Emergency Planning And Community Right to Know Act (EPCRA)

4 Provisions of EPCRA
1. Emergency Planning
2. Emergency Release Notification
3. Community Right-to-Know Requirements
4. Toxic Release Inventory

EPCRA was enacted on what date?
November 1986

Federal Register 40 Parts
300
350
355
370
372
– National Oil and Hazardous Substances Pollution Contingency Plan
– Trade Secrecy Claims for Emergency Planning and Community Right-to-Know Information: and Trade Secret Disclosure to Health Professionals
– Emergency Planning and Notification
– Hazardous Chemical Reporting: Community Rights-to-Know
– Toxic Chemical Release Reporting: Community Right-to-know

Materials Covered by EPCRA
1. Extremely Hazardous Substances (HRA)
2. CERCLA Hazardous Substance
3. Hazardous Chemicals
4. Toxic Chemicals
– any chemical that has immediate health effects.
– defined in sections 101 and 102 as any element, compound, mixture, solution, and substance which, when released into environment may present substantial danger to the public health, public welfare, or the environment.
– are designated as a physical or health hazard by the OSHA
– any chemical that may cause severe illness, birth defects, disease, or death and poses an environmental hazard.

1.EMERGENCY PLANNING
– First Funciton of EPCRA
– Includes Emergency response plans (Sect. 301-303)
– State governors established State Emergency Response Commission ( SERC)

2.Emergency Release Notification
– involving transportation incidents can be met by dialing 911, or in the absence of a 911 emergency number, calling the operator.
– Any known or anticipated acute or chronic health risks associated with the emergency and, where necessary, advice regarding medical attention for exposed individuals one of the emergency notification requirement.
– Failure to comply SERC and LEPC can result up to $75,000 fine per day.

3. Community Right To Know Requirements
– Under OSHA, employers must maintain a material safety data sheet (MSDS) for any hazardous chemicals stored or used in the work place
– Approximately hat have 500,000 products have MSDS
– Section 311 requires facilities that has MSDSs for chemicals held above certain quantities to submit either copies pf their MSDSs or a list of MSDS chemicals to the SERC, LEPC, and local fire department
– Under EPCRA Section 312 facilities that need to submit MSDSs or chemical lists under Section 311 also need to submit an annual inventory report for the same chemicals.

4. Toxic Release Inventory ( TRI)
– EPCRA Section 313 requires certain facilities to complete a toxic chemical release inventory form annually for specified chemical.
– the for must be submitted to EPA and the state on July 1st.

Determine The Source
– gather information from personnel working with the chemical
– gather information from container markings
– gather information from MSDSs
– use direct reading materials like HAZMATID
– determine extent of damage possible to humans and environment

Determine the Pathway
– Determine physical nature of chemical
– Determine Transportation mechanisms

Determine the Receiver
– Determine location of population centers in the area
– Determine the ability of the chemical to reach population centers
– Determine sensitive flora and fauna in the area and ability of the chemical to reach them.

BE responsibilities under EPCRA
– Supports hazard identification, vulnerability analysis, capability assessment, Risk management for responses
– Identifies types and amount of HAZMAT
– provides technical assistance on evacuation planning and in place sheltering to minimize adverse health and environmental impact
– Also, collects, prepares, arranges for transport, analyzes, and interprets result of environment sample to support HAZMAT.
– provides oversight and technical consultation
– Oversees worker and environmental protection
– Assists the Commander in Identifying Hazmat releases.

Rapid Review Pharmacology

Absence seizures
Ethosuximide

Acute gout attack
NSAIDs, colchicine, glucocorticoids

Acute promyelocytic leukemia (M3)
All-trans retinoic acid

ADHD
Methylphenidate, CBT, atomoxetine

Alcoholism
Disulfiram, acamprosate, naltrexone, supportive care

Alcohol withdrawal
Long-acting benzodiazepines

Anorexia
Nutrition, psychotherapy, mirtazapine

Anticoagulation during pregnancy
Heparin

Arrhythmia in damaged cardiac tissue
Class IB antiarrhythmic (lidocaine, mexiletine)

B12 deficiency
Vitamin B12 supplementation (work up cause with Schilling test)

Benign prostatic hyperplasia
α1-antagonists, 5α-reductase inhibitors, PDE-5 inhibitors

Bipolar disorder
Mood stabilizers (e.g., lithium, valproic acid, carbamazepine), atypical antipsychotics

Breast cancer in postmenopausal woman
Aromatase inhibitor (anastrozole)

Buerger disease
Smoking cessation

Bulimia nervosa
SSRIs

Candida albicans
Topical azoles (vaginitis); nystatin, fluconazole, caspofungin (oral/esophageal); fluconazole, caspofungin, amphotericin B (systemic)

Carcinoid syndrome
Octreotide

Chlamydia trachomatis
Doxycycline (+ ceftriaxone for gonorrhea coinfection),
erythromycin eye drops (prophylaxis in infants)

Chronic gout
Xanthine oxidase inhibitors (e.g., allopurinol, febuxostat)

Chronic hepatitis B or C
IFN-α (HBV and HCV); ribavirin, simeprevir, sofosbuvir
(HCV)

Chronic myelogenous leukemia
Imatinib

Clostridium botulinum
Antitoxin

Clostridium difficile
Oral metronidazole; if refractory, oral vancomycin

Clostridium tetani
Antitoxin

CMV
Ganciclovir, foscarnet, cidofovir

Crohn disease
Corticosteroids, infliximab, azathioprine

Cryptococcus neoformans
Fluconazole (in AIDS patients)

Cyclophosphamide-induced hemorrhagic cystitis
Mesna

Depression
SSRIs (first-line)

Diabetes insipidus
Desmopressin (central); hydrochlorothiazide, indomethacin, amiloride (nephrogenic)

Diabetes mellitus type 1
Dietary intervention (low carbohydrate) + insulin replacement

Diabetes mellitus type 2
Dietary intervention, oral hypoglycemics, and insulin (if
refractory)

Diabetic ketoacidosis
Fluids, insulin, K+

Enterococci
Vancomycin, aminopenicillins/cephalosporins

Erectile dysfunction
Sildenafil, tadalafil, vardenafil

ER ⊕ breast cancer
Tamoxifen

Ethylene glycol/methanol intoxication
Fomepizole (alcohol dehydrogenase inhibitor)

Haemophilus influenzae (B)
Rifampin (prophylaxis)

Generalized anxiety disorder
SSRIs, SNRIs (first line); buspirone (second line)

Granulomatosis with polyangiitis (Wegener)
Cyclophosphamide, corticosteroids

Heparin reversal
Protamine sulfate

HER2/neu ⊕ breast cancer
Trastuzumab

Hyperaldosteronism
Spironolactone

Hypercholesterolemia
Statin (first-line)

Hypertriglyceridemia
Fibrate

Immediate anticoagulation
Heparin

Infertility
Leuprolide, GnRH (pulsatile), clomiphene

Influenza
Oseltamivir, zanamivir

Kawasaki disease
IVIG, high-dose aspirin

Legionella pneumophila
Macrolides (e.g., azithromycin)

Long-term anticoagulation
Warfarin, dabigatran, rivaroxaban and apixaban

Malaria
Chloroquine, mefloquine, atovaquone/proguanil (for blood schizont), primaquine (for liver hypnozoite)

Malignant hyperthermia
Dantrolene

Medical abortion
Mifepristone

Migraine
Abortive therapies (e.g., sumatriptan, NSAIDs); prophylaxis (e.g., propranolol, topiramate, CCBs, amitriptyline)

Multiple sclerosis
Disease-modifying therapies (e.g., β-interferon, natalizumab); for acute flares, use IV steroids

Mycobacterium tuberculosis
RIPE (rifampin, isoniazid, pyrazinamide, ethambutol)

Neisseria gonorrhoeae
Ceftriaxone (add doxycycline to cover likely concurrent
C. trachomatis)

Neisseria meningitidis
Penicillin/ceftriaxone, rifampin (prophylaxis)

Neural tube defect prevention
Prenatal folic acid

Osteomalacia/rickets
Vitamin D supplementation

Osteoporosis
Calcium/vitamin D supplementation (prophylaxis);
bisphosphonates, PTH analogs, SERMs, calcitonin,
denosumab (treatment)

Patent ductus arteriosus
Close with indomethacin; open or maintain with PGE
analogs

Pheochromocytoma
α-antagonists (e.g., phenoxybenzamine)

Pneumocystis jirovecii
TMP-SMX (prophylaxis in AIDS patient)

Prolactinoma
Cabergoline/bromocriptine (dopamine agonists)

Prostate adenocarcinoma/uterine fibroids
Leuprolide, GnRH (continuous)

Prostate adenocarcinoma
Flutamide

Pseudomonas aeruginosa
Antipseudomonal penicillins, aminoglycosides, carbapenems

Pulmonary arterial hypertension (idiopathic)
Sildenafil, bosentan, epoprostenol

Rickettsia rickettsii
Doxycycline, chloramphenicol

Schizophrenia (negative symptoms)
Atypical antipsychotics

Schizophrenia (positive symptoms)
Typical and atypical antipsychotics

SIADH
Fluid restriction, IV hypertonic saline, conivaptan/tolvaptan, demeclocycline

Sickle cell disease
Hydroxyurea (inc fetal hemoglobin)

Sporothrix schenckii
Itraconazole, oral potassium iodide

Stable angina
Sublingual nitroglycerin

Staphylococcus aureus
MSSA: nafcillin, oxacillin, dicloxacillin (antistaphylococcal penicillins); MRSA: vancomycin, daptomycin, linezolid, ceftaroline

Streptococcus bovis
Penicillin prophylaxis; evaluation for colon cancer if linked to endocarditis

Streptococcus pneumoniae
Penicillin/cephalosporin (systemic infection, pneumonia),
vancomycin (meningitis)

Streptococcus pyogenes
Penicillin prophylaxis

Temporal arteritis
High-dose steroids

Tonic-clonic seizures
Levetiracetam, phenytoin, valproate, carbamazepine

Toxoplasma gondii
Sulfadiazine + pyrimethamine

Treponema pallidum
Penicillin

Trichomonas vaginalis
Metronidazole (patient and partner)

Trigeminal neuralgia (tic douloureux)
Carbamazepine

Ulcerative colitis
5-ASA preparations (e.g., mesalamine), 6-mercaptopurine, infliximab, colectomy

UTI prophylaxis
TMP-SMX

Warfarin reversal
Fresh frozen plasma (acute), vitamin K (chronic)

USMLE Step 2 CS Minicases

21 yo F presents with several episodes of
throbbing left temporal pain that lasts
for 2-3 hours. Prior to its onset, she sees
fl ashes of light in her right visual fi eld
and feels weakness and numbness on the
right side of her body for a few minutes.
Headaches are often associated with
nausea and vomiting. She has a family
history of migraine.
Migraine (complicated)
Tension headache
Cluster headache
Pseudotumor cerebri
Trigeminal neuralgia
CNS vasculitis
Partial seizure
Intracranial neoplasm

CBC
ESR
CT—head
MRI—brain
LP

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
Sinusitis
Pseudotumor cerebri
Trigeminal neuralgia
Intracranial neoplasm

CBC
ESR
CT—head
MRI—brain
LP

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

CBC
ESR
CRP
Temporal artery biopsy
Doppler U/S—carotid
MRI—brain

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 sinusitis.
Sinusitis
Migraine
Tension headache
Meningitis
Intracranial neoplasm

CBC
XR—sinus
CT—sinus
LP

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 signifi cant stress in her life.
Tension headache
Migraine
Depression
Caffeine or analgesic
withdrawal
Hypertension
Cluster headache
Pseudotumor cerebri
Intracranial neoplasm

CBC
Electrolytes
ESR
CT—head
LP

35 yo M presents with sudden severe
headache, vomiting, confusion, left
hemiplegia, and nuchal rigidity.
DDX:
1 – Subarachnoid hemorrhage
2 – Migraine
3 – Meningitis/encephalitis
4 – Intracranial hemorrhage
5 – Intracranial neoplasm, vertebral a. dissection, intracranial venous thrombosis, acute htn

W/U:
1 – CBC, PT/PTT, CT head w/o contrast, MRI/MRA brain
3 – LP

25 yo M presents with high fever, severe
headache, confusion, photophobia, and
nuchal rigidity. Kernig’s and Brudzinski’s
signs are positive.
Meningitis
Migraine
Subarachnoid hemorrhage
Sinusitis/encephalitis
Intracranial or epidural abscess

W/U:
CBC
CT—head
MRI—brain
LP—CSF analysis (cell count,
protein, glucose, Gram stain,
PCR for antigens, 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

W/U:
Urine hCG
CBC
CT—head
LP—opening pressure and CSF
analysis

57 yo M c/o daily pain in the right cheek
over 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 dysfunction
Intracranial neoplasm

W/U:
CBC
ESR
MRI—brain

81 yo M presents with progressive
confusion over the past several
years together with forgetfulness
and clumsiness. He has a history of
hypertension, diabetes mellitus, and two
strokes with residual left hemiparesis. His
mental status has clearly worsened after
each stroke (stepwise decline in cognitive
function).
Vascular (“multi-infarct”)
dementia
Alzheimer’s disease
Normal pressure hydrocephalus
Chronic subdural hematoma
Intracranial tumor
Depression
B12 defi ciency
Neurosyphilis
Hypothyroidism

W/U:
CBC
VDRL/RPR
Serum B12
TSH
MRI—brain
CT—head
LP—CSF analysis (rare)

84 yo F brought by her son c/o
forgetfulness (e.g., forgets phone
numbers, loses her way back home) along
with diffi culty performing some of her
daily activities (e.g., bathing, dressing,
managing money, using the phone). The
problem has gradually progressed over
the past few years.
Alzheimer’s disease
Vascular dementia
Depression
Hypothyroidism
Chronic subdural hematoma
Normal pressure hydrocephalus
Intracranial neoplasm
B12 defi ciency
Neurosyphilis

W/U:
CBC
VDRL/RPR
Serum B12
TSH
MRI—brain (preferred)
CT—head
LP—CSF analysis (rare)

72 yo M presents with memory loss, gait
disturbance, and urinary incontinence for
the past six months.
Normal pressure
hydrocephalus
Alzheimer’s disease
Vascular dementia
Chronic subdural hematoma
Intracranial neoplasm
Depression
B12 defi ciency
Neurosyphilis
Hypothyroidism

W/U:
CT—head
LP—opening pressure and CSF
analysis
Serum B12
VDRL/RPR
TSH

55 yo M presents with a rapidly
progressive change in mental status,
inability to concentrate, and memory
impairment for the past two months. His
symptoms are associated with myoclonus
and ataxia.
Creutzfeldt-Jakob disease
Vascular dementia
Lewy body dementia
Wernicke’s encephalopathy
Normal pressure hydrocephalus
Chronic subdural hematoma
Intracranial neoplasm
Depression
Delirium
B12 defi ciency
Neurosyphilis

W/U:
CBC, electrolytes, calcium
Serum B12
VDRL/RPR
MRI—brain (preferred)
CT—head
EEG
LP—CSF analysis
Brain biopsy

70 yo insulin-dependent diabetic M
presents with episodes of confusion,
dizziness, palpitation, diaphoresis, and
weakness.
Hypoglycemia
Transient ischemic attack
Arrhythmia
Delirium
Angina

W/U:
Glucose
CBC, electrolytes
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 two
minutes.
Subdural hematoma
SIADH (causing hyponatremia)
Creutzfeldt-Jakob disease
Intracranial neoplasm

W/U:
Electrolytes
CT—head
MRI—brain
LP

68 yo M presents with a two-month
history of crying spells, excessive sleep,
poor hygiene, and a 7-kg weight loss, all
following his wife’s death. He cannot
enjoy time with his grandchildren
and reluctantly admits to thinking he
has seen his dead wife in line at the
supermarket or standing in the kitchen
making dinner.
Normal bereavement
Adjustment disorder with
depressed mood
Major depressive disorder with
psychotic features
Schizoaffective disorder
Depressive disorder not
otherwise specifi ed (NOS)

W/U:
Physical exam
Mental status exam
TSH
CBC
Urine toxicology

42 yo F presents with a four-week history
of excessive fatigue, insomnia, and
anhedonia. She states that she thinks
constantly about death. She has suffered
fi ve similar episodes in the past, the fi rst
in her 20s, and has made two previous
suicide attempts. She further admits to
increased alcohol use in the past month.
Major depressive disorder
Substance-induced mood
disorder
Dysthymic disorder

W/U:
Physical exam
Mental status exam
Blood alcohol level
TSH
CBC
Urine toxicology

26 yo F presents with a 3-kg weight loss
over the past two months, accompanied
by early-morning awakening, excessive
guilt, and psychomotor retardation.
She does not identify a trigger for the
depressive episode but reports several
weeks of increased energy, sexual
promiscuity, irresponsible spending,
and racing thoughts approximately six
months before her presentation.
Bipolar I disorder
Bipolar II disorder
Cyclothymic disorder
Major depressive disorder
Schizoaffective disorder

W/U:
Physical exam
Mental status exam
Urine toxicology

19 yo M c/o receiving messages from
his television set. He reports that he
did not have many friends in high
school. In college, he started to suspect
his roommate of bugging the phone.
In the same time frame, he stopped
going to classes because he felt that his
professors were saying horrible things
about him that no one else noticed. He
rarely showered or left his room and
has recently been hearing a voice from
his television set telling him to “guard
against the evil empire.”
Schizophrenia
Schizoid or schizotypal
personality disorder
Schizophreniform disorder
Psychotic disorder due to a
general medical condition
Substance-induced psychosis
Depression with psychotic
features

W/U:
Mental status exam
Urine toxicology
TSH
CBC
Electrolytes

28 yo F c/o seeing bugs crawling on her
bed over the past two days and reports
hearing loud voices when she is alone
in her room. She has never experienced
symptoms such as these in the past. She
recently ingested an unknown substance.
Substance-induced psychosis
Brief psychotic disorder
Schizophreniform disorder
Schizophrenia
Psychotic disorder due to a
general medical condition

W/U:
Urine toxicology
Mental status exam
TSH
CBC
Electrolytes, BUN/Cr, AST/
ALT

48 yo F presents with a one-week history
of auditory hallucinations, stating, “I am
worthless” and “I should kill myself.” She
also reports a two-week history of weight
loss, early-morning awakening, decreased
motivation, and overwhelming feelings
of guilt.
Schizoaffective disorder
Mood disorder with psychotic
features
Schizophrenia
Schizophreniform disorder
Psychotic disorder due to a
general medical condition

W/U:
Mental status exam
Beck Depression Inventory
TSH
CBC
Electrolytes

35 yo F presents with intermittent
episodes of vertigo, tinnitus, nausea, and
hearing loss over the past week.
Ménière’s disease
Vestibular neuronitis
Labyrinthitis
Benign positional vertigo
Acoustic neuroma

W/U:
CBC
VDRL/RPR (syphilis is a cause
of Ménière’s disease)
MRI—brain

55 yo F c/o dizziness for the past day.
She feels faint and has severe diarrhea
that started two days ago. She takes
furosemide for her hypertension.
Orthostatic hypotension due
to dehydration (diarrhea,
diuretic use)
Vestibular neuronitis
Labyrinthitis
Benign positional vertigo
Vertebrobasilar insuffi ciency

W/U:
Orthostatic vital signs
CBC
Electrolytes
Stool exam (occult blood, fecal
leukocytes

65 yo M presents with postural dizziness
and unsteadiness. He has hypertension
and was started on hydrochlorothiazide
two days ago.
Drug-induced orthostatic
hypotension
Vestibular neuronitis
Labyrinthitis
Benign positional vertigo
Brain stem or cerebellar tumor
Acute renal failure

W/U:
Orthostatic vital signs
CBC
Electrolytes
BUN/Cr
MRI—brain

44 yo F c/o dizziness on moving her
head to the left. She feels that the room
is spinning around her head. Tilt test
results in nystagmus and nausea.
Benign positional vertigo
Vestibular neuronitis
Labyrinthitis
Ménière’s disease

W/U:
MRI—brain
Audiogram

55 yo F c/o dizziness that started this
morning. She is nauseated and has
vomited once in the past day. She had a
URI two days ago and has experienced
no hearing loss.
Vestibular neuronitis
Labyrinthitis
Ménière’s disease
Benign positional vertigo
Vertigo associated with cervical
spine disease/injury
Vertebrobasilar insufficiency

W/U:
CBC
Electrolytes
Electronystagmography
MRI/MRA—brain

55 yo F c/o dizziness that started this
morning and of “not hearing well.” She
feels nauseated and has vomited once in
the past day. She had a URI two days ago.
Labyrinthitis
Vestibular neuronitis
Ménière’s disease
Acoustic neuroma
Vertebrobasilar insuffi ciency

W/U:
Audiogram
Electronystagmography
MRI/MRA—brain

26 yo M presents after falling and losing
consciousness at work. He had rhythmic
movements of the limbs, bit his tongue,
and lost control of his bladder. He was
subsequently confused (as witnessed by
his colleagues).
Seizure, grand mal (now called
complex tonic-clonic seizure)
Convulsive syncope
Substance abuse/overdose
Malingering
Hypoglycemia

W/U:
CBC, electrolytes, glucose
Urine toxicology
EEG
MRI—brain
CT—head
LP—CSF analysis
ECG

55 yo M c/o falling after feeling dizzy
and unsteady. He experienced transient
LOC. He has hypertension and is on
numerous antihypertensive drugs.
Drug-induced orthostatic
hypotension (causing
syncope)
Cardiac arrhythmia
Syncope (vasovagal, other
causes)
Stroke
MI
Pulmonary embolism

W/U:
Orthostatic vital signs
CBC
Electrolytes
CT—head
ECG
V/Q scan
CT—chest with IV contrast

65 yo M presents after falling and losing
consciousness for a few seconds. He
had no warning prior to passing out but
recently had palpitations. His past history
includes coronary artery bypass grafting
(CABG).
Cardiac arrhythmia (causing
syncope)
Severe aortic stenosis
Syncope (other causes)
Seizure
Pulmonary embolism

W/U:
ECG
Holter monitoring
CBC, electrolytes
Glucose
Echocardiography
CT—head

68 yo M presents following a 20-minute
episode of slurred speech, right facial
drooping and numbness, and right hand
weakness. His symptoms had totally
resolved by the time he got to the ER.
He has a history of hypertension, diabetes
mellitus, and heavy smoking.
Transient ischemic attack
(TIA)
Hypoglycemia
Seizure
Stroke
Facial nerve palsy

W/U:
CBC
Glucose
Electrolytes
ECG
CT—head
MRI—brain
Doppler U/S—carotid
Echocardiography
EEG

68 yo M presents with slurred speech,
right facial drooping and numbness, and
right hand weakness. Babinski’s sign is
present on the right. He has a history
of hypertension, diabetes mellitus, and
heavy smoking.
Stroke
TIA
Seizure
Intracranial neoplasm
Subdural or epidural hematoma

W/U:
CBC, electrolytes
PT/PTT
CT—head
MRI—brain (preferred)
Doppler U/S—carotid
Echocardiography

33 yo F presents with ascending loss of
strength in her lower legs over the past
two weeks. She had a recent URI.
Guillain-Barré syndrome
Multiple sclerosis
Polymyositis
Myasthenia gravis
Peripheral neuropathy
Tumor in the vertebral canal

W/U:
CBC, electrolytes
CPK
LP—CSF analysis
MRI—spine
EMG/nerve conduction study
Tensilon test
Serum B12

30 yo F presents with weakness, loss of
sensation, and tingling in her left leg
that started this morning. She is also
experiencing right eye pain, decreased
vision, and double vision. She reports
feeling “electric shocks” down her spine
upon fl exing her head.
Multiple sclerosis
Stroke
Conversion disorder
Malingering
CNS tumor
Neurosyphilis
Syringomyelia
CNS vasculitis

W/U:
CBC, ESR
VDRL/RPR
MRI—brain
LP—CSF analysis
Retinal evoked potentials

55 yo M presents with tingling and
numbness in the hands and feet (gloveand-
stocking distribution) over the past
two months. He has a history of diabetes
mellitus, hypertension, and alcoholism.
There is decreased soft touch, vibratory,
and position sense in the feet.
Diabetic peripheral
neuropathy
Alcoholic peripheral neuropathy
B12 defi ciency
Hypocalcemia
Hyperventilation
Paraproteinemia/myeloma

W/U:
HbA1c
ESR
Calcium
Serum B12
Serum and urine protein
electrophoresis

40 yo F presents with occasional double
vision and droopy eyelids at night with
normalization by morning.
Myasthenia gravis
Horner’s syndrome
Multiple sclerosis
Intracranial tumor compressing
CN III, IV, or VI
Amyotrophic lateral sclerosis

W/U:
Tensilon test
ACh receptor antibodies (in
serum)
CXR
CT—chest
MRI—brain
EMG

25 yo M presents with hemiparesis (after
a tonic-clonic seizure) that resolves over
a few hours.
Todd’s paralysis
TIA
Stroke
Complicated migraine
Malingering

W/U:
CBC, electrolytes
EEG
MRI—brain
Doppler U/S—carotid

40 yo F c/o feeling tired, hopeless,
and worthless and of having suicidal
thoughts. She recently discovered that
her husband is homosexual.
Depression
Adjustment disorder
Hypothyroidism
Anemia

W/U:
CBC
TSH
HIV/STD testing (given
husband’s possible risk
factors)

44 yo M presents with fatigue, insomnia,
and nightmares about a murder that he
witnessed in a mall one year ago. Since
then, he has avoided that mall and has
not gone out at night.
Post-traumatic stress disorder
(PTSD)
Depression
Generalized anxiety disorder
Psychotic or delusional disorder
Hypothyroidism

W/U:
CBC
TSH
Calcium
Urine toxicology

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

W/U:
Rectal exam, stool for occult
blood
CBC, electrolytes, calcium,
BUN/Cr, AST/ALT, TSH
Colonoscopy
Barium enema

40 yo F presents with fatigue, weight
gain, sleepiness, cold intolerance,
constipation, and dry skin.
Hypothyroidism
Depression
Diabetes
Anemia

W/U:
TSH, FT3, FT4
CBC
Glucose, HbA1c

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

W/U:
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

W/U:
Glucose tolerance test, HbA1c
UA
CBC, electrolytes, glucose
BUN/Cr

35 yo M policeman c/o feeling tired and
sleepy during the day. He changed to the
night shift last week.
Sleep deprivation
Sleep apnea
Depression
Anemia

W/U:
CBC
Nocturnal pulse oximetry
Polysomnography

30 yo M presents with night sweats,
cough, and swollen glands of one
month’s duration.
Tuberculosis
Acute HIV infection
Lymphoma
Leukemia
Hyperthyroidism

W/U:
PPD
CBC
CXR
Sputum Gram stain, acid-fast
stain, and culture
HIV antibody
TSH, FT4

25 yo F presents with a three-week history
of diffi culty falling asleep. She sleeps
seven hours per night without nightmares
or snoring. She recently began college
and is having trouble with her boyfriend.
She drinks 3-4 cups of coffee a day.
Stress-induced insomnia
Caffeine-induced insomnia
Insomnia with circadian rhythm
sleep disorder
Insomnia related to major
depressive disorder

W/U:
Polysomnography
Mental status exam
Urine toxicology
CBC
TSH

55 yo obese M presents with several
months of poor sleep and daytime
fatigue. His wife reports that he snores
loudly.
Obstructive sleep apnea
Daytime fatigue in primary
hypersomnia
Insomnia with circadian rhythm
sleep disorder
Insomnia related to major
depressive disorder

W/U:
CBC
TSH
Polysomnography
ECG

33 yo F c/o three weeks of fatigue and
trouble sleeping. She states that she falls
asleep easily but wakes up at 3 A.M. and
cannot return to sleep. She also reports
an unintentional weight loss of 3.5 kg
along with an inability to enjoy the
things she once liked to do.
Insomnia related to major
depressive disorder
Primary hypersomnia
Insomnia with circadian rhythm
sleep disorder

W/U:
Mental status exam
TSH
CBC
Polysomnography

26 yo F presents with sore throat, fever,
severe fatigue, and loss of appetite for
the past week. She also reports epigastric
and LUQ discomfort. She has cervical
lymphadenopathy and a rash. Her
boyfriend recently experienced similar
symptoms.
Infectious
mononucleosis
Hepatitis
Viral or bacterial
pharyngitis
Acute HIV infection
Secondary syphilis

W/U:
CBC, peripheral smear
Monospot test
Throat culture
AST/ALT/bilirubin/alkaline
phosphatase
HIV antibody and viral load
Anti-EBV antibodies
VDRL/RPR

26 yo M presents with sore throat, fever,
rash, and weight loss. He has a history of
IV drug abuse and sharing needles.
HIV, acute retroviral
syndrome
Infectious
mononucleosis
Hepatitis
Viral pharyngitis
Streptococcal tonsillitis/
scarlet fever
Secondary syphilis

W/U:
CBC
Peripheral smear
HIV antibody and viral load
CD4 count
Monospot test
Throat culture
VDRL/RPR
AST/ALT/bilirubin/alkaline
phosphatas

46 yo F presents with fever and sore
throat.
Pharyngitis (bacterial
or viral)
Mycoplasma
pneumonia
Acute HIV infection
Infectious
mononucleosis

W/U:
Throat swab for culture and rapid
streptococcal antigen
Monospot test
CBC
HIV antibody and viral load

30 yo M presents with shortness of
breath, cough, and wheezing that worsen
in cold air. He has had several such
episodes over the past four months.
Asthma
GERD
Bronchitis
Pneumonitis
Foreign body

W/U:
CBC
CXR
Peak fl ow measurement
PFTs
Methacholine challenge test

56 yo F presents with shortness of breath
as well as with a productive cough that
has occurred over the past two years for
at least three months each year. She is a
heavy smoker.
COPD—chronic bronchitis
Bronchiectasis
Lung cancer
Tuberculosis

W/U:
CBC
Sputum Gram stain and culture
CXR
PFTs
CT—chest
PPD

58 yo M presents with pleuritic chest
pain, fever, chills, and cough with
purulent yellow sputum. He is a heavy
smoker with COPD.
Pneumonia
Bronchitis
Lung abscess
Lung cancer
Tuberculosis
Pericarditis

W/U:
CBC
Sputum Gram stain and culture
CXR
CT—chest
ECG
PPD

25 yo F presents with two weeks of a
nonproductive cough. Three weeks ago
she had a sore throat and a runny nose.
Atypical pneumonia
Reactive airway disease
URI-associated (“postinfectious”)
Postnasal drip
GERD

W/U:
CBC
Induced sputum Gram stain
and culture
CXR
IgM detection for Mycoplasma
pneumoniae
Urine Legionella antigen

65 yo M presents with worsening cough
over the past six months together with
hemoptysis, dyspnea, weakness, and
weight loss. He is a heavy smoker.
Lung cancer
Tuberculosis
Lung abscess
COPD
Vasculitis (i.e., Wegener’s)
Interstitial lung disease
CHF

W/U:
CBC
Sputum Gram stain, culture,
and cytology
CXR
CT—chest
PPD
Bronchoscopy

55 yo M presents with increased dyspnea
and sputum production over the past
three days. He has COPD and stopped
using his inhalers last week. He also
stopped smoking two days ago.
COPD exacerbation
(bronchitis)
Lung cancer
Pneumonia
URI
CHF

W/U:
CBC
CXR
PFTs
Sputum Gram stain and culture
CT—chest

34 yo F nurse presents with worsening
cough of six weeks’ duration together
with weight loss, fatigue, night sweats,
and fever. She has a history of contact
with tuberculosis patients at work.
Tuberculosis
Pneumonia
Lung abscess
Vasculitis
Lymphoma
Metastatic cancer
HIV/AIDS
Sarcoidosis

W/U:
CBC
PPD
Sputum Gram stain, acid-fast
stain, and culture
CXR
CT—chest
Bronchoscopy
HIV antibody

35 yo M presents with shortness of breath and cough. He has had unprotected sex with multiple sexual partners and was recently exposed to a patient with active tuberculosis.
Tuberculosis
Pneumonia (including
Pneumocystis jiroveci)
Bronchitis
CHF (cardiomyopathy)
Asthma
Acute HIV infection

W/U:
CBC
PPD
Sputum Gram stain, acid-fast
stain, silver stain, and culture
CXR
HIV antibody

50 yo M presents with a cough that
is exacerbated by lying down at night
and improved by propping up on three pillows. He also reports exertional dyspnea.
CHF
Cardiac valvular disease
GERD
Pulmonary fi brosis
COPD
Postnasal drip

W/U:
CBC
CXR
ECG
Echocardiography
PFTs
BNP

60 yo M presents with sudden onset
of substernal heavy chest pain that has
lasted for 30 minutes and radiates to
the left arm. The pain is accompanied
by dyspnea, diaphoresis, and nausea.
He has a history of hypertension,
hyperlipidemia, and smoking.
Myocardial infarction (MI)
GERD
Angina
Costochondritis
Aortic dissection
Pericarditis
Pulmonary embolism
Pneumothorax

W/U:
ECG
CPK-MB, troponin
CXR
CBC, electrolytes
Echocardiography
Cardiac catheterization

20 yo African-American F presents with
acute onset of severe chest pain. She
has a history of sickle cell disease and
multiple previous hospitalizations for
pain and anemia management.
Sickle cell disease—pulmonary
infarction
Pneumonia
Pulmonary embolism
MI
Pneumothorax
Aortic dissection

W/U:
CBC, reticulocyte count, LDH,
peripheral smear
ABG
CXR
CPK-MB, troponin
ECG
CT—chest with IV contrast

45 yo F presents with a retrosternal
burning sensation that occurs after
heavy meals and when lying down. Her
symptoms are relieved by antacids.
GERD
Esophagitis
Peptic ulcer disease
Esophageal spasm
MI
Angina

W/U:
ECG
Barium swallow
Upper endoscopy
Esophageal pH monitoring

55 yo M presents with retrosternal
squeezing pain that lasts for two minutes
and occurs with exercise. It is relieved by
rest and is not related to food intake.
Angina
Esophageal spasm
Esophagitis

W/U:
ECG
CPK-MB, troponin
CXR
CBC, electrolytes
Exercise stress test
Upper endoscopy/pH monitor
Cardiac catheterization

34 yo F presents with retrosternal
stabbing chest pain that improves when
she leans forward and worsens with deep
inspiration. She had a URI one week
ago.
Pericarditis
Aortic dissection
MI
Costochondritis
GERD
Esophageal rupture

W/U:
ECG
CPK-MB, troponin
CXR
Echocardiography
CBC
Upper endoscopy

34 yo F presents with stabbing chest pain
that worsens with deep inspiration and is
relieved by aspirin. She had a URI one
week ago. Chest wall tenderness is noted.
Costochondritis
Pneumonia
MI
Pulmonary embolism
Pericarditis
Muscle strain

W/U:
ECG
CPK-MB, troponin
CXR
CBC

70 yo F presents with acute onset of
shortness of breath at rest and pleuritic
chest pain. She also presents with
tachycardia, hypotension, tachypnea,
and mild fever. She is recovering from
hip replacement surgery.
Pulmonary embolism
Pneumonia
Costochondritis
MI
CHF
Aortic dissection

W/U:
ECG
CXR
ABG
CPK-MB, troponin
CBC, electrolytes
CT—chest with IV contrast
Doppler U/S—legs
D-dimer

55 yo M presents with sudden onset of
severe chest pain that radiates to the
back. He has a history of uncontrolled
hypertension.
Aortic dissection
MI
Pericarditis
Esophageal rupture
Esophageal spasm
GERD
Pancreatitis
Fat embolism

W/U:
ECG, CPK-MB, troponin
CXR
CBC, amylase, lipase
Transesophageal
echocardiography (TEE),
MRI/MRA—aorta
Aortic angiography
Upper endoscopy

70 yo diabetic M presents with episodes of
palpitations and diaphoresis. He is on insulin.
Hypoglycemia
Cardiac arrhythmias
Angina
Hyperthyroidism
Hyperventilation
episodes
Panic attacks
Pheochromocytoma
Carcinoid

W/U:
Glucose
CBC, electrolytes
TSH
BUN/Cr
ECG
Holter monitor

42 yo F presents with a 7-kg weight loss
over the past two months. She has a fi ne
tremor, and her pulse is 112.
Hyperthyroidism
Cancer
HIV infection
Dieting/diet drugs
Anorexia nervosa
Malabsorption

W/U:
TSH, FT4
CBC, electrolytes
HIV antibody
Urine toxicology

44 yo F presents with a weight gain
of > 11 kg over the past two months.
She quit smoking three 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

W/U:
CBC, electrolytes, glucose
TSH
24-hour urine free cortisol
Dexamethasone suppression test

75 yo M presents with dysphagia that
started with solids and progressed to
liquids. He is an alcoholic and a heavy
smoker. He has had an unintentional
weight loss of 7 kg over the past four
months.
Esophageal cancer
Achalasia
Esophagitis
Systemic sclerosis
Esophageal stricture
Amyotrophic lateral sclerosis

W/U:
CBC
CXR
Endoscopy with biopsy
Barium swallow
CT—chest

45 yo F presents with dysphagia for two
weeks together with fatigue and a craving
for ice and clay.
Plummer-Vinson syndrome
Esophageal cancer
Esophagitis
Achalasia
Systemic sclerosis
Mitral valve stenosis

W/U:
CBC
Serum iron, ferritin, TIBC
Barium swallow
Endoscopy

48 yo F presents with dysphagia for both
solid and liquid foods that has slowly
progressed in severity over the past year.
It is associated with regurgitation of
undigested food, especially at night.
Achalasia
Plummer-Vinson syndrome
Esophageal cancer
Esophagitis
Systemic sclerosis
Mitral valve stenosis
Esophageal stricture
Zenker’s diverticulum

W/U:
CXR
Endoscopy
Barium swallow
Esophageal manometry

38 yo M presents with dysphagia and pain
on swallowing solids more than liquids.
Exam reveals oral thrush.
Esophagitis (CMV, HSV, pillinduced)
Systemic sclerosis
GERD
Esophageal stricture
Zenker’s diverticulum

W/U:
CBC
Endoscopy
Barium swallow
HIV antibody
CD4 count

20 yo F presents with nausea, vomiting
(especially in the morning), fatigue, and
polyuria. Her last menstrual period was
six weeks ago, and her breasts are full
and tender. She is sexually active with
her boyfriend, and they use condoms for
contraception.
Pregnancy
Gastritis
Hypercalcemia
Diabetes mellitus
UTI
Depression

W/U:
Urine hCG
Pelvic exam
U/S—pelvis
CBC, electrolytes, calcium,
glucose
UA, urine culture
Baseline Pap smear, cervical
cultures, rubella antibody,
HIV antibody, hepatitis B
surface antigen, and VDRL/
RPR

45 yo M presents with sudden onset
of colicky right-sided fl ank pain that
radiates to the testicles, accompanied by
nausea, vomiting, hematuria, and CVA
tenderness.
Nephrolithiasis
Renal cell carcinoma
Pyelonephritis
GI etiology (e.g., appendicitis)

W/U:
Rectal exam
UA
Urine culture and sensitivity
BUN/Cr
CT—abdomen
U/S—renal
IVP

60 yo M presents with dull epigastric
pain that radiates to the back, together
with weight loss, dark urine, and
clay-colored stool. He is a heavy drinker
and smoker.
Pancreatic cancer
Acute viral hepatitis
Chronic pancreatitis
Cholecystitis/choledocholithiasis
Abdominal aortic aneurysm
Peptic ulcer disease

W/U:
Rectal exam
CBC, electrolytes
Amylase and lipase
AST/ALT/bilirubin/alkaline
phosphatase
U/S—abdomen
CT—abdomen

56 yo M presents with severe
midepigastric abdominal pain that
radiates to the back and improves when
he leans forward. He also reports
anorexia, nausea, and vomiting. He is an
alcoholic and has spent the past three
days binge drinking.
Acute pancreatitis
Peptic ulcer disease
Cholecystitis/choledocholithiasis
Gastritis
Abdominal aortic aneurysm
Mesenteric ischemia
Alcoholic hepatitis
Mallory-Weiss tear

W/U:
Rectal exam
CBC, electrolytes, BUN/Cr,
amylase, lipase, AST/ALT/
bilirubin/alkaline phosphatase
U/S—abdomen
CT—abdomen
Upper endoscopy
ECG

41 yo obese F presents with RUQ
abdominal pain that radiates to the right
scapula and is associated with nausea,
vomiting, and a fever of 101.5°F. The
pain started after she had eaten fatty
food. She has had similar but less intense
episodes that lasted a few hours. Exam
reveals positive Murphy’s sign.
Acute cholecystitis
Hepatitis
Choledocholithiasis
Ascending cholangitis
Peptic ulcer disease
Fitz-Hugh-Curtis syndrome

W/U:
Rectal exam
CBC
AST/ALT/bilirubin/alkaline
phosphatase
U/S—abdomen
HIDA scan

43 yo obese F presents with RUQ
abdominal pain, fever, and jaundice. She
was diagnosed with asymptomatic
gallstones one year ago.
Ascending cholangitis
Acute cholecystitis
Hepatitis
Choledocholithiasis
Sclerosing cholangitis
Fitz-Hugh-Curtis syndrome

W/U:
Rectal exam
CBC
AST/ALT/bilirubin/alkaline
phosphatase
Viral hepatitis serologies
U/S—abdomen
MRCP
ERCP

25 yo M presents with RUQ pain, fever,
anorexia, nausea, and vomiting. He has
dark urine and clay-colored stool.
Acute hepatitis
Acute cholecystitis
Ascending cholangitis
Choledocholithiasis
Pancreatitis
Acute glomerulonephritis

W/U:
Rectal exam
CBC, amylase, lipase
AST/ALT/bilirubin/alkaline
phosphatase
UA
Viral hepatitis serologies
U/S—abdomen

35 yo M presents with burning epigastric
pain that starts 2-3 hours after meals.
The pain is relieved by food and
antacids.
Peptic ulcer disease
Gastritis
GERD
Cholecystitis
Chronic pancreatitis
Mesenteric ischemia

W/U:
Rectal exam
Amylase, lipase, lactate
AST/ALT/bilirubin/alkaline
phosphatase
Endoscopy (including H. pylori
testing)
Upper GI series

37 yo M presents with severe epigastric
pain, nausea, vomiting, and mild fever.
He appears toxic. He has a history of
intermittent epigastric pain that is
relieved by food and antacids. He also
smokes heavily and takes aspirin on a
regular basis.
Peptic ulcer perforation
Acute pancreatitis
Hepatitis
Cholecystitis
Choledocholithiasis
Mesenteric ischemia

W/U:
Rectal exam
CBC, electrolytes, amylase,
lipase, lactate
AST/ALT/bilirubin/alkaline
phosphatase
AXR
Upright CXR
Endoscopy (including H. pylori
testing)

18 yo M boxer presents with severe LUQ
abdominal pain that radiates to the left
scapula. He had infectious
mononucleosis three weeks ago.
Splenic rupture
Kidney stone
Rib fracture
Pneumonia
Perforated peptic ulcer
Splenic infarct

W/U:
Rectal exam
CBC, electrolytes
CXR
CT—abdomen
U/S—abdomen

40 yo M presents with crampy
abdominal pain, vomiting, abdominal
distention, and inability to pass fl atus or
stool. He has a history of multiple
abdominal surgeries.
Intestinal obstruction
Small bowel or colon cancer
Volvulus of the bowel
Gastroenteritis
Food poisoning
Ileus
Hernia

W/U:
Rectal exam
CBC, electrolytes
AXR
CT—abdomen/pelvis
CXR

70 yo F presents with acute onset of
severe, crampy abdominal pain. She
recently vomited and had a massive dark
bowel movement. She has a history of
CHF and atrial fi brillation, for which
she has received digitalis. Her pain is out
of proportion to the exam.
Mesenteric ischemia/infarction
Diverticulitis
Peptic ulcer disease
Gastroenteritis
Acute pancreatitis
Cholecystitis/choledocholithiasis
MI

W/U:
Rectal exam
CBC, amylase, lipase, lactate
ECG, CPK-MB, troponin
AXR
CT—abdomen
Mesenteric angiography
Barium enema

21 yo F presents with acute onset of
severe RLQ pain, nausea, and vomiting.
She has no fever, urinary symptoms, or
vaginal bleeding and has never taken
OCPs. Her last menstrual period was
regular, and she has no history of STDs.
Ovarian torsion
Appendicitis
Nephrolithiasis
Ectopic pregnancy
Ruptured ovarian cyst
PID
Bowel infarction or perforation

W/U:
Pelvic exam
Rectal exam
Urine hCG
UA
CBC
Doppler U/S—pelvis
CT—abdomen
Laparoscopy

68 yo M presents with LLQ abdominal
pain, fever, and chills for the past three
days. He also reports recent onset of
alternating diarrhea and constipation. He
consumes a low-fi ber, high-fat diet.
Diverticulitis
Crohn’s disease
Ulcerative colitis
Gastroenteritis
Abscess

W/U:
Rectal exam
CBC, electrolytes
CXR
AXR
CT—abdomen

20 yo M presents with severe RLQ
abdominal pain, nausea, and vomiting.
His discomfort started yesterday as a
vague pain around the umbilicus. As the
pain worsened, it became sharp and
migrated to the RLQ. McBurney’s and
psoas signs are positive.
Acute appendicitis
Gastroenteritis
Diverticulitis
Crohn’s disease
Nephrolithiasis
Volvulus or other intestinal
obstruction/perforation

W/U:
Rectal exam
CBC, electrolytes
AXR
CT—abdomen
U/S—abdomen

30 yo F presents with periumbilical pain
for six months. The pain never awakens
her from sleep. It is relieved by
defecation and worsens when she is
upset. She has alternating constipation
and diarrhea but no nausea, vomiting,
weight loss, or anorexia.
Irritable bowel syndrome
Crohn’s disease
Celiac disease
Chronic pancreatitis
GI parasitic infection
(amebiasis, giardiasis)
Endometriosis

W/U:
Rectal exam, stool for occult
blood
Pelvic exam
Urine hCG
CBC
Electrolytes
CT—abdomen/pelvis
Stool for ova and parasitology,
Entamoeba histolytica
antigen

24 yo F presents with bilateral lower
abdominal pain that started with the fi rst
day of her menstrual period. The pain is
associated with fever and a thick,
greenish-yellow vaginal discharge. She
has had unprotected sex with multiple
sexual partners.
PID
Endometriosis
Dysmenorrhea
Vaginitis
Cystitis
Spontaneous abortion
Pyelonephritis

W/U:
Pelvic exam
Rectal exam
Urine hCG
Cervical cultures
CBC/ESR
UA, urine culture
U/S—pelvis

67 yo M presents with alternating
diarrhea and constipation, decreased
stool caliber, and blood in the stool for
the past eight months. He also reports
unintentional weight loss. He is on a
low-fi ber diet and has a family history
of colon cancer.
Colorectal cancer
Irritable bowel syndrome
Diverticulosis
GI parasitic infection (ascariasis,
giardiasis)
Infl ammatory bowel disease
Angiodysplasia

W/U:
Rectal exam
CBC
AST/ALT/bilirubin/alkaline
phosphatase
Colonoscopy
Barium enema
CT—abdomen/pelvis

28 yo M presents with constipation (very
hard stool) for the last three weeks. Since
his mother died two months ago, he and
his father have eaten only junk food.
Low-fi ber diet
Irritable bowel syndrome
Substance abuse (e.g., heroin)
Depression
Hypothyroidism

W/U:
Rectal exam
TSH
Electrolytes
Urine toxicology

30 yo F presents with alternating
constipation and diarrhea and abdominal
pain that is relieved by defecation. She
has no nausea, vomiting, weight loss, or
blood in her stool.
Irritable bowel syndrome
Infl ammatory bowel disease
Celiac disease
Chronic pancreatitis
GI parasitic infection (ascariasis,
giardiasis)
Lactose intolerance

W/U:
Rectal exam, stool for occult
blood
CBC
Electrolytes
Stool for ova and parasitology
AXR
CT—abdomen/pelvis

33 yo M presents with watery diarrhea,
vomiting, and diffuse abdominal pain
that began yesterday. He also reports
feeling hot. Several of his coworkers are
also ill.
Infectious diarrhea
(gastroenteritis)—bacterial,
viral, parasitic, protozoal
Food poisoning
Infl ammatory bowel disease

W/U:
Rectal exam, stool for occult
blood
Stool leukocytes and culture
CBC
Electrolytes
CT—abdomen/pelvis

40 yo F presents with watery diarrhea
and abdominal cramps. Last week she
was on antibiotics for a UTI.
Pseudomembranous
(Clostridium diffi cile) colitis
Gastroenteritis
Cryptosporidiosis
Food poisoning
Inflammatory bowel disease

W/U:
Rectal exam
Stool leukocytes, culture, occult
blood
C. diffi cile toxin in stool
Electrolytes

25 yo M presents with watery diarrhea
and abdominal cramps. He was recently
in Mexico.
Traveler’s diarrhea
Giardiasis
Amebiasis
Food poisoning
Hepatitis A

W/U:
Rectal exam
Stool leukocytes, culture,
Giardia antigen, Entamoeba
histolytica antigen
Electrolytes
AST/ALT/bilirubin/alkaline
phosphatase
Viral hepatitis serology

30 yo F presents with watery diarrhea
and abdominal cramping and bloating.
Her symptoms are aggravated by milk
ingestion and are relieved by fasting.
Lactose intolerance
Gastroenteritis
Infl ammatory bowel disease
Irritable bowel syndrome
Hyperthyroidism

W/U:
Rectal exam
Stool exam
Hydrogen breath test
TSH

33 yo M presents with watery diarrhea,
diffuse abdominal pain, and weight loss
over the past three weeks. He has not
responded to antibiotics.
Crohn’s disease
Gastroenteritis
Ulcerative colitis
Celiac disease
Pseudomembranous colitis
Hyperthyroidism
Small bowel lymphoma
Carcinoid

W/U:
Rectal exam
Stool exam and culture
CBC, electrolytes
TSH
CT—abdomen
Colonoscopy
Small bowel series
Urinary 5-HIAA

45 yo F presents with coffee-ground
emesis for the last three days. Her stool is
dark and tarry. She has a history of
intermittent epigastric pain that is
relieved by food and antacids.
Bleeding peptic ulcer
Gastritis
Gastric cancer
Esophageal varices

W/U:
Rectal exam
CBC, electrolytes
AST/ALT/bilirubin/alkaline
phosphatase
Endoscopy (including H. pylori
testing if ulcer is confi rmed)

40 yo F presents with epigastric pain and
coffee-ground emesis. She has a history
of rheumatoid arthritis that has been
treated with aspirin. She is an alcoholic.
Gastritis
Bleeding peptic ulcer
Gastric cancer
Esophageal varices
Mallory-Weiss tear

W/U:
Rectal exam
CBC, electrolytes
AST/ALT/bilirubin/alkaline
phosphatase
Barium swallow
Endoscopy

67 yo M presents with blood in his stool,
weight loss, and constipation. He has a
family history of colon cancer.
Colorectal cancer
Anal fi ssure
Hemorrhoids
Diverticulosis
Ischemic bowel disease
Angiodysplasia
Upper GI bleeding
Inflammatory bowel disease

W/U:
Rectal exam
CBC, PT/PTT
AST/ALT/bilirubin/alkaline
phosphatase
CEA
Colonoscopy
CT—abdomen/pelvis
Barium enema

33 yo F presents with rectal bleeding and
diarrhea for the past week. She has had
lower abdominal pain and tenesmus for
several months.
Ulcerative colitis
Crohn’s disease
Proctitis
Anal fi ssure
Hemorrhoids
Diverticulosis
Dysentery

W/U:
Rectal exam
CBC, PT/PTT
AXR
Colonoscopy
CT—abdomen/pelvis
Barium enema

58 yo M presents with bright red blood
per rectum and chronic constipation. He
consumes a low-fi ber diet.
Diverticulosis
Anal fi ssure
Hemorrhoids
Angiodysplasia
Colorectal cancer

W/U:
Rectal exam
CBC, PT/PTT
Electrolytes
Colonoscopy
CT—abdomen/pelvis

65 yo M presents with painless
hematuria. He is a heavy smoker and
works as a painter.
Bladder cancer
Renal cell carcinoma
Nephrolithiasis
Acute glomerulonephritis
Prostate cancer
Coagulation disorder (i.e., factor
VIII antibodies)
Polycystic kidney disease
Genitourinary exam

W/U:
UA, urine cytology
BUN/Cr, PSA, CBC, PT/PTT
Cystoscopy
U/S—renal/bladder
CT—abdomen/pelvis
IVP

35 yo M presents with painless
hematuria. He has a family history of
kidney problems.
Polycystic kidney disease
Nephrolithiasis
Acute glomerulonephritis (e.g.,
IgA nephropathy)
UTI
Coagulation disorder
Bladder cancer

W/U:
Genitourinary exam
UA
BUN/Cr, PSA, CBC, PT/PTT
U/S—renal
CT—abdomen/pelvis
IVP

55 yo M presents with fl ank pain and
blood in his urine without dysuria. He
has experienced weight loss and fever
over the past two months.
Renal cell carcinoma
Bladder cancer
Nephrolithiasis
Acute glomerulonephritis
Pyelonephritis
Prostate cancer
Genitourinary, rectal exam

W/U:
UA, urine cytology, BUN/Cr,
PSA, CBC, PT/PTT
U/S—renal
CT—abdomen/pelvis
IVP

60 yo M presents with nocturia, urgency,
weak stream, and terminal dribbling. He
denies any weight loss, fatigue, or bone
pain. He has had two episodes of urinary
retention that required catheterization.
Benign prostatic hyperplasia
(BPH)
Prostate cancer
UTI
Bladder stones

W/U:
Rectal exam
UA
CBC, BUN/Cr, PSA
U/S—prostate (transrectal)

71 yo M presents with nocturia, urgency,
weak stream, terminal dribbling,
hematuria, and lower back pain over the
past four months. He has also
experienced weight loss and fatigue.
Prostate cancer
BPH
Renal cell carcinoma
UTI
Bladder stones

W/U:
Rectal exam
UA
CBC, BUN/Cr, PSA
U/S—prostate (transrectal)
CT—pelvis
IVP

18 yo M presents with a burning
sensation during urination and urethral
discharge. He recently had unprotected
sex with a new partner.
Urethritis
Cystitis
Prostatitis

W/U:
Genital ± rectal exam
UA
Urine culture
Gram stain and culture of
urethral discharge
Chlamydia and gonorrhea PCR

45 yo diabetic F presents with dysuria,
urinary frequency, fever, chills, and
nausea over the past three days. There is
left CVA tenderness on exam.
Acute pyelonephritis
Nephrolithiasis
Renal cell carcinoma
Lower UTI (cystitis, urethritis)

W/U:
UA
Urine culture and sensitivity
CBC, BUN/Cr
U/S—renal
CT—abdomen

47 yo M presents with impotence that
started three months ago. He has
hypertension and was started on atenolol
four months ago. He also has diabetes
and is on insulin.
Drug-related ED
ED caused by hypertension
ED caused by diabetes mellitus
Psychogenic ED
Peyronie’s disease

W/U:
Genital exam
Rectal exam
Glucose
CBC

40 yo F presents with amenorrhea,
morning nausea and vomiting, fatigue,
and polyuria. Her last menstrual period
was six weeks ago, and her breasts are full
and tender. She uses the rhythm method
for contraception.
Pregnancy
Anovulatory cycle
Hyperprolactinemia
UTI
Thyroid disease

W/U:
Pelvic exam
Urine hCG
U/S—pelvis
CBC, electrolytes
UA, urine culture
Prolactin, TSH
Baseline Pap smear, cervical
cultures, rubella antibody,
HIV antibody, hepatitis B
surface antigen, and VDRL/
RPR

23 yo obese F presents with amenorrhea
for six months, facial hair, and infertility
for the past three years.
Polycystic ovary syndrome
Thyroid disease
Hyperprolactinemia
Pregnancy
Ovarian or adrenal malignancy
Premature ovarian failure

W/U:
Pelvic exam
Urine hCG
U/S—pelvis
LH/FSH, TSH, prolactin
Testosterone, DHEAS

35 yo F presents with amenorrhea,
galactorrhea, visual fi eld defects, and
headaches for the past six months.
Amenorrhea secondary to
prolactinoma
Pregnancy
Thyroid disease
Premature ovarian failure
Pituitary tumor

W/U:
Pelvic and breast exam
Urine hCG
Prolactin
LH/FSH, TSH
MRI—brain

48 yo F presents with amenorrhea for the
past six months accompanied by hot
fl ashes, night sweats, emotional lability,
and dyspareunia.
Menopause
Pregnancy
Pituitary tumor
Thyroid disease

W/U:
Pelvic exam
Urine hCG
LH/FSH, TSH, prolactin,
testosterone, DHEAS
CBC
MRI—brain

35 yo F presents with amenorrhea, cold
intolerance, coarse hair, weight loss, and
fatigue. She has a history of abruptio
placentae followed by hypovolemic shock
and failure of lactation two years ago.
Sheehan’s syndrome
Premature ovarian failure
Pituitary tumor
Thyroid disease
Asherman’s syndrome

W/U:
Pelvic exam
Urine hCG
CBC
LH/FSH, prolactin
TSH, FT4
ACTH
MRI—brain
Hysteroscopy

18 yo F presents with amenorrhea for the
past four months. She has lost 95 pounds
and has a history of vigorous exercise and
cold intolerance.
Anorexia nervosa

W/U:
CBC
TSH
FT4
ACTH
FSH
LH

29 yo F presents with amenorrhea for the
past six months. She has a history of
occasional palpitations and dizziness. She
lost her fi ancé in a car accident.
Anxiety-induced amenorrhea

W/U:
CBC
TSH
FT4
ACTH
Urine cortisol level
Progesterone challenge test
FSH/LH/estradiol levels

17 yo F presents with prolonged,
excessive menstrual bleeding occurring irregularly over the past six months.
Dysfunctional uterine bleeding
Coagulation disorders (e.g., von
Willebrand’s disease,
hemophilia)
Cervical cancer
Molar pregnancy
Hypothyroidism
Diabetes mellitus

W/U:
Pelvic exam
Urine hCG
Cervical cultures, Pap smear
CBC, ESR, glucose
PT/PTT
Prolactin, LH/FSH
TSH
U/S—pelvis

61 yo obese F presents with profuse
vaginal bleeding over the past month. Her last menstrual period was 10 years ago. She has a history of hypertension and diabetes mellitus. She is nulliparous.
Endometrial cancer
Cervical cancer
Atrophic endometrium
Endometrial hyperplasia
Endometrial polyps
Atrophic vaginitis

W/U:
Pelvic exam
Pap smear
Endometrial biopsy
U/S—pelvis
Endometrial curettage
Colposcopy
Hysteroscopy

45 yo G5P5 F presents with postcoital bleeding. She is a cigarette smoker and takes OCPs.
Cervical cancer
Cervical polyp
Cervicitis
Trauma (e.g., cervical
laceration)

W/U:
Pelvic exam
Pap smear
Colposcopy and biopsy

28 yo F who is eight weeks pregnant
presents with lower abdominal pain and vaginal bleeding.
Spontaneous abortion
Ectopic pregnancy
Molar pregnancy

W/U:
Pelvic exam
Urine hCG
U/S—pelvis
CBC, PT/PTT
Quantitative serum hCG

32 yo F presents with sudden onset of left lower abdominal pain that radiates to the scapula and back and is associated with vaginal bleeding. Her last menstrual period was fi ve weeks ago. She has a
history of PID and unprotected
intercourse.
Ectopic pregnancy
Ruptured ovarian cyst
Ovarian torsion
PID

W/U:
Pelvic exam
Urine hCG
Cervical cultures
U/S—pelvis
Quantitative serum hCG

28 yo F presents with a thin, grayish white, foul-smelling vaginal discharge.
Bacterial vaginosis
Vaginitis—candidal
Vaginitis—trichomonal
Cervicitis (chlamydia,
gonorrhea)

W/U:
Pelvic exam
Wet mount
Cervical cultures
KOH prep (“whiff test”)
pH of vaginal fl uid

30 yo F presents with a thick, white,
cottage cheese-like, odorless Vaginal discharge and vaginal itching.
Vaginitis—candidal
Bacterial vaginosis
Vaginitis—trichomonal

W/U:
Pelvic exam
KOH prep (“whiff test”)
Wet mount
Cervical cultures
pH of vaginal fl uid

35 yo F presents with a malodorous,
profuse, frothy, greenish vaginal
discharge with intense vaginal itching and discomfort.
Vaginitis—trichomonal
Vaginitis—candidal
Bacterial vaginosis
Cervicitis (chlamydia,
gonorrhea)

W/U:
Pelvic exam
Wet mount
Cervical cultures
pH of the vaginal fl uid
KOH prep (“whiff test”)

54 yo F c/o painful intercourse. Her last menstrual period was nine months ago. She has hot fl ashes.
Atrophic vaginitis
Endometriosis
Cervicitis
Depression
Domestic abuse

W/U:
Pelvic exam
Wet mount, KOH prep, cervical
cultures
U/S—pelvis

37 yo F presents with dyspareunia,
inability to conceive, and dysmenorrhea.
Endometriosis
Cervicitis
Vaginismus
Vulvodynia
PID
Depression
Domestic violence

W/U:
Pelvic exam
Wet mount, KOH prep, cervical
cultures
U/S—pelvis
Laparoscopy

28 yo F c/o multiple facial and bodily
injuries. She claims that she fell on the stairs. She was hospitalized for some physical injuries seven months ago. She presents with her husband.
Domestic violence
Osteogenesis imperfecta
Substance abuse
Consensual violent sexual
behavior

W/U:
XR—skeletal survey
CT—maxillofacial
Urine toxicology
CBC

30 yo F presents with multiple facial and physical injuries. She was attacked and raped by two men.
Rape

W/U:
Pelvic exam
Urine hCG
Wet mount, KOH prep, cervical
cultures
XR—skeletal survey
CBC
HIV antibody
Viral hepatitis serologies

30 yo F presents with wrist pain and
a black eye after tripping, falling,
and hitting her head on the edge of a
table. She looks anxious and gives an inconsistent story.
Domestic violence
Factitious disorder
Substance abuse

W/U:
XR—wrist
CT—head
Urine toxicology

30 yo F secretary presents with wrist pain and a sensation of numbness and burning in her palm and the fi rst, second, and third fingers of her right hand. The pain
worsens at night and is relieved by loose shaking of the hand. There is sensory loss in the same fi ngers. Exam reveals a positive Tinel’s sign.
Carpal tunnel syndrome
Median nerve compression in
forearm or arm
Radiculopathy of nerve roots C6
and C7 in cervical spine

W/U:
Nerve conduction study
EMG

28 yo F presents with pain in the
interphalangeal joints of her hands
together with hair loss and a butterfly
rash on her face.
Systemic lupus erythematosus
(SLE)
Rheumatoid arthritis
Psoriatic arthritis
Parvovirus B19 infection

W/U:
ANA, anti-dsDNA, ESR, C3,
C4, rheumatoid factor (RF),
CBC
XR—hands
UA

28 yo F presents with pain in the
metacarpophalangeal joints of both
hands. Her left knee is also painful and red. She has morning joint stiffness that lasts for an hour. Her mother had rheumatoid arthritis.
Rheumatoid arthritis
SLE
Disseminated gonorrhea
Arthritis associated with
infl ammatory bowel disease
Osteoarthritis

W/U:
ANA, anti-dsDNA, ESR, RF,
CBC
XR—hands, left knee
Cervical culture
Arthrocentesis and synovial
fl uid analysis

18 yo M presents with pain in the
interphalangeal joints of both hands. He also has scaly, salmon-pink lesions on the extensor surface of his elbows and knees.
Psoriatic arthritis
Rheumatoid arthritis
SLE

W/U:
RF, ANA, ESR
CBC
XR—hands
XR—pelvis/sacroiliac joints
Uric acid

65 yo F presents with inability to use
her left leg and bear weight on it after tripping on a carpet. Onset of menopause was 20 years ago, and she did not receive HRT or calcium supplements. Her left leg is externally rotated, shortened, and
adducted, and there is tenderness in her left groin.
Hip fracture
Hip dislocation
Pelvic fracture

W/U:
XR—hip/pelvis
CT or MRI—hip
CBC
Serum calcium and vitamin D
Bone density scan (DEXA)

40 yo M presents with pain in the right groin after a motor vehicle accident. His right leg is fl exed at the hip, adducted, and internally rotated.
Hip dislocation—traumatic
Hip fracture

W/U:
XR—hip
CT or MRI—hip
CBC
PT/PTT
Blood type and cross-match
Urine toxicologyand blood
alcohol level

56 yo obese F presents with right knee stiffness and pain that increases with movement. Her symptoms have gradually worsened over the past 10 years. She noticed swelling and deformity of the
joint and is having diffi culty walking.
Osteoarthritis
Pseudogout
Gout
Meniscal or ligament damage

W/U:
XR—knee
CBC
ESR
Knee arthrocentesis and
synovial fl uid analysis (cell
count, Gram stain, culture,
crystals)
MRI—knee

45 yo M presents with right knee pain with swelling and redness.
Septic arthritis
Gout
Pseudogout
Lyme arthritis
Trauma
Reiter’s arthritis

W/U:
CBC
Knee arthrocentesis and
synovial fl uid analysis (see
above)
Blood, urethral cultures
XR—knee
Uric acid
Lyme antibody

65 yo M presents with right foot pain. He has been training for a marathon.
Stress fracture
Plantar fasciitis
Foot sprain or strain

W/U:
XR—foot
Bone scan—foot
MRI—foot

65 yo M presents with pain in the heel of the right foot that is most notable with his first few steps and then improves as he continues walking. He has no known
trauma.
Plantar fasciitis
Heel fracture
Splinter/foreign body

W/U:
XR—heel
Bone scan

55 yo M presents with pain in the
elbow when he plays tennis. His grip is impaired as a result of the pain. There is tenderness over the lateral epicondyle as well as pain on resisted wrist dorsiflexion
(Cozen’s test) with the elbow in
extension.
Tennis elbow (lateral
epicondylitis)
Stress fracture
W/U:
XR—arm
Bone scan
MRI—elbow

27 yo F presents with painful wrists and elbows, a swollen and hot knee joint that is painful on fl exion, a rash on her limbs, and vaginal discharge. She is sexually active with multiple partners and occasionally uses condoms.
Disseminated gonorrhea
Rheumatoid arthritis
SLE
Psoriatic arthritis
Reiter’s arthritis

W/U:
Knee arthrocentesis and
synovial fluid analysis (cell
count, Gram stain, culture)
ANA, anti-dsDNA, ESR, RF,
CBC
Blood, cervical cultures
XR—knee

60 yo F presents with pain in both legs that is induced by walking and is relieved by rest. She had cardiac bypass surgery six months ago and continues to smoke heavily.
Peripheral vascular disease
(intermittent claudication)
Leriche’s syndrome (aortoiliac
occlusive disease)
Lumbar spinal stenosis
(pseudoclaudication)
Osteoarthritis

W/U:
Ankle-brachial index
Doppler U/S—lower extremity
Angiography
MRI—lumbar spine

45 yo F presents with right calf pain. Her calf is tender, warm, red, and swollen compared to the left side. She was started on OCPs two months ago for dysfunctional uterine bleeding.
DVT
Baker’s cyst rupture
Myositis
Cellulitis
Superfi cial venous thrombosis

W/U:
Doppler U/S—right leg
CBC
CPK
D-dimer
PT, aPTT, fi brinogen
XR—right leg

60 yo F c/o left arm pain that started
while she was swimming and was relieved by rest.
Angina/MI
Tendonitis
Osteoarthritis
Shoulder dislocation

W/U:
CPK-MB, troponin, ECG
CBC
ESR
XR—shoulder
CXR
Echocardiography
Stress test

50 yo M presents with right shoulder pain after falling onto his outstretched hand while skiing. He noticed deformity of his shoulder and had to hold his right arm.
Shoulder dislocation
Fracture of the humerus
Rotator cuff injury

W/U:
XR—shoulder
XR—arm
MRI—shoulder

55 yo M presents with crampy bilateral thigh and calf pain, fatigue, and dark urine. He is on simvastatin and clofibrate for hyperlipidemia.
Rhabdomyolysis due to
simvastatin or clofi brate
Polymyositis
Inclusion body myositis
Thyroid disease

W/U:
CBC
CPK
Aldolase
UA
Urine myoglobin
TSH

45 yo F presents with low back pain that radiates to the lateral aspect of her left foot. Straight leg raising is positive. Thepatient is unable to tiptoe.
Disk herniation
Lumbar muscle strain
Tumor in the vertebral canal

W/U:
XR—L-spine
MRI—L-spine

45 yo F presents with low back pain that started after she cleaned her house. The pain does not radiate, and there is no sensory deficit or weakness in her legs. Paraspinal muscle tenderness and spasm
are also noted.
Lumbar muscle strain
Disk herniation
Abdominal aortic aneurysm
Vertebral compression fracture

W/U:
XR—L-spine

45 yo M presents with pain in the lower back and legs during prolonged standing and walking. The pain is relieved by sitting and leaning forward (e.g., pushing a grocery cart).
Lumbar spinal stenosis
Lumbar muscle strain
Tumor in the vertebral canal
Peripheral vascular disease

W/U:
XR—L-spine
MRI—L-spine
(preferred)
CT—L-spine
Ankle-brachial index

17 yo M presents with low back pain that radiates to the left leg and began after he fell on his knee during gym class. He also describes areas of loss of sensation in his left foot. The pain and sensory loss do not
match any known distribution. He insists on requesting a week off from school because of his injury.
Malingering
Lumbar muscle strain
Disk herniation
Knee or leg fracture
Ankylosing spondylitis

W/U:
XR—L-spine/knee
MRI—L-spine

20-day-old M presents with fever,
decreased breast-feeding, and lethargy. He was born at 36 weeks as a result of premature rupture of membranes.
Neonatal sepsis
Meningitis
Pneumonia
UTI

W/U:
Physical exam
CBC, electrolytes
UA
Urine culture
Blood culture
CXR
LP—CSF analysis

3 yo M presents with a two-day history of fever and pulling on his right ear. He is otherwise healthy, and his immunizations are up to date. His older sister recently had a cold. The child attends a day care center.
Acute otitis media
URI
Meningitis
UTI

W/U:
Physical exam (including
pneumatic otoscopy)
CBC
UA

12-month-old M presents with fever
for the last two days accompanied by a maculopapular rash on his face and body. He has not yet received the MMR vaccine.
Measles (or other viral
exanthem)
Rubella
Roseola
Fifth disease
Varicella
Scarlet fever
Meningitis

W/U:
Physical exam
CBC
Viral antibodies/titers
Throat swab for culture
LP

4 yo M presents with diarrhea, vomiting, lethargy, weakness, and fever. The child attends a day care center where several children have had similar symptoms.
Gastroenteritis (viral, bacterial,
parasitic)
Food poisoning
UTI
URI
Volvulus
Intussusception

W/U:
Physical exam
Stool exam and culture
CBC
Electrolytes
UA, urine culture
AXR

9 yo M presents with a two-year history of angry outbursts both in school and at home. His mother complains that he runs around “as if driven by a motor.” His teacher reports that he cannot sit still in
class, regularly interrupts his classmates, and has trouble making friends.
Attention-defi cit hyperactivity
disorder (ADHD)
Oppositional defi ant disorder
Manic episode
Conduct disorder

W/U:
Physical exam
Mental status exam

12 yo F presents with a two-month
history of fi ghting in school, truancy, and breaking curfew. Her parents recently divorced, and she just started school in a new district. Before her parents divorced,
she was an average student with no
behavioral problems.
Adjustment disorder
Substance intoxication/abuse/
dependence
Manic episode
Oppositional defi ant disorder
Conduct disorder

W/U:
Physical exam
Mental status exam
Urine toxicology

15 yo M presents with a one-year history of failing grades, school absenteeism, and legal problems, including shoplifting. His parents report that he spends most of
his time alone in his room, adding that when he does go out, it is with a new set of friends.
Substance abuse
Conduct disorder
Oppositional defi ant disorder
Adjustment disorder

W/U:
Urine toxicology
Mental status exam

5 yo M presents with a six-month
history of temper tantrums that last
5-10 minutes and immediately follow a disappointment or a discipline. He has no trouble sleeping, has had no change
in appetite, and does not display thesebehaviors when he is at day care.
Age-appropriate behavior
ADHD
Oppositional defiant disorder

W/U:
Physical exam
Mental status exam

First Aid and Safety: Exam #2: Dressings and Bandages:

Securing Bandages:
Apply _ _ :
remove _ and hold by _ _
peel back _ _ and place on _
pull away _ _ and press _ and _ down
Securing Bandages:
Apply adhesive strip:
remove wrapping and hold by protective strip
peel back protective strip and place on wound
pull away protective strip and press ends and edges down

Securing Bandages:
Pass ends in _ _ around _ _ and _
Securing Bandages:
Pass ends in opposite directions around body part and tie

Securing Bandages:
_ _ Method
_ ends of bandages _
_ to prevent further _
Securing Bandages:
Split Tail Method
Split ends of bandages lengthwise
Knot to prevent further splitting

Securing Bandages:
Loop Method:
_ body part with _ and _ end and _ end together
Securing Bandages:
Loop Method:
Encircle body part with loose and free end and tie end together

Securing Bandages:
_ Method:
_ direction of _ by looping around _ or _ and working _
Securing Bandages:
Loop Method:
Reverse direction of tape by looping around finger or thumb and working backwards

Securing Bandages:
_ _
_ _
_ that come with bandages
Securing Bandages:
Adhesive Tape
Safety Pins
Clips that come with bandages

For ankle roller bandages:
make several _ _ _ , _ each other, advancing up the _

Finish with _ _ _ around _; _ end

For ankle roller bandages:
make several figure eight turns, overlap eachother, advancing up the leg

Finish with two straight turns around leg; secure end

For ankle roller bandages:
make _ _ _ around _-_

make _ _ turn across front of _ , around _ , under _

For ankle roller bandages:
make two straight turns around in-step

make figure eight turn across front of foot, around ankle, under arch

For hand roller bandages:
make several _ _ _ , _ eachother

Finish with _ _ _ around _; _ end

For hand roller bandages:
make several figure eight turns, overlapping eachother

finish with two straight turns around wrist; secure ends

For hand roller bandages:
make two _ _ around _

carry bandage _ across _ of _ , around _ and back of _

For hand roller bandages:
make two straight turns around wrist

carry bandage diagonally across back of hand, around wrist, and back of palm

Applying a roller bandage:
Elbow or Knee:
Finish with _ _ _ to _ _
Applying a roller bandage:
Elbow or Knee:
Finish with two straight turns to secure ends

Applying a roller bandage:
Elbow or Knee:
Make one _ below _, overlapping _ _ turn

continue _ _

Applying a roller bandage:
Elbow or Knee:
Make one turn below joint, overlapping first straight turn

continue alternating turns

Applying a roller bandage:
Elbow or Knee:
Make _ _ turns over _

Make one _ above _, overlapping the _ _

Applying a roller bandage:
Elbow or Knee:
Make two straight turns over joint

Make one above joint, overlapping the first turn

Applying a __ Bandage:
make _ , _ _ turns

make _-_ turns

finish with two _ _ turns and _

Applying a Roller Bandage:
make two straight anchoring turns

make criss-cross turns

finish with two straight turns and secure

Apply Cravant Bandage to Palm of Hand:
Wrap _ , crossing over _ and around the _
Apply Cravant Bandage to Palm of Hand:
Wrap bandage, crossing over fingers and around the wrist

Apply Cravant Bandage to Palm of Hand:
Tie _ at the _
Apply Cravant Bandage to Palm of Hand:
Tie bandage at the wrist

Apply _ Bandage to _ of _ :
Place _ _ or _ in _ of _ and close _
Apply Cravant Bandage to Palm of Hand:
Place bulky dressing or pad in palm of hand and close fingers

Apply _ Bandage to _ of _ :
Wrap one end around _ and the other end around _
Apply Cravant Bandage to Palm of Hand:
Wrap one end around fingers and the other end around wrist

Apply Cravant Bandage to Arm or Leg:
wrap _ of _ over dressing

Turn one end going _ the _ and one _ going _ the dressing

Apply Cravant Bandage to Arm or Leg:
wrap center of bandage over dressing

turn one end going up the dressing and one end going down the dressing

Apply Cravant Bandage to Arm or Leg:
Tie _ over _
Apply Cravant Bandage to Arm or Leg:
Tie bandage over dressing

Apply Cravant Bandage continued:
_ two _ _ snugly

bring _ back around and _ _

Apply Cravant Bandage continued:
Cross two ends snugly

Bring ends back around and tie knot

Applying a _ _ to Head:
Place _ of _ over _ and wrap around _
Applying a Cravant Bandage to Head:
Place middle of bandage over dressing and wrap around head

Types of Bandages:
_ _ and _
Types of Bandages:
Adhesive tape and strip

Types of Bandages:
_ bandages: _ , _
Types of Bandages:
Triangular bandages: slits, cravants

Types of Bandages:
_ _ _ : provides __
Types of Bandages:
Elastic Roller Bandages: provides compression

Types of Bandages:
_ _ : _-elastic, _
Types of Bandages:
Gauze Roller: non-elastic, cotton

Types of Bandages:
_-_ or _ Bandages: _, _-like
Types of Bandages:
Self-Adhering or Conforming Bandages: elastic, gauze-like

Types of Bandages:
_ _ : various _ , _ , types of _
Types of Bandages:
Roller Bandages: various widths, lengths, types of material

Signs Bandages may be too tight:
_ _ on _ _ or _ _
_ or _ skin color
_, loss of _
_
inability to move _ or _
inability to feel _
Signs Bandages may be too tight:
blue tinge on finger nails or toe nails
blue or pale skin color
tingling, loss of sensation
coldness
inability to move fingers or toes
inability to feel pulse

__: should be _ but not be _
* holds a _ in place
* apply _ _
* prevents or reduces _
*provides _ and _ to _ or _
Bandages: should be clean but not be sterile
*holds a dressing in place
* apply direct pressure
* prevents or reduces swelling
* provides support and stability to extremity or limb

Apply a _ dressing:
wash _ and wear _ _
hold _ by _ _ and place over _
*do not _ over _
* do not _ dressing

cover with _

Apply a sterile dressing:
wash hands and wear exam gloves
hold dressing by 1 corner and place over wound
* do not slide over wound
* do not touch dressing
cover with bandage

Improvised Dressing:
Should be _, _ , _ , and _ of _ as much as possible
Improvised Dressing:
Should be clean, sterile, soft, and as free of lint as much as possible

Types of Dressing:
_ dressing: _ , _ , _
Types of Dressing:
Trauma dressing: large, thick, absorbent

Types of Dressing:
_ _ : for _ cuts and _
Types of Dressing:
Adhesive Strip: for small cuts and abrasions

Types of Dressing:
_ _ : for small wounds
Types of Dressing:
Gauze Pad: for small wounds

Purpose of a Dressing:
control _
prevent _ and _
absorb _ and _
protect _
Purpose of a Dressing:
control bleeding
prevent infection and contamination
absorb blood and fluid
protect wound

A dressing should be :
_
_ than the _
_, _ , and _
_ free
A dressing should be :
sterile
larger than the wound
thick, soft, compressible
lint free

__: covers an _ _ and touches the _
Dressing: covers an open wound and touches the wound

medical coding chapter 17

1.the more the complex subsection referred to in the text were Integ, Musculo, resipratory, Cardio, Digestive, and
Female genital

2. The info in the ___ contains info that is necessary to correctly code in the section, & the info is not repeated elsewhere
Guidelines

3.Notes may appear before subsec, subhead, ___ & subcategories
Categories

4. when a note is present, that note must be read and ___ if the coding is to be accurate
Followed

5. w/in the surgery Guidelines the ___ procedure codes are presented in a list by anatomic site
Unlisted

6. according to the CPT maunal “Pertinent info [in the ___ report] should include an adequate def. or description of the nature, extent, need, time, effort, and equip. necessary to provide the service
Special

7. there are minor and ___ procedure designations for the purposes of a surgical package
Major

8. the breast biopsy and mastectomy of the left breast were preformed during the same operative session would both procedures be reported
Yes

9. if a breast and right knee operation were preformed during the same operative session would both procedures be reported
Yes

10. The CPT manual describes the surg. pkg as including one related preop E/M service the operative procedure, and immediate ____ care
Follow up care

11. Local infiltration is considered ___ anesthesia
Local

12. this term means a worsening as described in the text
Exacerbations

13. this type of anesthesia is not part of the surgical package
General anesthesia

14. the predeifined number of days before and after a surgical package
Global Period

15. what is the CPT code that reports a surgical tray
99070

16. what is the HCPCS code that reports a surgical tray
A4550

17. according to the medicare guidlines a surg, pkg includes the treatment of complications by the ___ physician
Same

18. At an off. visit a decision for surgery was made. the surgical procedure was scheduled 21 days later. would the office visit service be
A. reported separtely

19. Splitting open of the wound is
Dehiscence

20. Inclusion or exclusion of a procedure in the cpt manual implies health insurance coverage or no health insurance coverage
True

21. the code range in the surgical section is
10021-69990

22. the subsection that follows the digestive system is the ___ system
Urinary

23. what type of microscope has a section of the surgery section
Operating scope

24.the difference between 10021 and 10022 is that one is with ___ ____ and one is without
Imaging guidance

25. according to the parenthetical info following the code 10022 for a precutaneousneedle biopsy other than fine needle aspiration, see ____ for salivary gland
42400

26. according to the surgery guidelines codes designated as ____ _____ should not be reported in addition to the code for the totao procedure or service of which it is considered an integral component
Separate procedure

27. according to the surgery guidelines follow up care for ____ surgical procedures includs only that care which is usually a part of the surgical procedure
Therapeutic

28. according to the surgery guidelines the code range for maternity care and delivery is
59000-59899

29. according to the surgery guidelines this is the code for unlisted procedures of the lip
40799

30. according to the surgery guidelines this is the code for unlisted procedures of the urinary system
53899

Missed Questions An Advanced Review of Speech-Language Pathology, 4th Edition: Practice Examinations questions

Various arteries help supply blood to the face and the brain. Neurogenic communication
disorders are associated with interrupted blood supply to the brain. Of the following
statements about the arteries that supply blood to the brain.
Broca’s area and Wernicke’s area are supplied by the middle cerebral artery.

Two or more sounds of different frequencies are called
complex tones

The range in a distribution can be defined as
the difference between the highest and lowest scores in a distribution.

A researcher who developed a language acquisition test claims that her test measures
what it is supposed to measure because the scores are progressively higher across age
groups. She is claiming that her test has what kind of validity?
Construct validity

Some researchers have claimed that stuttering may be an operant behavior, which is
behavior that is
changed by its consequences.

Select the statement that applies to the normal distribution.
It is based on the arithmetic mean of scores or values.

The concept of adequate construct validity means that
test scores are consistent with theoretical concepts or expectations.

You just completed an assessment of an 8-year-old boy who stutters. When you are
offering post-assessment counseling to the boy’s parents, they ask you, “What do you think
caused stuttering in our son?” How would you answer their question? Select the best among
the alternatives given.
“We can’t say for sure in individual cases, but both complex genetic susceptibility and
environmental factors may be involved in its causation.”

James, a 4-year-old boy, attends your cleft palate center for a speech evaluation. James
was born with a complete bilateral cleft lip and palate. He is unable to close his
velopharyngeal port and, as a result, has difficulty producing non-nasal sounds. This
patient’s non-nasal speech sounds would have which of the following characteristics?
Hypernasality

What are cartilages that are cone shaped and located under the mucous membrane that
covers the aryepiglottic folds called?
Cuneiforms

Waves that repeat themselves at regular intervals are known as
periodic waves

A graduate school that bases its admission decisions on a student’s GRE scores believes
that
GRE scores have predictive validity

What is one difficulty with cross-sectional studies?
The investigator observes differences between subjects of different ages to generalize about
developmental changes that would occur within subjects as they mature.

A graduate school that bases its admission decisions on a student’s GRE scores believes
that
GRE scores have predictive validity

According to Halliday, what are four of the seven functions of communicative intent that
develop between 9 and 18 months of age?
Heuristic, imaginative, interactional, personal

A 48-year-old patient who had a tracheostomy tube in place was referred for an
evaluation. The speech-language pathologist noted that the tube was cuffed and quizzed her
student intern about the differences between cuffed and uncuffed tracheostomy tubes. The
student replied that an inflated tube
may restrict laryngeal elevation

Select the statement that is not true.
A. Dysarthria and Broca’s aphasia may coexist.
B. Excessive or even stress on syllables is not a part of ataxic dysarthria.
C. Roughly 94% of Parkinson’s patients have hypokinetic dysarthria.
D. Spastic-ataxic and flaccid-spastic are frequently mixed in the mixed variety of dysarthria.

A 48-year-old patient who had a tracheostomy tube in place was referred for an
evaluation. The speech-language pathologist noted that the tube was cuffed and quizzed her
student intern about the differences between cuffed and uncuffed tracheostomy tubes. The
student replied that an inflated tube
may restrict laryngeal elevation

Hearing loss that occurs when the middle ear and the inner ear are not functioning
properly is known as
mixed hearing loss

You are assessing a preschool child who comes from an AAE-speaking home. Which of
the following utterances reflects typical patterns of AAE?
“You was helping me.”

Which of the following is a limitation of standardized speech-language tests?
Inadequate participant and response sampling

James, a 4-year-old boy, attends your cleft palate center for a speech evaluation. James
was born with a complete bilateral cleft lip and palate. He is unable to close his
velopharyngeal port and, as a result, has difficulty producing non-nasal sounds. This
patient’s non-nasal speech sounds would have which of the following characteristics?
Hypernasality

Standardized tests are limited in their usefulness because
they sample participants (children) and responses in a limited manner

James, a 4-year-old boy, attends your cleft palate center for a speech evaluation. James
was born with a complete bilateral cleft lip and palate. He is unable to close his
velopharyngeal port and, as a result, has difficulty producing non-nasal sounds. This
patient’s non-nasal speech sounds would have which of the following characteristics?
Hypernasality

A patient complains of muscle fatigue in her larynx. She visits her local hospital, and the
specialist decides to insert needle electrodes into the peripheral laryngeal muscles to
directly measure laryngeal function. The specialist informs the patient that this procedure is
used to study the pattern of electrical activity of the vocal folds and view muscle activity
patterns. This procedure is called
electromyography

In a therapy session with a clinician and 3-year old child with a language impairment,
the child says “more juice.” The clinician replies with “You want more of that tasty grape
juice poured in your cup.” The clinician has just used the technique of:
Extension

You are treating a patient who has been diagnosed with Alzheimer’s disease. You decide
to use an emotion-oriented therapy by playing audio recordings of relatives of the patient.
You believe that this approach will decrease the agitation and improve the well-being of the
patient. This type of approach is called
simulated presence therapy (SPT)

When a vowel (usually /o/ or /u/) is substituted for a syllabic consonant (e.g., a child may
say “bado” instead of “bottle,” or “noodoo” instead of “noodle”), it is called…
vocalization

An 81-year-old bilingual man from Thailand has had a stroke, and you are seeing him for
therapy. He is recovering both his primary language and his English skills, but you are
working only in English. No interpreters are available, unfortunately, and the family has
indicated that they would prefer treatment to be conducted in English, anyway, because
many of the patient’s grandchildren speak English fluently. Which one of the following
productions would be an example, on the patient’s part, of English influenced by his primary
language of Thailand and not the stroke?
“They going over there today.”

A father comes to you regarding his daughter, who is 8 months old. The daughter’s
hearing loss is bilateral, and she is profoundly deaf. The father states that he wishes for his
daughter, as she grows older, to “fit in with children with normal hearing.” He is interested
in any possible amplification and says that he wants his daughter to lead a life that is “as
normal as possible.” Which training approach would best fit this father’s wishes?
Aural/oral method

True of speech-language sampling
Frequently repeat what the child says.

You are taking a language sample from an 8-year-old child. One of his utterances is “I
will go to school tomorrow if I am not sick.” This is an example of a
complex sentence with an independent and a dependent clause.

A technique used by some speech-language pathologists during swallowing assessments,
in which a stethoscope is placed over the thyroid cartilage to amplify sounds during
swallowing, is called
cervical auscultation

The definition of stuttering as “speech that contains 5% or more disfluencies” is based
on
certain listener evaluation studies.

To obtain a reliable measure of a child’s language skills through language sampling, you
should
repeat the language sample.

The disorders of the pharyngeal phase of swallow include
delayed or absent swallowing reflex

What is one difficulty with cross-sectional studies?
The investigator observes differences between subjects of different ages to generalize about
developmental changes that would occur within subjects as they mature.

Which of the following statements is false regarding a null hypothesis?
It states that two variables are causally related

Which of the following primarily vibrate and produce sound?
Internal thyroarytenoids

According to Halliday, what are four of the seven functions of communicative intent that
develop between 9 and 18 months of age?
Heuristic, imaginative, interactional, personal

Hearing loss that occurs when the middle ear and the inner ear are not functioning
properly is known as
mixed hearing loss.

Standardized tests are limited in their usefulness because
they sample participants (children) and responses in a limited manner.

ATI Pharm Review

Jaundice
Pt starting antituberculosis tx w rifampin (Rifadin) — be sure to report which indication of serious adv s/e of this drug?

Rash
Pt starting amoxicillin (amoxil) to tx ear infection. Report what?

Tinnitus
Pt resp tract infection being tx w gentamicin (Garamycin). Report what adv effect?

Vancomycin (Vancocin)
Which drug to tx MRSA?

Metronidazole (Flagyl)
Which drug to tx Trichomoniasis?

Amphotericin B (Fungizone)
Which drug to tx Systemic candiidiasis?

Chloroquine (Aralen)
Which drug to tx Malaria?

Report mouth pain. Take it 1 hr before meals. Wear sunscreen & protective clothing.
Pt starting oral tetracycline (Sumycin) to treat acne vulgaris. Which instructions to include?

Seizure Disorder
Adm imipenem-cilastatin (Primaxin) cautiously w pts who have what?

Sore throat
Pt starting Bactrim to tx UTI. Instruct pt to report what serious adverse effect?

Acyclovir (Zovirax)
What drug to tx viral infections?

Isoniazid (INH)
What drug to tx tuberculosis?

Ketoconazole (Nizoral)
What drug to tx fungal infections?

Cephalexin (Keflex)
What drug to tx gram-pos infections?

Take it w food to reduce gastric distress. Take it with 8 oz of orange juice to increase absorption.
Pt starting ketoconazole (Nizoral) to tx systemic mycoses. Include what pt teaching?

Increase pt’s fluid intake.
What intervention needs implemented to prevent a serious adv reaction in pt receiving IV acyclovir (Zovirax)?

Swish the suspension in the mouth before swallowing it.
What instruction should be included for pt taking antifungal preparation such as Mycostatin to tx oral candida albicans?

Cardiac Dysrhythmias
Adm E-Mycin to a pt w pneumococcal pneumonia, monitor what adv effect?

Acetaminophen (Tylenol) & diphenhydramine (Benadryl)
Which drugs are given prior to administering amphotericin B (Fungizone) IV to minimize adv reactions during the administration?

Take an antacid at least 2 hr after taking the drug (because antacids decrease the absorption of the drug).
Pt taking ciprofloxacin (Cipro) to tx a resp tract inf reports dyspepsia. What instructions should be given?

BUN. This drug can cause renal toxicity. Pt’s urine output, BUN, & crt levels, and ^ fluid intake to hydrate & flush the kidneys.
Pt is going to take Zovirax to tx herpes infection. What lab should be monitored?

Creatinine. This drug can affect renal function & should get a reduced dose if they have renal insufficiency.
Pt is going to take Keflex to tx bact meningitis. Which lab should be monitored?

Urine output. This drug can cause nephrotoxicity.
Pt is going to take Garamycin to tx infection. What should be monitored?

Numbness & tingling of the hands and feet.
What adv effects does Isoniazid (INH) cause?

renal dysfunction.
A lower dose of aztreonam (Azactam) for a pt who has resp tract infection & also has _________

Gynecomastia (paresthesias)
Pt is about to begin taking ketoconazole (Nizoral) to tx fungal infection. Pt should report what adv effect of drug?

E-mycin.
Pt has streptococcal pharyngitis & is allergic to penicillin — what med is an acceptable alternative?

Use additional contraceptive methods to prevent unwanted pregnancy. Rifadin can increase the metabolism of oral contraceptives, reducing their effectiveness.
Pt takes an oral contraceptive & is about to begin rifampin (Rifadin) therapy to treat tuberculosis. What instructions should be given?

Wear sunglasses. Avoid driving. Take the drug with food.
Pt instruction for taking chloroquine (Aralen) to prevent Malaria.

Metronidazole (Flagyl) & Cefotetan (Cefotan)
Which drugs to treat a pt (w a gynecologic infection & a hx of alcohol abuse) can cause a reaction similar to disulfiram (Antabuse).

Tendon Pain. (Cipro can cause Achilles tendon to rupture, esp in pt who take glucocorticoids or in older adults)
Pt is taking ciprofloxacin (Cipro) to treat a UTI & has RA, for which he takes prednisolone (Prelone). W the adverse effects of ciproflaxacin, the pt should report what?

Seizure disorder.
Pt is about to begin to take metronidazole (Flagyl) to tx a anaerobic intra-abdominal bacterial infection. Cautious use pf the drug is indicated if the pt also has ____________.

Jaundice, numbness of the hands, dizziness.
Pt is about to begin taking isoniazid (INH) to treat tuberculosis. What adv effects should be reported?

Pseudomembranous enterocolitis
Pt taking tetracycline (Sumycin) orally to tx chlamydia reports severe blood-tinged diarrhea. What should be suspected?

Cough. This is indicative of an allergic reaction & warrants immediate discontinuation of the drug.
Pt is about to begin taking Macrodantin to tx UTI. What adv effect should be reported?

Suprainfection.
Pt taking imipenem (Primaxin) to tx a bacterial infection reports inability to eat r/t mouth pain. What should be suspected?

Furozemide (Lasix)
Gantamicin (Garamycin) is contraindicated with patients that are also taking ____________.

dehydration
Pt is about to begin taking Zovirax IV to tx viral infection. Cautious use should be recoginized if the pt also has ___________.

bleeding.
Warfarin & Bactrim being taken together can increase the pt’s risk for ________.

Call emergency services immediately.
Pt taking amoxicillin reports rash & wheezing. What instructions should be provided?

Stop the infusion.
While administering IV Cefotan to a pt the nurse finds the IV insertion site warm & reddened. What action should be taken?

Intro to ICD-10-CM

The code next to the main term is called
default code

The fourth character further defines
the site, etiology and manifestation or state of the disease condition.

The fifth and sixth character subclassifications
represent the most accurate level of specificity regarding the patient’s condition or diagnosis

The seventh character MOST be in the
seventh position

What is a placeholder
it fills in for the empty character.

NOS
not elsewhere specified. Is the equivalent of unspecified. (yellow) (usually have a 9 or 0 in code)

NEC
Not elsewhere classifiable. Represents “other specified” (gray) (usually have a 8 or 9 in code)

Brackets are used in the Tabular List to
enclose synonyms, alternate wording, or explanatory phrases.

Brackets [] are used in the Index to Diseases and Injuries to identify
manifestation codes in which multiple coding and sequencing rules will apply.

Parentheses () are used to enclose
supplementary words that may be present or advent in the statement of disease or procedure, without affecting the code number to which it is assigned.

The terms in the parentheses are referred to as
nonessential modifiers

Excludes1 means
should not be used at the same time as the code above when the two diagnoses are related.

Excludes2 means
note indicates that the condition excluded is not part of the condition represented by the code, but a patient may have both conditions at the same time. It is acceptable to use both the code and the excluded code together.

Use additional code
code should be used after a primary code

Code first
is not intended to indicate that a code is to be the principal diagnosis. Instead, the note indicates the two codes are needed to report a condition and requires that the underlying disease (etiology) be recorded first, and the particular manifestation be recorded second.

Use additional code, if applicable
a causal condition note indicates that this code may be assigned as a diagnosis when the causal condition is unknown or not applicable

What is an eponym?
is a disease or syndrome named after a person

Modifiers are
sub terms indented two spaces and listed in alpha order below the main term.

“and” means
“and” or “or”

see
directs you to a more specific term under the correct code can be found.

see also
indicates additional information is available that may provide an additional diagnostic code.

.-Point Dash
indicates that the code is incomplete and go to that category or subcategory of codes to complete that code.

Default code
a code listed next to a main terms in the index to diseases and injuries is referred to as a default code. The default code represents that condition is the most commonly associated with the main term or is the unspecified code for the condition. If a condition is documented in a medical record without any additional information, such as acute or chronic, the default code should be assigned.

COPD – search under Obstruction, obstructed, obstructive/lung/disease,chronic
Chronic obstructive pulmonary disease, unspecified (j44.9)

see condition means
look under the condition , not the anatomic site

Diabetes Type I
referred to as juvenile diabetes

Type of diabetes mellitus not documented
defaults to Type II (E11.-) See guidelines Section IC4a2

Signs and symptoms in the outpatient setting
do NOT code a diagnosis unless it is certain.

Words that identify uncertainty
probable, suspected, questionable, rule out , differential, working

When a definitive diagnosis has not been determined, code
signs, symptoms, and abnormal test results(s) or other reason for the visit.

Inpatient setting for facility diagnosis coding
it is appropriate to report suspected or rule out diagnoses as if the condition does exist. Exception to the rule HIV. HIV must be confirmed.

Signs,symptom and ill-defined conditions are not to be reported as diagnoses when a related definitive diagnosis has been established, unless
otherwise instructed by the classification. If you are unsure if a symptom is part of a disease process, the physician should be queried.

Conditions that are not an integral part of the disease process
Code for signs and symptoms that are not routinely associated with other definite diagnosis should be reported.

Multiple Coding for a single condition
Index to Diseases and Injuries: Code for both etiology and manifestation of a disease appear following the subentry term, with the second code in brackets. Assign both codes in the same sequence in which they appear in the Index to Diseases and Injuries.

Multiple Coding for a single condition #2
– Code first, -code, if applicable, any causal condition first, -code also, -use additional code

Acute and Chronic – when both conditions are documented, there is a separate code for each, report both codes. Which is recorded first?
Always sequence the Acute code first

Chronic conditions treated on an ongoing basis may be coded as many times as required for treatment and care of the patient. True or False
True

History is reported using a ____ code?
Z . Do not code previously treated, or those that no longer exist. Only code if the history affects patient care or provides the need for a patient to seek medical attention.

When can you use combination codes?
fully identify an instance in which two diagnoses, or a diagnosis with an associated secondary process (manifestation) or complication, are included in the description of a single code number.

Sequelae (late effects) …
residual effect (condition produced)….due to an old injury., due to a previous illness

Sequelae coding require two codes
the residual condition is coded first, and the code for the cause of the sequela are reported as secondary

Where do you find sequelae in front of book
External Cause of Injuries Section

What other sections of the book are separate
Table of Drugs, Table of Neoplasm, and External Cause of Injuries

Define etiology
the cause of disease or condition

define manifestation
a sign or symptom

Impending or Threatened condition
when a patient is discharged with a condition described as impending or threatened, review the Index to disease and Injuries for the sub term impending or threatened wonder the main term of the condition. If the sub term does not exist, reference Impending or Threatened as the main term, with the condition as a sub term. If a suitable code does not exist, report the signs and symptoms that led the provider to suspect as impending or threatened condition.

Laterality can be coded either of two ways
If no bilateral code is provided and the condition is bilateral, assign separate codes for both the left and the right side.

Documentation for BMI and Pressure Ulcer Stages
Codes for BMI and pressure ulcer stage codes can be reported based on documentation from any clinician involved in the patient’s case. (Nurse). The BMI codes should only be reported as secondary diagnoses.

BMI
Body Mass Index

Syndromes (Alstom Syndrome) – If you can’t find the syndrome in the Index to Disease and Injuries,
code the patient’s sign and symptoms.

Documentation of Complications of Care
There must be a suave and effect relationship between the care provided and the condition that the patient has contracted due to the surgery or medical care. The provider must also specifically document that the condition is a complication.

Borderline Diagnosis
Are coded as confirmed diagnoses unless there is an Index entry of borderline for that classification.

Signs/Symptoms/Unspecified Codes
Signs and symptoms are reported unless a definitive diagnosis has been established. If a sufficient clinical information isn’t known or available about a particular health condition to assign a more specific code, it is acceptable to report the “unspecified” code.

Outpatient guidelines are found in what section of the official coding guidelines
Section IV

Conventions and Terms are found in what section of the official coding guidelines
Section I

What is the difference between inpatient coding and outpatient coding?
the coding of uncertain diagnosis

Inpatient coding codes uncertain diagnosis? True or False
True – with the exception of HIV

Outpatient coding codes uncertain diagnosis? True or False
False – report the patients signs and symptoms

Uncertain diagnosis words
“probable”, “suspected, “Likely”, questionable”, , “possible”, “still to be ruled out”

Rules of Outpatient Coding
The first listed diagnosis is used in lieu of principal diagnosis.
In determining the first listed diagnosis, the coding conventions of ICD-10-CM, as well as the general and disease specific guidelines, take precedence over the outpatient guidelines.

When a patient presents for outpatient surgery,
the reason for the surgery is the first-listed diagnosis even if the surgery is not performed due to complications.

When the patient presents for outpatient surgery and develops complications requiring admission to observation,
the reason for the surgery is the first-listed diagnosis followed by the codes for the complications.

Signs and Symptoms are in chapter of the code book
Chapter 18

Code all co-existing codes at the time of
encounter/visit

History codes (z8-z87) will be used as
secondary codes if the historical condition or family history has an impact on current care of influence treatment.

How do you code for patients receiving diagnostic services only
sequence first the diagnosis, condition, problem or other reason for encounter/visit shown in the medical record to be chiefly responsible for the outpatient services provided during the encounter/visit. Codes for other diagnoses (chronic conditions) may be sequenced as additional diagnoses.

For encounters for routine laboratory/radiology testing in the absence of any sign, symptoms, or associated diagnosis, assign
Z01.89 encounter for other specified special examinations.

For outpatient encounters for diagnostic tests that have been interpreted by a physician, and the final report is available at the time of coding,
code any confirmed or definitive diagnosis(es)

Therapeutic services only are
sequence first the diagnosis, condition, problem, or other reason for encounter/visit shown in the medical record to be chiefly responsible for the outpatient services provided during the encounter/visit. Codes for other diagnoses (chronic conditions) may be sequenced as additional diagnoses.

The only exception to this rule (therapeutic service) is when the primary reason for the admission/encounter is
chemotherapy, radiation, or rehabilitation. The appropriate Z code for the service listed first, and the diagnosis or problem for which the service is being performed is listed second.

Patients receiving preoperative evaluations only
sequence a code from subcategory Z01.81 Encounter for pre procedural examinations to describe the pro-operative consultations. Assign a code for the condition to describe the reason for the surgery as an additional diagnosis. Code also any findings related to the preoperative evaluation.

Find pre-operative screening exams are found in the index to diseases and injuries by looking for
examination/pre-procedural (per-operative)

Ambulatory (outpatient care) surgery
If the postoperative diagnosis is known to be different from the preoperative diagnosis at the time the diagnosis is confirmed, select the postoperative diagnosis for coding because it is the most definitive.

Routine Outpatient Prenatal visits
when no complications are present, a code from category Z34 Encounters for supervision of normal pregnancy should be used as principal diagnosis. These codes should not be used with chapter 15 codes. It would be inappropriate to code Z34.80 encounter supervision of other normal pregnancy, unspecified trimester if the patience is diagnosed with a condition that complicates the pregnancy

Acute
A condition with a rapid and short course.

Chronic
a condition that develops slowly and lasts a long time.

Rubrics
Three character categories

Septicemia
A systemic disease associated with microorganisms or toxins in the blood. These toxins are caused by bacteria, viruses, fungi, or other organisms.

Sepsis
Whole body inflammatory state. It generally refers to SIRS that is due to an infection

Severe Sepsis
Sepsis with associated acute organ dysfunction.

Z codes
Codes used to describe circumstances or conditions that could influence patient care.

Surgical Procedures – Week 2 terms

1. Airborne transmission precautions
Precautions that prevent airborne transfer of disease organisms in the environment.

2. Blood-borne pathogens
Harmful microorganisms that may be present in and transmitted through human blood and body fluids.

3. Electrocution
Severe burns, cardiac disturbances, or death as a result of electrical current discharged into the body.

4. Electrosurgical unit (ESU):
Medical device commonly used in surgery to coagulate blood vessels and cut tissue.

5. Eschar
Burned tissue fragments that can accumulate on the electrosurgical tip during surgery; eschar can cause sparking and become a source of ignition.

6. Flammable
Capable of burning.

7. Grounding
A path for electrical current to flow unimpeded through a material and disperse back to the source or disperse into the ground.

8. Hypersensitivity:
A cell-mediated immune response to a substance in the body.

9. Impedance (resistance):
The ability of a substance to stop or alter the flow of electrons through a conductive material.

10. Latex:
A naturally occurring sap obtained from rubber trees that is used in the manufacture of medical devices, supplies, and patient care items.

11. Neutral zone (no-hands) technique:
A method of transferring sharp instruments on the surgical field without hand-to-hand contact. A neutral zone is identified, and sharps are exchanged in this zone.

12. Occupational exposure:
Exposure to hazards in the workplace; for example, exposure to hazardous chemicals or contact with potentially infected blood and body fluids.

13. Oxidizers:
Agents or substances capable of supporting fire.

14. Oxygen-enriched atmosphere (OEA):
An environment that contains a high percentage of oxygen and therefore presents a high risk for fire.

15. Personal protective equipment (PPE):
Clothing or equipment that protects the wearer from direct contact with hazardous chemicals or potentially infectious body fluids.

16. Post-exposure prophylaxis (PEP):
Recommended procedures to help prevent the development of blood-borne diseases after an exposure incident such as a needle stick injury.

17. Risk:
The statistical probability of a given event based on the number of such events that have already occurred in a defined population.

18. Sharps:
Any objects that can penetrate the skin and have the potential to cause injury and infection. Sharps include but are not limited to needles, scalpels, broken glass, broken capillary tubes, and exposed ends of dental wires.

19. Smoke plume:
Smoke created during the use of an electrosurgical unit (ESU) or laser. This smoke contains toxic chemicals, vapors, blood fragments, and viruses.

20. Standard Precautions:
Guidelines issued by the Centers for Disease Control and Prevention (CDC) to reduce the risk of transmission of blood-borne and other pathogens.

21. Transmission-based precautions:
Standards and precautions to prevent the spread of infectious disease by patients known to be infected.

22. Underwriters Laboratories (UL):
A nonprofit agency that tests and certifies electrical equipment in the United States.

23. Volatile:
A substance with a low boiling point such as alcohol that converts to a vapor at low temperature.

1. What is the definition of risk? What is meant by risk management?
Risk is the statistical probability of a given event based on the number of such events that have already occurred in a certain population. Risk management is the study of the risk, a plan of action to reduce it, and monitoring to evaluate the need for change in the plan of action.

2. Under what circumstances might Peri-operative personnel bypass safety precautions?
The staff in the operating room is exposed to high environmental risks every day. However, they may ignore risk factors because they believe they somehow will escape harm. They know that risk exists but may believe it does not apply to them personally.

3. Describe the elements of the fire triangle.
Fire requires three components:
Oxygen (available in the air or as a pure gas)
Fuel (a combustible material)
Source of ignition (usually in the form of heat)

4. What characteristics of oxygen make it particularly dangerous in the perioperative environment?
The operating room is considered an oxygen-rich atmosphere because of the higher levels of oxygen in the environment. Oxygen is heavier than air and settles under drapes and in body cavities. It can speed the ignition of items that normally are not flammable in room air.

5. What is an endotracheal fire?
A fire in the endotracheal tube is usually caused by use of a laser or by a spark, usually during a head and neck procedure.

6. Define the RACE procedure during a fire.
• Rescue patients in the immediate area of the fire.
• Alert other people to the fire so that they can assist in patient removal and response. Also, activate the fire alarm system.
• Contain the fire. Shut all doors to slow the spread of smoke and flame. Always shut off the zone valves that control in-line gases to the room.
• Evacuate personnel in the areas around the fire.

7. What are the elements of the PASS procedure for using a fire extinguisher?
• Pull
• Aim
• Squeeze
• Sweep
…..PASS….

8. What is the rationale behind Standard Precautions?
Standard Precautions are guidelines recommended by the Centers for Disease Control and Prevention (CDC) to reduce the risk of transmission of blood-borne and other pathogens. Every patient is considered a potential source of disease transmission, and Standard Precautions should be applied.

9. Why were Standard Precautions developed?
Standard Precautions are an extension of Universal Precautions, which were originally formulated to prevent the spread of HIV/AIDS. These standards were expanded to include the potential transmission of all blood-borne diseases.

10. Describe post-exposure prophylaxis.
Post-exposure prophylaxis is the recommended procedure for helping to prevent the development of blood-borne diseases after an exposure incident, such as a needle stick injury. The post-exposure prophylaxis process includes rapid reporting and response, testing for blood-borne disease, and administration of prophylactic drugs to prevent blood-borne diseases within 72 hours of exposure.

11. Define hazardous waste.
Hazardous waste is determined by the Environmental Protection Agency (EPA). Medical waste that falls into this category includes:
• Soiled or blood-soaked bandages
• Culture dishes and other glassware
• Discarded surgical gloves after surgery
• Discarded surgical instruments and scalpels
• Needles used to give shots or draw blood
• Cultures, stocks, and swabs used to inoculate cultures
• Removed body organs (e.g., tonsils, appendices, limbs)

12. What is the minimum safe distance from a source of ionizing radiation during radiography?
The minimal safe distance is 6 feet.

13. What is a Material Safety Data Sheet (MSDS)?
For a given chemical, the MSDS describes the handling precautions, associated hazards, firefighting techniques, and first aid for exposure.

14. What is the safest way to lift a heavy object from floor level?
The knees should always be bent when raising or lowering a heavy object. This method takes pressure off the lower back and uses the body’s heaviest muscles to do the work. The back should be kept straight, and the legs should be wide apart with both feet flat on the floor for balance. The surgical technologist should never lock the knees and bend over to pick up an object. This puts stress on the lower back and does not permit use of the thigh muscles to help lift the body.
…YOU ONLY HAVE ONE BACK…

15. How can you protect against musculoskeletal stress when standing for long periods?
Proper body mechanics prevent musculoskeletal injury. Peri-operative personnel can reduce muscle fatigue while standing by placing the feet shoulder-width apart. Well-fitted comfortable shoes and support stockings can also reduce musculosketal stress.

Power Point Chapter 8

Risk
is the statistical probability of a harmful event; it is defined as the number of harmful events that occur in a given population over a stated period.

Statistics
are collected and analyzed so that risk can be measured and policies put in place to prevent future accidents

A culture of safety is crucial to injury reduction in the workplace.
This means that staff members must have awareness of the risk, accept the responsibility for harm reduction, and act on prevention measures.

Three types of potential injury that represent the most common sources of accidents:
• Technical risk factors: Hazards related to medical devices and energy sources
• Chemical risk factors: Hazards related primarily to liquid, gas, and solid chemicals in the perioperative environment
• Biological risk factors: Hazards related to the transmission of infectious disease

Technical risks
related to medical devices remain high in spite of increased awareness and safety programs in health care facilities

Fire Triangle
Fire requires three components:
•Oxygen (available in the air or as a pure gas)
•Fuel (a combustible material)
•Source of ignition (usually in the form of heat)

Normal air contains about 21% oxygen.
An environment that contains a greater concentration of oxygen is called an oxygen-enriched atmosphere (OEA).

KEY POINT
**The risk of fire is high.***

Oxygen is heavier than air…
so it settles under drapes and in confined areas, such as body cavities, where it remains trapped.

Fuel
Any material capable of burning is potential fuel for a fire. Materials and substances that burn are called flammable.
Note.. that the words flammable and inflammable have the same meaning; both indicate combustibility.

Many items used in the surgical setting are considered “flame resistant” or “flame retardant,” they may easily catch fire and continue to burn when ignition occurs in an OEA.

Flammable Chemicals

Alcohol is now commonly used in skin prep solutions and is a high risk source of fuel in surgical fires

Most skin prep solutions contain 70% alcohol.

Vapor from alcohol can be trapped under drapes. When the vapor is ignited, the fire is hidden from view.

Brachial Plexus Pathology

What are the nerves involved in Erb’s Palsy?
C5 and C6 roots

What are the muscles involved in Erb’s Palsy?
Deltoid, supraspinatus, infraspinatus, and biceps brachii

Describe erb's palsy
Describe erb’s palsy
Shoulder rotate forward, arm diminished in length and girth, muscle atrophy, scolliosis, “waiter-tip,” “bird-winging”

How does Erb’s palsy occur in infants? Adults?
– Lateral traction on the neck during delivery
– Trauma where the head is pushed or pulled away from shoulder

Which nerves are involved in Klumpke’s palsy?
C8-T1 roots

How does Klumpke’s palsy occur in infants? Adults?
– Upward force on the arm during delivery
– Trauma (grabbing tree branch to break fall)

What are the muscles affected with Klumpke’s palsy?
Intrinsic hand muscles (lumbricals, interossei, thenar, hypothenar)

What’s the clinical presentation of klumpke’s palsy?
Total claw hand (extended MP joints and flexed at IP joints)

What causes thoracic outlet syndrome?
– Compression of brachial plexus and subclavian artery due to compression of anterior scalene and middle scalene
– Anterior scalene pull first rib up –> clavicle compresses artery, nerves, or vein

What causes winged scapula?
Lesion of long thoracic nerve (C5, C6, C7 roots)

What are the functional deficits of winged scapula?
– Can’t anchor scapula to thoracic cage
– Can’t abduct arm above horizontal position