PK's CCS cases... First wk of march

CCS 1)… a 13 yo female came to office with mother with c/o increase amount fo bleeding and weakness. . Period are heavy from last two time. C/o back pain and taking some NSAID. Feeling week and some pale.
H/o of father bleed excessively in past during dental extraction. Two brothers are ok.
My provisional Dig was VONWILLEBRAD DISEASE.
I will briefly tell what I did and where I found problem with soft wear of CCS.
1) CBC, Preg teat, ua, sma7. pt, ptt
2) result shows anemia Hb 8, pt normal ptt slightly elevated and preg neg.PLT ok. I ordered BT , factor vllI, Xi, von willibrad factor, transfer to hospital. Repeat Cbc in 2 hours . IVF, type and cross
3) BT was 17, I started DDAVP cryopreccitate, transfuse one RBPC.
4) Pt ok in in next 6-8 hors bleeding reduced and feeling better.
5) could not DC pt but advised general counseling age appropriate and counseling to brothers, watch for bleeding in future, avoid ASP. etc


CCS 2 )a 45 yo male. MVA. No seat belt, steering broken, no loss of consciousness pt breathing ok, pain on chest bruised, conscious.
My initial impressions was Cardiac temponade or Aortic rupture.

1) Did ABC, IVF, oxygen, cervical spine precautions,
2) cbs,EKG, , sma7, pt , ptt, blood alchol level, xary chest, aary extremites, spine, abd xray et, VS, m onitoring. Pain killer
3) chest xray sternal fracture, all ok, pt some SOB and distress,
4) Ct chest, called ortho,
%0 orths said no intervention needed, Ct showed fluid in pericardial space
5) stat pericardiocentesis, admit to ICU, monitoring,
6) pt got better. Next day much better
Again time is very short in CCS , I could not do repeat CT or DC pt . B/c when we orders so many thing its take time to see result and by the time case end.
7) Did some counseling, seat belt, age related and etc


CCS 3 ) 7 yo Black kid with arm pain, chest pain, fever, mild distress ( office )

pt know case of sicke cell disease and on prophylactic penicillin and had pnumo vacine.
1) cbc, sma7, ua, chest xray , ul abdomen, LFTs, bilirubin, ivf, oxygen, meperidine.
i did not order peripheral smear or Hb electrophoresis as knowing that its known case of SSD and we are going to see sickle cell.

My prov Dig was SICKEL CELL CRISIS AND ACUTR=E CHEST SYNDROME
2) Hb 7, last was 8.Transfer to hospital with continue oxygen , meperidine iv, cefatriaoxne , IVF
# pt better next day. Dc iv meperidine, started PO ,
3) advised Hydroxyurea and hydration. )-
Again it’s hard to keep track with time of soft wear and to understand when to dc drug or dc patient.
4) did some counseling with drug adherence, hydration Dc cefatrione and stated PO, was already on PNC and vaccine.


CCS 4)A 35 you hispanice female, s/p repair of femur fracture, next day nurse said

UOP 80 cc in last 8 hours. Pt ok but c/o some pian.
Other exam ok. pT IS ON SOME CEPHALOSPORIN( PROBABLY CFOREXIME AND SOME PAON KILLER which was not apparent NSAID, was like phenylpyrazone ?? ot Meperidine ( dont remember exactly).
MY PROV DIAGNOSIS WAS ATN

1) did initial labs, Urine cretainne, urine essinophil, urine sodium ( did not do FeNa) .
2) there was granular cast an dno leukocyte, so I ruled out interstitila nephrits and urine NA was 45.BUN 28 and cret 4.5
I was sure its renal Failyre due ti internsic problem and culprit is eigther cefalo or pain killer. Iwas not sure pain kille ris NASAID or not so i d/c cephalosorin.
I am not sure I idi right or wring. I checked and idi not see cehlao cause ATN, they cause nepfrits.
3) continue with Frusemide and fliud and some basic counseling
Tried to counsel to avoid nephrotoxic but could not.
Final diagnosis I made ATN and Renal failure.

CCS5)57 yo WM c/o mild cough , no other symptoms,no weight loss, h/o smoking but quit 3 years back, mild fever.
Chest exam with decrease BR on left base
My initial impression was b/w CAP or cancer
1) stared with simple test CBC, sputum gram stain. ua, chest x-*** .eat,
CBC with wbc high, net, chest xray with lft lower consolidation and sputum with big amount of fram pos cocci.
I treat with Azithromycn, cough syryp and f/u in one week . also orders sputum c/s
2) did not get well in 10 week , c/o some blood in sputum. . Did Ct chest anf found mass at l lung.
3) request bronchoscope , consult oncologist and
diagnose os Post obstructive Pneumonia and Lung cancer.
By bnthe time case finished.

CCS6 ) A 72 yo with mild progressive SOB, hx of HTN and MI , on enalapril , office, PND and otherwise ok.
On exm am some b/l pitting edema and no JVP or other s/s of acute heart Failure or Pulk edem a.

My prov diaganois was Con hear failure sec to HTN or IHD
1) CBC, Sma7. cxr, ekg , echocard, lipid.etc as an out patiet.
2) results showed hyertrophy, axis dev, akinasia , EF was not given in report.
3)staresd on next vist in 3 days, HCTZ and Digoxi, coucseeling few things , low sad, ,ow choles, exercise, complaince with drug and f/u in 2weeks.
4) pt was better, I chked sma 7. ( I did mistakes and forgot to see Dig level but there was no /s/ of tyoxixity) pt was better.
4) f/u in 4w, and 3 monts pt better.
Final Diag CHF ( I did not add B blocker b/c was not sure about EF and he was already on ACE inhibitor. For got to add ASA too.

CCS7 ) a 45 yo IV drug abuser, fever, SOB, track marks
My initil impressin was Acute bac endocarditis ( like every one wil do)
1.ivf, oxygen, orders initial test , Bloob c/s, cxr, cbs, urine tox, hep pannel , VDRL, etc
2) started on iv nafficilln and genata.
3) admitted to ICU ( I don’t know floor was better, let me know)/with cardian monitoring.
4) did not get temp down next day. Cont AB and send another set of Blood c/s. consent for HIV test. orders Echo, showed, vegetation on TV.
again its very hard to keep track of pt and what test to order here. its theoretically looks easy but soft wear is strange. May I did not do much practice, but I did practice. I could not see result of V Blood c/s in one week. Time was running.
So I changes AB to Vanco and Genta b/a pt was still having fever.
5) did some counseling, safe sex, druge ete etc, HIv test idi not came bacj but hep and vdrl was negetaive.

My Final Giag wae Av cute Bacerila Endocraditis, I did two important step like blood c/s and start AB before result which are life saving. I did know this is what USMLE want to see or to manage case entirely which was difficult for me.
4) in one week pt temp same


CCS8) 35 yo legal assistance female with non bloody diarrhea
weakness and pain in RLQ,
My initial impression was, CROHNS disease
1) did usual lab after IVF. LFT, CBS, PT, stool ova nd parasite, c/s, sma7.iron study, b12, FA
2) bi2 was low, iron very low anemic, mass on RLQ, abd series ok.
3) did barium ( upper GI) some time we can do colconscopy or sigmiod, I choosed to do Barium
, admit to ward, NPO, TPN, B12, Iron,
4) barium neg , did colon scope showed ileum with cobble stone pattern no mucosa infalmed.
5) stated Masamine and predinisone and all nutritional aids.
6) counseling few things, high fiber diet. and drug compliance and education.
could not f/u or DC . It was chronic problem , to DC pt and f/u . B/c management takes time and every case finished in1-=20 minutes or earlier
Finla Diag was Crohns disase
I mean I could not see how pt did and long term follow up . How much it is imporant in CCS. ??


CCS9) 45 yo female with discharge/ itching came to office other wise healthy

healthy and lst pap smear was 15 months back and normal
My initial Impression was Bacterila vaginosis
1) did preg test, ua, koh preo, wet mount smear, CBC
2) showed no huphes ar trichomonoas and lot of clue celle
3) treated with Meteo gel
4) Pt was happy in next 10 days.
5) Schedulled Pap smear and mamogram in next mont ( to get rid of infaction.
General couselling.