disease

PEx: Complete neurologic exam (Romberg test, nystagmus, tilt test, gait, hearing, Weber and Rinne), HEEN, cardiovascular

Typical Presentations DDx Workup
Intermittent episodes of vertigo, tinnitus,
nausea, hearing loss
Menieres disease
Vestibular neuronitis
Labyrinthitis
Benign positional vertigo
Acoustic neuroma
CBC
VDRL/RPR (syphilis)
MRI brain
Dizziness on moving head to one side
Lasts sec to mins
Room-spinning/vertigo
Tilt test -> nystagmus and nausea
BPPV (benign paroxysmal
positional vertigo)
Vestibular neuronitis
Labyrinthitis
Menieres disease
MRI brain
Hearing test