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  1. #1
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    USMLE Step 3 CCS

    Please add any recent CCS cases or solutions to this thread. Good luck.


    Recent CCS posted by someone

    1. A 30 year old female patient with a cold and infraorbital headache --maxillary sinusitis.
    2. A Latino 30 yr old pharmacist with low grade fever and PPD test positive -- treatment of tuberculosis.
    3. A Latino male who is s/p colon carc resection and admitted to hosp. for treatment of pneumonia developed chest pain - pul.edema/chf.
    4. A Latino alcoholic female who is pale and tired; cbc shows hyperseg. neutrophils and increased MCV--folic acid deficiency anemia.
    5. A Latino 12 month old child with high fever (40 C) --blood culture showed gram positive coocci in pairs(work up of sepsis)
    6.A 25 year old female with H/o DM Type I came to er with n/v loss of appetite ---DKA with urinary tract infection ( as UA showed positive nitrites and leukocytes)
    7. A young female with burning urination and foul smelling vag discharge--Trich vaginitis.
    8. A 60 year old female with headaches and stiffness of joints----Polymyalgia rheumatica.

  2. #21
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    Batch#4

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    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 ray 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 ray, 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.

  3. #22
    Anonymous is offline Unregistered Guest
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    Batch#5

    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

  4. #23
    Anonymous is offline Unregistered Guest
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    Batch#6

    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-ray .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.

  5. #24
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    Batch#7

    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-ray of the affected joints
    Chest X-Ray
    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 ray 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

  6. #25
    Anonymous is offline Unregistered Guest
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    Batch#8

    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-ray 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-ray.

    *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-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- pid
    June 10 2003 at 11:12 PM

    young woman complaining of abdominal pain and vaginal discharge. dx: PID secondary to N. gonorrhea.
    -Acute salpingitis
    PE
    Gen exm
    Lungs
    Heart
    Pelvic/vaginal

    Investigations
    CBC with diff
    urine pregnancy,
    ultrsound – abdominal and transvaginal
    gono/chly vag culture,
    bl culture
    SMA 7
    ua and culture
    pap smear
    cervical culture
    pelvic ultrasound
    KOH slide and wet mount
    HIV testing

    Treatment
    IVF
    Admit to ward and order i/v antibiotics
    Clindamycin and gentamycin
    On discharge give councelling on Educate patient/family accordingly...
    eg. exercise, smoking, drug use, safe sex; etc..

    1. not all of pt need for in-pt tx
    2. in-pt criteria: all nulliparous and adolescents, HIV+, out-pt tx no response, GI symptoms.
    3. give doxycycline if tubo-overian abx+
    4. cont. iv antibiotics for 48 h if symptom improving




    **************
    Gastric ulcer bleeding
    64yo female epigastric pain ibuprofen hx. For bursitis, stool ob positive.
    PE:
    vital signs: BP, Pulse, Resp. Rate, Temp. (order from order sheet)
    appearance, skin, CV, Lung, Abd, Rectal
    Investigations:
    Monitor Hb and Hct q6h
    CBC,
    SMA-7 (BUN/Cr: >36---UGI bleeding)
    stool guaiac-positive
    PT,PTT,INR
    LFTs,
    CXR
    X-ray abd
    NG tube aspiration, NG Positive bleeding
    Endoscopy ( Sclerotherapy or endoscopic variceal ligation for bleeding varices.)
    If still no Dx,
    Active bleeding --- angiography
    Inactive bleeding ---- GI series
    NG negative bleeding
    Sigmoidscopy----- bleeding stoped----colonoscopy or BE
    Active bleeding---angiography or radionuclides studies

    Management
    NPO,
    IV access
    NG tube,
    IV fluid d51/2 NS
    Chest X- ray transfer pt to ward
    PT/PTT
    Blood type and cross
    Blood transfusion if needed
    Therapy
    treat underlying disease
    Endoscopy - Sclerotherapy or endoscopic variceal ligation for bleeding varices.

    SBE prophylaxis when there is risk factor.
    No choice regurding aviod NSAID'
    Only about aspirin
    In aspirin list there is 'abstain from aspirin'
    In aviod list "avoid oral aspirin"
    clerk cant order > breath urea test
    have to order H-pylori antibody serum.

  7. #26
    Anonymous is offline Unregistered Guest
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    Batch#9

    pid work up

    Acute PID/ Acute salpingitis

    -young woman complaining of abdominal pain and vaginal discharge. dx: PID secondary to N. gonorrhea.
    -Acute salpingitis

    PE
    Gen exm
    Lungs
    Heart
    Pelvic/vaginal

    Investigations

    CBC with diff
    urine pregnancy,
    ultrsound – abdominal and transvaginal
    gono/chly vag culture,
    bl culture
    SMA 7
    ua and culture
    pap smear
    cervical culture
    pelvic ultrasound
    KOH slide and wet mount
    HIV testing

    Treatment

    IVF
    Admit to ward and order i/v antibiotics
    Clindamycin and gentamycin
    On discharge give councelling on Educate patient/family accordingly...
    eg. exercise, smoking, drug use, safe sex; etc..

    1. not all of pt need for in-pt tx
    2. in-pt criteria: all nulliparous and adolescents, HIV+, out-pt tx no response, GI symptoms.
    3. give doxycycline if tubo-overian abx+
    4. cont. iv antibiotics for 48 h if symptom improving



    ***************
    chf

    congestive cardiac failure
    -Pt with progressive SOB in office - CHF
    -Middle age man with Decompensated Congestive Heart Failure seen in your office

    PE:

    As the person is in the office a complete H & P

    Investigations:

    1. EKG
    2. chest X-ray
    3 CBC
    4 SMA 7/12
    5 Lipid profile
    6. LFT
    7. Urinalysis
    8. Cardiac enzymes
    9. Echocardiogram

    Treatment:

    If patient is stable and doesn’t require further workup or workup can be done outpatient then discharge patient home.

    1. low sodium diet
    2. lasix
    3. digoxin
    4. ACE Inhibitor

    usual concelling and schedule f/u appt.

    1. EF<40%->systolic, >40% -> diastolic
    2. Ca block for diastolic
    3. beta-blocker not for acute
    4. f/u: flu shot, check K level





    ***************************
    PE

    PE...trip to Australia
    PE without classic pleuritic pain but with classic trip from Australia

    PE
    General examination
    Lungs
    CVS
    HEENT
    EXT

    Investigations.
    Chest x-ray
    ABG
    Pulse Ox
    EKG
    Ventilation-perfusion scan
    Sma 6
    PT/INR, PTT
    (Protein c and s level
    Anti Thrombin III not emergency but eventually
    D dimer
    Factor V assay)

    Treatment in ER
    1. Administer oxygen as soon as possible. (even before all the investigations are sent)
    2. Heparin bolus, followed by infusion to maintain PTT X 2
    3. Coumadin maintaian INR at 2.5-3

    Transfer to ward

    Continue anticoagulation and discarge when theraputic anticoagulation is attatined and anticoagulation to be maintained for atleast 6 months.

    Discharge

    Educate patient/family accordingly, medication complance.
    eg. exercise, smoking, drug use, safe sex; etc..
    Schedule F/U




    **********************
    PDR, this is all from previous posting about RA case, sorry no work flow..yet..

    40 F SOB low grade fever,and wrists hurt->ESR+, RF-, ANA+ CXR shows LL Effusion -> thoracocentesis,(pt feels better afterword) low glucose, no bugs-> gave ibuprophen and prednisone, got better =RA




    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.


    Liu: Looks like RA, but not sure why pleural fluid got infected..? is it common, or in general,RA induced pleural effusion shd contain WBC as inflammatory process.... any ref..(just like joint fluid analysis)

    Jb: 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?

    can you explain why the pleural fluid had lot of neutrophils?
    It is an exudative pleural eff Rheumatoid effusion caracteristics:
    Turbid, 1000-20000 WBC, differential mono and polymorphonuclear RBC <1000, Glu <40

    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.





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

    CCS- TTP-

    Thrombotic thrombocytopenic purpura:
    Working flow:
    History and PE

    Lab work:
    CBC with differential
    Blood peripheral smearing
    LDH, total and direct bilirubin
    Direct coombs test
    Cr/BUN
    PT/aPTT
    Dimer/fibrinogen
    UA
    HIV screening
    vWF-cleaving protease activity
    Images: Head CT without contrast if stroke is suspected

    Management:
    Admit patient
    Plasma exchange
    Prednisone
    Aspirin can be used
    Vincristine can be used for refractory case
    Platelet should not be transfused unless intracranial bleeding
    Consult hematology
    Consult nephrology if dialysis is needed
    Examine patient every day
    Repeat CBC, LDH, bilirubin, Cr every 3 days
    Discharge patient when all these are normal
    Follow up patient in one week with CBC and LDH

  8. #27
    Anonymous is offline Unregistered Guest
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    Batch#10

    SAMPLE SOLUTION TO THE CCS QUESTIONS

    CASE #1: 65-year-old white man with chest pain
    Case Introduction: Essential Facts
    · Patient is white, in mid-sixties
    · Has sharp, right-sided chest pain, accompanied by respiratory distress
    · He was brought to the emergency department
    Comments
    There is nothing that connects being white with having chest pain. This patient could have been of any racial origin and still present with these clinical features. However, the patient’s age will affect our choice of differential diagnoses. Chest pain in an older man is more likely to be of cardiac origin than the same pain in young patients.
    Possible differential diagnoses at this stage include
    · Pulmonary embolism (PE) because of chest pain, respiratory distress
    · Lobar pneumonia (chest pain, respiratory distress)
    · Tension pneumothorax (chest pain, respiratory distress)

    · Musculoskeletal chest pain (pain in a specific location)
    · Pleuritic chest pain
    · Cardiac pain (this is less likely, though possible. A patient with dextrocardia who develops myocardial infarction may have right-sided chest pain. However, since this test is based on clinical conditions commonly seen in practice, we are not going to be too concerned with this differential)
    Initial Vital Signs: Essential Facts
    · There is tachypnoea and tachycardia
    · Blood pressure is low
    · Temperature is normal
    · The patient is obese (BMI of 29)
    Comments
    Pneumonia as a cause of this patient’s chest pain is effectively ruled out because of the normal temperature. Still high on our list are PE, pneumothorax, and the other differentials listed above. Patient’s obesity will be addressed at a later time
    Initial History: Essential Facts
    · Chest pain began 10 minutes before arrival at the ER

    · This is the first episode of chest pain

    · Patient has had chronic lung diseases that may predispose to pneumothorax
    · Chest pain increases with respiration
    · He was not involved in strenuous activities immediately before the onset of chest pain
    Comments
    Although, this pain increases with respiration, a musculoskeletal cause is unlikely, going by the patient’s recent history. He is an accountant who suddenly developed an excruciating chest pain while at work. There is no recent history of chest trauma.
    Because of his long-standing history of asthma and emphysema, we will add emphysema to his differentials, since the latter can cause a measure of chest discomfort, especially if there is associated chronic obstructive pulmonary disease (COPD). However, uncomplicated emphysema does not cause sudden sharp chest pain.

    It is time to perform the physical examination. Click the button labeled Interval History or PE and select
    · General Appearance
    · Chest/Lungs and
    · Heart/Cardiovascular
    We are interested in the general appearance (this is standard when interacting with most patients. You should always examine the patient’s general appearance). Moreover, because the primary complaint is in the chest region, we would naturally want to examine that area. Also, considering the patient’s age and the possibility that his heart might be the cause of his problems, we want to examine the heart as well. We cannot do more detailed examination of other systems because this is an emergency. Press OK to confirm your choice.
    History and Physical: Essential Facts
    · Patient is cyanotic and in marked respiratory distress
    · There is chest asymmetry, with hyper-resonance on right side. Breath sounds are also absent on that side
    · Cardiac examination essentially normal
    · Peripheral pulses present but weak
    · No pulsus paradoxus (a fall in pulse amplitude with quiet inspiration)
    Comments
    Notice the results of physical examination. We seem to have enough reason here to believe that this patient has tension pneumothorax. However, we would still like to confirm this with further tests.
    FAQ: Since this patient is in severe pain, and his vital signs are abnormal, why can’t we just go ahead and treat?
    Answer: Although this is a relative emergency, it is clear that we have enough reason to investigate the cause of the patient’s problems further before we initiate treatment. First, we can still measure his blood pressure (although this is low). There is no pulsus paradoxus. We are not going to waste time on nonessential investigations however. It is important to try and establish the cause of patient’s problems, if possible, before we initiate treatments.
    Now, let us write orders. If the result of the History and Physical is still visible, click OK to close it. Next, click the button labeled Write Orders or Review Chart.

    Next, click Order button at the bottom of the screen, and enter the following orders (one on each line):
    . Chest x-ray
    · Oxygen
    · Morphine
    · ECG
    Confirm the orders by clicking the Confirm Order button. For chest x-ray order verification, choose Chest x-ray, portable. Click OK. Urgency: stat.
    Note: Although, Chest X-ray PA/lateral may give you more detailed information, it takes more time. Moreover, the patient has to be wheeled to the X-ray department before the films can be taken. Portable chest x-ray can be done right there at the ER, and it takes very little time.

    For oxygen, choose Inhalation for route and Continuous for frequency. For morphine, choose Intravenous for route and Continuous for frequency.

    Note: morphine is almost always given through the intravenous route for most conditions. In any situation where you have need to use morphine, consider this fact. Don’t let the frequency that we chose mislead you. Continuous administration here means that it is given at fixed times (e.g. 6 hourly, 8-hourly, etc).

    For ECG order verification, choose ECG 12-lead; Urgency: stat.

    Now that we have initiated treatment, it is time to review that patient with the next available result. From our Order Sheet, we can determine that the result of the portable chest x-ray will be ready within 10 minutes. So let us advance the clock to that time.

    Click the button Obtain Results or See Patient Later at the top of the screen, and choose Review Patient with Next Available Result. The test result is displayed.

    Chest X-ray findings: Right tension pneumothorax
    Next, we are going to write more orders for this patient. Click the Order button at the bottom of your screen and type thoracentesis. Scroll to the bottom of the form and choose Thoracostomy tube. Confirm your choice. The result of this procedure is immediately displayed. When you click OK, the result of the 12-lead ECG will be displayed, showing essentially normal findings.

    It is now time to advance the clock, so we can re-evaluate our patient in 15 minutes. Click on the clock at the top of the screen and choose

    · Re-evaluate case In, then
    · type 15 in the Minutes box (you may also use the upward pointing arrow to do this). Click OK

    Now that our patient has been stabilized, we would like to perform an interval follow up before we admit him for further management.
    Towards the left side of the screen, click Interval History button, and choose

    · Interval Follow Up,
    · Chest/Lungs under the Physical Examination section
    The important findings this time are:
    · Patient is a smoker (for 45 years)
    · He has a positive family history of cardiac disease, hypertension, obesity, and stroke.
    · As noted earlier, the patient is obese (he has a body mass index of 29)
    · Patient does not engage in regular exercise (dyspneic after 1 minute of brisk walk)
    · The chest is now symmetrical
    Some of this information will come in handy when it is time to address the patient’s health maintenance issues. For now, we would like to send him to the intensive care unit.

    FAQ: Since the patient has been stabilized, why can’t we just admit him to the ward instead of the ICU?
    Answer: Under the British medical care system (and, incidentally, this is also true of many third world countries), we would have sent the patient to the ward. However, in the United States, patients like these are sent to the Intensive Care Unit.
    FAQ: Why can’t this patient be discharged home right away, since he has been relieved of his problems?

    Answer: he has a chest tube in place. The general consensus is that the chest tube should remain in place until we are sure it is no longer needed (i.e it does not show any bubbles in the water seal.) Even then, some hospitals prefer to clamp the tube and observe for some more time, before they remove the tube entirely.
    Click the Change Location button, and select Intensive Care Unit (ICU). Confirm move. Recorded vital signs are displayed (much better this time around). Click OK.
    We must now add more treatment for the patient. Click Order Sheet on the left side of the screen, and Order button at the bottom. Enter the following orders (one per line):

    · Albuterol (inhalation, continuous)
    · Atrovent (inhalation, continuous)
    · Advise patient, smoking cessation (routine, start now)
    · Advise patient exercise program (routine, start later)
    · Advise patient, weight reduction (routine, start later)
    Next, we are going to re-evaluate the patient in 1 day. Click the clock, and advance the next evaluation to 1 day. The dialog appears telling you you have five minutes more, and asking for the final diagnosis.
    Final diagnosis: Tension pneumothorax
    End of case
    source:
    http://www.passfirst.com/publication...ccssamples.asp




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

    Work flow for Ectopic pregnancy
    Work flow for pneumonia


    Ectopic pregnancy: manage this patient in ER
    Work flow: History and PE including rectal and pelvic
    Lab:
    serum h-CG quantitation
    CBC with differential
    Blood type and Rh
    UA
    Intravaginal ultrasound
    Management:
    IV access
    NSS IV
    OB/GYN consultation
    Laparoscopy
    RhGAM
    Educate patient on safe sex, drug, alcohol, smoking, exercise, breast examination, pap smearing, vaccine update



    ********************
    Pneumonia in a 6-yr with fever and SOB:
    Work flow:
    History and PE
    Lab:
    CBC with differential
    UA
    Sputum gram staining
    Sputum culture
    AST/ALT
    ABG
    Images: CXR
    Management:
    Admit to ward if kid looks toxic
    Pulse oximetry
    Oxygen inhalation if SOB is moderate to severe
    Penicillin IV
    Erythromycin IV
    Acetaminophen
    Check patient every day
    Repeat CBC every 48 hr
    D/S erythromycin IV when afebrile for 24 hr
    D/C patient on erythromycin
    Follow up patient in 1 week with CBC and CXR
    Educate patient and parent: nutritious food, hand wash, update vaccination, home safety



    you can substitute athroat culture if you like.


    ********************
    do we need to do DRE.....

    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.

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




    CCS posted by someone in (march/ april 2003 )

    1. A 30 year old female patient with a cold and infraorbital headache --maxillary sinusitis.
    2. A Latino 30 yr old pharmacist with low grade fever and PPD test positive -- treatment of tuberculosis.
    3. A Latino male who is s/p colon carc. resection and admitted to hosp. for treatment of pneumonia developed chest pain - pul.edema/chf.
    4. A Latino alcoholic female who is pale and tired; cbc shows hyperseg. neutrophils and increased MCV--folic acid deficiency anemia.
    5. A Latino 12 month old child with high fever (40 C) --blood culture showed gram positive coocci in pairs(work up of sepsis)
    6.A 25 year old female with H/o DM Type I came to er with n/v loss of appetite ---DKA with urinary tract infection ( as UA showed positive nitrites and leukocytes)
    7. A young female with burning urination and foul smelling vag discharge--Trich vaginitis.
    8. A 60 year old female with headaches and stiffness of joints----Polymyalgia rheumatica.




    Sanjana's CCS ( mot recent cases APRIL 2003)

    are --

    1.erosive gastritis
    2.cholilithiasis in a sickle cell pt
    3.pid
    4.uti in a pregnant
    5.military recruit
    6.idiopathic thrombocytopenic purpura
    7.right lower lobe pneumonia
    8.pulmonary emboli
    9.iron deficiency anaemia in 18 month old baby





    CCS posted by billo ( march 17th 2003 )


    1. PE..pt was in the hopital treated for pneumonia 71 yr old...sob

    2. 42 yr old female with the breast mass surgeon wants to do surgery send to PMD for other medical disease. she had an upper respiratoy infection deve;lop some purpura...........came to u with nose bleed.......... her platelet was low but her BT wa 20......

    3.Gastritis

    4. Obese 16 yr old came for military recuritment
    5. Bacteriuria in a pregnant 6 wk
    6. 18 month old with loss of apetite........shows anemia
    7. Sickle cell with intermitent abdominal pain

    8.vaginal discharge

    9. 70 yaer old with abdominal pain .......obstruction series shows rt lower quadrant pneumonia




    Someone Named Rao's CCS cases ( march 2Oth )

    ccs case.
    my ccs were
    UTI
    ADENOCARCINOMA IN WOMEN IN FIFTIES
    DOUDENAL ATRESIA
    LEAD POISINING IN 18 MO OLD
    PERICARDITIS
    PERICARDIAL EFFUSION
    DUB
    UNCONSCIOUS MAN IN 40 WITH R/R 8

    there was also a question set on Gulf war syndrome 4 qustions, mostly how would u responde to his qustions





    another Set of recent CCS cases ( 2nd wk of march 2003)

    My ccs cases were
    G6PD
    CIN III
    Iron def anaemia
    General check up of a boy with HTN.& obesity.
    pulm embolism in colon ca pt
    Cystitis,
    Cholelithiasis
    pnuemonia
    Diverticulitis
    In real exam ccs cases r really slow,,it takes its own sweat time ,,so practice well so that u dont spend time thinking there






    CCS posted by zoella ( March 5th 2003 )

    I was able to manage 6 out of 9 cases well,in the rest I am not sure .In two cases time ran out before I could do something significant.Anyway its done now and I have left it to God.

    Regarding my cases I got:

    1. colon cancer
    2.ITP
    3.1 child with anemia which I could not get the exact diagnosis.
    4.cystitis
    5.pulmonary embolism in a cancer patient.
    6.sedative poisoning
    7.pneumonia
    8 obesity
    9cholecystitis




    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 .




    Some one named Ji's CCS january 2003

    CF,
    angina,
    dematia,
    DKA,
    newly Dxed DM type-II,
    50yo F regulur physical.
    duodunal ulcer


    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!!!!
    4 acute 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-dm II (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.




    Anant's CCS ( december 2002)

    young woman-ac asthma,gets better with Iv steroids and albuterol
    2-kid with icterus,g6PD def
    3-woman with no complaint except fatigue-post infectious thyroiditis(T4 high,TSH normal)propranolol took care of the symptoms
    4-male middle aged-tired(like us all)we can have the luxary of saying we are depressed,he was,give SSRI
    5-overweight female(slightly)...routine visit,tired pees a lot at night,only in the US they dont think its BM..give oral hypoglycemic she wont get up at night to flush
    6-trip to Australia..leg swolllen.I wanted a picture post card but there was this little problem of PE sent her into cyber space with elevated bleeding count..last i heard of her she was doing well.I will do well too if you pay me a trip to Australia.
    warfarin etc after usual ultrasound(the damned leg is swollen) and PQ to tell higher-souls that you know it exists...CCS have nothing-well only a little- to do with what we do in real life(exam wise){p<.ooo5)
    7-I take a break


    Another set of CCS posted in december 2002

    1-Acute cholicystitis
    2-ITP
    3-UGI Bleeding
    4-DKA
    5-Bacterial Vaginosis
    6-Hypothyroidism + Iron deficiency anemia
    7-Alcohol Abuse
    8-Pneumonia
    9-foriegn body aspiration(peanut)

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    Vetan's CCS

    All CCS in one page
    March 2 2003 at 5:23 PM


    I compiled all the cases in one page for easy printability.. Good luck

    Acute Gout AttackJanuary 16 2003 at 11:51 AM Ferritin (Login ferritin)from IP address 12.234.186.166


    hey vetan,iam not good at this but I will try.Please feel free to delete this if does not fit in here.Step 1:keep foot elevatedStool guaic.Labs:cbc, sma7,Uric acid,UA with microsynovial fluid :for light polarising micrograph.C&S,Gramstain,glucose,protein,cell count.X-RAY JOINT.24 hour urine for UADiet:low purineMedication:Motrin PO or IndomethacinPo for 2 days,then hypouricemic therapy:Probenicid increase until UA level falls below 6.5..Allopuinol ,after attack.symptomatic:Ranitidine bid.Meperidine or Vicodine
    CCS- Splenic RuptureFebruary 26 2003 at 4:16 PM vetan (no login)from IP address 65.66.15.248


    diagnosis : splenic hematoma HPI23 y/o male after MVA.ABCPEfocusLabs:serum glucose and rapid bedside glucose determination CBCserum chemistriesamylaselftsuacoagulation studiesblood type and matchabg, blood ethanolurine drug screens.Bedside u/s, DPL(for unstable), CT(for stable) and emergent surgeon consult.Chest x-ray, supine & erect abdomen x-rayAbdominal sono(er) or abdominal CTVital, Cardiac, and BP monitoring on bed side.Foley cather and Urine output check.Ringer's lactate sol I.V before results from Lab.Transfer to ICU if patient is not stable.posted by raavii02good work upI would add surgical consult for repair also prefer NS as IVF rather than LR because in case he develops rhabdo. (MVA) NS is fluid of choice.
    CCS- AMIDecember 23 2002 at 7:17 PM vetan vetan (no login)from IP address 66.141.67.118


    History of present illness:A 45 yrs old patientbrought to the e.r.with excruciating stabbing pain on his chest and inner arm for 20 min .the pt.has no history of previous attack but is a hypertensive candidate with BP 190/ 96 when last taken. pt. is conscious but looks anxious. vital sign; temp-97, pulse-86/min,resp. rate-33/min, Step I : Emergent management: A, B, C, D- O2, IV access, Step II : Physical Examination Focus PE Heent/Neck, Chest/Lungs, Heart/Cv, Abdomen, ExtremitiesStep III : Diagnostic Investigations: EKG, CXR, CK-mb, Troponin-I, CBC, Chem –7, continues cardiac monitoringTreatment:1. NTG 0.4mg sl2. Aspirin3. Morphine if patient is in pain4. ACEI (ramipril)5. Depending on time since onset consider t-PA if not contraindicated or cardiac cat.6. Consider nitroglycerin drip. Other antihypertensive you may consider is labatelol or nipride( more severe cases).Step IV: Decision about changing patients location 1. Admit the patient to CCU, if patient is symptomatic send to ward.2. repeat cardiac markers 3. discountiue cardiac monitor after 24 hours if patient is stable4. When patient is stable consider submaximal exercise test5. All patient with MI should go home on B-blockers6. check lipid profile7. consult on healthy life style prior to discharge8. make appointment to see him in about a weekSTEP V: Educate patient family.console patient, stop smoking, diet, excercise.STEP VI: Final Diagnosis.AMI

    CCS-PIDFebruary 8 2003 at 6:14 AM vetan (no login)from IP address 65.66.18.199


    HPI25 Year old WF c/o lower abd pain.PE:Pregnancy testCBCChem7Endocervical gram stain-for gram-negative intracellular diplococciEndocervical culture-for gonorrheaEndocervical culture or antigen test-for chlamydiaTREATMENT:Outpatient, normallyHospitalization recommended in the following situations:Uncertain diagnosisSurgical emergencies cannot be excluded, e.g., appendicitisSuspected pelvic abscessPregnancyAdolescent patient with uncertain compliance with therapySevere illnessCannot tolerate outpatient regimenFailed to respond to outpatient therapyClinical follow-up within 72 hours of starting antibiotics cannot be arrangedHIV-infectedGENERAL MEASURES Avoidance of sex until treatment is completedInsure that sex partners are referred for appropriate evaluation and treatment. Partners should be treated, irrespective of evaluation, with regimens effective against chlamydia and gonorrhea.SURGICAL MEASURES Reserved for failures of medical treatment and for suspected ruptured adnexal abscess with resulting acute surgical abdomenInpatient treatment; Cefoxitin IV cefotetan IV (or other cephalosporins such as ceftizoxime, cefotaxime, and ceftriaxone) plus doxycycline orally or IV Therapy for 24 hours after clinical improvement and doxycycline continued after discharge for a total of 10-14 daysClindamycin plus gentamicin loading dose IV or IM Therapy for 24 hours after clinical improvement with doxycycline after discharge as aboveOutpatient treatmentceftriaxone plus doxycycline orally for 10-14 daysOfloxacin orally for 14 days plus either clindamycin orally or metronidazole PATIENT MONITORING Close observation of clinical status, in particular for fever, symptoms, level of peritonitis, white cell countsafe sex practices education-particularly for those who have had an episode of PID
    CCS- DepressionFebruary 21 2003 at 5:44 PM vetan (no login)from IP address 65.66.18.2


    HPI:40 years old executive man comes to the office with chief complaint of headache.Later he gives history of financial problem and starts crying.First pay attention to history for alcohol or recent drug use.you should check HPI to see when these headaches started ,is it reoccurent?, is patient's energy level has change recently, etc..R/O medical cause.PE:completeLabs:CBC- posssibly WNLChem-7UA- WNLAlcohol and Urine Drug screening- need to rule out drug use.TSH- probably WNL- rule out thyroid problem.if all above normal. depression index- response to 20 question indicates depression.start antidepressant- if patient is obese use celexa otherwise any ssri would be fine.schd. psychotherapy (with psychiatrist) to augment medication.schd. patient for follow-up in 3 weeks.

    CCS- Spleen ruptureFebruary 9 2003 at 7:38 AM vetan (no login)from IP address 65.66.15.120


    HPI23 y/o male after MVA.ABCPE;focusLabs:serum glucose and rapid bedside glucose determination CBCserum chemistriesamylaselftsuacoagulation studiesblood type and matchabg, blood ethanolurine drug screens.Bedside u/s, DPL(for unstable), CT(for stable) and emergent surgeon consult.Chest x-ray, supine & erect abdomen x-rayAbdominal sono(er) or abdominal CTVital, Cardiac, and BP monitoring on bed side.Foley cather and Urine output check.Ringer's lactate sol I.V before results from Lab.Transfer to ICU if patient is not stable.

    CCS- chron's diseaseFebruary 8 2003 at 9:58 AM vetan (Login run24)Forum Ownerfrom IP address 66.141.67.67


    HPI28 y/o female comes to office c/o diarrhea for several days.PE:Complete- Labs:CBC- check for leukocytosisChem7Guiac - positive for bloodstool culture- WNLstool for ova and paraside- WNLColonoscopy- biopsy- inflammatory process consistence with chron's diseasTreatment:mesalamineantidiarrhealreevaluate patient in couple days- patient diarrhea has improved. Patient is feeling better.see patient in 2 weeksdiagnosis:chron's disease
    CCS- Sickle-cell crisis(oofice)February 8 2003 at 6:00 AM vetan (no login)from IP address 65.66.18.199


    HPI6 Year old AAM was broght to your office because of pain he has a history of sickle cell disease.PE:Complete PElabs:CBCChem 7Type and crossTreatmentulse oxo2Iv Fluidmorphineexchange blood transfusion- if patient doesn't improve or Hgb is low.floic acidimmunization: H.influenzae B and pneumoccal vaccinesAminocaproic acid for hematuriaIf recurrent CVA, chronic transfusion programEduationCounsel

    CCS- Sq. Lung cancerFebruary 8 2003 at 3:05 PM vetan (Login run24)Forum Ownerfrom IP address 66.141.67.229


    HPI67 y/o female with 30 years history of smoking come to office c/o cough.PE:completeLabs:Pluse oxo2CBCChem 7CXR- mass on left upper lobebiopsy- sq. cell carcinomasurgical and onconlogy consultdiagnosis:sq. cell carcinomayou may ask how I am going to treat this patient. You probably won't have time to do any kind of treatment because when you make the diagnose case will end.

    CCS- ASTHMADecember 23 2002 at 7:20 PM vetan vetan (no login)from IP address 66.141.67.118


    History of present illness:5yo child with acute asthmatic attackNote vital signs: BP, Pulse, Resp. Rate, Temp. Step I : Emergent management: A, B, C, D- O2 , broncodilaters MDI or nebulizer, depending on severity consider systemic corticosteroids.Step II : Physical Examination General appearance, HEET/Neck, Chest/Lung, Heart/CVStep III : Diagnostic Investigations: 1. O2 sat.2. PEF3. CBC4. Chem 75. CXR6. ABG- should be considered in severe distress of when FEV1 <30% of predicted values after initial treatment.Treatment: 1. O22. Beta 2 agonist with MDI or Nebulizer every 20 mins 3. methyprednisolone IV q6h for first 24-48 hours then inhaled steroidsStep IV: Decision about changing patients location Discharge home if symptoms resolve quickly or FEV1 is greater than 70% of predicted or personal best.Recommendation for hospitalization1. response to treatment is poor2. recent hospitalization for asthma3. failure of aggressive outpatient management4. previous life- threatening attack.5. If PEF or FEV1 is less than 50%6. arterial carbon dioxide tension is greater than 427. If patient is confused of drowsy8. If no easy access to ERIf patient is discharge need to return to office within 5-7 days for follow up.Step V: Educate patient and family:Instruct patient/family to avoid factors that aggravate patients disease.Instruct on proper use of MDI STEP VI: Final Diagnosis.Acute Asthma Attack

    CCS- Nortryptiline ToxicityFebruary 8 2003 at 8:14 AM vetan (Login run24)Forum Ownerfrom IP address 65.66.18.199


    HPI27 y/o female was found unconcious with a bottle of pill.ensure ABCPE:Heent/Neck, skin, CV, Lung, ABDlabs:CBCChem13Puls oxEKGABGdrug levelTreatment:Gastric lavageActivated charcoal with intermittent gastric suctioningInduce alkalinisation with NaHCo3 to maintain pH of 7.45 to7.55If he is intubated hyperventilate to a PCo2 <35 and >25mmHgFoleyIf ECG normal and patient is asymptomatic, observe for 6 hrs in ER otherwise admit to icuAfter Admission ECG should be normal for 24hrs to discharge for psychiatric disposition

    CCS- Sickle-cell crisis(office)
    HPI
    6 Year old AAM was broght to your office because of pain he has a history of sickle cell disease.
    PE:
    Complete PE

    labs:
    Blood smear
    Hb electrophoresis
    BUN & Cr
    Lfts
    Electrolyates
    Xay skeletal

    Tx
    pulse ox
    o2
    Iv Fluid
    morphine
    type and cross
    exchange blood transfusion
    hydroxyurea
    Penicillin V 125 mg bid up to age 3; then 250 mg bid up to age 5
    floic acid
    immunization: H.influenzae B and pneumoccal vaccines
    Aminocaproic acid for hematuria
    If recurrent CVA, chronic transfusion program
    Bone marrow transplation

    Eduation
    Counsel

    CCS- COMMUNITY ACQUIRED PNEUMONIAFebruary 8 2003 at 6:36 AM vetan (no login)from IP address 65.66.18.199


    HPI64 Year old WF comes to your office c/o several days of cough.PE:completeLabs:CBC - leukocytosis with an immature shift on differentialChem 7- hyponatremia (SIADH)ABG - hypoxemiasputum culture and sensitivityIMAGING Chest roentgenogram -(with lateral decubitus views if pleural effusion present)Lobar or segmental consolidation (air bronchogram)BronchopneumoniaInterstitial infiltratePleural effusion (free-flowing or loculated)TREATMENT: Community-acquired outpatient for mild case,inpatient for moderate to severe case such as hypoxemia, altered mental status, hypotension, significant co-morbid illness, and age extremes.Empiric antimicrobial therapy oxygen - for patients with cyanosis, hypoxia, dyspnea, circulatory disturbances or deliriumAnalgesia- for painElectrolyte correctionInitial therapycommunity-acquired pneumonia requiring hospitalization a specific cephalosporin (cefotaxime or ceftriaxone) or cefuroxime) or ampicillin-sulbactam plus macrolide or a pneumococcal-active fluoroquinolone alonePATIENT MONITORING If outpatient therapy, daily assessment of the patient's progress, and reassessment of therapy if clinical worsening or no improvement in 48-72 hoursReduce risk factors where possible (quit smoking)Annual influenza vaccine for high risk individuals

    CCS- APKDFebruary 8 2003 at 6:22 AM vetan vetan (no login)from IP address 65.66.18.199


    HPI32 y/o male for routine check up. PE:completeLABORATORY CBC- Hematocrit - elevated in 5% of casesUrinalysis - may have hematuria and mild proteinuriaChem 7- Serum creatinine may be elevatedKidney U/S - stones usually calcium oxalateIMAGING Ultrasonography:> 5 cysts in the renal cortex or medulla of each kidney, in children, 2 or more cysts in either kidneyCT scan-more sensitive85% of patients can be detected by age 25TREATMENT:Outpatient-except for complicating emergencies (infected cysts require 2 weeks IV antibiotics then long-term oral antibiotics)GENERAL MEASURES bed rest and analgesics for Pain ACTIVITY Avoid contact activities that may damage enlarged organs.DIET Low protein diet may retard progression of renal disease.PATIENT EDUCATION Genetic counseling is criticalAvoidance of nephrotoxic drugsTreatment: No drug therapy available for polycystic kidney diseaseHypertension - ACE inhibitors; avoid diuretics (possible adverse effects with cyst formation)

    CCS- Cystic FibrosisFebruary 7 2003 at 5:40 PM vetan (Login run24)Forum Ownerfrom IP address 65.66.14.226


    HPI7 month old child with fool smelling stools and recurrent episodes of bronchiolitis (cystic fibrosis)PE:General appearance, Heent/Neck, skin, chest/lung, heart/CV , AbdomenLabs:CBCChem-13sweating test(Cl>60mEq/dl dgn)CXRPulmonary function testABG'sSputum culture & sensitivities of cultured organismsTreatment:Antibiotics if signs of infection -iv ceftriaxone+gentamycin for pulm.infections (I/V Semi-synthetic Penicillin or Cephalosporin with Anti pseudomona activity-Ceftazidime)Albuterol inh-BronchodilatorsChest physiotherapy: postural drainage + percussionbreathing exercisevigorous coughingexercise programPain medication if neededNutritional support: high calorie diet, oral pancreatic enzymes, vitamin A,D,E and K supplement.

    CCS-Child AbuseFebruary 4 2003 at 10:12 PM vetan (no login)from IP address 66.141.67.163


    HPI4 y/o boy brought to ER for evaluation by mom.ORDER SHEETSkeletal SurveyUrinalysisCBC with differentialPTPTTbleeding timeopthalmologic consult (?) for retinal hemorrhagesCXRElectrolytes, serumCreatinine, SerumBlood Urea NitrogenBilirubin, Serum Total and DirectIf sexual abuse considered, cultures of mouth,rectum /vag, urethra, VDRLADMIT to WARDDiet: Full regular dietSocial Worker Consult Child's Protective Agencyreport to local autorities (state protection agency)DISCHARGE: When the child gains his health, assure his safety and the hospital knows his destination.

    CCS- ATNFebruary 4 2003 at 6:11 PM vetan (no login)from IP address 65.66.18.246


    HPIpatient after MVA had developed decreased urine out put.o2 pulseo2 if need toLabs:CBCChem7UACPKTreatment:1. IVF with NS2. Diuresis with Lasix3. Sodium bicarb.Patient improves.

    CCS- ovarian cancerFebruary 4 2003 at 6:06 PM vetan (no login)from IP address 65.66.18.246


    C/cold lady with abdominal mass,ascitiesstable vitals or mild resp distress dur to pl.effusionLabs:cbc,sma7, uaesr,lft,fob,CXRabdominal u/sif mass positive ct for metastaislaproscpic biopsy of the mass- adeno/beginif adeno- debulkingparacentesis if severe symptamaticlateral decubitus >10mm do thoracocentesisf/u her cbc and counsle

    CCS- Premature labor(Office)February 2 2003 at 5:57 PM vetan (no login)from IP address 65.66.12.222


    26 y/o 32 weeks gestation presented with two 30 sec contractions in 10 minutes cervix 3 cm dilated. Effacement 70% .Transfer to Ward.Labs:CBC with differential.U/S for fetal size, position, placental location.Amniocentesis for eqivocal fetal maturityUrinalysis, urine culture (urine obtained by catheter)Electrolytes, serum glucose,Treatment: bed rest, hydrationIf this fails tocolysis with mag. Sulfate/ ritodrineGlucocorticoids for lung maturity Note-(contraindications for tocolysis: ruptured membrances, cervical dilation>4 cm, effacement >80%, fetal death, fetal distress, IU infection, polyhydramnios, IUGR, erythroblastosis, sever maternal hypertension, maternal pulmonary, cardiac disorders, abruptio placenta, placenta previa).

    CCS-Trichomonas vaginits (Office)February 2 2003 at 5:50 PM vetan (no login)from IP address 65.66.12.222


    24 y/o female complaining vaginal discharge and itching.Labs:CBCChem7wet mount (saline and KOH) test to identify the organismDX of trichomonas: pruritis, fishy oder , gray or yellow-green discharge, PH>4.5.Treatmen:metronidazole 2gm x1 and treat parter.At discharge consult pt. For safe sex.

    CCS- Colon cancerDecember 23 2002 at 7:27 PM vetan vetan (no login)from IP address 66.141.67.118


    History of present illness:60 year old male presenting to office for regular checkup. VITAL SIGNS- BP (N= 90-140/60-90), Pulse (N= 60-90, Mean- 72), RR (N= 12-20, Mean- 16), Temp.( N= 37C, 98.6F)Allergy: NKAStep I : Emergent management: A, B, C, D-Not neededStep II : Physical Examination Complete- General appearance, Skin, Lymph Nodes, HEET/Neck, Chest/Lung, Heart/CV, Abdomen, Genitalia, Extremities, Neuro.Step III : Diagnostic Investigations: 1. CBC 2. UA3. Chem-124. Lipid profile5. Because of his age he needs Guiac stool, If positive followed by colonoscopy. result will show evidence of colon cancer.6. Liver function tests, Chest x-ray to look for metastatic disease.Step IV: Decision about changing patients location 1. After initial workup admit patient for elective surgery.2. Surgery consult. Get type and cross, CBC, Chem 12, EKG, CXR, PT, PTT, LFT, inform consent, NPO, and CEA level prior to surgery.STEP V: Educate patient and family:After surgery patient should be evaluated every 3-6 months for 3-5 yrs with history, physical examination, fecal occult blood testing, liver function tests, and CEA determinations. Clonoscopy is performed within 6-12 months after operation to look for evidence of recurence and then every 3-5 years.Step VI: Final Diagnosis:Colon Cancer
    turners syndromeJanuary 16 2003 at 5:19 AM kim kim (Login mercysaba)from IP address 205.188.208.166


    mother brings a 16 yr old girl with no menstruationor16 yr old for normal physical exam, menstruating1.no need of abc as it is a office visit for routine chech up2,physical- complete,you will get the webbed neck,widely spaced nipple, ahort stature, lack of breast development3.cbcsma 7uacxr- pulmonary hypoplasiaekg- coa, bp different in armsecho- coa, bicuspid aortic valveu/s abd- horeshoe kindneykaryotype- xo4.reassurancef/u in 2 weeks in officeif confirmed- < 12 yrs- growth hormone im injection+striods<12 yrs-e+p (hrt)counsilconsult cardioldy/urology/gyn(for streak ovary renoval)f/u in 4 weeks

    CCS-Alzheimer's Dementia.January 16 2003 at 10:28 PM Auguste Duplan Auguste Duplan (Login duplana)from IP address 24.191.17.124


    CCS-Alzheimer's Dementia.Affects 15% of people over age 65. Occurs in Down's syndrome pts at younger ages (30-40). Gradually progressive, neurofibrillary tangles.Alzheimer's Disease: senile degenerative dementia (50%-90 of dementia pts) - Loss of cortical tissue (cerebral atrophy) with increased senile plaques. Criteria for the clinical diagnosis of probable Alzheimer's disease * Dementia established by clinical examination and documented by the Mini-Mental State Examination, include: Blessed Dementia Scale, or some similar examination and confirmed by neuropsychologic tests. Deficits in two or more areas of cognition. Progressive worsening of memory and other cognitive functions No disturbance of consciousness * Onset between ages 40 and 90, most often after age 65 * Absence of systemic disorders or other brain diseases that could account for the progressive deficits in memory cognition Lab. Orders: CBC, Lytes, TFTs, PRP all normal. UA toxicology -ve. CT: Evidence of cerebral atrophy with progression documented by serial observation MRI shows changes highly suggestive of Alzheimers - tangled spaghetti patches. Certain dx: not till autopsy - on PM see structural changes, abnormal proteins in brain biopsy. See shrinkage < neurons in cognitive areas of brain. Early Signs: subtle loss of memory. Person neglect, ADL. Gradual loss continues. Loss of communication skills. Later: ultimate loss of short and long term memory. Normal life span. May have good physical health. Med Intervention: No real medical therapy. Nursing support primary. Med Rx: Donepezil (Aricept) 5-10 mg tablet /dayTacrine (Cognex) Not a cure. Does not appear to stop progression as was hoped. Acts to increase amount of acetylcholine in brain to improve memory. Helps to improve in a minority of patients.Side effects: Hepatic failure, GI, abd. Pain, skin rash. Rivastigmine tartrate (Exelon) 6-12 mg cap/day Premarin for ladies Multivitamins 1 tb qd po Aspirin For vascular dementia Other supportive med Rx therapy for agitation: antidepressants, antipsychotic, sleeping aids. Nursing focus: Safety, Help maintain function as long as possible, Care for caregiver. Continuing Care: Medicare doesn't cover custodial long term. Must become impoverished to go on medicaid. Few families able to cope with entire trajectory of the illness. Nursing home care essential for some. As for Alzheimer: Remember, on the exam, when ever you counsel it takes 5 minutes for it. - Social services consult- counsel, no driving- counsel, advance living will- reassure patient/family- counsel medical alert bracelet

    CCS- Hypothyroidism (office visit)
    History of present illness:
    A 55 year old black woman with fatigue, weight gain, loss of lateral third of eyebrow, obese and other nonspecific signs/symptoms presented to office.
    Note vital signs- 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
    Step I: Emergent management:
    A, B, C, D- Not needed.

    Step II : Physical Examination
    Physical Examination
    General appearance, HEET/Neck, Heart/CV, Lymph Nodes, Skin, Chest/Lung, Abdomen, Extremities, Neuro.

    Step III : Diagnostic Investigations:
    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).
    Thyroid Panel
    Chem 12
    EKG – To rule out Cardiac disease. Patient with cardiac diseases should be started on low dose (25 Mcg) and monitored closely.
    lipid profile- patient is obese and at risk for CHD.
    Treatment:
    levothyroxine – Plasma TSH should be measured 2-3 months after initiation of therapy.

    Step IV: Decision about changing patients location
    Move patient home with follow-up appointment in 4 weeks.
    Stool guiac as part of yearly exam in this old pt.
    pap smear is due or have not been done.

    Step V: Educate patient and family:
    Advised patient on low cholesterol, low fat, and low na (high bp) diet, exercise program, etc.
    when 5min left screening warning, ordered repeat TSH in 4 weeks (to make sure, it is going down).

    Step VI: Final Diagnosis:
    Final Diagnosis: hypothyroidism
    67 y o lady with HX of fatigue (Dyspeptic symptoms with weight loss)

    VITAL SIGNS- 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
    CCS-Gastric Cancer
    January 13 2003 at 6:53 PM

    Step I: Emergent management:
    A, B, C, D-Not needed

    Step II: Physical Examination
    Complete- General appearance, Skin, Lymph Nodes, HEET/Neck, Chest/Lung, Heart/CV, Abdomen, Genitalia, Extremities, Neuro

    Step III: Diagnostic Investigations:
    1. CBC (Iron Deficiency Anemia)
    2. Peripheral Smear
    3. RI
    4. TSH
    5. Chem-7
    4. Occult blood test stool (+++): because of her age she needs to go directly to:

    Step IV: Decision about changing patient’s location
    Transfer Patient to Medical Ward (Colonoscopy is a hospital procedure)
    1.Emergent Lower colonoscopy and work based on the result (here will be -)
    2.Emergent upper endoscopy with cytologic brushing and biopsies (adeno cell Ca)
    3.LFT (metastasis)
    4.Abdominal CT for identifying distant metastases.
    5.Pre op workup such as blood type/cross match, CXR, EKG, PT, PTT, BT, start iron, Zantac.
    6.Consult Surgery/Oncology/: Message surgery will be available shortly
    DO interval/brief physical exam

    STEP V: Provide counseling from the list (Pt/family/advance directive)
    Case will end here

    Step VI: Final Diagnosis:
    Gastric Cancer


    CCS-Folic Deficiency Anemia (Office)January 13 2003 at 9:38 PM vetan (no login)from IP address 65.66.15.240


    History of present illness:A 52 year old man come to office complaining fatigue. He has a history of drinking.Note vital signs- BP (N= 90-140/60-90), Pulse (N= 60-90, Mean- 72), RR (N= 12-20, Mean- 16), Temp.( N= 37C, 98.6F) Allergy: NKAStep I : Emergent management: A, B, C, D- Not needed.Step II : Physical Examination General appearance, HEET/Neck, Heart/CV, Lymph Nodes, Skin, Chest/Lung, Abdomen, Extremities, Rectal, Neuro.Step III : Diagnostic Investigations: CBC/Diff (MCV > 110), Leukopenia, thrombocytopenia.Peripheral Smear- anisocytosis, poikilocytosis and macro-ovalocytes, hypersegmented neutrophils.RITSH (Ultrasensitive)Occult blood test (-)Chem 7LFT- LDH and bilirubin may be elevatedLipid profile- if patient has risk factorOrder Folic acid (low/ B 12 level)- serum B12 and RBC folate levels. if level equivocal do Homocystine level.Initial Treatment: Start Folic Acid ContinuousMultivitamin dailyMessage: pt is feeling betterDo Interval History and physical examStep IV: Decision about changing patients location Move patient homeSchedule 1 weekRefer for Substance abuse evaluation Step V: Educate patient and family:Quit AlcoholQuit SmokingExercise programAdvance directive Case will end here Step VI: Final Diagnosis: Folic Deficiency Anemia


    CCS-Erosive GastritisJanuary 13 2003 at 6:39 PM SAM (no login)from IP address 12.77.88.219


    History of present illness:

    55 yr old African American pt with history of Arthritis/chronic aspirin therapy presented to office with c/o fatigue

    VITAL SIGNS- 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

    Step I: Emergent management:
    A, B, C, D-Not needed

    Step II: Physical Examination
    Complete- General appearance, Skin, Lymph Nodes, HEET/Neck, Chest/Lung, Heart/CV, Abdomen, Genitalia, Extremities, Neuro.

    Step III: Diagnostic Investigations:
    1. CBC (Normocytic Normochromic Anemia)
    2. TSH
    3. Chem-12
    4. Occult blood test stool (+++): because of his age he needs to go directly to:
    5. Colonoscopy (-) followed by endoscopy (++ for gastric ulcer, no evidence of malignancy)
    6. DC ASA
    7. Start Acetaminophen, Zantac
    8. from the counseling list: Quiet smoking
    9. from the counseling list Quiet alcohol
    10. Advanced directive

    Step IV: Decision about changing patient’s location

    Home with 2 weeks follow up
    Pt comes feeling better
    Do Interval history and physical exam
    Repeat CBC only

    STEP V: Educate patient and family: and case will end here

    Step VI: Final Diagnosis:
    Erosive Gastritis

    CCS- Transient Ischemic Attack (ED)January 11 2003 at 9:36 AM vetan (no login)from IP address 65.66.17.115


    Transient Ischemic Attack (ED)History of present illness:Patient 54 years old with a hx of Hypertension, hypercholesterolemia, smoking and DM . wife brought her husband because he dropped a plate on the floor & he was unable to understand what she was saying, she asked him to write, he wrote couple of sentences that didn't make any sense, episode lasted few hrs. she brought her husband to ER.Note vital signs- BP (N= 90-140/60-90), Pulse (N= 60-90, Mean- 72), RR (N= 12-20, Mean- 16), Temp.( N= 37C, 98.6F) Allergy: NKADX:TIA Thrombotic or embolic strokeSubdural hematomaSeizureStep I : Emergent management: A, B, C, D- Not needed.Step II : Physical Examination General appearance, HEET/Neck, Heart/CV, Lymph Nodes, Skin, Chest/Lung, Abdomen, Extremities, Neuro.Physical: BP 170/98 P 100A loud bruit was auscultated over left carotid, no murmurs, rubs or bruits were heard over pericardium. neuro was nonfocal.Step III : Diagnostic Investigations: Initial Test:1. CBC2. Chem-63. CT- (remember CT takes about 2hrs, is this patient stable enough to send to CT(YES), are there any other tests(blood tests) you should do before you send him to CT. Think reason before you do a test, do not write all possible tests you could do . "Save cost, do less invasive tests, save time, be focused on that particular case, effective decisions. If CT questionable, MRI is more accurate. Why do you do a CT in this case? To rule out hemorrhage! Will the hemorrhage show in CT?, in which time phrase?Hemorrhage will show within 24 hrs, but infarcts will take few days.Why do you want to exclude hemorrhage?There is a carotids stenosis,neurological deficit we want to think, to give anticoagulation to this patient, if there is a hemorrhage he will bleed more with anti coagulation!Test results: after 2 hrs, remember patient is in YOUR care for TWO hrs now!CT: NEGATIVEDiagnosis: Considering , HX, physical, & the test you have done: this patient has 'expressive aphasia left temp,because the deficit lasted only few hrs it is TIA. TIA by definition, deficit lasting <24hrs. CT scan most of the time will not show any deficits in first 24 hrs.THere is a bruit on carotis, might represent a plaque that sent a small embolus to the brain. Step IV: Decision about changing patients location Admit to wardFurther Diagnostic Plan: 4. Carotis doppler5. Angiography6. 24hrs Holter7. EchocardiogramResults;>70% stenosis77% stenosisno arrhythmiano valvular disease, no evidence of ThrombusTreatment Plan:1. Antiplatelet-Aspirin2. Heparin3. Vascular surgent consult for elective CEA- A Multidisciplinary Consensus Statement from the American Heart Association concluded that carotid endarterectomy is of proven benefit for symptomatic patients, including those with single or multiple TIAs or those who have suffered a mild stroke within a 6-month interval, who have stenosis of greater than 70% with a surgical risk of less than 6%. 100% stenosis ; NO CEA-causes hyperperfusionStep V: Educate patient and family:Stop smokingBetter BP control-(exercise, diet, Pharma.....)DM control(exrecise, diet, pharma) Continue aspirin or plavixStep VI: Final Diagnosis: Transit Ischemic Attack.

    CCS- Narcotic Overdose (ED)January 11 2003 at 8:53 AM vetan (no login)from IP address 65.66.17.115


    History of present illness:25-yr- lady brought in unconscious with bradycardia, hypotensive and pinpoint pupils classic case of narcotic overdose.Note vital signs- BP (N= 90-140/60-90), Pulse (N= 60-90, Mean- 72), RR (N= 12-20, Mean- 16), Temp.( N= 37C, 98.6F) Allergy: NKAStep I : Emergent management: A, B, C, DA: Airway suction, Pulse Ox Q 1 hr or continueous monitoting, O2 B: Endotracheal intubation in O2 sat. does not improve with O2 nasal or PaO2<55, or PCO2>50, C: IV access (KVO), cardiac monitor, catheter Foley, finger stick glucose D: Drugs: thiamine, dextrose 50% and naloxone-all are IV bolus one time doseStep II : Physical Examination General appearance, HEET/Neck, Heart/CV, Lymph Nodes, Skin, Chest/Lung, Abdomen, Extremities, Neuro.Step III : Diagnostic Investigations: 1. B-HCG2. ABG 3. CBC4. Chem 13 5. PTT/PT 6. EKG12 lead 7. CXR portable8. UA, UDS, BAL, Barbaturate level( level> 80-100 causes coma), blood aspirin and blood acetaminophen level.Initial Treatment:Order gastric lavage gets the result (which revealed pills fragments)Order Activated Charcoal Started naloxone drip, if evidence or BZD use, give flumazenil.Alkalinisation of the urine is useful with phenobarbital and barbital overdoseInterval HX on brief physical Step IV: Decision about changing patients location Move patient to ICU Check lytes again DC Intubation if patient has improved DC NG Tube Cont cardiac/ox pulse 24 hrs DC NaloxonStep V: Educate patient and family:Psych consult (result will tell, the hx consistent with suicidal attempt)Order suicide precautionsMove pt to ward Basically the Psych ward DC IV line Start regular dietStart patient on Antidepressent Step VI: Final Diagnosis: Narcatic overdose

    CCS- Acute Pericarditis (ED Setting)January 3 2003 at 8:13 PM vetan (no login)from IP address 65.66.12.236


    History of present illness:45 year-old lady with substernal chest pain, Hx of previous URIOrders: O2, Iv Line (KVO) Cardiac monitoring, pulse monitoringPhysical Examination General Appearance, HEET/Neck, Extremities, Chest/Lung, Heart/CVDiagnostic Investigations: O2 saturationEKG (ST elevation in all leads)Cardiac enzymes, Troponin I (-)Chem 7 (WNL)CXR Portable (WNL)ABG (WNL)CBCTreatment:Start ASA continuous (can use indomethacin or in severe cases corticosteroids)Next order in the ED ECHO (result was some fluid, but not severe)Next DC O2, MonitoreNext ReassuranceEducate patient and familyDC to home and F/U office. Final Diagnosis: Acute Pericarditis

    CCS- Solitary Pulmonary Nodule (office)January 2 2003 at 9:13 PM vetan (no login)from IP address 65.70.118.167


    Solitary Pulmonary Nodule (office)History of present illness:55 year-old smoker male with history of blood in the sputum Note vital signs- BP (N= 90-140/60-90), Pulse (N= 60-90, Mean- 72), RR (N= 12-20, Mean- 16), Temp.( N= 37C, 98.6F) Allergy: NKAStep I : Emergent management: A, B, C, D- Not needed.Step II : Physical Examination Complete Physical Examination Step III : Diagnostic Investigations: CBCChem 7Sputum: Gram stain. AFB, C&SPPDCXR PA/L Nodule in the R U Q LungSpirometry EKG Pulse OXNext order in the office Chest CT ( it will give you the size of the nodule 2.5 mg)Bronchoscopy and biopsy (result was SC Ca)Next consult surgeryOrder now LFT, Head Ct, Blood type/cross matchStep IV: Educate patient and family:Stop smokingNext educate patient and familyStep V: Final Diagnosis:Solitary Pulmonary Nodule Case end here

    CCS- Active TuberculosisDecember 24 2002 at 12:04 PM vetan (no login)from IP address 66.141.65.214


    TB (Sudan immigrant Case): officeHistory of present illness:55 yr old immigrant psychiatrist came in with classical symptoms of pulmonary TB Note vital signs- BP (N= 90-140/60-90), Pulse (N= 60-90, Mean- 72), RR (N= 12-20, Mean- 16), Temp.( N= 37C, 98.6F)Allergy: NKAStep I : Emergent management: A, B, C, D- Not neededStep II : Complete Physical ExaminationStep III : Diagnostic Investigations: Order the following:1. CBC2. PPD3. Chem. 12, LFT4. UA5. Sputum smears AFB6. Sputum TB culture and PCR test(result will be ready by PCR within 24 hrs)Now get the results of (AFB was negative. PCR came positive after couple days).Order CXR and the result was (upper apical infiltrate/cavity).Now you need to decide to admit or treat as an outpatient (remember hospitalization for the initial therapy of TB is not necessary in most patients Step IV: Decision about changing patients’ location Treatment plan:1. Notify the health dept. 2. Start treatment with 4 drug regimen: INH, Rifampin, Pyrazinamide, and either Ethambutol or Streptomycin 3. Weekly sputum smear and cultures and then monthly once they test negative. 4. Ordered f/u appt with f/u sputum study.5. influenza/pneumonia vaccine, multivitamin6. HIV Test in all pts with TBStep V: Educate patient and family: Counseling and Education. Step VI: Final Diagnosis: Active Tuberculosis

    CCS- G6PDDecember 23 2002 at 7:29 PM vetan vetan (no login)from IP address 66.141.67.118


    History of present illness:young boy present with pallor, jaundice and splenomegaly. Recent history of URI treat with Bactrim(sulfa).First note vital signs – make sure patient is stable.Step I : Emergent management: Not needed.Step II : Physical Examination General Appearance, skin, lymph nodes, HEENT/Neck, Chest/Lungs, Heart/Cardiovascular, Abdomen, extremities, Neuro.Step III : Diagnostic Investigations: HPI describe a patient with splenomegaly, anemia, and jaundice. Patient was treated with bactrim few days prior to presentation which makes you think of G6PD. Patient should be workup for anemia especially G6PD.1. CBC/D- will show Normochromic Normocytic Anemia2. Peripheral Smear- Heinz bodies (bite cells) only seen on crystal violet staining of peripheral Smear. Will not be seen on wright-stained blood smear.3. reiculocyte index >3% (reticulocytosis)4. LFT- Serum bilirubin elevated5. Urinalysis- Hemoglobinuria6. Erythrocyte G6PD Assay- Low enzyme level.7. Type and cross- If hemoglobin is low- severe cases may need transfusionTreatment: Stop BactrimIv Access and IV fluid-NSStep IV: Decision about changing patients location Admit to wardContinue IV fluid until diagnosis is established and patient has improved.If evidence of infection – Treat with non- sulfa drugsWhen patient is stabilized Cancel IV and Move patient home.Step V: Educate patient and family:Console patient on food and medications that can cause problem1. seek medical attention for any infection2. avoid food containing fava beans3. Medications including: acetanilid, dapsone, Bactrim, nitrofurantoin, sulfacetamide, sulfamethoxazole, sulfonamide, sulfapyridine doxorubicin, methylene blue, nalidixic acid, napthalene, phenazopyridine, phenylhydrazine, primaquine, quinidine, quinine,on ccs you may not have option to console patient for specific food or drug use, just select console patient!STEP VI: Final DiagnosisG6PD

    CCS- Panic AttackDecember 23 2002 at 7:28 PM vetan vetan (no login)from IP address 66.141.67.118


    History of present illness:A young man with Palpitation, pounding heart, anxiety come to ER for evaluation.Whenever a patient, regardless of age or risk factors, reports to an emergency room with symptoms of a potentially fatal condition i.e MI, a complete medical history must be obtained and a physical examination performed. DDX is numerous including: cardiovascular d/o, Pulmonary diseases such as asthma, Neurological diseases, endocrine disorders, Drug intoxication, Drug withdrawal such alcohol, and Anaphylaxis.VITAL SIGNS- make sure patient is stable- BP (N= 90-140/60-90), Pulse (N= 60-90, Mean- 72), RR (N= 12-20, Mean- 16), Temp.( N= 37C, 98.6F)Allergy: NKAStep I : Emergent management: Not needed. Unless respiratory distress is present.Step II : Physical Examination General Appearance, skin, HEENT/Neck, Chest/Lungs, Heart/Cardiovascular, Abdomen, Neuro.Step III : Diagnostic Investigations: Following labs will eliminate any possible cause. With normal tests, panic attack is diagnosed. Presence of atypical symptoms such as vertigo, loss of bladder control and unconsciousness or the late onset of the first panic attack >45 years old require further evaluation.1. O2 SAT. Ashtma, COPD.2. CBC- rule out anemia, Infection3. Chem 12- electrolyte abnormalities( glucose, Ca, BUN, Cr).4. TSH- Hyperthyroidism5. LFTs6. UA7. Urine Drug screening8. EKGTreatment: Usually not needed but can use Xanax 0.5mg once. Step IV: Decision about changing patients location 1. If All test results are Negative and patient is stable, Move patient home. Schedule office appointment 2. If patient continues to have panic attacks at a later time/date, consider drug treatment with Benzodiazepines, SSRI, TCA, MOAIs, Treat for 8-12 months. Consider adding cognitive and behavior therapies as combination is superior than either one alone. SSRI are considered the initial drug of choice i.e sertraline.Step V: Educate patient and family:Avoid caffeine and medications that can cause panic attack including: yocon, pondimin, flumazenil, cholecystokinin, and isuprel.STEP VI: Final DiagnosisPanic Attack

    CCS- Tension pneumothoraxDecember 23 2002 at 7:26 PM vetan vetan (no login)from IP address 66.141.67.118


    This case is from a CD that is being sold at http://www.passfirst.com the CD claim to have all 5 cases of usmle sample solved like this one and multiple questions. I don't know how good this CD is. If anyone has used it please let us know if is worth the price.NOTE: FOR COPYRIGHT REASONS, WE ARE NOT ALLOWED TO REPRODUCE THE QUESTIONS. YOU MAY HAVE TO DOWNLOAD THE TEST FROM THE USMLE'S WEBSITE, AND INSTALL THEM ON YOUR PC BEFORE YOU REVIEW THIS SOLUTIONCASE #1: 65-year-old white man with chest painCase Introduction: Essential Facts• Patient is white, in mid-sixties• Has sharp, right-sided chest pain, accompanied by respiratory distress• He was brought to the emergency departmentCommentsThere is nothing that connects being white with having chest pain. This patient could have been of any racial origin and still present with these clinical features. However, the patient’s age will affect our choice of differential diagnoses. Chest pain in an older man is more likely to be of cardiac origin than the same pain in young patients.Possible differential diagnoses at this stage include• Pulmonary embolism (PE) because of chest pain, respiratory distress• Lobar pneumonia (chest pain, respiratory distress)• Tension pneumothorax (chest pain, respiratory distress)• Musculoskeletal chest pain (pain in a specific location)• Pleuritic chest pain• Cardiac pain (this is less likely, though possible. A patient with dextrocardia who develops myocardial infarction may have right-sided chest pain. However, since this test is based on clinical conditions commonly seen in practice, we are not going to be too concerned with this differential)Initial Vital Signs: Essential Facts• There is tachypnoea and tachycardia• Blood pressure is low• Temperature is normal• The patient is obese (BMI of 29)CommentsPneumonia as a cause of this patient’s chest pain is effectively ruled out because of the normal temperature. Still high on our list are PE, pneumothorax, and the other differentials listed above. Patient’s obesity will be addressed at a later timeInitial History: Essential Facts• Chest pain began 10 minutes before arrival at the ER• This is the first episode of chest pain• Patient has had chronic lung diseases that may predispose to pneumothorax• Chest pain increases with respiration• He was not involved in strenuous activities immediately before the onset of chest pain CommentsAlthough, this pain increases with respiration, a musculoskeletal cause is unlikely, going by the patient’s recent history. He is an accountant who suddenly developed an excruciating chest pain while at work. There is no recent history of chest trauma.Because of his long-standing history of asthma and emphysema, we will add emphysema to his differentials, since the latter can cause a measure of chest discomfort, especially if there is associated chronic obstructive pulmonary disease (COPD). However, uncomplicated emphysema does not cause sudden sharp chest pain.It is time to perform the physical examination. Click the button labeled Interval History or PE and select • General Appearance• Chest/Lungs and • Heart/CardiovascularWe are interested in the general appearance (this is standard when interacting with most patients. You should always examine the patient’s general appearance). Moreover, because the primary complaint is in the chest region, we would naturally want to examine that area. Also, considering the patient’s age and the possibility that his heart might be the cause of his problems, we want to examine the heart as well. We cannot do more detailed examination of other systems because this is an emergency. Press OK to confirm your choice.History and Physical: Essential Facts• Patient is cyanotic and in marked respiratory distress• There is chest asymmetry, with hyper-resonance on right side. Breath sounds are also absent on that side• Cardiac examination essentially normal• Peripheral pulses present but weak• No pulsus paradoxus (a fall in pulse amplitude with quiet inspiration)CommentsNotice the results of physical examination. We seem to have enough reason here to believe that this patient has tension pneumothorax. However, we would still like to confirm this with further tests.FAQ: Since this patient is in severe pain, and his vital signs are abnormal, why can’t we just go ahead and treat?Answer: Although this is a relative emergency, it is clear that we have enough reason to investigate the cause of the patient’s problems further before we initiate treatment. First, we can still measure his blood pressure (although this is low). There is no pulsus paradoxus. We are not going to waste time on nonessential investigations however. It is important to try and establish the cause of patient’s problems, if possible, before we initiate treatments.Now, let us write orders. If the result of the History and Physical is still visible, click OK to close it. Next, click the button labeled Write Orders or Review Chart.Next, click Order button at the bottom of the screen, and enter the following orders (one on each line):• Chest x-ray• Oxygen• Morphine• ECGConfirm the orders by clicking the Confirm Order button. For chest x-ray order verification, choose Chest x-ray, portable. Click OK. Urgency: stat.Note: Although, Chest X-ray PA/lateral may give you more detailed information, it takes more time. Moreover, the patient has to be wheeled to the X-ray department before the films can be taken. Portable chest x-ray can be done right there at the ER, and it takes very little time.For oxygen, choose Inhalation for route and Continuous for frequency. For morphine, choose Intravenous for route and Continuous for frequency. Note: morphine is almost always given through the intravenous route for most conditions. In any situation where you have need to use morphine, consider this fact. Don’t let the frequency that we chose mislead you. Continuous administration here means that it is given at fixed times (e.g. 6 hourly, 8-hourly, etc).For ECG order verification, choose ECG 12-lead; Urgency: stat. Now that we have initiated treatment, it is time to review that patient with the next available result. From our Order Sheet, we can determine that the result of the portable chest x-ray will be ready within 10 minutes. So let us advance the clock to that time.Click the button Obtain Results or See Patient Later at the top of the screen, and choose Review Patient with Next Available Result. The test result is displayed.Chest X-ray findings: Right tension pneumothoraxNext, we are going to write more orders for this patient. Click the Order button at the bottom of your screen and type thoracentesis. Scroll to the bottom of the form and choose Thoracostomy tube. Confirm your choice. The result of this procedure is immediately displayed. When you click OK, the result of the 12-lead ECG will be displayed, showing essentially normal findings.It is now time to advance the clock, so we can re-evaluate our patient in 15 minutes. Click on the clock at the top of the screen and choose • Re-evaluate case In, then • type 15 in the Minutes box (you may also use the upward pointing arrow to do this). Click OKNow that our patient has been stabilized, we would like to perform an interval follow up before we admit him for further management.Towards the left side of the screen, click Interval History button, and choose • Interval Follow Up, • Chest/Lungs under the Physical Examination sectionThe important findings this time are:• Patient is a smoker (for 45 years)• He has a positive family history of cardiac disease, hypertension, obesity, and stroke. • As noted earlier, the patient is obese (he has a body mass index of 29)• Patient does not engage in regular exercise (dyspneic after 1 minute of brisk walk)• The chest is now symmetricalSome of this information will come in handy when it is time to address the patient’s health maintenance issues. For now, we would like to send him to the intensive care unit. FAQ: Since the patient has been stabilized, why can’t we just admit him to the ward instead of the ICU?Answer: Under the British medical care system (and, incidentally, this is also true of many third world countries), we would have sent the patient to the ward. However, in the United States, patients like these are sent to the Intensive Care Unit. FAQ: Why can’t this patient be discharged home right away, since he has been relieved of his problems?Answer: he has a chest tube in place. The general consensus is that the chest tube should remain in place until we are sure it is no longer needed (i.e it does not show any bubbles in the water seal.) Even then, some hospitals prefer to clamp the tube and observe for some more time, before they remove the tube entirely. Click the Change Location button, and select Intensive Care Unit (ICU). Confirm move. Recorded vital signs are displayed (much better this time around). Click OK.We must now add more treatment for the patient. Click Order Sheet on the left side of the screen, and Order button at the bottom. Enter the following orders (one per line):• Albuterol (inhalation, continuous)• Atrovent (inhalation, continuous)• Advise patient, smoking cessation (routine, start now)• Advise patient exercise program (routine, start later)• Advise patient, weight reduction (routine, start later)Next, we are going to re-evaluate the patient in 1 day. Click the clock, and advance the next evaluation to 1 day. The dialog appears telling you you have five minutes more, and asking for the final diagnosis.Final diagnosis: Tension pneumothoraxEnd of case

    CCS- Cardiac TamponadeDecember 23 2002 at 7:24 PM vetan vetan (no login)from IP address 66.141.67.118


    History of present illness:A 59 year old man involved in MVA, chest impacts the steering wheel, comes in with distant heart sounds, dyspnea, obtundation.Vital signs- BP. Pulse, RR, Temp.This patient requires Step I with ABCD.With Steering wheel injuries one should be concern about fracture of sternum, ribs, trauma to lungs, spleen, Liver, and myocardial contusion. This patient with distant heart sound give you the clue to possible pericardial effusion. Signs of cardiac tamponade include, the following: distended neck veins, decreasing blood pressure, narrowing pulse pressure, muffled heart sounds, pulses paradoxus, and equalization of hemodynamic pressures (CVP).Step I : Emergent management: A, B, C, D- Supplemental oxygen , Cardiac monitoring, Intravenous access Step II : Physical Examination General appearance HEET/Neck- check for distended neck JVDHeart/CV- Distant heart soundChest/Lung, Abdomen, Extremities, Neuro.Step III : Diagnostic Investigations: 1. EKG- electrical alternans2. CXR3. Echocardiography- the most sensitive and specific noninvasive test for the presence of fluid in the pericardium.Treatment:1. IV Fluid2. Pericardiocentesis3. If vital signs are lost in ER, an immediate thoracotomy is indicated.4. Consult for thoracotomy5. Presurgical workup- CBC, BMP, CXR, PT, PTT, EKG, Type and cross match, IV antibiotic.6. Urine drug screening7. BALStep IV: Decision about changing patients location After surgery transfer patient to ICU and monitor EKG, repeat CXR and complete physical exam.When patient is table move to ward, then move home.Step V: Final Diagnosis:Cardiac Tamponade

    CCS- HEAD INJURYDecember 23 2002 at 7:23 PM vetan vetan (no login)from IP address 66.141.67.118


    HEAD INJURYHistory of present illness:An 18 year old white male fell to the ground while playing soccer and was unconscious for 2 mints. He is complaining of headache but he cannot recall the incident.His friends state that after the time of injury,he has difficulty walking.VITAL SIGNS- Check vitals to make sure pt is hemodynamically stable. 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: 1)Concussion 2)Contusion 3)Epidural/Subdural Heamatoma. Step I : Emergent management: ABCD- if patient unstable O2, IV accessStep II : Physical Examination Focus: Heent/Neck, chest/lungs Heart/CV, abdomen, Extremities, Neuro/Psych.Step III : Diagnostic Investigations: 1. CBC2. Chem-73. Type and cross match4. Continueous monitoring of vital signs, oximetry, EKG2. Order CT SCAN of head without contrast. 3. Move the clock and get results. 4. If CT Scan shows epidural or subdural hematoma and patient is stable get Neurosurgical consult for Emergent Evacuation of the Hematoma.5. If patient is unstable due to increased inracranial pressure do #4 and start IV mannitol. If not effective then #66. Intubate the pt. and hyperventilate to pCO2 of 35mm Hg Step IV: Decision about changing patients location 1. Patient with Neurologic signs should have emergent surgery. 2. Neurological check up every 1 hrs . 3. Repeat CT afetr 24 hrs. If CT is Normal and patient is stable move home with office follow up in 5-7 days.STEP V: Educate patient and family:Patient with head trauma and initial normal CT should be informed to return to hospital Immediately if he develops Neurologic signs which requires Emergent CT.STEP VI: Final Diagnosis.Epidural Hematoma

    CCS- Pneumocystis Carinii Pneumonia with Candida Viginitis.December 23 2002 at 7:22 PM vetan vetan (no login)from IP address 66.141.67.118


    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: NKADDX- Pneumocystis pneumonia- Top of your list because of risk factor and OI at presentation.CytomegalovirusKaposi 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 workup2. 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-126. 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 count10. PCR assay11. Saline or KOH Vaginal secretion (wet mount).12. LFTs13. VDRL, Toxoplasma IGG, and hepatitis B and C serologies.14. Cervical papanicolaou Smear15. 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 NNRTI8. 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

    CCS- Sigmoid VolvulusDecember 23 2002 at 7:21 PM vetan vetan (no login)from IP address 66.141.67.118


    History of present illness:63 years old man brought to Emergency Room complaining of colicky abdominal pain.When reading HPI note following:VITAL SIGNS- make sure patient is stable- BP (N= 90-140/60-90), Pulse (N= 60-90, Mean- 72), RR (N= 12-20, Mean- 16), Temp.( N= 37C, 98.6F)Allergy: NKADDX- Bowel obstruction, -carcinoma Pseudo-obstruction (ileus)Giant sigmoid diverticulumConstipationStep I : Emergent management: ABCD- Not neededStep II : Physical Examination General appearance Abdomen- Examination reveals a tympanitic/distended abdomen, and a palpable mass may be present. Severe pain and tenderness suggests ischemia/perforation. Bowel sounds are usually absent.Rectal exam- Rectal examination shows only an empty rectal ampulla. Skin, Chest/Lung, Heart/CV, Extremities, Neuro.Step III : Diagnostic Investigations: 1. CBC- Leukocytosis (in some cases Leukocytosis may be absent)2. Chem 7- to evaluate any electrolyte abnormality3. X-ray of Abdomen- Diagnosis of sigmoid volvulus can be made by using plain abdominal radiographic findings Plain radiographs show a markedly distended sigmoid loop, which assumes a bent inner tube or inverted U-shaped appearance, with the limbs of the sigmoid loop directed towards the pelvis. Also dilated gas-filled lumen, can result in a coffee bean–shaped structure; this is the coffee bean sign. 4. If diagnosis is questionable Barium Enema will confirm diagnosis but is contraindicated in suspected perforation.Treatment: 1. IV access- IV Fluid with LR2. GI consult- reason for consult, evaluation and decompression of possible sigmoid Volvulus.3. Sigmoidoscopy- decompression and untwisting of the sigmoid loop with placement of long soft tubeStep IV: Decision about changing patients location 1. Admit to ward2. Continue IV fluid3. Monitor patient for 2-3 days after decompression for persistent abdominal pain and bloodstained stools, signs that may herald ischemia and indicate the need for surgical intervention.4. Consult General surgery- Surgery is reserved for patients in whom tube decompression fails or for those in whom signs of ischemia are suggested. Surgery also has a role in an elective situation when the volvulus repeatedly recurs.5. After patient is stabilized, move patient home with office follow-up in 5-7 days. Step V: Educate patient and family:Console patient to seek medical care if Nausea, Vomiting , Rectal bleeding or abdominal pain reoccur.Console on low fat, high fiber diet.STEP VI: Final DiagnosisSigmoid Volvulus

    CCS- DKA vs Hyerosmolar stateDecember 23 2002 at 7:19 PM vetan vetan (no login)from IP address 66.141.67.118


    History of present illness:25 yo woman, with abdominal discomfort and confusion (blood sugar over 600 mg/dL).Note vital signs: BP, Pulse, Resp. Rate, Temp. Check vitals to make sure pt is hemodynamically stable. Is there History of diabetes? (new onset ?)DDX: KDA vs hyperosmolar stateStep I : Emergent management: A, B, C, D- IV acess followed by 0.9 NS ( pt. with hyperosmolar and hypotension from hypovolemia use NS otherwise ½ NS is prefered because of marked hyperosmolar state) , IV insulinStep II : Physical Examination General appearance, skin, HEENT/ Neck, Chest/Lung, Heart/ CV Abdomen, Neuro/PsychStep III : Diagnostic Investigations: 1. CBC2. Chem 123. FSBS4. ABG5. UA6. ABG7. serum ketone8. Amylase and Lipase ( usually positive in abd. Cause)9. serum osmolality10. EKG11. HGb A1cTreatment: 1. Continue IV hydration with NS until blood suger is around 250 mg% then consider D5 ½ NS. Change insulin to subq instead of IV.2. Monitor potassium , phosphate and Mag. And replace.Step IV: Decision about changing patients location 1. Patient need to admitted to ICU initially then to ward when stable2. After patient is stabilized investigate the cause if is still unclear.3. Discharge home with follow up visitStep V: Educate patient and family:Educate patient on diabetic diet, exercise , signs of hypoglycemiaFinal Diagnosis:Key points in differentiation between DKA and Hyperosmolar is as followDKA:1. hyperglycemia >250 Mg/dl2. Acidosis with blood PH< 7.33. Serum bicarbonate <15 meq/dl4. serum positive for ketonesHyperglycemic hyperosmolar state:1. Hyperglycemia >600 Mg/dl2. Serum osmolality >310 mosm/kg3. No acidosis; blood PH above 7.34. Serum bicarbonate >15 meq/L5. Normal anion gap (<14 meq/L).

    CCS- Acute cholecystitisDecember 23 2002 at 7:18 PM vetan vetan (no login)from IP address 66.141.67.118


    History of present illness:Most likely a 42 year old female was having lunch developed abd pain with nausea and vomiting. Note: BP, P, RR, HR, quality of pain, duration of pain.DDX-1. Acute pancreatitis2. Ulcer3. Diverticulitis4. Pneumonia5. hepatic abscess6. hepatic tumors7. irritable bowel disease8. Non- ulcer dyspepsia9. PancreatitisStep I : Emergent management: Most likely not needed.Step II : Physical Examination General appearance,Heent/Neck, skin, chest/lung, heart/CV , AbdomenStep III : Diagnostic Investigations: 1. CBC w/diff. – (leukocytosis 12000- 15000) ,Chem12, amylase, lipase,LFT (Ast, Alt, and GGt will be slightly elevated), fasting Lipid profile.2. Upright abdominal X-Ray ( 15% calcium stones)3. USG if questionable do Tc-99m-IDA (HIDA)- if USG shows no stone and HIDA is positive consider Acalculous cholecystitis.4. pregnancy test especially if result not clear or medication is to be givenTreatment: For patient who are sick enough to be admitted.1. NPO2. IV Fluid3. demerol for pain4. Nasogastric suctionStep IV: Decision about changing patients location 1. If mild can be treated outpatient with low fat diet and actigal2. Admit If pain is >6 hour and showing toxicity, Jaundice, rigors, or requiring narcotics for pain. 3. Admit to ward4. surgical consult- if no perforation or CBD obstuction5. If surgery is to be done prepare with CBC, chem7, CXR, PT, PTT, cross and match, EKG6. Antibiotics cefotetan, or clindomycin and gentamicin7. when patient stablize discharge homeSTEP V: Educate patient and family:Avoid fatty meals, stop smoking, excerciseSTEP VI:Final Diagnosis.Acute cholecystitis

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    Vetan's CCS cont

    CCS- DYSFUNCTIONAL UTERINE BLEEDINGDecember 23 2002 at 7:16 PM vetan vetan (no login)from IP address 66.141.67.118


    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 patient2. Family history of bleeding disorder3. history of irregular cycles4. evidence of bleeding problem on physical exam i.e. petechiaDifferential diagnosis of vaginal bleeding 1. dysfunctional uterine bleeding secondary to anovulation2. endometrial neoplasia3. endogenous source of estrogen i.e. granulosa cell tumor4. uterine myomas with submucous myomas5. hematologic disorders such as leukemia and idiopathic thrombocytopenia6. endometritis and endometrial polypsIn 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 stepIIStep II : Physical Examination Do a focus PE: general, skin, chest/lung, heart, abd, genitalia, extremitiesStep III : Diagnostic Investigations: 1. Pregnancy test2. CBC- will show Hgb 7.0 – do cross and match if patient is hypotensive or symptomatic start IV access and consider NS3. Chem 12 (glucose included), coagulation profile, TSH, ESRMost 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 tidBleeding 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 OCP3. MVI one daily 4. Continue ferrous sulfate 325 po tidIf patients Hgb is stable discharge patient home with office follow up in one weekConsult 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 diagnosisYSFUNCTIONAL UTERINE BLEEDING

    CCS- Alzheimer DementiaDecember 23 2002 at 7:15 PM vetan vetan (no login)from IP address 66.141.67.118


    History of present illness:A 79 year old female comes to your office complaining of forgetfulness. The first and most important initial evaluation of patient with dementia is History and Physical examination. Important clues such as onset, duration, etc.. will narrow your diagnosis and required investigating labs.Note vital signs- BP (N= 90-140/60-90), Pulse (N= 60-90, Mean- 72), RR (N= 12-20, Mean- 16), Temp.( N= 37C, 98.6F)Allergy: NKADDX:Alzheimer’s dementia- Most common.Vascular dementia- 2nd Most common.Pick’s disease –3rd most common.Lewy body diseaseHuntington’s diseaseParkinson’s diseaseHIV- Related dementiaHead trauma related dementiaStep I : Emergent management: A, B, C, D- Not needed.Step II : Physical Examination General appearance, Skin, Lymph Nodes, HEET/Neck, Chest/Lung, Heart/CV, Abdomen, Extremities, Neuro/Psych.Step III : Diagnostic Investigations: There are several diagnostic investigations for workup of dementia but H&P exam will narrow the list.1. MMSE2. CXR3. EKG4. CBC/D- To check for anemia.5. UA6. SMA-12- check for electrolyte abnormality7. TSH- to rule out thyroid problem.8. VDRL- To rule out syphilis 9. B12 level10. BAL- guided by H&P11. Urine Drug screening and heavy metals- guided by H&P 12. HIV test – guided by H&P13. CT – guided by H&P14. LP- guided by H&PInitial Treatment:Not needed.Step IV: Decision about changing patients location 1. Some of the test you order may not be available right away, move patient home and schedule office appointment when all results are available.2. Need to see patient initially weekly then monthly.Treatment:1. When diagnosis of Alzheimer is made by H&P and exclusion of other possible causes of dementia, start either Tacrine or aricept .2. Add Vitamin E – it has shown that may slow progression of Alzheimer3. Treat other complains that patient may have such as insomnia etc.Step V: Educate patient and family:1. Educate patient and family about the disease 2. Console patient on driving restriction3. Educate patient on Living will.4. educate patient on exercise and Alzheimer support group.Step VI: Final Diagnosis:Alzheimer Dementia

    Chemotherapy Induced NeutropeniaDecember 23 2002 at 7:13 PM vetan (no login)from IP address 66.141.67.118


    History of present illness:A 50 year old lady with a history of chemotherapy post a successful breast surgery who came to the office with a low grade fever.Patient with history of chemotherapy and fever should make you think about possible infection secondary to immunocompromised status. First step is to get a good history and Physical exam. PE will help you eliminate any opportunistic infection.Note vital signs- BP (N= 90-140/60-90), Pulse (N= 60-90, Mean- 72), RR (N= 12-20, Mean- 16), Temp.( N= 37C, 98.6F)Allergy: NKAStep I : Emergent management: A, B, C, D- Not needed.Step II : Physical Examination Complete physical exam: General appearanceSkin- check for skin lesionsBreasts, Lymph Nodes, HEET/Neck- evidence of fungal infection.Chest/Lung- evidence of respiratory infection i.e. decreased Breath sound, rales, rhonchi. Lungs are the most frequent site of infection in Immunocompromised patients.Heart/CV, Abdomen Genitalia Rectal - look for evidence of fungal infection Extremities, Neuro/Psych.- mental status evaluation looking for meningism or focal deficitsStep III : Diagnostic Investigations: 1. CBC/D2. Peripheral blood smear3. Urinalysis, urine culture, sensitivity and Gram stain.4. Blood cultures5. stool culture6. Sputum Gram stain, AFB stain and cultures.7. If skin lesion present culture it8. LP- guided by H&P9. CXR –check for infiltrates, lobar consolidation, cavitary lesionsStep IV: Decision about changing patients location 1. If any of the diagnostic test result is positive or patients' Temp. >38.5 C with Neutrophil count of less than 500 or three elevated Temp. >38 C in 24 hours , patient should be moved to ward and board- spectrum antibiotics should be started.2. Neutropenic patient without fever can be monitored outpatient.Treatment: 1. IV access 2. Antibiotics- A. ceftazidime, carbapenemsB. Mezlocillin, piperacillin or azlocillin plus an aminoglycoside or third generation cephalosporin. Treat for 10-14 days or until Neutrophil count is >500.3. Consider use of Neupogen (G-CSF) Step V: Educate patient and family:Console patient to avoid people with cold/flu Console patient to seek medical help if a fever developsStep VI: Final Diagnosis:Chemotherapy Induced Neutropenia

  11. #30
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    ccs cases from last 3 months

    sep10. Most of the CCS from you r website
    1) 16 yr old for RHM had elevated BP also..... So with weight loss it came down
    2) 18 yr old came with dysuria..... Preg test positive therefore did all the prenatal workup and had a uti so treated with amox
    3) Patient 74 yr old admitted on the floor with pneu developed SOB turned out to be PE
    4) 15 month old infant brought for lethargy and tiredness ....... was Iron def anemia
    5) 30 yr old with menorrhagia and bruising .....platelets low, other labs normal.... was ITP
    6)60 yr brought for suicide attempt, took unknown tablets.....pupil 4, .........messed up on this because was not able to find what she had taken
    7) 54 yr old came to office with CAP

    8) 50 year old man with H/O asthma and came with weakness to office.......did cbc, sma7, .................Went round and round started inhaled steroids but no improvement ...............then hb came low did fobt which was positive so did colonoscopy which was negative.....did EGD which showed duodenal ulcer with hpylori positive treated for hypylori patient felt better
    9) 35 year lady with history of sickle cell came with abdominal pain RUQ.....did US showed cholelithiasis..........surgery consult and then went for surgery

    Aug 1st ccs ))Office-Heart filure,because of CAD,on ACE inhibitor,needed diuretic and digitalis but!!!! because of initial renal failure and hyperkalemia,already Ibuprofen because of osteoarthitis you have to cancel it-IBU, immediately and give him acetaminofen,not addmision,home with follow up.
    2.)))ER,Heroin addict,high fever,abcess on the arm=infective endocarditis ,put him on meticillin,you will get blood culture resistance than,than !!cancel meticillin and put him on vancomycin.BUT he has articular pain and agitated because of apstinention,put him on methadon,iv,of course.
    From this two cases you can see,not just to menage,you have second problem too,that is why are the people supprized that they didn'd do well ,they expected.
    3.)))13 young girl,massive menstrual bleeding,give her conjugated estrogen,AND,AND,mamy has a question!!!What is the cause,take coagulation batery,you will see-von Wil!!! if you read hystory dady had some coagulation problems(-dominant-vW,canot be hemofilia and factor VIII,you will lose th case)
    4.))Sickle cell,give him O2,hidration,Morphine,dont give him transfuzion,you will get the answer"parents doesn't wnaht to give consent"
    5.Chron's-order colonoscopy,she was young,not sigmoidoscopy,hasn't cancer,you will get minus points.give her steroids.
    6)).Crash-sy,hyperkalemia 1.calcium iv 2.bicarbonate,hydration,massure urine output,put him on dialysis if needed

    7)).cardiac tamponade,young lady,car acc.-JUST physical,a)general app,b)heart,c)lung,they will tell you pulsus paradoxus,AND!!!!!!!!!pericardiocenthesis on the spot otherwise you will lose.After!!!EKG,ENZYMES, X-Ray because she had fracture of the sternum,give her somethihg strong for her pain iv,don't forget PAIN,send her in intensive c.

    July 30 th a1.30r found to have 1 cm lump in breast. has already seen gen surg and is scheduled to have it removed. Now needs pre-operative clearance. On exam she has bruises on her legs and petechiae. CBC is normal except for 10,000 platelets. She has ITP.

    2. 18 yo girl comes in for pre-college physical. no complaints but she has a bp of about 180/95. She is a little overweight (145 lbs at 64 in), smokes and is sexually active. She needs a pap/pelvic exam. With diet modifications, smoking cessation and losing weight, her bp is normal at the follow up in a month.

    3. 60ish lady in the hospital for strep pneumonia getting better on abx but suddenly has shortness of breath. Nothing else on exam (no leg pain even). She ends up having a PE. This case annoyed me because even after I anticoagulated her and gave her pain meds she wasn't getting any better, She ended up needing to go to the OR for a thrombus-ectomy and then the case said that she was recuperating well.

    4. 19ish month old male who is a fussy eater and only drinks a ton of milk and a pint of juice a day. refuses all meats and veggies. He is pale and fatigued, he has iron deficiency anemia. (lead level is okay) Mom needs to be counseled on less cow milk. He sees nutrition and takes FeSO4 and he's better in a month.

    5. lady in her 60s found by boyfriend with half a bottle of alcohol and lots of empty priscription bottles next to her. no one knows which meds. Sh comes to you comatose. - has a little benzos, a little TCAs, a little etoh.
    6 Guy in his 60s c/o feelign tired all the time and occasional heartburn type chest pain. On exam he is really pale. no stool in his rectal vault to guiac so you have to type "hemoccult stool" as an order. it comes back positive and his CBC has a low Hb (like 8ish). I thought I have to find out if he's got an active bleed so i sent him to the er and had him NG lavaged (clear) and then scoped fom up and down. he had a duodenal ulcer and a positive H Pylori. Gave him meds and he felt better a month later at follow up.

    7 26 yr old came to office for dysuria. hx says married and "occasionally" uses condoms for protection with husband. Urine HcG positive and UA has like 3 wbcs and + leuk esterase. you tx everything in pregnant ladies so i gave her some amox. cx came back with >100000 cfu ecoli sens to amox. she felt better and she and her husband were excited about the baby. I also gave her prenatal vitamins and did a pap/pelvic and some titers (rubella, VDRL/HIV screen)


    aug 1st ccs
    1. 5 yrs old blk kid brought by mother for yellow eyes .had otitis media and was given bactrim for treatment.otherwise ok .vaccines utd expet varicella.
    wu cbc,ua,haptaglbn,ldh,bili d&t,coombs
    rest at home. dc bactrim,mother was con cern about yellow color, reassured mother.
    fu in a wk .case finish .
    i gave vericella vacn and g6pg after 2 months

    2. 22m old kid brought by motherfor regular chek up .
    driks a lot of milk. teenage mother works and grandmother babysits .baby is pale.stool guiac +
    wu cbc,ua lead level
    microcytic hypocromic anemia
    so ferritin ,iron and tibc level
    irn & frtn were low but tibc was in highnl rang
    put him on ferrous sulfate
    could not tell mther to reduce milk so i just put him on diet high in irn
    forgot to give him varicella shot .called him in 10 days to do a retic

    3. 27 yrs old girl goes to college .multiple sexual patners.comes for physical
    wu cbc,ua,pap smear + CIN3 colpocsopy, cin3+ so did cervical cryo ablation,age appt counselling

    4. 18 yrs old ss disease feels pain in epigastrium 4 mts some time wake up at night,
    wu cbc, retic, cxr, us abd
    ther were gallstone in the bladder so i asked for surgery, they said it willbe done so i prepared for sugery exept i for got to admit her. after 5 min come you caanot change the location.

    5. 22 yrs old woman comes with urn frequcyn and irritation. divorced lives with boyfriend last prd were little
    wu ua, bhcg,cbc, she is pragnent, leukocit estrase + nitrite + bactria in urine gave her ampicilline
    did rubella screen, vdrl, forgot hb sreen, but asked for pap smear

    6. 70 yrs old fe came in er with dificulty breathing otherwise very healthy bad teeth
    wu cxr cbc esr she had pneumonia admitted her put her on cefuroxim, she felt better the next day so i changed her to po ceclor.case finished

    7. 16 byrs old fat boy for sport phyl bp 145/95
    wu cbc,ua,total choles, cheked bp 3 times than advised him diet exercise ,he came back in a moth with nl bp gave age appr councelling

    8. 54 yrs old with pain abd llq.
    wu cbc, xr abd,ct which showed diverticulitis gave him bactrim iv and ceftriaxon, felt better in 2 days
    case finished

    9. 58 yrs old librarian admitted for pneumonia. colon surgery 2 yrs ago on ceftriaxon and zithro, 2 days after addmission is sob
    wu cxr nl , cbc, abg (forgot),vq scan +for pe
    i did an echo also which was nl they said pt is having difficulty breathing i gave him frusamide as ther were some crepitus which was probably wrong



    July 29 th

    . 55 year old man, smoker, COPD, SOB, Weight loss (10 lbs without diet), hurt burn. (I did not get diagnosis) (Turn out to be GI malignancy)
    2. 25 year old female, left breast mass, aspirate (fluid and disappear), left breast has brown black discoloration, extremities show petecheal hemorrhage. (ITP)
    3. 15 month old child, failure to growth, started at two months ago, drink milk, no vegetable (FE deficiency anemia)
    4. 60 yr old female, unconscious, alcohol ¾ gone, empty multiple pill bottle (I did not get diagnosis)
    5. 25 yr old female, dysuria, preg test +ve, never been pregnant (Looks like pregnancy)
    6. 18 yr old female, check up for college entrance, 156/90, 175 lb. (Hypertension and over weight)
    7. 19 yr old female, history of sickle cell disease, right upper quadrant pain (Cholecystitis)
    8. 75 yr old female, pneumonia, 2 day of hospital admission, shortness of breath (VQ scan positive and times up)
    9. I forgot.?????????????


    jb ccs
    August 20 2003 at 10:53 PM jb (no login)
    from IP address 128.125.223.183

    --------------------------------------------------------------------------------

    1. 5 yo white boy brought in by mom with past two wk of mild to moderate SOB. wheezing, symptoms are more obvious when kid plays outside. some mentioning of allergic rhinitis. Vac upto date. in office, give albuterol, symptom improve. O2 sat ok no need for oxy. mild, no prednisone given. sent home with cromyn. case of asthma. there is a asthma education found under asthma. case closed pretty soon.

    2. spousal abuse. 30 yo female came in complain of some sort of chest pain (not like cardiac origen), and I sensed it is abuse from very begining. did CXR ekg and almost complete PE and found forarm bruise and left chest wall abuse mark. EKG nl and CXR 6,7ribs fracture. nothing else. Consult social and ortho for ribs. give pain meds. and message showing that the women found a shelter with her little girl. do some consel and case ends.

    3.Turner. 13 yo AAF came in with mom for school related exam. girl is short and weight low but play piano, meaning ID fine. She has two other brothers are fine. There are some physical decription pointing to Turner. FSH comes back 7O and karyotype confirmed Turner. Endocrinology consult comes back saying will initiate growth and estrogen treatment, so I just prescribe them. Cardiac and GI have nothing to say. Did Echo showing bicus aortic valve etc and sent another request for cardiothoracic team to look after long term (in 5 min mark). TSH nl. I did bone age, indicating 11 year old, but no sign of constitutional delay. case closed no troble.

    4. 50 somethig male comes in with fatigue and sob and PE show aortic region murmur. EKG LVH and xray indicating widening in the assending aortic/mediastinal region. Did Echo show aortic stenosis, 0.6 is the number. Sent a sonsult to cardiology and guess what saying that surgery is scheduled. I did other thing related, preop, conseling etc. and case end- aortic stenosis.

    5. 60 y lady (not principle but a home worker) unconcious brought in by neibor with no clue of any etoh or drug. mentioning about the depression but no bottle found etc. RR 7, other vitals not that bad, so against my gut feeling, I ordered a HEENT and heart/lung: which only shows a 6 mm pupils. So in ABCs I did not give naloxone, becouse finger glucose is 110 so no dextrose given, i did not bother thiamine. and order the minimum, only cbc, chem 7 abg and pulse. pulse low 89 so i intubate and start mechenical. Started lavage and showing yellow fluid with fragmenets of pill etc. EKG tachy and QRS .13 so some clue of TCA shows. ALso head CT normal. Meantime, some how urine tox back only shows positive for amitriptyline. after this, the HUSBAND showed up with a bottle (labled with amitriptyline) found near the pillow at home with a suicide note. What a husband. Knowing the serum level is not useful, I still ordered TCA at this moment. Move pt to ICU with frequent ABG and EKG monitering. end.

    6. old lady with llq mass and pain, some time diarrhea, did xray ok, barium shows signs of diverticulitis and CT confirmed with sigmoid diverticulitis. managed wiht cipro/metronidazol at home and pt improved. Sigmoid diver.

    7. 54 yo american indian with typical sign of DM II. Vision prob, especially at night, foot sensery etc. glucose 380. after mange with insulin lower the glucose a bit sent home metfromin and all the consult. eye doc answers back with take care his retinopathy etc. edcuate patient and etc.

    8. 50 male in Ward, post TURP has fever 39.5, chill. UA posive for nitrae and protein. I started bactrim and temp improved. I aslo give saline etc because his low BP. not sure if it is a septic case and blood culture never back. UTI

    9. 5 month old hispanic baby with h/o OM x2 and vacciniation are not clear, brought by mom. Baby is pale and listless. full w/u indicating high WBC, which I started ceftriaxone and later CSF showed gram + stain. Patient improved in ICU with message showing he can drink now so i stopped iv half saline. patient improved, and i did some education and ordered some vaccination because his unclear history on this. The computer is so slow and that it freezed when I tried
    to type in the bacterial meni. I reported to the center. I also had some other problems with computer so the center stuff awared, like that the HPI is moving around so I cannot read them easily and spent some unnessesary minits on it. The center verify those and aske me to report.


    ccs-june03
    June 21 2003 at 9:52 PM BTU (no login)


    --------------------------------------------------------------------------------

    1.tubo ovarian abscess
    2.splenichematoma
    3.chf+pe
    4.appendicitis
    5.dka+uti
    6.pid
    7.perforated sigmoid abscess
    8.lobar [pneumonia-6yold]
    9.g6pd


    CCS cases
    May 31 2003 at 2:39 PM bkar (no login)


    --------------------------------------------------------------------------------

    1) pneumonia
    2)PE
    3) Sickle Cell Crisis
    4)Pregnancy (normal in a 23y/o on routine visit
    5)TTP
    6)Fever in 8 week old baby
    7)duodenal ulcer

    ccs- August 14 2003, 2:51 PM

    12 hour born baby, flappy and difficult to feed in ward.physicals
    show flate face and lower bridged nase.

    x-ray abdomin with no air distal to duodenum.
    It's a down's syndrom with duodenal atresia. Ordered TPN and nG tube then IV afluids
    then ordered U/s abd and then small bowel follw through -
    diagnoses came as Duodenal atresia,
    then ordered chrmosoaml study
    and then case ended ordered surgical consult and echo to look for
    heart but there were no signs of immediate CHF on examination
    .

    Ther is a 4o something old policeman with hx of depression on
    fluoxitin complain extrem fatig. The occult blood is positive,
    but the colonoscopy is neg. Hx of sometimes heartburn.
    I did upperscope, showed GERD. The damadge is that the presentation
    is so vage and missleading you for colon cancer. However, it's just
    a simple office H2 block manage. So GERD mangaed

    14 year old with mnorrhgia,
    6 month duration since the menarc.
    Hg 8.2 and keeps bleeding x 10 days.
    All coagulation w/u is neg. PT/PTT and Bt are all neg.
    P/V vaginal clots found and gave her high dose estrogen and
    low progesterone and sent home. BUT at the evening the pt BP
    is 90/60 - ( should have given IV estrogen in the office)
    so called back and admitted in ward with IV RL .
    pt better the next day.--- DUB
    a 62 yo femal came to office complain intermittent
    left lower abd pain. x-ray neg, stool neg but Hg is
    9.can't remember. sigmoid scope is done showed polyps.
    and polypectomy reported adenocarcinoma without involve the stalk.
    The case presentation is very vag. -
    adenocarcinoma of colon refered to surgery.

    40 yo m with sob, vitals stable .ekg show flate votage on all leads,
    BMP normal. LFT normal. did start him on furosimide and then ordered
    echo which showed dialted cardiomyopathy.
    added low salt diet , upright posture and ace inhibitor
    case ended , added digoxin in the end,

    50 year old with chest pain, sharp and related
    with position change. hx of one week ago with cold. ICU admitted.
    Ekg showed all st diffuse elevation enzymes normal gave 0 2 and
    asprin and prednisolone after 6 hrs patient not getting better
    so did an echo globular swelling showing minimal effusion with pp 10
    here unnecessarily ordered pericariocentesis.
    got 5cc fluid and pt felt some what better.

    case ended here

    18 month old for regular check, picking eater,
    pale and thin.
    S.ferritin decreased. and
    folate and b12 are neg.
    CBC hypochromic and basophilic stippling
    Ferritin decresed lead is 48. treated with Feso4 and oralsuccsimer

    21 yo f with urinary irritate. UA positive and culture
    sensitive foe ampic and Tmp-smz. HCG neeg. treated with tmp-smz.
    getting better out patient.

    middle aged m, neibor find comatose. no history available.
    bring to er. No hx of time lag, no trace for what
    he is taking. RR 8/mt BP 150/100.pupils normal
    I gave all cokatail and ventilated did CT hemarraghe.
    cancelled after got CT scan result. Gave Nitroglycerin and nimodipine and
    pt didnot improve and case ended.

    sep 28


    1- Exacerbation of asthma
    2-G 6 PD deficiency with sulfa allergy
    3-UTI with pregnancy
    4-Ovarian cancer
    5-MI with high blood sugar
    6-erforated peptic ulcer
    7- DKA
    8-Colon cancer
    9- Normal Physical exam with HTN in young male

    October 1

    MVA with 3rd degree heart block
    Down syndrome with duodenal atresia
    ovarian torsion
    cardiomyopathy
    DUB
    lead poisoning
    SAH
    colon carcinoma
    oct 1st

    7 yo URI take sulfa, jaundice, G6PD
    62 yo pneumonia hospitalized, acute cp, PE
    55yo s/p endoscope, retrosternal cp, perforation
    22 yo 8w preg, grave's dz
    16 yo routine physical
    32 yo s/p mva, splenic rupture
    18 yo uti
    51 yo diverticulitis
    10 yo aamb, scd, acute chest syn

    thanks
    hank

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