USMLE Step 3 CCS

[Anonymous]

Someone Named anonymous's CCS ( posted jan 2003)

1- polycystic kidney disease: 50 y.o.w.m with PMH of HTN presented with mental problem (I dont remmber). I did UA, sma7 and then Echo which was diagnostic. hemodialysis..
2- angioderma: shellfish with edema in face and lips and SOB. epineph and o2...discharge.
3- pneumonia (60 y.o.w with right upper abdominal pain had URI three days ago): CXR and erythromycin only!!!!
4acute diverticulitis (50 y.o.AA.w. with left lower abdominal pain, no Occult blood), exam abdomen and rectum only!, showed mass, KUB: dilated loops. metro and cefotaxim and sendf home on diet.
5- chf with sob, R/O MI and supportive care and add HCTZ for his regimen which included aspirin and ACEI.
6-dmII (tricky). prostate problem in a 60 y.o.m presented with thirst and improved urinary problems.. glucose only...350.. workup diet and other junk staff and send home and F/U...The only thing happen in this case that he was still thirsty which i called him in and hydrate him..and then all massges were ok.
7- sickle cell anemia with chest pain. supportive ICU and hydroxyurea.
8- HTN, stage I: AA boy wants to be involved in football teem HTN repeat and repeat....then diet, smoke alcohol, drugs.... improves over 3 months...and happy!!!!
9- pid classic easy.

I knew the dx right away and I ordered only related tests. no patient had any complain. All massages were positive. I did the best cost effective approach.
If I pass I would tell you what to do.
good luck for all of you. It is really a good forum, three of my cases have been posted here before exactly the same story which helped a lot.

[Anonymous]

CooL's CCS cases from Past year ...

1)ectopic pregnancy
2)perforated PUD
3)Anginal pain
4)Fe deficiency anaemia in pregnancy
5)Vaginal discharge,culture negative
6)known NIDDM with c/o lethargy,leg pain?
7)PID
8)ITP
9)postmenauposal female c/o of hot flashes
10)Tension pneumothorax

[Anonymous]

very nice solved 9 CCS cases , posted by a nice fellow

1. 55 yr old black woman with fatigue, weight gain, loss of lat third of eyebrow, obese and other nonspecific signs/sy presented to office (got a sense of hypothyroidism)--------did cbc, tsh(don't jump right away to whole thyroid function test as tsh is cost effective compared to whole thyroid pannel....if tsh comes abnormal then do whole thyroid pannekl), comprehensive met pannel,ua and ana...tsh was high so ordered whole thyroid pannel which comfirmed hypothyroidism......so started on levothyroxine and scheduled wk f/u appt....now i also ordered ekg (h/o obesity and slight elevated bp) then i struggleed about ordering about cxr but didn't instead preferred to order lipid profile(i was very ambivalent about ordering lipid profile in this guy from cost effectiveness/expense/unncessary vs necessary test etc) but surprisingly this guy had bad lipid profile so advised him low cholesterol,low fat, and low na(highbp) diet, exercise pgm, etc.....i also did stool guiac as part of yearly exam in this old pt but it was negative.......case ended on time and when 5min left screening warning came, i ordered repeat tsh (to make sure,it is going down)

2. 60 yr old african american pt with h/o arthritis and s/p chronic aspirin therapy presented to office with c/o fatigue(firsth thing came in mind was peptic ulcer dz vs gastritits)..........ordered cbcd, lyte plus, tsh,ua.......normocytic normocho anemia with slightly low h/h........did upper barium study came negative......pt was feeling still same.........started on famotidine and advised to stop aspirin.......ordered couple days f/up and ordered gasstroenterology consult......still no improvement......then finally did endoscopy......and result was positive for erosive gastritis.......i continued famotidine(she was taking antacid with marginal relief), advised to quiet aspirin, quiet smoking, quiet alcohol, started her on acetaminophen for pain and case ended...........( also advise this pt about routine self breast exam, exercise pgm, mamography, advanced directive etc......Keep these age appropriate counselling in mind for every case ... cash extra few positive points.......always give pt opportunity to discuss about advanced directive....i this is new medicare and medicaid requirement and it is a law that hospital/clinic discuss advanced directive issue with all pt irrespecitve of their age)

3. 18 months infant presented with wheezing/coughing for six hours (knew right away foreign body apiration).....started o2, iv access, cbcd, bl culture, lyptes, pulse ox, abg.....ordered cxr portable.....ordered pulmonology consult(u can ordered either pulmonology or cardiothoracic surgery consult for bronchoscopy)......message reads continue managing pt...no additional comments.........ordered endoscopy.......pt felt better.......transferred to ward.......ordered clindamycin first iv and then oral therapy(for postob pneumonia)........pt got better..message read peanut was revealed in bronchoscopy........case ended on time.....(i forgot to order postbronchoscopy material for c/s as per std textbook instead started clindamycin empirically)

465 yr old man with unilateral headache/tenderness.......classic case of temporal arteritis......ordered cbc, tsh, esr, lyte plus......esr was 100.....started on prednisone......ordered f/u appt and gave age appropriate counselling.....case ended

5.yound woman brought in unconscious with bradycardia, hypotensive and pinpoint pupils classic case of narcotic od.......ordered oxygen, iv access and gave triple combo (thiamine, dextrose 50% and naloxone-all are iv bolus one time dose)......pt got awake.(Don't go first for physical exam in this case. Unconsciousness/unstable pt warrants urgent treatment).....i then did brief physical of 3min......meanwhile i started her on normal saline, did cbcd, lyte plus, ekg 12 lead, cxr portable, pulseox, ekg monitoring, ua, urine drug scrren, blood alcohol, blood aspirin and bl acetaminophen level, ordered gastric lavage(which revealed pills fragments).......started naloxone drip.....transferred to icu..at one time i have to start here ng tube and intubation...........she eventually got better......transferred her then to ward...........ordered psy consult, advice for relaxation techquine to ease with stress ........(now can u belive what big mistake i did.....i had overdose protocol in my mind and i was writing all orders as it popped out of my mind......there i ordered charcol along with gastric lavage...this was big blunder........but surprisingly pt got better......i imagine i have her already on intubation.....even with this big mistake CASE ended peacefully)

6 young girl with fever, headache and generalized maculopapular rash of one day onset..........classical case of toxic shock syndrome......ordered symptomatic rx...admitted and ordered cbcd, urine pregnancy, gono/chly vag culture, bl culture, cbcd, comp met pannel, ua ....started her on iv oxacillin and then oral dicloxacillin.....pt got better (now in physical, it read "tempon removed")..........still i go ahead and wrote remove tempon(computer has this order in storage)......did contraception, drug, alcohol, smoking, safety counselling being teenager. In the case i was confused about one thing i.e. culture and sensitivity.....i was not sure where to take specimen from? so i ordered bl culture, vaginal stapyloccoal culture, and then tempon c/s (someone can help with this issue).......case ended appropriately

7. 55 yr old immigrant psychiatrist came in with classical sy of pul tb------hemoptysis, wt loss, night sweats............so did cbcd, ppd, cmp, ua, sputum afb smear, tb culture and pcr test.......(afb was negative.....pcr came positive after couple days)......pt was in office.......i wanted to order resp isolation but computer won't accept it and same token case was not appropriate for admission as she was young and independent and relatively healty......now i wanted to do sputumx3 (practical and theoritical approach) but computer won't accept it 2nd time).....ppd was 12mm, cxr revealed upper apical infilt/cavity........started her on inh, pyridoxin, rifampin, etham....ordered f/u appt with f/u sputum study.......orderd inf/pneum vaccine, multivitamin/notify health dept........i also did hiv counselling in this pt.........other things to check......hep b surface antigen........( lady was not drug addcit so i didn't do rpr)

8 one case was 50 yr old guy with symptoms of dka, abdominal pain......treated as dka but case kept dragging on and on........

9. s/p mva, s/p internal fix of tibia # in 50 yr old guy in inpt setting.......nurse runs with c/o decreased urine outpt.........case of acute renal failure..........treated this case as mva.....don's assume that this pt has everything on place......start with abc....o2, iv ring lac, foley cath, spine, cxr, pelvi xray...........orderd abg, ua, lyte plus.......significantly low calcium, and k was 7.5.........ordered calcium chloride, ekg 12 lead and cont monitor......case ended exactly at 14min.....diagnosis.........arf/hperkalemia/hypocalcemia......

impt points:
1. first always decide pt is stable or unstable.....if unstable/unconscious start treatment first and then do physical..........
2. it takes 2-3 min to load pt.........i was scared becasue in all my pts, it was either 3rd or 4th min when i was able to wirte first order.......i think one has to be patience as computer takes little while to load info
3. always do age app counselling....
4. think twice before u write any order......think about cost/necessity/futility/whether it will change your mx (like always go first with tsh and then order whole pannel......first do nonfasting cholesterol before going to fasting sample)

Do practice,practice and practice...... i have reviewed all ccs cases within last 4months from this site and practiced those couple times.........it really helped me lot in the exam......Best thing would be discuss with friend. In my case, me and my friend used to discuss everyday 5 case on the phone. while talking to eachother through cell phone, we kept our computer open and practiced on those 5 std cases. we pretended case of asthma instead of pneumothorax and wrote all ordereds/treatment of astham and watched the capability of computer and how it comes up with words........say for example while doing osteoporosis case before the test, when I ordered DEXA scan, computer doesn't recognize it but after several attempts, i was able to come up with right word"bone absorbtiometry" and computer picked up it right away so if u know this thing it will save time in real test.....thaks....

[Anonymous]

Recent CCS cases-Mid June

1) (messed up this one!) Female in Ward after surgery(joint). On pneumatic compressions for DVT proph. and LMWH. Has IV at high flow rate(overloaded). Complains of SOB. I thought fluid overload? CCF? Renal failure? PE. Did not get any results back. Case ended. I diagnosed her as CCF!
2) Female in 60's brought to ER. Found unconcious by neighbor. Neighbor said she was depressed lately.I did everything...ABC's, IV, Glucose, Thiamine, Narcan, Toxicology screen, Stomach wash. Everything negative. ILast minute I ordered CT head. It showed SAH. Called neuro, Nimodipine etc.
3)Child in office, pale, smear-basophilic stippling. Lead poisoning-Rx. Succiner. Got better!
4)Elderly genleman in office with weight loss, tiredness, hemoccult positive. CT of abdomen with biopsy-Adenocarcinoma of Colon!
5)Elderly female with similar complaint as gentleman above. However her cT was N. EGD-Showed metaplasia of some sort. H. pylori negative...I thought Barett's esophagus. I started her on Ranitidine?!
6)Child, 6 hr, on Ward, Down's Syndrome, vomiting. Duodenal Atresia. Got better with NG tube!! Consult!
7)16 yr old girl with PV bleeding. Father has some bleeding problems. All her labs except Hb. were N. I was thinking of VWD! Could not come to diagnosis-I rx. her as DUB?
8)Straightfoward case of female with ITP. Better on Prednisolone!
9)Pt with clinical picture of pericardial effusion. Pericardiocetesis-negative. ECHO-Dilated cardiomyopathy!

Hope this helps!

[Anonymous]

Another CCS posted February 15 2003

1) young female with lower abdominal pain , usg showed a ovarian cyst , consulted gynac : said will schedule surgery continue medical management .
it was torsion ovarian cyst .

2) child 6 yrs old african american comes with pain in right upper quadrant and epigastric aregion and cough : rt lower lobe pneumonia on chest xray .

3) appendicitis : rt lower quadrant pain

4) DKA in a 17 year old girl who presented with UTI symptoms . if you guys remember some body had this case and it was posted here .

5) acute bacterial prostatitis :
trucker male with low back pain and perinael pain and discomfort . asked for prostatic massage and culture of secretion : came positive for ecoli . treat bactrim .

6) alcoholic trauma patient with dizziness and abdominal left upper quadrant discoomfort rib frature : diagnosis : splenic hematoma

7) young female with vaginal discharge : acute PID

8) 53 year old female with pain in abd : sigmoid diverticulitis with abcess around the sigmoid .

9) pulmonary embolism with ccf : elderly hypertensive male with shortness of breath and history of long airtravel .

[Anonymous]

Can you send me some information on succiner. I have a child who has been diagnosed with higher levels of lead. 2.28 ppm (normal is 1.5 I believe). He also has ITP. I am seeing a Naturopath. He put him on a vitamin chelating tretment and chlorella is that enough?
Thanks
*******a

[Anonymous]

My approach:

Intravenous access, Oxygen, morphine, nitroglycerin SL, if pain persists after 3 SL, assume MI and start IV nitroglycerin, and titrate dose upwards until pain relieved). Monitor vital signs (how often, not sure).

ECG (how often), chem7, CBC, UA, Chest X ray, lipid profile
Troponin T, I, CK-MB
Stress test to risk stratify

If stable, follow earlier discussion on stable angina
If unstable, then admit the patient, prepare for coronary angiography, and consider ballon angiography with or w/o a stent in the same session.

tPA
metoprolol, IV (if no contraindications)
aspirin
low molecular heparin, IV
IIb/IIIa blockers: abciximab or tirofoban, or eptifibatide

treat any arrythmias and other complications

Admit if: new angina
accelerating angina
admit to a monitored bed.

If angiography single vessel: PTCA, triple or left main (esp. w/ LV dysfunction): CABG, double and some triple, either PTCA or CABG, if no major stenosis, medical therapy, but be wary of acute coronary syndrome still, consider stress test, if inconclusive still, consider additional stress echocardiogram, or stress myocardial perfusion scintigram. If none of these positive (inclucding ECG), investigate other organ systems.

Long term management:

Aggressive and extensive risk factor modification
Continue LMW heparin if recurrent and high risk for MI in whom revascularization not possible.
Beta-blockers: metaprolol
quit smoking,
lipid lowering therapy
ACE inhibitors

Please try to develop a better algorithm and change any sequence if you think anything I did was not in the right order.

[Anonymous]

Appendicitis





INITIAL STABILIZATION
· ABCs
· NPO
· Fluid resuscitation with LR or 0.9%NS
· Observe tachycardia and urine output

ESSENTIAL WORKUP
· Suggestive history and physical exam sufficient to establish a preoperative diagnosis and warrant surgical consultation

LABORATORY
· If diagnosis is uncertain, send labs and observe and reexamine
· CBC
· Electrolytes, BUN, Cr, glucose
· Urinalysis
· Amylase/lipase
· Pregnancy test for females of child-bearing years
· Order CT if a palpable mass is present in the RLQ to define phlegmon vs. abscess

IMAGING/SPECIAL TESTS
· Not necessary unless the diagnosis is unclear
· CXR: to exclude RLL pneumonia that may have symptoms similar to appendicitis
· Plain films of the abdomen
· Ultrasound: sensitivity 75–94%; specificity 84–94%
· CT: sensitivity 96%; specificity 89%
· Barium enema

ED TREATMENT
· Immediate surgical consult for convincing history and physical exam
· Preoperative antibiotics (cefoxitin or ampicillin sulbactam)
· Analgesics once diagnosis confirmed and patient to go for surgery

MEDICATIONS
· Ampicillin sulbactam (unasyn): 3 g (peds: 100–200 mg ampicillin/kg/24hrs) q 6 hrs IV
· Cefoxitin (mefoxin): 1–2 g (peds: 80–100 mg/kg/24hrs) q 6 hrs IV

ADMISSION CRITERIA
· Surgical intervention of acute appendicitis
· Observation and/or further diagnostic workup if diagnosis is uncertain

DISCHARGE CRITERIA
· Patients with abdominal pain thought not to be appendicitis may be discharged if
o Resolved or resolving symptoms
o Minimal or no abdominal tenderness
o Able to tolerate po intake
o Adequate social support and able to return if symptoms worsen

CONSIDERATIONS IN THE PREGNANT PATIENT
· Enlarging uterus displaces the appendix upwardly and laterally
· Hyperemesis gravidarum and other nonsurgical causes of vomiting should not cause abdominal tenderness

SPECIAL PEDIATRIC CONSIDERATIONS
· Diagnosis much more difficult. Presentations often non-specific and difficult to localize
· 70–94% perforation rate in young children (< 2 yrs old) much higher due to delays in presentation and diagnosis
· Ask when the child last ate a good meal
o Not be able to complain of anorexia
o A half-eaten meal hours before complaints of pain may more accurately indicate the duration of symptoms
· Observe the child before the examination for subtle indications of local inflammation
o Limping gait
o Hesitation to move or climb
o Flexed right hip

DIFFERENTIAL DIAGNOSIS
· Pelvic inflammatory disease
· Gastroenteritis
· Tubo-ovarian abscess
· Ovarian cyst/torsion
· Renal stone
· Meckel's diverticulum
· Testicular torsion
· Bowel obstruction
· Diverticulitis (right-sided)
· Urinary tract infection
· Cholecystitis
· Pancreatitis








Tuberculosis (pulmonary):






-CXR
-order sputum AFB smear
-if + notify health department
-if sick adm. In solation with good ventlation.
-Start 3drugs + one if high risk.
-check sputum smear and culture weekly and then monthly once test negative.
-check close contact.(PPD)
The most common presentation is of reactivation of disease in the upper lobes. Tuberculosis can also present with lymphatic disease, osteomyelitis, genitourinary symptoms, military TB, TB meningitis, peritonitis, or pericarditis. Most cases are dir to reactivation and not to primary infection.
S&S:
Fatigue, weight loss, anorexia, low-grade fever and NIGHT SWEATS and cough.
DX:
Sputum AFB smear
Is made with testing of sputum for TB culture and drug sensitivity. Less definitive is a sputum that is positive for an AFB stain. Note that non-tuberculous mycobacteria may also be AFB-positive.
Serology testing elisa is new
Treatment:
1. notify health department
2. hospitalized patient should be put in respiratory isolation.
3. if resistance is a possibility (not <4%) then patient should be treated with at least 4 drugs. Once isoniazid and rifampin sensitbvity is established, the patient can be treated with isoniazid, rifampin and pyrazinamide for 8 weeks , followed by 16 weeks of isoniazid and rifampin alone. For hiv + need to use for 9 months or 6 months beyond cluture conversion.non hiv + 3 month after culture conversion.
4. pregnant women should not be treated with pyrazinamide or streptomycin (causes deafness in fetus). The appropriate regimen here is isoniazid, rifampin, and ethambutol.
5. patients under treatment should have a sputum smear and cultures checked weekly and then monthly once they test negative. If sputum is still positive after three months of treatment, suspect either noncompliance or drug resistance.
TB drugs:
1. Isoniazide- S.E. B6 deficincy(peripheral neuritis), and hepatitis – check AST and ALT.
2. rifampin- S.E. hepatitis, and rash- check AST and ALT.
3. ethambutal- SE. optic neuritis(reversible), and rash- check visual acuty
4. pyrazinamide-SE. hepatotoxicity and hyperuricemia- check uric acid and AST , ALT.
5. streptomycin- SE. 8 nerve deafness and nephrotoxicity- check vestibular function and BUN and creatinine.
TB skin testing:
Consider a PPD positive if:
1. =>5 mm of induration in an HIV+ patient , in a contact of a known case, or in a patient with characteristic chest x-ray findings.
2. =>10 mm of induration in immigrants from an endemic area, prisoners, homeless, IV druf users, nursing home residents, or in high-risk minorities.
3. => 15 mm of induration in patients not in any of the high risk groups.
Treat with prophylatic isoniazid (300 mg for 6-12 months ) if the patient has:
1. a new conversion to a positive PPD at any age.
2. a history of untreated TB or chest X-ray evidence of a previous infection.
3. a positive PPD in a patient less then 35 years old.
4. a positive PPD in a patient at high risk for active disease
5. a positive PPD in a patient with close contact to someone with active tuberculosis.
Rifampin is also use as prophylaxis in meningococus meningitis – cipro also can be use but not in children <17 years because of bone and ligament problem. Achills lig. Rupture.
<35 yrs does not require LFT
= or > 35yrs INH use must do LFT’s (may be as high as 3x normal).










CCS..ECLAMPSIA...Real





Dos and Don'ts in this case:

(The Dos are in the software)..this case is not mentioned in the usmleworld.com..it is a real case though..

Location: Emergency

Order:

Airway suction
Intubate
Pulse oximetry
Oxygen
lateral decubitus position (available in the list..this is important to help imrove uterine blood flow and obstruction of the inferior vena cava by the gravid uterus)
NPO
NG tube
IV access
IV NS 0.9%(should be isotonic 0.9%..don't chose the hypotonic 0.45% or the hypertonic).
Foley cather
Urine output
BP monitoring
Cardiac monitoring
fingerstick glucose
dipstick urine protein
Fetal monitoring (Fetal heart sound monitoring)

Now, the immediate treatment:

IV magnesium sulphate, continuous

DON'T TRY TO ABORT THE SEIZURE BY ORDERING ANY OTHER ANTICONVULSANT ..

Hydralazine IV, bolus

CBC
chem12
urine analysis
24-hour urine protein



The patient now should be stabilized..The patient will regain consiousness
D/C intubate
D/C NS

order
Cesearan section
Consult Obs. Reason (For further evaluation and termination of pregnancy by Cesearan section).

So now prepare the patient for the operation..

Blood type and cross match
PT,PTT
Rhogam if the mother is Rh-ve.

Any additions????















Two real CCS in thyroid...Hypothyroidism 2ry to hasihmoto and hyperthyroisim 2ry to Graves..







HYPO





Location: Office..

Order:

CBC
THYORID PACKAGE 2 (available in the list)
Lipid profile
EKG, 12 lead (will show low voltage).
ECHO..may show effusion or cardiomegaly..
Lipid profile (may show hypercholesterolemia).
Thyroid scan..(to detect any nodules or infiltrative disease)..
You can also order FNA, thyroid..Fine needle aspiration is very useful in Hashimito..

After you receive the results of the above tests, order:

thyroid, anutoantibodies...recall that hashimotos is an autoimmune disease in which the antibodies destroy the tiisue causing the hypothyroidism..


Now the tx will be levo-thyroxine ORAL ..available in the list..
Advise patient (medication compliance)..
advise, diet LOW CHOLESTEROL..

Schedule follow-up after two weeks..
When the patient comes up, measure TSH level (should be lower) and thyroxine serum level (available in the list)..






HYPER....Grave's disease..








Recall that Grave's is also an anutoimmune disease but the type of anitbodies are different!!

Thyroid anti-peroxidase antibodies (available in the list)
Immunoglobulin, thyorid stimulating (in the list)

Both can be positive..

Don't forget to make ophthalmology consult...Reason (For evaluation of possible thyroid eye disease)..

In the dx studies, you can also add (THYROID IODINE UPTAKE)..


Tx

Propranolol
Methimazole or propylthiouracil...The SECOND ONE in pregnancy..

I always like propylthiouracil..becuse methimazole has many s.e. like agranulocytosis and hepatitis...so I advise to stick to propylthiouracil

Radioactive iodide type (IODIDE or I 131)..NO IN PREGNANCY..
If type IODINE...will take you to (THYROID IODINE UPTAKE)which is a diagnostic study..not therapeutic..becareful..

SUBTOTAL THYROIDECTOMY is the last resort...

Recall Lugol's solution in Thyroid storm..


I hope these help..















lung cancer






My approach is just for the SOFTWARE!

Scenario: weight loss/hemoptysis
Location: OFFICe

Order:

CBC
CXR
EKG, 12 lead (if there is chest pain!!)
Spirometry (if there is SOB)
PT,PTT,BT
BMP

Results: The CXR may show solitary puolmonary nodule...

Move to the WARD...

IF THE CHEST XARY SHOWS PLEURAL EFFUSION< DON"T FORGET TO ORDER PLEURAL TAP.....ALWAYS ORDER THORACENTESIS IN PLEURAL EFFUSION AND THEN ORDER
complete pleural fluid analysis
PLEURAL FLUID, LDH
PLEURAL FLUID, cytology
PLEURAL FLUID, glucose
Pleural fluid, protien
PLeural fluid, gram stain
PLeural fluid, C&S

BY THE WAY,YOU CAN GUESS THE TYPE OF THE CANCER FROM ITS LOCATION..IF CENTRAL.SMALL CELL CA OR SQUAMOUS BRONCHOGENIC CA...IF PERIPHERAL, ADENOCA. OR LARGE CELL CA. !!!

so order CT, SPIRAL, thoracic..SPIRAL IS MUCH MORE SENSITIVE IN LUNG CANCERS..

ALso order:
Abdominal CT..(to detect any metastasis..if any!)
*******BONE SCAN***********

BROCHOSCOPY...When you type bronchoscopy, the software will take you to the consult ..

Or you can order BIOPSY..then select BIOPSY, TRANBRONCHIAL...ESPECIALLY IF YOU SEE THE MASS CENTRAL ON THE XRAY AND CAT SCAN..

IF IT IS PERIPHERAL, TRANSBRONCIAL BIOPSY WILL BE DIFFICULT..
SO SELECT, BIOPSY..transthoracic..(this is important for the mcq)..it doesn't matter here becuase whatever route of the bx you choose, the softeware will take you to the consult..
select, consult, throacic surgery

Reason..For further evaluation,lung biopsy and ..
possible lobectomy..


SIGN YOU RECEIVE: patient is chedule for surgery..continue in the management..

Consult..oncology
consult..radiotherapy
So prepare the patient for surgery


Blood match and type
*****pulmonary function test..
*****ABG
very important for preoperative fitness evaluation....

Consult..ONCOLOGY

Reason (for possible adjuvant chemotherapy/radiotherapy)


DON"T FORGET::::::

ADVANCE DIRECTIVE
ADVISE PATIENT, LIVING WILL!!!!!!!

aDVISE..
******sTOP SMOKING*******
no alcohol



wHAT IS MENTIONED IS HOW I WAS EXPOSED TO MANAGEMENT OF PATIENTS WITH LUNG CANCER

[Anonymous]

Ectopic Pregnancy CCS






30 yrs old patient comes to the ER with Lower Abd Pain/Mass

Initial Orders :

.Pulse Ox

.IV Access

.Urine HCG

Interval History :Gen Exam,CVS,RS,Abd,EXT,Pelvic

Further Orders :

.CBC

.SMA7

Obtain Results of HCG------> +

Further Orders :

Pelvic Ultrasound

Obtain Results of U/S-------> Ectopic Pregnancy

Further Orders :

.PT/PTT

.Type and Cross Match

.Blood Type and Rh Factor

.Patient's Consent

.Anesthesia Consult

.OB Consult-------------> Case is Accepted for Surgery

.5 MINUTES WINDOW APPEARS

.FINAL DIAG : Ectopic Pregnancy


Final Message Appears : Thankyou FOR TAKING CARE OF THE PATIENT











Acute pancreatitis





Here are my tips..ACCORDING TO THE SOFTWARE

Location: Emergency

After the P/E..order:


FIRST....ARRANGE THE PATIENT FOR YOUR MANAGEMENT!!
Don't order iv Normal saline before the iv access

iv access
pulse oximetry
NPO
NG (select NGT, to staright drain...Recall you have to bowel decompression!)
Foley catheter
Urine output
complete bed rest

NOW THE PATIENT IS READY TO RECEIVE WHAT YOU WANT TOGIVE ..SO GO AHEAD!
IV Normal saline 0.9% (to support the circulation)..DON'T ORDER D5W% AS THE PATIENT MAY HAVE HYPERGLYCEMIA ..PAY ATTENTION TO THE TYPE OF THE IV FLUID!!

The patient in pain..so relieve the pain!!

IV percocet (OR IV meperidine)..Recall that morphine iv is a serious mistake..you know why
NO NEED TO GIVE ANTIBIOTICS UNLESS THE PATIENT HAS FEVER. IF SO, THE ABS OF CHOICE ARE IMPENEM/CILASTATIN..

iv Zantac..to prevent stress ulcer!!
iv promethzine or phenergan (anti-nausea!!)

BEFORE YOU MOVE THE CLOCK AND WITH YOUR INITIAL MANAGEMENT, ORDER THE LAB WORK:

CBC
SAM 12 (or CHEM 12)

SAM 12 incluses the Liver function tests , electrolytes, renal function tests and glucose but not amylase and lipase!..so order them separately..

SERUM LIPASE
SERUM AMYLASE
crp(c-REACTIVE PROTIEN) AND ESR

THEN..MOVE THE CLOCK..

Now you stabilized the patient and it is the time of identifying the cause of the disease..so let's go to the imaging studies..What will you order??

THREE STUDIES USUALLY ORDERED TOGETHER:

Abdominal xray ..you may see sentinel bowel loop (dilated bowel loop near pancreas)..

Abdominal U/S..very important to see any gall bladder stones..

Abdominal CT scan...to detect the extent of pancreatic inflammation and development of seuelae of pancreatitis...

Move to the ward..

D/C NS
D/C NGT
but continue NPO, urine output!!

Order
D5W NSS
bed rest with bathroom privilages
Go to the interva/ follow up history and examination..to see how is your patient!!
order again..the amylase, lipase and BMP (or chem 7)

move the clock for one day..

D/c D5W
order diet, high liquid
advise
**ABSTEIN** alcohol intake
smoking cessation
no illicit drugs



Move home..

Follow-up after one week

When he comes back, order bmp , lipase and amylase

before you exit the case, if the patient is female..order FOBT, mammography, pap smear as routine health tests ..make them after one year..

let's make ccs rediculously simple


Remeber RANSON CRITERIA!!! IMPORTANT TOPIC










CCS..ECLAMPSIA...Real





Dos and Don'ts in this case:

(The Dos are in the software)



Location: Emergency

Order:

Airway suction
Intubate
Pulse oximetry
Oxygen
lateral decubitus position (available in the list..this is important to help imrove uterine blood flow and obstruction of the inferior vena cava by the gravid uterus)
NPO
NG tube
IV access
IV NS 0.9%(should be isotonic 0.9%..don't chose the hypotonic 0.45% or the hypertonic).
Foley cather
Urine output
BP monitoring
Cardiac monitoring
fingerstick glucose
dipstick urine protein
Fetal monitoring (Fetal heart sound monitoring)

Now, the immediate treatment:

IV magnesium sulphate, continuous

DON'T TRY TO ABORT THE SEIZURE BY ORDERING ANY OTHER ANTICONVULSANT ..

Hydralazine IV, bolus

CBC
chem12
urine analysis
24-hour urine protein



The patient now should be stabilized..The patient will regain consiousness
D/C intubate
D/C NS

order
Cesearan section
Consult Obs. Reason (For further evaluation and termination of pregnancy by Cesearan section).

So now prepare the patient for the operation..

Blood type and cross match
PT,PTT
Rhogam if the mother is Rh-ve.

Any additions????




That was great!BTW, should we include fundoscopy in the work up?













practice ccs like this : if u want to score Good and be safe in exam





A 57 yo male comes to OFFICE with complaints of fatigue, lethargy, appears pale and slow
patient drinks 4-5 glass of wine dialy at dinner. past hx is positive for smoking.

THIS IS JUST A SAMPLE NOT 100% ACCURATE ( ONE CAN DO MINOR CHANGES ACCORDING TO THIER WISH )

#1

FIRST PHYSICAL EXAM:
general APPEARANCE,heent, CHEST/RESP, ABDOMEN, EXTREMITIES, RECTAL

in EXAM RESULT U WILL SEE THIS : pale appreance, FOBT( fecal occult blood test) negative.

rest of the exam is normal


#2 ORDERS:

CBC with diff
SMA12
UA
TSH ( PT HAve symptoms like hypothyrodism )
FOLIC ACID ( patient appears anemic and hx of alchol use)
B12 ( same reason as above )
CHEST XRAY

DISCHARGE PT HOME WITH F/U IN 2-3 DAYS
before dc .. console patient, reassure pt .

WHEN PATIENT WILL COME BACK TO u FOR F/U BY THAT TIME U WILL HAVE LAB RESULTS AVILABLE:

THESE ARE THE RESULTS:
CBC = HG 10 hcT 32 MCV 108
folic is less then normal
B12 is normal
rest of the labs are fine
if this anemia was IRON deficiency and FOBT was positive in exam, U wud have done COLONOSCOPY definately but in this patient both findings are absent

now START TREATMENT :
prescribe FOlic acid
prescribe multivitamins
advise avoid alcohol
advice some other health maintance stuff.

DC patient with 2-4 wks f/u

now when patient will come back he will say he feels better, improved energy, drinks less but continues to drink on and off

this visit
repeat CBC.
consider influnza vaccine
consider TD booster if he is due
advice safety, discuss advance directive etc etc

DC patient again with 4-6 wks f/u

MOST likely your case will end here

U will see 5 minute screen.
here u will recommend

AA groups if he is still drinking
some other advice,

avoid drinking and driving etc etc

FINAL screen
diagnosis = folic acid deficiency anemia secondary to alcohol abuse

THE end.



NOW THE WHOLE POINT OF THIS CCS presentation is ... PRACTICE CCS cases like this seperately DONT mix this with ur MCQ's.....Best way is to have a clear plan of most often repeated CCS in your mind before u start.

CCS cases are more anxiety provoking while U are preparing for exam BUT in exam these are MUCH MUCH easy then u can imagine, if u Know the RITUAL of what to do.
its like VIDEO games if u practice the game/scenario , u will know where the next bullet is gonna come from.

IF u do this... most ccs cases will run smooth

Thanks for the wonderful advice, I have a question, lets say his fobt is postive, now the next test is colonscopy, now would you send him home and have him come back for colonoscopy and how do you prepare him for colonoscopy like bowel prep, golytely etc. thanks friend


Re: practice ccs like this : if u want to score Good and besafe in exam


for colonoscopy u will do the same, send pt home, let him come for follow up, and Type colonoscopy.


we dont have to prepare for CCS purposes

lets say u did colonoscopy , wich came positive, with cancer, u can still send the patient home with orders like this, consult GI / consult oncology/ consult surgery

(type this in consult request..57 yo male with abd pain, fobt +, anemia, biopsy + for adenocarcinoma of colon plz evaluate pt.)
they will say ,,, manage pt urself , if problem arises consult again.

dc pt home , f/u 1 wk, now admit pt to WARD... request surgery consult, then prepare for surgery like this:

IV access, iv fluids, NPO, type and cross match, PT/ PTT/ coagulation profile, FOley cath.

NOW order COLONECTOMY or COLON resection

case will definately END here


sorry i missed this


before surgery U wud like to do CT abdomen and chest xray .... for staging / MEtastasis




*********************


Hispanic lady of 35 yr coming to your office because of left chest pain. She has blues & says she fell.
CXR shows Fx of rib. suddenly she cries & says she has been abused by her husband.
Things I could do:
CBC, Pt, Ptt, CXR,
Tylenol
Counsel, safety plan
Counsel, educate patient!

Questions:
How to ask her to report the abuse herself?
How to ask her if the children are being abused?
How to ask her to put end to the abusive relation, that it would get worse if she doesn't leave, that the abuse is illegal, that it's not her fault.....

Please put your thoughts here. Exam in a week.
Thanks,
Sean

First you have to tx this pt with pain medication for her rib fx if her vital sign is normal

Work-up based on hx:
agree CBC, Pt, Ptt, CXR,
add to: EKG for R/O Myocardial contussion.
agree: Tylenol, may be need stronger than this, such as codeine...

Counsel, safety plan
Counsel, educate patient!
maybe age related health exam..

Questions:
(1). How to ask her to report the abuse herself?
ans.: you don't have to ask her to report spouse abuse, she make her decision whether she want to report or not. b'coz she is competent..

(2). How to ask her if the children are being abused?
Ans.: if she has a child(ren), type child protective consult..

(3). How to ask her to put end to the abusive relation, that it would get worse if she doesn't leave, that the abuse is illegal, that it's not her fault.....
ans.: you can ref (counsel) her to victim shelter and consult to social worker..





***********************
FEW complicated ccs cases recently appeared in exam:



we all know the case of child abuse but this is how it was presented

A 2 yr old kid brought to the er, he was found unconsious at home, mom said he was unconsious for 45 minutes, per mom he fell down the stairs and got a bruise on the head.

kid was very anxious in exam, mental status exam and neuro exam within normal range

phsycial exaination revealed brusies in arms , legs and abdomen,


this question can get easily confused with


3 scenerios?

1

off course everyone will think it may be INTRA cranial hemmorage with loss of consiousness,,

u do CT wich will come negative , so this is out fo the diffrential

2

now one wud think maybe he was some kind of bleeding disorder by looking at bruises all over the body

3

is child abuse,

in this case u do skeletal survey and u will find out patient has multiple fracture in diffrent stages of healing.

von wollibrand factors ,factor vIII all negative in lab

in this case u admit the patient to the floor, get social worker consult, inform mother by typing console patient(this is probably how u get mothers approval for admission ) and in the end report child protective service by ordering a consult child protective services

case will end there



THIS CASE IS REAL TRICKY: i never heard of this before


47 yo immigrant ( in usa since age 5), smoked ciggarettes for 20 yrs in blast, works in shipyaard, comes with cough, chills, hemoptysis, fatigue , wt loss x 6-8 months

everyone wud think it is TB... as we all go to tb as soon as we SEE immigrant word.

labs chest xray cavitory lesion in rt.upper lobe
PPD is 12mm

sputum AFB (acid fast baccili ) negative

this case was confusing,,,

ordered CT chest same upper lobe cavitory lesion

this case was going on and on... finally i decided to do BRonchoscopy wiht biposy

case ended there


I think now this case was ASBESTOSIS( mesothelioma)

one cud get into these 3 d/d TB , lung cancer (2ndry to smoking) and MEsothelioma( secondary to asbestos exposure)


THE THING about ccs cases is this,,,,one got to be careful in a way...MOST cases are exactly the same as u see in this forum...but sometimes cases are diffrent when u see them in exam,, the reason for this is..recallers JUST tells u the final diagnosis not the whole history fo the cases.


AGAIN this is not to scare you guys,,,, i am going to repeat this again,,,, MOST CCS cases are exactly the same as u see in the forum except for few..( maybe this is thier new pool of ccs cases which are not posted so far by the exam takers)

this again brings us to the same point,,,,PLZ try to post ur cases as accurate one can post.

Out of nine cases i knew 6 cases immediately as soon i heard the chief compliant.. in 3 cases i had a hard time


cases are..


1)

a 9 month old kid with fever 104.5, irritable, and tachycardic with vomitting.

u did every lab possible( B culture, Lp, ua, urine culture etc etc) but nothing turned out to be possible

pt was given tylenol suppository, and broad spectrum antibiotics, admit the patient on floor.

one day later pt was CALM and fever came down to 102.0

then the case ended there
final diagnosis : fever of unkown origin or fever without focus: ( this is my i cud be wrong in diagnosis)



2)

young black female with vaginal dc, sexually active, came to outpatient clinic,
initial labs (vaginal smear revealed trichomoas budding hyphye etc etc )

given metronizadole dc home f/u in 4-5 days, she was cured
do appropraite counselling case will end there



3)

47 yo alcholic with fatigue , pale , etc etc

do basic lab work u will see folic acid deficiency anemia,,,, (hb low, hct low, folic level low,)
started him on folic acid and multivitamins
pt felt better in few days
case ended there

4)

young female with nausea vomitting, lives with friend, comes to er with abdominal pain, nausea and vomitting... in HPI u will see she has insulin dependent diabetes x few yrs

as soon as read this HPI u know this is going to be a DKA
with some kind of infection

it was in ER.
u check blood glucose( finger stick ) it was 487
urine ketone 4 +
ua is positive for nitrate and estrease ( means pt has UTI)
make sure u do urine pregnancy test wich was negative

now u know the diagnosis DKA with uti

managed the patient as u do for DKA and treat UTI with antibiotic

like this roughly idea

iv acces
saline
insulin( regular )
repeat finger stick q 2-3 hours
repeat ketone laters

ABG
add potassium if its low

antibiotic for uti ( bactrim or anything u like)

next day patient is better, glucose came down to 300 something


THIS is just a idea,, not the exact management for DKA , plz follow ur own format


5)

a young lady with rt upper quadrant pain, nausea vomitting , chill, fever

us positive for gall stone and inflamed gall bladder

after ROUTINE drama (labs tc etc ) u order surgery consult, surgeon will say conitnue pt management, u prepare patient for surgery

iv antibiotics for cholecystitis
NPO
foley cath
pt/ptt coag profile
compozine for nausea
input output
AFTER this

order cholecystectomy (laproscopic) case will end there

5)

polymylgia rheumatica with temporal artheritis
this was a complicated case, as patient was depress too,
labs positive for microcytic anemia

first thing first give PREDNISONE for temporal arthritis immediately

now manage the patient for anemia and depression

i was very confused about this case, i did many unnecessay labs and infact i end up admitting the patient in hospital wich i think was not necessary

I dont know exactly what is the management of this patient

try to prepare this case


THIS is all i can post now,,,

Good luck