04-14-2007, 02:03 PM
APPROACH TO CCS CASES:
Use following as templete to work with cases.
History of present illness:
Note vital signs: BP, Pulse, Resp. Rate, Temp.
Check vitals to make sure pt is hemodynamically stable.
Pay attention to quality of pain, dull, sharp, pleuritic, constant, etc. this can give you clues to the possible cause. For example pleuritic pain make you think of pericarditis, pulmonary embolism, pneumothorax, pneumonia, and infectious pleuritis.
You should formulate a differential diagnosis after you have read presentation and vital signs. Determine if the patient needs immediate care, if so do step I.
Step I : Emergent management:
A, B, C, D ie
airway, breathing, circulation, defibrillation/ drugs
Step II : Physical Examination
Complete vs focus- depending on situation. If someone is in your office for annual check or routine visit you should do a complete exam.
Step III : Diagnostic Investigations:
Think which one of the labs or imaging you need to do to give you more clues to make your diagnosis.
Imagining:
1. CXR
2. EKG
3. Echocardiogram
4. CT
5. USG
6. Colonscopy-sigmoidoscopy
7. Barium enema- Barium swallow
8. Broncoscopy- rigid vs flexible
9. VQ Scan- Venogram
10.Doppler Sonogram
11.ERCP
Labs:
1. CBC
2. Chem7/12
3. Lipid profile
4. LFT
5. Urinalysis
6. Cardiac enzymes
7. Culture & Sensitivity
8. CPK
9. TSH, free T4
10.Drug levels
11.Coagulation profile
12.D-dimer
13. stool guiac
14. folate, B12, peipheral smear, iron, feritin level
15. Lipase and amylase
Treatment:
Treat if need to “ if patient has pain give pain killer, if has PE start heparin.
Patients who needs consult for surgery etc.. get consult. If patient needs surgery start presurgical orders including: CBC, Chem-12, Coagulation profile, EKG, CXR, LFT, NPO (at least 6hours prior to surgery), and start Antibiotics. Most common antibiotics used are Ancef , Mefoxin, and Cefatetan. Especially for GI surgery. All given IV.
Step IV: Decision about changing patients location
After you have stablized the patient you need to move patient to appropraite location:
If patient is stable and doesn™t require further workup or workup can be done outpatient then discharge patient home.
If patient came with chest pain/ cardiac problem transfer to CCU.
If patient is stable but need further evaluation move to ward.
When patient is stablize discharge home with office follow up.
You dont need to keep giving the pt a tour of the hospital, use common sense. Example a patient with pneumonia like I said could easily be treated as an outpatient, but you can't predict if they will comply with therapy. So if your pt is stable there is no need to take them to the ICU, the oncall team will never accept them anyway, take them to the wards and discharge as soon as feeling better (few days). Now if your pt is breathing rapidly > 20bpm and a pulse ox shows 86% then you give oxygen and send another ABG, still your pt is hypoxic you may think about intubation and then ICU, the oncall team will remember you but they have no choice!!
The epistaxis or nose bleeding case as you refer to in the samples is very interesting in the way that you need to have the reflex and to be familiar with classical presentations. In this case this pt had a cold followed by bruises and bleeding you should automatically think of immune thrombocytopenia but you need to make sure it's not leukemia so you admit do bone marrow biopsy and meanwhile start steroids(Prednisone). the biopsy is neg and you discharge quickly on steroids. Case closed.
Vague abd pain and weight loss in elderly. Do CBC to look for anemia ( anemia is a symptom not a dz) and do chem 7 for electrolyte disturbance. do guaiac for subtle GI bleed, most common. If positive always do colonoscopy first and if neg do EGD and treat accordingly. If CA Colon do colectomy, if ulcer give PPIs and so on. If female think ovarian ca, do USG. Now DM pts can have DKA with abd Pain as first manifestation becarefull!! Acute diarrhea in kids or anybody, do stool cx and gram stain as well as fecal leucocytes and treat accordingly, do intake/ output if he is dehydrated give lots of fluids.
IN AIDS WE GIVE VACCINE OF
1 IPV NOT OPV
2 MMR
3 PNEUMOCCOCL
4 VARICEELA IG NOT VACCINE
5 H INF
6INFLUENZA
Use following as templete to work with cases.
History of present illness:
Note vital signs: BP, Pulse, Resp. Rate, Temp.
Check vitals to make sure pt is hemodynamically stable.
Pay attention to quality of pain, dull, sharp, pleuritic, constant, etc. this can give you clues to the possible cause. For example pleuritic pain make you think of pericarditis, pulmonary embolism, pneumothorax, pneumonia, and infectious pleuritis.
You should formulate a differential diagnosis after you have read presentation and vital signs. Determine if the patient needs immediate care, if so do step I.
Step I : Emergent management:
A, B, C, D ie
airway, breathing, circulation, defibrillation/ drugs
Step II : Physical Examination
Complete vs focus- depending on situation. If someone is in your office for annual check or routine visit you should do a complete exam.
Step III : Diagnostic Investigations:
Think which one of the labs or imaging you need to do to give you more clues to make your diagnosis.
Imagining:
1. CXR
2. EKG
3. Echocardiogram
4. CT
5. USG
6. Colonscopy-sigmoidoscopy
7. Barium enema- Barium swallow
8. Broncoscopy- rigid vs flexible
9. VQ Scan- Venogram
10.Doppler Sonogram
11.ERCP
Labs:
1. CBC
2. Chem7/12
3. Lipid profile
4. LFT
5. Urinalysis
6. Cardiac enzymes
7. Culture & Sensitivity
8. CPK
9. TSH, free T4
10.Drug levels
11.Coagulation profile
12.D-dimer
13. stool guiac
14. folate, B12, peipheral smear, iron, feritin level
15. Lipase and amylase
Treatment:
Treat if need to “ if patient has pain give pain killer, if has PE start heparin.
Patients who needs consult for surgery etc.. get consult. If patient needs surgery start presurgical orders including: CBC, Chem-12, Coagulation profile, EKG, CXR, LFT, NPO (at least 6hours prior to surgery), and start Antibiotics. Most common antibiotics used are Ancef , Mefoxin, and Cefatetan. Especially for GI surgery. All given IV.
Step IV: Decision about changing patients location
After you have stablized the patient you need to move patient to appropraite location:
If patient is stable and doesn™t require further workup or workup can be done outpatient then discharge patient home.
If patient came with chest pain/ cardiac problem transfer to CCU.
If patient is stable but need further evaluation move to ward.
When patient is stablize discharge home with office follow up.
You dont need to keep giving the pt a tour of the hospital, use common sense. Example a patient with pneumonia like I said could easily be treated as an outpatient, but you can't predict if they will comply with therapy. So if your pt is stable there is no need to take them to the ICU, the oncall team will never accept them anyway, take them to the wards and discharge as soon as feeling better (few days). Now if your pt is breathing rapidly > 20bpm and a pulse ox shows 86% then you give oxygen and send another ABG, still your pt is hypoxic you may think about intubation and then ICU, the oncall team will remember you but they have no choice!!
The epistaxis or nose bleeding case as you refer to in the samples is very interesting in the way that you need to have the reflex and to be familiar with classical presentations. In this case this pt had a cold followed by bruises and bleeding you should automatically think of immune thrombocytopenia but you need to make sure it's not leukemia so you admit do bone marrow biopsy and meanwhile start steroids(Prednisone). the biopsy is neg and you discharge quickly on steroids. Case closed.
Vague abd pain and weight loss in elderly. Do CBC to look for anemia ( anemia is a symptom not a dz) and do chem 7 for electrolyte disturbance. do guaiac for subtle GI bleed, most common. If positive always do colonoscopy first and if neg do EGD and treat accordingly. If CA Colon do colectomy, if ulcer give PPIs and so on. If female think ovarian ca, do USG. Now DM pts can have DKA with abd Pain as first manifestation becarefull!! Acute diarrhea in kids or anybody, do stool cx and gram stain as well as fecal leucocytes and treat accordingly, do intake/ output if he is dehydrated give lots of fluids.
IN AIDS WE GIVE VACCINE OF
1 IPV NOT OPV
2 MMR
3 PNEUMOCCOCL
4 VARICEELA IG NOT VACCINE
5 H INF
6INFLUENZA