USMLE Step 3 CCS

[Anonymous]

CCS- DYSFUNCTIONAL UTERINE BLEEDING








History of present illness:
A 14 yr AAF girl with profuse vaginal bleeding comes to ER. She had her menarche 3 months ago and had irregular bleeding since then.
1. Note vital signs: BP, Pulse, Resp. Rate, Temp.
2. Check vitals to make sure pt is hemodynamically stable. If patient unstable do step I.

For any female with abnormal vaginal bleeding you should check:
1. age of the patient
2. Family history of bleeding disorder
3. history of irregular cycles
4. evidence of bleeding problem on physical exam i.e. petechia

Differential diagnosis of vaginal bleeding
1. dysfunctional uterine bleeding secondary to anovulation
2. endometrial neoplasia
3. endogenous source of estrogen i.e. granulosa cell tumor
4. uterine myomas with submucous myomas
5. hematologic disorders such as leukemia and idiopathic thrombocytopenia
6. endometritis and endometrial polyps

In this 14 year old female with h/o irregular cycles and no other signs on physical exam you should think of DUB secondary to anovulation which usually occurs in extremes of reproductive age, menarch and perimenoposal women.

Step I : Emergent management:
A, B, C, D- if patient stable move to stepII

Step II : Physical Examination
Do a focus PE: general, skin, chest/lung, heart, abd, genitalia, extremities

Step III : Diagnostic Investigations:
1. Pregnancy test
2. CBC- will show Hgb 7.0 – do cross and match if patient is hypotensive or symptomatic start IV access and consider NS
3. Chem 12 (glucose included), coagulation profile, TSH, ESR
Most likely in this case all test will be neg. except abnormal CBC.
Treatment:
This patient is bleeding profusely and her Hgb is 7.0 so start estrogen IV 25mg q4h x3. And Ferrous sulfate 325 mg. Po tid
Bleeding should stop. Recheck CBC.

Step IV: Decision about changing patients location

1. Move patient to ward because her Hgb is low.
2. Repeat CBC following day and start OCP
3. MVI one daily
4. Continue ferrous sulfate 325 po tid
If patients Hgb is stable discharge patient home with office follow up in one week
Consult on safe sex.
In office repeat CBC if has improved follow up in 3 weeks at that time you may D/C OCP and iron pills if you want to. ( 3 weeks of treatment is recommended with OCP). If patient desires you can continue OCP.

Final diagnosis:
DYSFUNCTIONAL UTERINE BLEEDING



CCS- Pneumocystis Carinii Pneumonia with Candida Viginitis.










History of present illness:
40 year old homosexual female, cough and fever, vaginal itching .
Note where the patient is on presentation, if she is in your office after initial work up, patient should be transferred to Ward or ICU (depending on presentation but most likely to ward). Unless the symptom are mild in that case treat patient in the office.
VITAL SIGNS- will help you to determine if patient is stable or unstable. BP (N= 90-140/60-90), Pulse (N= 60-90, Mean- 72), RR (N= 12-20, Mean- 16), Temp.( N= 37C, 98.6F)
Allergy: NKA

DDX-
Pneumocystis pneumonia- Top of your list because of risk factor and OI at presentation.
Cytomegalovirus
Kaposi Sarcoma
Legionellosis
Lymphocytic Interstitial Pneumonia
Mycoplasma Infections
Nocardiosis
Bacterial Pneumonia
Fungal Pneumonia
Viral Pneumonia
Pulmonary Embolism
Tuberculosis

Step I : Emergent management:
A, B, C, D- depending on presentation and assessment of O2 sat. if O2 sat is low. Start with one litter O2 and get IV access.


Step II : Physical Examination
Any suspect HIV/AIDS patient should have a complete physical exam.
General appearance, Skin, Lymph Nodes, HEET/Neck, Chest/Lung, Heart/CV, Abdomen, Genitalia, Extremities, Neuro.

Step III : Diagnostic Investigations:
1. O2 sat.- Pulse oximetry is obtained as part of the initial workup
2. ABG- with signs of respiratory distress.(hypoxemia)
3. LDH- Levels are noted to reflect disease progression. High levels during treatment indicate therapy failure and worse prognosis.
4. CBC/D-
5. Chem-12
6. CXR- The classic finding is diffuse central (perihilar) alveolar or interstitial infiltrates. Normal CXR is found in 5-10% of cases.
7. Sputum- by-sputum induction for Wright-Giemsa stain or direct fluorescent antibody (DFA) for Pneumocystis if PCP is strongly suspected. If negative and PCP suspicion is high next step is bronchoalveolar levage.
8. HIV test- when you order a test like HIV that requires patient consent, it will tell you that patient consented to the test and result will be available in 7 days.
9. CD4 count
10. PCR assay
11. Saline or KOH Vaginal secretion (wet mount).
12. LFTs
13. VDRL, Toxoplasma IGG, and hepatitis B and C serologies.
14. Cervical papanicolaou Smear
15. TB skin test.

Treatment:
1. IV fluid –NS (In moderate- severe cases).
2. If suspicions is high for PCP start treatment with Bactrim-DS po bid for 14-21 days. If patient is hypoxic, start with Bactrim IV.
3. Report positive result to Department of Health and Human services.

Step IV: Decision about changing patients location
1. Mild-to-moderate disease refers to patients with milder symptoms and a nontoxic clinical appearance. They generally are not hypoxic and may even have a normal CXR. Outpatient oral therapy can be considered for these patients.
2. Moderate-to-severe disease describes patients with severe respiratory distress, hypoxemia, and, often, a markedly abnormal CXR. Inpatient management with rapid diagnosis and treatment is essential.
3. Admit patient to ward for moderate to severe disease. (ICU if patient unstable). Mild cases should be managed outpatient.
4. Discontinue IV fluid if patient is taking po and is not dehydrated.
5. Continue Bactrim -
6. Treat Vaginal candidiasis with antifungal such as nystatin, clotrimazole, miconazole vaginally.
7. When diagnosis of AIDS is established start Antiviral therapy with:
A. 2 NRTIs + 1 or 2 PIs.
B. 2 NRTIs + an NNRTI
8. Vaccines: Influenza, Hepatitis A and B, Pneumococcal vaccine.
9. when patient is stabilized cancel IV fluid, move patient to home with follow-up in your office in 5-7 days.
10. Continue Bactrim and antifungal- discontinue antifungal when patient returns for follow –up unless symptoms still persist in that case consider changing antifungal.

Step V: Educate patient and family:
1. Educate patient on safe sex.
2. Educate patient on Medication compliance.
3. Console patient on HIV support group. When you request this option it tells you arrangements for follow-up has been make.

Step VI: Final Diagnosis:
Pneumocystis Carinii Pneumonia (PCP) with Candida Viginitis.







Cystic fibrosis in 5yo child






O2 mask
Labs:
sweating test(Cl>60mEq/dl dgn)
CXR
Pulmonary function test
ABG's
Sputum culture & sensitivities of cultured organisms

Tx:
Ab-iv ceftriaxone+gentamycine for pulm.infections
Albuterol inh
Chest physiotherapy:
postural drainage+percussion
breathing exercise
vigourous coughing
exercise program

Recombinant human deoxyribonuclease-jet nebuliser



Case4
Child living in an old house coming to regular checkup
CBC
Blood lead(>25 micro/dl)
Free erythrocyte protoporphyrin(>35micro/dl)
urinalysis
knee&wrist Rx->increased density in metaphyseal plate long bones=lead lines

Tx
report to local health board
remove child fron enviroment
Tx:
EDTA+dimercaprol for 5 days
penicilamine for 3-6 months




Child abuse






Admit the child in ward room
labs:
CBC
PT
PTT
bleeding time
opthalmologic consult for retinal hemorrhages
CXR
skeletal RX
social worker
report to local autorities






spousal abuse






Aside for specific investigations&tx suggested by P/E reffer the patient to victim assistance service

eldery abuse

as in above cases )investigations and tx suggested by P/E,than refferal to elder protective services
N.B.whenever you are uncertain about were you should reffer the patient type:"reffer the patient" and choose from the list.]]





Uncomplicated MI approach








Here is my management for an uncomplicated MI:
So->presentation of chest pain suggestive for MI:
P/E-chest,abdomen,extremities=3 minutes
1)Aspirin chewing
2)O2 mask
3)IV line
4)ECG 12 lead
5)ECG monitoring
6)vitals monitoring
7)cardiac enzymes(CPK-MB,cTnT)
pulseoxymetry monitoring
9)Morphine sulphate i.v.
other Labs:CBC with diff
ABG's
Lytes
Chem 7
PT&aPTT
blood type &crossmatching
LFT's
Urinalysis,creatinine,BUN
glucose serum
TSH
imagistic:
CXR
abd plain films
cardiac ECHO

if no inferior MI/no hypotension->nitroglycerin iv

Look for CI to thrombolysis->if no CI->heparin iv
then streptokinase bolus
if CI to thrombolysis->stenting PTCA call interventional cardio

the patient is stabilised->transfer in ICU
d/c oxygen
adm.methoprolol iv
continue monitoring for 3 days
Diet liquid
Psyllum cysapride to prevent constipation
2'nd day
Tc scintigram-evaluation of affected miocardum
complete P/E
3'rd day continue measures- early ambulation (go to the bathroom)
4'th day non-stress submaximal effort test
discontinuation of monitoring,
transfer in ward room
5'th day D/c of iv medication
propranolol p.o.(chose because of lowcost)
cord-pulmon examination
look for patient immunisation status
if no influenza&pneumo
advise patient to stop smoking &drinking
6'th day begin solid alimentation
7'th day again submaximal treadmill test
discharge
Final recomandations:
diet low salt low cholesterol
continue aspirin indefintite
come back to control in one month
rest at home for 3 months








Chronic cardiac failure






admit patient
1)search for cause->most freq Hypertension&CAD
2)classification acording NYHA
monitor:weight,vitals,fluid intake,urinary output
nonpharmacologic measures:
restriction of physical activity
weight loss
dietary Na&water restriction
O2 mask for dyspneea
pharma:
ACEI(enalapril)
nitrates
hydralazine->in combination with nitrates improve survival
Digoxin when no ci
diuretics(HCTZ)
Special considerations:
HF+MS->avoid phys.exercise
Lasix
heparin followed by long term warfarin
treat AF with cardioversion if unstable or with digoxin if stable
prphylaxis for inf. endocarditis

HF+AS as in MS but diuretics with caution.Avoid nitrates.

HF+chronic mitral regurgitation
inf.endocarditis prophylaxis
enalapril
diuretics
nitrates

Acute mitral regurgitation
sodium nitroprusside
furosemide
intraaortic baloon counterpulsation



These are just some cases, TRy to make your own FORMAT etc etc




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

CCS case from somebody who took test recently



1.

8 hours old baby showed vomiting after feeding, low muscle tone, extremities blue, low cry sound. PE showed low ridge of nose, I-II grade heart murmer. check every thing including upper GI series, ECG, echocardiogram, result ¡°OK¡± but not check abdominal x *** or ultrasound. Karyotyping found Down Syndrome. Educated Parent for feeding, genetic counseling and case closed.

2.

40 yo female visited office c/o palpitation and fatigue with recent hx of URI. PE: bilateral heart failure. ECG: all terminal low voltage and echocardiogram showed four heart chambers enlargement and mild pericardial effusion. ESR increased. CXR showed bilateral lung base infiltration and one side plural effusion. Admitted to ICU and treated heart failure including lasix, ACE inhibitor, ibuprofen etc. Case not closed ¡*..

3.

80 yo male drove his car into a electric pole with mild injury and was sent to ER. Pt was OK with everything except confusion. PE found mild injury with normal Bp and heart rate and lung/abdomen. Check Cervical x ***, CXR, head CT, chem 7 etc with no abnormal findings. Pt suddenly have heart rate 30-40/min. ECG found 3rd heart block and pace maker was given and pt was admitted to ICU. At this time heart rate back to 70-80/min but pt still confusion. Counseled cardiologist and case was closed. (should order abdominal CT to rule out internal bleeding?).

Let's discuss these trouble cases and some one gives more appropriate management.If the discussion is productive, I'll try my best to obtain and post more recall question. Hopefully, everybody in the forum work harder and join force to help each other.

[Anonymous]

Dilated cardiomyopathy post-viral case


Hi!
I think dopamine or dobutamine for acute CHF is a good choice. Also, consider heart transplant if severe persisting HF (consult, thoracic surgeon, informed consent, living will , pre-surgery blood work. Also, water restriction & Lasix if water in lungs. Oxygen & nitrates IV of course.
Any comments?
*********
MVA Case

I think what u did was good plus echocardiogram (tamponade), and chest ultrasound (aortic rupture). Triple X-rays of cervical spine, CXR(u did it) & pelvis are classic x-rays in all kind of trauma patients. We can have confusion after trauma without any obvious & visible cause on CT, conservative management.
Thanks for cases,
Any comments?


*************
I worked on these three cases, hope they are correct





1. Working flow:




PE: whole body: general appearance, HEET, lung/heart, abdominal, extremities
Order: CBC with differential
U/A
Electrolytes including Na, Cl, K, Ca, P, Mg
ABG for acidosis
Serum Glucose
CXR and abdominal XR
EKG
Ultrasound of abdominal and Echocardiography

Management: Nothing by mouth
NG with suction
IV fluid
¼ NSS IV
10% Glucose IV
Surgery consultation

Further management: Karyotyping
Education parents on feeding, genetic counseling, cardiological follow-up.

Transfer to surgery ward for duodenotomy

Diagnosis: Down syndrome
Duodenum atresia
Ventricular septal defect





2. Working flow:





History and PE: focused on general appearance, edema, lung/heart
Order: EKG
CXR
ESR, CRP
TSH
Chemical panel
Liver function
BUN/Cr
Echocardiography

Management: admit patient to ICU
Pulse oximetry
Mask O2 inhalation if SOB
Bedrest
Na restrict to 2 g/day
Silax
Captopril
Dobutamine IV
Nitroglyceride IV
Digoxin if heart rate is fast

Education on diet, exercise, and pneumonia prevention

Diagnosis: Cardiomyopathy
Heart failure





3. Working flow:




History and PE: GCS scale, lung and heart, abdominal
Order: Cervical AP and lateral views
EKG
Admit to ICU
Cardiometry
Pulse oximetry
NSS IV
Pace maker insertion
CXR
CPK, CPK-MB, troponin I (MI protocol)
CBC with differential
Chemical panels
TSH
ABG
U/A
BUN/Cr
Liver functions

Management: Hearing and visual testing
CT head
MMSE
Cardiologist consulation
Education patient on safety of driving and living environment and medications.

Diagnosis: A-V conduct block
Mild head trauma
Delirium





**********************
Alziemher pt drugs and side effects given. I selected don’t give Aluminum containing medications....

as I have seen it some where......had no idea about....the other medications.....



here are some meds for dementia/alzheimer June 22 2003, 12:06 PM

Management: Specific concerns in Dementia
Dementia Related Malnutrition
Behavior Problems in Dementia
Agitation in Dementia
Sleep Problems in Dementia
Wandering Behavior in Dementia


Management: Medications
Cholinesterase Inhibitors
Efficacy
Improve neuropsychiatric scores 7 points
Seven point improvement equals ~1 year of decline
Benefits may persist for 1-2 years
Rogers (1998) Arch Intern Med 158:1021-31
Agents
Donepezil (Aricept)
Rivastigmine (Exelon)
Galantamine (Reminyl)
Tacrine (Cognex)
Not first line due to hepatotoxicity
Vitamin E
Vitamin E 400 to 1000 IU bid
Slows functional decline
Alternative: Selegiline (Eldepryl) 10 mg PO qd
Vitamin E is less expensive and as effective


NSAIDS (insufficient evidence to date)
Netherlands Study (n=6989 over age 55, for 8 years)
Continuous NSAID use decreased Alzheimer's risk
Relative Risk Reduction 80% for >2 years of use
Aspirin did not confer same benefit as NSAID use
In'tVeld (2001) N Engl J Med 345:1515-21
Johns Hopkins Retrospective study (n=209)
NSAIDS (n=32) slowed Alzheimer's progression
Based on MMSE, Boston Naming, and Benton scales
Rich (1995) Neurology 45:51-5
Alternative Medicine (insufficient evidence to date)
Ginkgo Biloba 40 mg PO tid
Appears mildly effective in improving cognition
Appears safe over one year of testing
Reference (Study: n=327, DB PCT)
Le Bars (1997) JAMA 278: 1327-32
Sleep Disturbance
Trazodone 25 to 150 mg PO qhs



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

1.

60 yom with colon ca came admit in hosp. for chemo. in hosp. During stay, he develop fever and productive cough. He was dx as pneumonia and tx with antibiotic. Pt develop SOB in last couple of hours. RR 28, BP and HR are NL.
Tx: O2 and IVF
EKG, CBC, Chem 7 are noncontributive. Pulse Oxi show O2 sat 90%, CXR: resolving pneumonia of MRL.
V/Q: high possibility of PE
Tx: heparin, warfarin, revisit pt in 1 hour
still sob, same vital
Tx: tPA, revisit in 1 hour
still sob, same vital
the case closed.
What is going on here?

I think you managed this patient right.

SOB probably due to pulmonary embolism also considering the toxicity of the chemo drugs such as bleomycin, which is toxic to lung, or dauxorubicin, which is cardiac-toxic. Generally, I agree this is the PE case.

Management: CBC with differential
ABG
U/A
Electrolytes with BUN/Cr
EKG
CXR
HRCT
P/E
PT, TT, aPTT, INR
Duplex ultrasound of legs


Order: O2 inhalation
Heparin
Warfarin
Monitor PLT, TT, and INR
Repeat ABG

Educate patient on anticoaggulant use
If ABG is better, reassure patient because SOB could be an objective or subjective.

This is all I can think of. tPA usually only used when there is hemodynamically instability and within several hours of symptoms.

Suggestions

ABC
Thanks for the thought.
I also thought about pul. fibrosis due to chemo. The onset should be gradual. But this has a acute onset.
Pericarditis? Pt has not JVD and edema.
Another possibility is tumor emboli due to pt's hx of colon ca. This kind of PE will not be responsive to heparin tx. But I don't know how to tx.
I still have no idea what is the cause of SOB.
What is your thought about the other 2 cases?



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



********************
Let's work on this recent CCS on the "step by step" rather than a few word comments. Someone could give detailed management and other provide "make up". If the dicussions are healthy. Mor to come.

1.

60 yo male in patient with colon cancer developed right low lobe pneumonia (fever and productive cough) during chemotherapy. His pneumonia was treated with antibiotics and improved significantly. Patient suddenly had SOB about two hours ago and you were called to see the patient. CXR showed the resolving infiltrate in right low lobe. Pt had normal Bp, and fast RR: 28/min. Immediately started oxygen and iv fluid. Ordered pulse oximetry (90% sat), ABG (Po2 down), EKG (non-specific), CXR (same), CBC, Chem 7. Then order V/Q scan which showed high probability of PE in right upper lob. Started heparin, iv and coumadin. Waited one hour to re-check patient who still had SOB. Vital signs and pulse oximetry were not changed. At this time, started Tpa (thrombolysis). One hour later, patient still had SOB and vital signs did not change. Case was going on and on. …… Finally time was out and case was closed.

2.

20 yo female came to office c/o of fatigue and other symptoms which was not related ITP. However, platelet was found very low (20,000) during the regular work up (CBC, Chem 7, UA, ECG, CXR, et al). Then checked the coagulation profile (normal). BT prolonged, Anti-platelet Ab (+?). Gave prednisone, po and IVIG, iv. Sent Patient to home for one week follow up (should have admitted to floor). And case was closed.

3.

60 yo male with hx of depression came to office for the regular check-up. But his looked fatigue and has not seen Dr. for long time. Complained to have heart burn sometimes. Gave the full PE and found “pale” and occult test +. Lab found minor anemia. Started low GI work up with barium enema and colonoscopy which were both -. Then did upper endoscopy which showed a ulcer in duodenal and biopsy with H. pylori +. H. pylori Ab + and urea breath test +. Started to treat patient with amoxicilin + azithromycin + omeprazole, ferrous and sent patient to home for one week follow up. When patient came back, it was found the occult was still positive. Did sigmoidoscopy which was also -. CBC still showed mild anemia. But patient claim that heart burn was improved. Case was going on and on and finally the time was out. Case was closed.

4.

60 yo female school principal was sent to ER by her boyfriend who found that she was unconscious in the office with a bottle of alcohol and several bottle of drug without label. Gave “ABC” including intubation and did PE. Found pupil enlarged and RR 20. Ordered alcohol level (300) and serum drug screen (-) ABG, pulse oximetry, etc. At the same time did gastric lavage + charcol and found yellow color fluid without pill. Gave triple treatment (naloxane + thiamine + Glucose , iv). Patient was still unconscious. Then treat alcohol. Patient was still not improved and at this time only 5 min left. Order hemodialysis and case was closed.




***************************
My work on three cases. hope this can a little more help.

Case 1. Von Willebrand's Dis.

CBC
BT
PT
PTT
Factor VIII
Factor XI
VWF antigen
Ristocetin cofactor activity
Factor VIII:C

Admit to ward
IV line with normal saline
Desmopression (DDAVP), iv
Recheck patient
If severe, give cryopricipate Factor VIII or vWF
I am not sure whether estrogen, iv can be used in menorrhagia caused by von Willebrand disease and I check ref and counld not find its use in this dis.

If patient is improved, discharge to home
Advice: avoid NSAID which causes or increases bleeding in this dis.
Ferrous, po
Advice iron riched diet
Educate pt about this dis
Genetic counselling for family
Follow up in one week




Case 2. Endocarditis complicated with pneumonia

CBC
Blood culture
Sputum Gram stain
Sputum c/s
Chem 12
LFT
UA
ECG
CXR
Echocardiogram

IV line + D5 normal saline
Nafcillin IV
Penicillin IV
Gentamicin, IV
If allergic to penicillin, Vacomycin IV

Admit to ward

Recheck Pt and lab results
If pneumonia not improved, change antibiotic based sputum c/s and blood c/s

If 5 min. left

Check HbsAg
HCV
HIV
Counsel for drug abuse




Case 3. Sickle cell crisis

If pt is very sick
O2
IV line

CBC
Reticulocyte
Serum bilirubin
H electrophoresis
Blood culture
UA + urine c/s
Mycoplasma titer
Chem 12
ECG
CXR

IV fluid D5 1/2 or 1/4 NSS
Morphine or meperidine, IV
Cefotoxime, IV
If HB < 7, blood crossmatch and transfusion

Admit to ICU

Order MRI for painful arm to r/u osteomyolitits
Follow up patient and check more results of lab
Patient can be discharged 72 hours later if improved and
Change antibiotics to oral (cefto)
Influenza vaccine and check immunization status and make it up if missing something
Penicillin for prevention
Genetic councel and education patient/family

Comments are wellcome

[Anonymous]

given below are PK's Cases:::

U CAN SEE HOW 2 PEOPLE have diffrent approaches with the same cases


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 ACUTE 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 PAIN 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 and no leukocyte, so I ruled out interstitil nephrits and urine NA was 45.BUN 28 and cret 4.5
I was sure its renal FailUre due tO internsic problem and culprit is eigther cefalo or pain killer. I was not sure pain killer is NASAID or not so i d/c cephalosorin.
I am not sure I Did 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 and found mass at lt lung.
3) request bronchoscope , consult oncologist and
diagnose os Post obstructive Pneumonia and Lung cancer.
By that 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 Cong. heart 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)started 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 diag. was 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 last pap smear was 15 months back and normal
My initial Impression was Bacteril 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.




************************
New ccs case try to solve

1.

middle aged lady c/o pain in the small joints of the hand and SOB and fever.
PE
labs;cbc, Rh factor, ANA,CXR,Chem7,EKG and then admitted to ward from the office ( as she was mildly breathless and had fever)
cxr showed small pleural effusion
needle aspiration of pleral fluid and sent for analysis.Came as abundant neutrophils in pleural fluids,Low PH, Low sugar,protein ( do not remember)
Patient was relieved of SOB immediately after needle aspiration.

Rxed with antibiotics.IS this correct?
For small joint pain started on indomethacin
Before Rh factor and ANA results time ran out.Soft ware was so slow.

2.

this is a case appeared before several times.DKA with UTI.
In this case DKA was managed well. the patient was started on TMP/SMX for UTI .But the patient kept on complaining about dysuria , difficult and discomfort in passing urine even on the second day.What should you do about this?
When you manage DKA should you cathetarize the patient and monitor ?? But since this patient is having UTI can we or should we do it??


3.

9 month old baby presented with fever and cough with pneumonia apparent on Cxr.
What emperic antibiotic do you start??
test taker started on Ampi and genta but fever didn't subside on second day.
How do you test a sputum sample in a baby in CCs .Do we just type sputum c/s. or should we say gatric aspirate as you cannot get a sputum sample from a baby


4.

In a suspected acute prostatitis case how do you test Prostatic fluid.Do you get it by prostatic massage.But one test taker had done it and clerk indicated that it was very painful to the patient.So how do we get a prostatic fluid sample?


above were some doubts that one test taker has had.your input is appreciated.


lady with joint pain and SOB

It looks like RA but then because the pulm/pleual involvement, it should r/o SLE. SLE has often involves pulm, pleual and renal etc, whereas simple RA rarely affect lung and renal. So if RF come back neg, should order C3, UA and renal function test to r/o SLE. Treatment is NSAID, steroid, antimalaria. If only small amount of pleural fluid present by imaging etc, usually it is nessisary for fluid analysis at first round.
coment?


think about SLE....

you may need to order anti-ds anti-smith, ANA first. you may need prednisone to control the flare-up.

your case closed early because you think it is RA.. no morning stiffness and other typical sx make RA less likely.


Acute bact. prostatitis

The diagnosis of acute bacterial prostatis (ABP) is based primarily on clinical findings, in association with positive results on urinalysis and urine culture.
So treatment with fluroquin or Bactrim should be started with high clinical suspicion and UA when waiting for urine culture, if wanted.

Care must be taken to avoid vigorous prostatic massage in a patient with suspected ABP to avoid bacteremia and sepsis, this is probably the reason the patient does not want the massage.



But u/a was NL. So had no choice but to do..............

prostatic fluid analysis.Culture takes time.patient had dysuira severely.
So my Question is if you need to test prostatic fluid you need to do a prostatic massage.Isn't that right?


Prostatic fluid, massage

Yes. If you have to get prostate fluid then do a massage to get about 4 drops into a slide.



9 m old fever and pneumo on CXR

Probably need to treat with cephtriaxone to cover pneumococcus, H.influ and S.aureos in this age group, while do sepsis work up to r/o bactremia etc. Outpatient can be treated with amoxi (or with clavulanate) or erythromycin plus sulfasoxazole. Ampi and gent are mostly used empirically for less than 2 month old. It is difficult to manage infant/toddler has fever with/without focal infection. This is from Kaplan note.

Please comment.



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

Working flow for acute prostatitis


PE: extragenital examination, rectal examination

Order:
CBC with differential
U/A
Urine culture and sensitivity
Blood culture may be needed
Also test gonorrhea and syphilis if indicated by sexual history

Management:
Treat this patient as outpatient
Acetaminophen
Ciprofloxacin po
If suspected of chlamidyl infection or gonorrhea, partner may need treatment as well

Follow up patient in 3 days
Adjust antibiotic according to sensitivity and the total length of antibiotics should be 30 days.

Educate patient on: Adequate fluid intake, STD and safe sex
Follow up patient in one month for regular check up including rectal prostate examination.

Final diagnosis: acute bacterial prostatitis.

Prostate message is detrimental and contraindicated in acute bacterial prostatitis.

The following information is from emedicine:

Etiology: Most infections (82%) involve only a single bacterial organism. Occasionally, 2 or 3 strains of bacteria may be involved. The organisms primarily responsible for ABP also are those responsible for most urinary tract infections. The most common causal organisms for ABP include the following: Escherichia coli, Proteus mirabilis, Klebsiella species, Enterobacter species, Pseudomonas aeruginosa, and Serratia species. Of these, E coli is involved most often.
Obligate anaerobic bacteria and gram-positive bacteria, other than enterococci, rarely cause ABP. Staphylococcus aureus infection may occur in the hospital due to prolonged catheterization. Other occasional causes include Neisseria gonorrhea, Mycobacterium tuberculosis, Salmonella species, Clostridium species, and parasitic or mycotic organisms. N gonorrhea should be suspected in sexually active men younger than 35 years.
Clinical: ABP usually presents as an acute illness with moderate-to-high fever, chills, low back and perineal pain, urinary frequency and urgency, nocturia, dysuria, and generalized malaise. Arthralgia and myalgia may accompany these symptoms. ABP also may result in acute urinary retention due to varying degrees of bladder outlet obstruction. The diagnosis of ABP is based primarily on clinical findings, in association with positive results on urinalysis and urine culture.
Rectal palpation usually reveals an enlarged, exquisitely tender, swollen prostate gland, which is firm, warm, and, occasionally, irregular to the touch. Care must be taken to avoid vigorous prostatic massage in a patient with suspected ABP to avoid bacteremia and sepsis.
Prostatic abscess is a potential indication for surgery. Prostatic abscess is an infrequent but well-described complication of ABP. Medical management often is not successful. Transrectal or perineal aspiration of the abscess is preferred and often is effective, especially if symptoms do not improve after 1 week of medical therapy.

Contraindications: Performing a prostate biopsy is contraindicated in suspected ABP because of the potential complication of seeding the bacterial infection in adjacent organs. Furthermore, prostate biopsy is extremely painful and may cause gram-negative sepsis.

Lab Studies:
• Prostatic secretions contain large numbers of leukocytes and fat-laden macrophages.
• Urinalysis, which shows leukocytes, and a positive result on urine culture are essential for diagnosis.
• Occasionally, blood culture results may be positive.
• Increased serum prostate-specific antigen (PSA) levels also are found but should not be used as a screening test for prostatitis.
Imaging Studies:
• Imaging studies, including a CT scan of the pelvis or prostate ultrasonography, should be reserved for those cases where laboratory analysis is equivocal or when no improvement is observed following medical therapy. Ruling out complications of prostatitis (eg, prostatic abscess) is a strong indication to proceed to imaging studies.
Diagnostic Procedures:
• Performing a prostate biopsy is contraindicated in suspected ABP because of the potential complication of seeding the bacterial infection in adjacent organs. Furthermore, prostate biopsy is extremely painful and may cause gram-negative sepsis.
Medical therapy: The intense inflammation in ABP makes the prostate gland highly responsive to antibiotics, which otherwise penetrate poorly into the prostate. Hospitalization is required for patients in whom acute urinary retention develops and in those who require intravenous antimicrobial therapy.
The choice of antibiotic is based on results of the initial culture and sensitivity. However, initial therapy should be directed at gram-negative enteric bacteria. Useful agents include fluoroquinolones, trimethoprim-sulfamethoxazole, and ampicillin with gentamicin. Antipyretics, analgesics, stool softeners, bed rest, and increased fluid intake provide supportive therapy. A Foley catheter can be inserted gently for drainage if severe obstruction is suspected. A punch suprapubic tube can be used if a catheter cannot be passed easily or is not tolerated by the patient. The catheter can be removed 24-36 hours later.
If the initial clinical response to therapy is satisfactory and the pathogen is susceptible to the chosen antibiotic, treatment is continued orally for 30 days to prevent sequelae such as chronic bacterial prostatitis and prostatic abscess formation.
For IV therapy, use trimethoprim-sulfamethoxazole (Bactrim), 8-10 mg/kg/d (based on the trimethoprim component) in 2-4 intravenous doses bid, tid, or qid until the culture and sensitivity results are known. An alternate regimen is gentamicin with ampicillin 3-5 mg/kg/d IV (gentamicin dose divided tid and 2 g ampicillin divided qid). After the patient is afebrile for 24 hours, an appropriate oral agent can be substituted for an additional 30 days.
For oral therapy, use trimethoprim-sulfamethoxazole (Bactrim), 160 mg of trimethoprim and 800 mg of sulfamethoxazole, PO bid for 30 days. Use ciprofloxacin, 500 mg PO bid; norfloxacin, 400 mg PO bid; ofloxacin, 400 mg PO bid; or enoxacin, 400 mg PO bid for 30 days when clinical response is favorable.
Complications:
Prostatic abscess is an infrequent but well described complication of ABP. Although very rare, it most often occurs in patients who are immunocompromised, patients who have diabetes, patients with urethral instrumentation or prolonged indwelling urethral catheters, or patients on maintenance dialysis. Coliform bacteria, especially E coli, cause more than 70% of prostatic abscesses. A prostatic abscess should be suspected when worsening clinical symptoms follow an initial favorable response to treatment of ABP or a fluctuant mass is developing in the prostate gland. The presence of the abscess is confirmed by transrectal ultrasound.
Once an abscess is diagnosed, anaerobic antimicrobial therapy should be added to the treatment regimen. Clindamycin intravenously at 600-900 mg q8h or orally at 150-450 mg q8h is a good choice. However, medical management often is not successful. Transrectal or perineal aspiration of the abscess is preferred and often is effective, especially if symptoms do not improve after 1 week of medical therapy. Transurethral resection of the prostate and drainage of the cavity is another approach. Recurrent abscesses are rare. The abscess should be allowed to drain and should be monitored closely if a spontaneous rupture occurs into the urethra.
Other potential sequelae of ABP are progression to chronic prostatitis, septicemia, pyelonephritis, and epididymitis.

[Anonymous]

SLE work up



Lab work:
CBC and Chem7
U/A
LE cell, ANA, anti-ds DNA, anti-Sm,VDRL

C3 level, ESR

LFT
BUN/Cr

Pleural fluid analysis

Images:
X-*** of the affected joints
Chest X-***
Echocardiography

Others:
ECG
Skin biopsy if possible
Kidney biopsy if needed

Diagnosis: SLE

Management:

Admit to ward

Aspirin for fever and arthritis
Prednison 60 mg po
Azathioprine PO or cyclophosphamide IV

Consult rheumotology

Patient education and consel about exercise and possible osteoporosis related to corticosteroid use.

I do not have the software yet, therefore, someone else there, would you please run this workout for me and other people.

Comments welcome!


***********************************
Which one of the following tests is not always recommended in the work-up of a patient suspected of having dementia?

A. Complete blood count.
B. Imaging test of the central nervous system (computed tomography or magnetic resonance imaging).
C. Mini-Mental State Examination (or other cognitive test).
D. Liver function tests.
E. Urinalysis.


D---- > LFT

The rest of the listed have to be done to work up a patient with Dementia



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


CCS




INtracerebral hemorrhage




patient presaents to ER with headache , nausea, vominting, altered sensorium, motor sensory changes cranial ns

1. Oxygen iv access cardiac and pulse monitor
If vitals show elevated bp iv nitroglycerin

2.rapid PE, heent( elevated ict), cns ,cvs ,lungs

3. stat ct without contrast
cbc
chem7
coag profile
lfts
cxr

D/D trauma, hypertension , av malformation, aneurysm, caog disorder

4. mgmt imm. neurosurgical consult for craniotomy and evacuation of hematoma

medical management is not much benefit except
if elevted ict or expanding hematoma iv mannitol, dexa ( no proven benefit )

awaiting surgery :-bedrest
npo
analgesics
adequate BP control
laxatives to prevent icrease ict
nimodipine po started
other preop prep

if CT shows evidence of aneurysm/ av malf.
order angiogram

can someone add


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


this case has been asked.

3O years old female presented to the ER after taking Aspirin------> CT scan showed ICH

this is a case of ICH and not SAH. Your management of SAH is fine.

INTRACEREBRAL HEMORRHGE:

Interval History:

Orders:

.O2
.PULSE OX
.CBC
.CHEM12
.COAG
.IV Access/NS
.CT HEAD Without Contrast
.EKG
.CXR--- Portable
.UA
.A-LINE
.FOLEY'S
.VITALS
.If Stable--------------------------->> ICU
.VITALS
.NEURO CHECK q1HR (Software recognises )
.Elevate Head of Bed ( Software regognises )
.Control BP only if >180/100
.Neuro Consult
.Anesthesia Consult
.Consent From Patient or Family
.Surgical Management

others correct me if I am wrong or missed something.

thanks


why to admit the patient to the ICU when he has to undergo neurosurgery?

and wat about preop MRI if aneurysm/ AV malf is suspected ?
sah was one of the considerations


Lab :
PT & PTT
bleeding time
LFT
ABG

If has nausia and vomiting - i/v prochlorperazine

I dont how stable was the Pt. -if needed intubation and mechanical ventilation to decrease ICP.


That's what I meant that only if patient is stable , should we move her to the ICU. But we will get the information in the ER itself once we start getting the result back and will base our plan on the labs and clinically and if her condition demands, will transfer to OR. I got this information from Fred Ferri. Your suggestions and input is Welcome.

Yes LFT can be added to the list. Coaug profile includes PT/PTT,Bleeding




************************
CCS


Upper Gi bleeding



massive bleeding.Low Bp .Hx sugg. of eso varices.

IV access.( 2 lines.But software doesn't allow 2 lines. So how to do this?)

Iv Ringer's lactate

Iv vasopressin( clerk doesn't identufy octreotide)

Iv Vit K bolus
NPO
NG
labs: cbc
Lft
Chem 7
coagulation prof
blod type & cross matCh
If bleeding continues stat Gi consult.

UGIE
Endoscopic sclerothrapy
Both these can we order.Or do we have to wait for GI opinion.If they suggest. we order.Am I correct?

When pt stable transfer to ward.
If bleeding has stopped and stasble d/c Iv fluids d/c Npo and start oral

Advice stop alcohol
refer alcohol anonymous.

please correct me if anything wrong or need to add more



Your orders are fine, you can add:

.foley's

.When you type Endoscopy---> software will ask for GI consult and then you can type in the reason for your consult

.Software does not recognise OCTREOTIDE or Somatostatin. IF you can find out let us know.

My understanding of Emergency Cases is that if you are in the right tract and if consult is justified, the case will end soon. If on the other hand if you get a prompt which tells you that the consult has nothing to offer, then either it is not required at all or you have to modify your management.


it is good at least you have come forward and went through the protocol of managing different cases. Because it is very difficult for me to type all 70 cases.No one except Texas and Radiance, wants to take the trouble of getting the protocol.

Let's keep it up.

Find out about OCTREOTIDE and Somatostatin


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


CCS



perforated peptic ulcer



PE
Orders
Iv line
Cbc/ chem 7/ s. amylase/s.lipase/ RBS/EKG/CXR/Abd xray/
bld type and croos mathc,
LFt
caog proflie
Ng
NPo
Iv meperidine bolus for pain relief ( I am not sure of this)
GI consult
Prep for sx

In this case do we do UGIE to confirm the diagnosis?

before discharge counsel limit alcohol. No aspirin, life style modification


Please add or omit.


stop smoking
and follow up for GI consultation...


Clinical diagnosis

PUD perforation usually is made clinically with abd X *** showing subdiaphgram free gas. I do think we need UGIE to make the diagnosis.

Narcotic analgesic is important.


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


CCS



Diverticulitis



PE Iv access
labs:
cbc/u/a /FOBT/chem 7/xray abd erect decubitus/Blood culture
CT abd

Iv fluids
NPO
NG
IV antibiotics ( Do you start even before CBc ? if so what Ab?for how many days? is it Iv Cefoxitin?)
Surgical consultation if no improvement or complicatios

later advice- high fiber diet




if patient presents to office and mild sypmtoms ....treat on outpatient basis.
Inv : cbc,chm7,fobt,ua
PO Cephlex and flagyl
high fibre diet antispasmodics
stool softener
and counsel exercise


If severe symptoms / admit to wards ...or if presents to ER:
iv access Iv RL
INV: CBC chem 7 blood culture& S fobt ua
ct abdomen

NPO ngt with suction reassure
IV Ampi genta flagyl---------------------------wards

If patient recovers
dc ngt and npo ....observe 24hrs soft diet
stable ..cancel iv and dischare on oral antibiotics

If not
repeat ct abdo to look for abscess and wait for senstivity reports
abscess: drain
or once sens reports available : change antibiotics


On discharge antisp, diet,stool soift,exercise

and follow up 5-7days
when stable sigmoidoscopy,colonoscopy

if missed/...pls add

[Anonymous]

acute gouty attack


Step 1
Keep foot elevated
Labs

cbc,chem7,uric acid level, 24 h uric acid,u/a,
Synovial fluid-gm stain,c/s,crystals,glucose ,protein cellcount,
xray joint
Diet
Low protein(No options for low purine diet)
Avoid alcohol
Increased fluid>2L/day (no options for this)
motrin po
colchicine po(if no esrd)
corticosteroid if stillcomplaints of pain
Allopurinol 24 hour urin uric acid>800 mg
probenecid 24 hour urin uric acid<800 mg
Bed rest24 hour
Avoid aspirin

ref CMDT 2002 PG 839



Treatment of choice for Acute attack
is
NSAIDS .....INdomethacin is usually given.
C/I : PUD,Renal impairment and allergic history

Colchine is also given but not favoured due to its GIT side effects.Only effective in first few hours

Corticosteroids are best reserved for those persons unable to take oral NASIDs

Other :
bed rest for 24 hr
avoid asprin
May need analgesics


Go for management between attacks.


Do we need to send this patient to the ward?, if he/she improves within the next hours when to discharge and schedule follow up?.




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

CCS



Turner Synd (Office )


14 year girl never menst,short stature,chubby

INTERVAL HIS :---->Complete

WRITE ORDERS :

CBC
CHEM7
UA
CXR
EKG
ABD Ultrasound
TSH
LFT
KARYOTYPE
BUCCAL SMEAR
Check Ekg--- report comes in 30 min
Change Loc-------------------------->HOME
Appointment in 7 days

Pt back for appoint
Reassure Pt
Counsel Parent
Surgical Consult
Estrogen and Progestin
Change Loc------------------>HOME
Appointment in 3-6 months

My Questions :'
1.Genetic counsel------> computer doesn';t recognise
2.family education-----> computer doesn't recognise
3.Do we do X-*** wrist
4.Estrogen and progestin ----> what formulation
5.Anything to be added/deleted



genetic counsel - counsel abt birth control or contraception ....will that be acceptable alternative ?
counsel parent - for family education

and wat abt echo ....for coarctation aorta?



*Agree, we will do wrist x-***.

*I think we do echo only if EKG abnormal

*Please let us know the formulation for E/P, because computer only recognises different combination. My concept is not very clear with the combination.

Therefore for this case what formulation of both Estrogen and progestrone before and after fusion

Also since we are discussing contraceptives, for DUB,do we manage the girl with premarim. If yes what combination of estrogen and progestrone do we start after premarin. And if we don't give premarin, what is the combination of E/P.



coarctation not diag on EKG


Need to do Echo and fasting Blood sugar,
genetic consult is there.
can give estrogen and progesterone separately, only concern is make sure that you Rx low dose estro before fusion of bone.

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


************************
CCS



Alz Dementia ( Office)


INTERVAL HISTORY :----------- >
.GA,HEENT,Chest/lungs,Heart,Abd,Ext,Neuro/Psych

WRITE ORDERS:
.CBC
.SMA7
.LFT
.FOLATE
.B12
.RPR
.EKG
.CXR
.CT HEAD
.UA
.Neuropsychiatric Test battery (Computer Recognises )
.Follow up the EKG and ask the patient to come back in
3 days. As far as patient is in safe envirnoment, you
can send the pt home.

Pt is back for the appointment:

. Start Aricept or Exelon
. Vitamin E
. Follow up in 4-6 weeks
. If patient is alone, you can ask for Home care


counsel regarding driving,safety at home and so on


U got to check thyroid profile...hypothyroidism is associated with mental slowing and memory difficulties.

second.... in terms of result of all these test...MOST of the result will come NEGATIVE if this patient has dementia..

u also have to rule out depression with is associated with PSeudo dementia..

lastly....if u decide to start meds ..start with Aricept..

exelon is associated with Serious GI s/e and u have to titrate dose very carefully
VIT e is not beneficial in ALzheimers dementia.



Some doctors do give Vit E ...

Apart from psychotropic medications and behavioral interventions, ChEIs, NMDA antagonists, and inhibitors of amyloid deposition, numerous other agents are proposed for the treatment of AD. These include free radical scavengers (based on the proposal that AD is caused by oxidative stress) and estrogen or selective estrogen receptor agonists (based on emerging evidence that estrogen has a trophic effect on certain neuronal populations that is lost after menopause). These 2 proposals are cited as justification of many practitioners' recommendation to employ high doses of tocopherol (1000 IU PO bid) in all patients and estrogen replacement therapy in postmenopausal women with AD. Emphasis should be placed on the fact that the common use of these agents in clinical practice is not mandated by federal or other institutional policy but reflects the widespread belief that they may be beneficial to patients

REF:http://www.emedicine.com/neuro/topic13.htm


Agree Vitamin E is given with Aricept


thanks for letting us know the S/E of exelon


i dont think VIT E is a standard of care,,,,u can give anything u want but it is not recom

In a trial including over 300 patients with moderately severe AD,trearment with Vit E (alpha tocopherol ) or the selective monoamine-B inhibitor selegine was found to lower rates of functional decline.
I got this information from the hospital and the attending confirmed that Vit E is being given to these Patients.

Hope that helps.thanks






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


DUB ( ER )


15 year old brought to the ER because of Vaginal Bleeding

Interval History:------- >
.GA,Skin,Breasts,Chest/Lungs,Heart/CVS,Abd,Genitalia,Ext

WRITE ORDERS :

.CBC
.CHEM7
.IV Access
.IV Fluids
.Serum HCG ( Quantitative )
.Pelvic Ultrasound
.TSH
.Coagulation Profile
.IV Premarin
.If Stable----------------- >WARD

.Vitals
.Follow up Labs
.Patient Better
.D/C IV
.D/C Premarin
.PO Low Dose Estrogen/Low Prog
.Change Location------------------> HOME

.Counsel Patient
.Appointment in 1 week

Friends, please add your input
My Questions:
1.which hcg do we do-Quantitative,Qualitative or Urine
2.Is the oral contraceptive combination of Low E/P OK
3.Anything to be added/deleted in this case.

thanks

i think the ocp should be low estrogen and high progesterone


if both are low the net effect of that ocp will be less.so its better to increase one and decrease another.we always use low dose estrogen. I think its better to use either medium or high dose progesterone

I think she needs Pap smear (if the pt is sexually active)






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


CCS



Cystic Fibrosis( ER )


By the time, you are through the first 3 screens, you kind of have an idea of what case it is.

INTERVAL HISTORY:---


WRITE ORDERS: ------->
.O2
.IV Access
.IVF
.CXR
.CBC
.CHEM7
.ABG
.SPUTUM---Gr St and C/S
.Blood Culture
.Sweat chloride
.IV Ceftazidime and Tobramycin (Pending the Results )

If patient Stable, Change Location------- WARD
.Vitals
.Chest physiotherapy
.Incentive Spirometry
.Follow up the Sputum/Blood Culture and give Abx accord
.pancreatic enzymes
.diet supplements

Patient feeling better:

.Counsel Deep Breathing Exercises
.Counsel Patient
.D/C IVF
.D/C IV Antibiotics
.Start PO Cefalexin or Clarithromycin or Augmentin
.Change Location------------------ HOME

.PFT
.Infuenza Vaccine
.Pneumococcal Vaccine
.Appointment in 7 days

Friends, suggestions Welcome


Please add------> Albuterol inhalation in Orders

Good mgt Add pulse ox on arrival in ER and again before sending to ward.




******************
CCS-Tuberculosis (pulmonary):
June 8 2003 at 9:16 PM

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-*** 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-*** 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 pr