Case 2 describes a 53-year-old graphic designer with a hand tremor, stiffness, slowness, and sleep problems affecting her work. Her exam finds mild facial expression changes and a mild intention tremor. Her history includes loss of smell and irregular periods. Differential includes neurological causes

1. Midterm Cases
Case #1
Presentation: Suzanne is a 35-year-old mother of three, presents at your office for her annual
physical.
“I’m so busy that I barely have time to sleep! And when I do get to bed, I’m having trouble
sleeping.”
Past medical history: Appendectomy, age 22. Seasonal allergies since childhood, vitiligo since
early teens.
Family history: Both parents are being treated for hypertension and heart disease. Her sister has
type 1 diabetes. Suzanne’s son was diagnosed with ADHD four years ago when he was 8 years
old.
Social history: Part-time, fourth-year law student applying for Law Review; husband also works
full-time. She has 6-year-old twin girls and a 12- year-old son. A live-in nanny takes care of the
children during the week. “I’m so busy that I barely have time to sleep! And when I do get to
bed, I’m having trouble sleeping.”
Review of systems: She is sleeping and eating poorly. Notes that she frequently feels “anxious,”
which is accompanied by tachycardia and sweating. Otherwise, no other significant complaints
– all WNL.
Medications: Antihistamines as necessary for seasonal allergy relief, NSAIDS for menstrual
cramps.
Physical examination: Appears restless, anxious, and somewhat agitated / distracted.
Height: 5’5” Weight: 118 lb, down 12 lb since a year ago
Temperature is normal. BP 150/72, HR 120
HEENT: Pupils dilated and equally reactive to light
Cardiac: RRR, no murmurs / rubs (tachycardic) – no JVD
Lungs: Breath sounds normal
ABD: Soft nontender positive – hyperactive bowel sounds
Skin: Patchy areas of decreased skin pigmentation on hands, neck and legs. Dry skin.
Remainder of physical examination is within normal parameters
Questions for development:
1- What would you include in your differential diagnosis? (What can be going on)
2- What does your work up include? (Other questions you would liked answered?)
3- What is your PLAN? (Medications, further testing, referral, etc..)

2. Midterm Cases
Case #2
Lisa Farmer is a 53-year-old, right-handed woman who presents to the clinic because of a mild
tremor in her right hand that has worsened over the past 6 months. It takes her longer to do
things because it takes a little more effort to get movement started, and her muscles feel a little
stiff. She also admits to waking up several times during the night. The stiffness, slowness,
tremor, and sleep problems have affected her job performance as a graphic designer, resulting in
her contemplating early retirement. She also complains of constipation, loss of sense of smell
for about 2 years, decreased libido for 6-8 months, night sweats that cause nighttime awakenings,
and very irregular menstrual periods for the past year.
Chief Complaint
"My work performance has declined because I have a tremor makes it difficult to type on the
computer, and I am slower with most tasks."
Physical Examination
Gen: The patient is a Caucasian woman who appears to be her stated age but with minimal
hypomimia.
Vs: BP 118/74 mm Hg sitting, 116/70 mm Hg standing; P 70 bpm; RR 13; T 36.8°C; Wt. 53 kg,
Ht 5'2"
Skin: Small amount of dry yellow scales in her eyebrows
HEENT: Decreased facial expression, decreased eye blinking; PERRLA; EOMI
Neck/Lymph Nodes: Supple, no masses, normal thyroid, no bruits
Lungs/Thorax: Clear, normal breath sounds, CTA
CV: RRR, no murmurs, no bruits
Abd: Soft, nontender, no palpable masses
Ext: Normal peripheral pulses and postural stability. No CCE.
Neuro: General neurologic exam intact, mentation, behavior, and mood WNL. Mild trouble with
handwriting, cutting food, tremor, and dressing [putting on nylon stockings and buttoning small
buttons]). She has no obvious problems with gait. She has some reduced arm swing on the right
when she walks. mild problems with facial expression
Questions to Consider:
What would you include in your differential diagnosis? (What can be going on)
What does your work up include? (Other questions you would liked answered?)
What is your PLAN? (Medications, further testing, referral, etc..)

3. Midterm Cases
Case #3
Chief complaint: “When I woke up yesterday my legs felt so stiff, I could barely walk. My
hands shake every time I try to paint. I feel uncoordinated, exhausted, and just not like myself
lately.”
History of present illness: Ms. N.S. is a 29 yo white female, came to clinic complaining of
frequent episodes of weakness, fatigue, and a tingling sensation in different areas of her body.
She states she first started noticing symptoms about 2 weeks ago and has been feeling
progressively worse. Patient has also reported some urinary frequency, but she has been
attributing it to her recent childbirth.
Past medical history
o Tonsillectomy, age 5 years
o Epstein-Barr virus, age 14 years
o Reports a “precancerous mole” that was removed at age
18 years with no complications
o Gave birth to first child 3 months ago with no
complications
Pertinent family history:
o Mother alive and healthy at age 58 years
o Father alive, patient reports he takes medication for
blood pressure but otherwise is healthy at age 59
years
o Patient has no siblings
o Maternal Aunt alive, living with multiple sclerosis, age
54 years
o Paternal grandfather died after suffering a stroke 2 years
ago
Pertinent social history:
o Former smoker, patient quit at age 23
o Recently moved to Columbus, Ohio from Toronto,
Canada
o Social drinker with approx. 1-2 alcoholic beverages per
week

4. Midterm Cases
o Patient is an artist, enjoys going to the gym 2-3 times per
week, and is currently working part time in an art
gallery
o Patient likes being outdoors and states she recently
returned from a several day hiking trip
Allergies:
o None known to patient
Medications:
o Pt states takes Tylenol “occasionally only for
headaches”
Focused physical exam:
o Height 5′ 6″
o Weight 135 lb.
o Skin: clear with no lesions or rashes
o Heart Sounds: S1, S2 Regular
o Lungs: Clear in all fields, respirations regular and
unlabored
o Abdomen: Soft nontender, active bowel sounds. Pt
reports last BM was this morning.
o Genitourinary: Patient reports urinary frequency, states
urine is clear and yellow with no foul odor
o Patient is alert, oriented x 4 to person, place, time,
situation
o Pupils are equal, round, and reactive
o Strength equal bilaterally in all extremities, patient has a
slight intention tremor present in both hands
o Patient reports feeling “pins and needles” in her left and
right lower legs
o Distal pulses are palpable in all extremities with no
abnormalities
Vital Signs:
o Temperature: 37.0 degrees celsius
o Pulse: 60

5. Midterm Cases
o Respiratory rate: 18
o Blood pressure: 108/76
o Oxygen saturation: 99% on room air
o Pain: 0/10 pt states: “No pain, I just feel tired and my
legs are tingling”
Lab Values/Imaging:
o CBC: unremarkable
o Antinuclear antibodies (ANA) test: negative
o Enzyme-linked immunosorbent assay (ELISA) test:
negative
o EKG: NSR
o Urinary analysis: unremarkable
o Urine culture: pending
o CT Scan: unremarkable
o MRI with IV contrast: results are positive
for inflammation in areas of the brain and spinal cord
What would you include in your differential diagnosis? (What can be going on) -- what
clues do you observe?
What does your work up include? (Other questions you would liked answered?)
What is your PLAN? (Medications, further testing, referral, etc..)

6. Midterm Cases
Case #4
Ms. Smith is a 63 y.o. patient that presents to your urgent care office today with a
history of coughing and wheezing for the past 5 days. Originally, she thought she was
getting a cold; however, her symptoms have been getting worse, and she states she
has never felt this "wiped out" from a cold. She has come to see you today because she
feels like she has become more short of breath over the past 24 hours.
Ms. Smith is triaged to a room, and the nursing assistant takes her vitals.
BP: 110/80, HR: 96, RR: 26, T: 101.6, SpO2: 94%, Ht: 5'5", Wt: 130lbs
HPI:
You go in to see Ms. Smith. She tells you that she started feeling sick approximately 5
days ago. It started with a dry cough; however, over the past couple days she has
expectorated some clear, and more recently, thicker rust-colored, mucous. She denies
frank blood in her sputum. She notices some wheezing after coughing spells. This
morning, Ms. Smith woke up in a "coughing fit" and she said she felt some sharp pain in
her chest. She rates the pain a 5/10 when it occurs. Ms. Smith has felt feverish over the
past few days; she sometimes gets the "chills." Her highest temperature was 102
degrees. She has taken Tylenol 650mg prn for fever with some relief. The last time she
took Tylenol was last night before bed. She has been increasingly fatigued over the past
several days; she states she feels like she was "hit by a bus." She denies headache,
nausea, vomiting, and diarrhea. Her appetite has been decreased ever since she
started feeling sick.
ROS:
Patient complains of increasing fatigue and malaise. Denies recent weight loss/ gain.
Denies headache, sinus pressure, changes in vision/ hearing, eye/ear pain, dizziness,
vertigo, and neck tenderness. States throat feels scratchy from coughing. Denies
palpitations, syncope, each bruising and bleeding, and edema. Feels short of breath at
rest after coughing and with activity. Denies history of lung disease including asthma
and COPD. Denies abdominal discomfort. Denies history of mental illness, including
anxiety and depression.
Past medical and surgical history: osteopenia (2011), hypertension (2004);
had hysterectomy at age 41 for uterine fibroids. Denies recent
hospitalizations. No known exposure to illnesses.
Allergies: denies allergies to food and medications; states she might have mild
seasonal allergies, but this has never been diagnosed
Medications:
Medication/Dose/Route Time/duration
Tylenol 650mg PO Q4-6 hours prn
Lisinopril 10mg PO Q day

7. Midterm Cases
Calcium 1000mg and Vitamin D 800
units PO
Q day
Social history: Patient works as a bank teller at Chase full-time. Lives at home alone;
husband died from MI approximately 10 years ago. Not currently sexually active. Has 2
children that live out of state. Tries to walk for 15-30 minutes 3-5 days a week; however,
has not been walking recently related to being sick. States she drinks wine occasionally
on the weekends. Denies use of tobacco products and recreational drugs. States she is
a never-smoker.
PE
General: Patient appears in mild distress from persistent cough and voice sounds
congested. Appears fatigued. Adequate hygiene and posture; generally healthy for age
except for recent illness.
Head and neck: Hair is evenly distributed over scalp, no alopecia or nits. Face and
neck appear symmetrical. Skin is dry and intact except for mild errythema around the
nasal folds, no drainage, crusting, or lesions visualized. No c/o pain/tenderness upon
palpation of frontal and maxillary sinuses. No cervical lymphadenopathy palpated.
Eyes: Skin around is eyes pink, dry, and intact without edema. Conjunctiva pink and
moist. Sclera white, capillaries intact. PERRLA. Red reflex visualized bilaterally with
ophthalmoscope; retinal background is yellow, capillaries are well-defined without
evidence of hemorrhage; no bulging or cupping of optic disc visualized bilaterally.
Ears: Skin is pink, dry, and intact without edema. Denies tenderness upon palpation.
Ears visualized with otoscope; ear canals are pink, dry, and intact with mild cerumen;
tympanic membranes are pearly gray, no bulging or discharge visualized.
Nose: Symmetrical, midline of patient's face. Skin slightly errythematous under folds.
Nostrils patent bilaterally. Nasal mucosa and inferior turbinates errythematous, moist,
and intact bilaterally. Mild amount of white nasal drainage visualized.
Mouth/ Throat: Lips are pink and mildly chapped. Oral mucosa, tongue, gums, and
teeth intact. Posterior pharynx mildly errythematous with some cobblestoning; uvula is
midline. No tonsillar edema visualized.
Lungs: Chest expansion symmetrical, respirations appeared unlabored and even.
Intermittant moist cough followed by short periods of tachypnea. Resonance percussed
over upper chest; area of dullness percussed over right lower lobe. Increased fremitus
palpated in left lower lobe. BS are clear bilaterally in upper lobes. Expiratory wheezing,
rales, and diminished BS auscultated right lower lobe. BS clear and diminished in left
lower lobe.
Heart: Heart rate and rhythm are regular. No murmurs, clicks, rubs, or adventitious
sounds auscultated. Skin in all 4 extremities is pink, warm, dry, and intact.
Preliminary labs:
Comprehensive Metabolic Panel:
Gluc: 93 mg/dL
BUN: 18 mg/dL
Creatinine: 1.05 mg/dL

8. Midterm Cases
eGFR: >60 mL/min
eGFR-AfAm: >60 mL/min
Na+: 139 mmol/L
K+: 4.4 mmol/L
Cl-: 107mmol/L
CO2: 33 mmol/L
Ca++: 9.2 mmol/L
Gap: 12
Osmo: 281 mOsm/kg
ALT: 33 IU/L
AST: 17 IU/L
ALK PH: 77 IU/L
What would you include in your differential diagnosis? (What can be going on)
What does your work up include? (Other questions you would liked answered?)
What is your PLAN? (Medications, further testing, referral, etc..)