11-19-2015, 07:52 AM
Our 50 CCS *STAR* Collection..
1. femur neck#--ER
2. Advanced maternal age with pregnancy with hx of bipolar office
3. Snake bite
4. HEPATIC ENCEPHALOPATHY
5. Post-op atelectasis.
6. Septic Abortion-
7. Incomplete abortion with heavy bleeding and acute PID.
8. Infected peripheral IV access
9. atrophic vaginitis
10. polycystic ovarian syndrome
11. gono
12. AGN
13. BPH
14. acute psychotic disorder
15. spontaneous abortion
16. malrotation
17. child with rash
18. obesity in adolescent
19. CTS
20. teenager comes for a pre-employment
21. JRA
22. kawasaki disease
23. Osteomyelitis
24. Hypoglycemia
25. Dilated cardiomyopathy
26. Down's Syndrome neonate
27. Preeclampsia
28. MM
29. Hypercalcemia-office
30. Hypercalcemia-ER
31. MS
32. HELLP
33. Endometrial Hyperplasia without Atypia
34. Gastric cancer
35. TURP-HYPONATREMIA
36. testicular pain-acute unilateral, child”ER
37. hypertensive crisis with SAH
38. Hypertension-secondary
39. fever unknown origin “ adult
40. septic shock
41. Alcohol withdrawal
42. retained placenta
43. Chronic renal failure
44. Acute renal failure
45. RAPE46. HUS 47. New onset DM-42 yr old c polydipsia & polyuria 48. Fever Unknown origin-child 49. Cx ca 50. Failure to Thrive
1-femur neck#--ER
Hx- 55 female post meno Exter. Rot. & shorten Right LL ,VS- stable
emerg.order: IVA oxy sat Pulse oxy cardiac monitor, vitals q1hr bp monitor EKG morphine
P/E general skin heent look for hematomaheart lung abd cns extr
Nss cbc q12hrs bmp q 12hrs ua x ray chest, hip(ap/lat) ,knee, fobt
Ca, phoph ,mg, PTH d-dimers
consent form
orthopedic consult ; reason hip fracture
surgery consult
interval+rest of exam
pre op surgery- npo cefazolin IV on time, pt ptt /inr q4hr
fobt blood type,crossmatch, omeprazole, hip replacemnet
admit to wd bed rest ,bathroom urine output foley
heparin sq- hb and hct q6
pneumatic stock surgery done-
calcium vit d
if shows patient improves,
discharged and f.u after 2wks
2min screen-f/u xray in 6weeks , vaccines
Counseling alendronate medicine comp
stop smoking limit alcohol seat belt
calcium rich diet
Age related
exa scan colonoscopy lipid
mammography
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2-Advanced maternal age pregnancy with hx of bipolar
office: PE—complete
HCG (+ve) move clock 1 min , transvag
CBC ,BMP ,UA, urine culture, LFTs, lipid profile/ atypical antibody
blood type & cross type and Rh
pt/ptt
EKG, pap smear
gonorrhea/ chlymydia/ RPR/ Hep B antibody/ HIV ELISA rubella titer / toxo titer
pregnatal counseling/prenatal vitamins/ foic /iron
no smoking,/ no drugs / no alcohol, safe sex, seat belt, safety plan
follow up after 1 month in 1st trimester
2nd visit full physical
vital(BP check),Weight UA
Fetal heart monitoring, (fundal height)
do triple screen --serum HCG, AFP, estradiol [MS AFP], if high Amniocentesis
Triple marker screen-TRIPLE TEST repeat trans vag us
Valproic acid level
send her home..
2 min screen: counsel
Genetic counseling
Amniocentesis
Karotyping of the fetal amniocytes....cells found in the amniotic fluid
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3-Snake bite
ER Location
25 y young guy “ 30min after hx of snake bite.
Havenâ brought snake,
emerg. order- vitals q2hrs/hr IV Access NS Pulse oxi q2 hrs O2 Abg Cont BP moniter Cardiac moniter ekg (q1hr neuro q1hr
PE-(complete) shows local cellulitis, noticed 2 fang sites on his ankle Neuro xam shows drowsiness
Cbc q12 hrs bmp q12hr ua, cxr blood culture esr xray of ankle
pt ptt q6/ hb n hct q6 fibrinogen level,
Bleeding time,
Blood type and cross match.
Polyvalent snake antivenom -SNAKE
Shift to ICu
Foley Urine output NPO
interval hx+rest Ex Bedrest
Ranitidine cefazolin
Inj TT
If Neuroparalyis symptoms---- (Atropine + Neostigmine IV)
If devloping resp failure---- intubate and mech ventilation
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4-HEPATIC ENCEPHALOPATHY
pt presented with altered state of mind... had h/o of cirrhosis of liver already. was given oxycodone my dentist following which he devleloped symptoms..HEP C cirrhosis
LOOK FOR-alkalosisi,low k,SBP,HIGH PROT diet,
ER- IV access, pulse oximetry, cont bp, cont cardiac moniter, neurochecks, vitaks, ekg ,fingers stick glucose Thiamine inj, naloxone
50% dxt
GPE( signs of cirrhosis, confused patient, asterixis)
npo/nss/dextrose /NGT suction (to look for variceal bleeding)
CBC Q 12HRS BMP Q 12 HRS, urine an ,cxr .NH3 Q 12HRS
LFT, PT, PTT, urine r/e, toxicology, blood alcohol level , ca Mg phos
URINE culture, BLOOD culture /esr, abd us, hepatitis profile
(pt marginally raised, lft deranged as for cirrhosis serum NH3 sky high)
GI consult
PARACENTESIS-SEND FLUID ascitic fluid anal
LEVOFLOXACIN----IF PARACENT+VE{>250CELL) CHANGE TO CEFTRIAXONE
Lactulose oral
spirnolactone
admit ICU
npo foley catheter, pneumatic stock, urine output, bed rest, continue thiamine, (HTN./ spironolactone
[Moniter PT/PTT/ cbc/bmp/ammo daily .)
shift to wards in 24 hrs or when better , Case usually ends after 6 hrs of pt getting better. propranolol to control portal diet salt restriction
ALCOHOL rehab AA, EGD, vaccines/hep
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5-Post-op atelectasis. [after 36 hr of Surgery]...in ward
DD's were: Pneumothorax-PE- Pneumonia
pulse ox q1 oxygen, abg, cardiac monitor ekg vitals
phys exam: brief
CXR--it showed Atelactasis
cbc bmp urine ana / blood n urine culture, crp/esr,
d-dimers,fibrinogen, pt ,ptt
Removed the Foley Catheter and put a new one
IV clindamycin iv Acetaminophen
a)*Incentive Spirometry...chest physiotherapy
b)if chest xary normal d-dimers high……think PE
if stable (no hypo) :fobt , heparin
if unstable : tPA
cbc Q12 hb n hct Q6 pt,ptt/inr Q6
Pulmonary consult
CT ANGIOGRAM, dopplers
If started tpa than dc start heparin than warfarin
c) phy exam decrease breath sounds n jvd distention: needle thoacotomy
chest xray : tracheal deviation…tension pneumothorax
surgery consult , need thoracotomy,chest tube , repeat chest xray.
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6-Septic Abortion-
Er orders , iva pulse ox oxg card mon ekg bp monitor, neurochecks npo abg
Phy exam : gen heent chest heart abd genital exam
bhcg q 12 hrs transvag us cbc q 12hrs bmp urine an /blood cult,urine cult, cervix cultures / esr,crp pt ptt,fibrinogen, lft,blood type and rh / Doppler for fetal heart
npo nss IV clindamycin and metronizadole, acetomin,phergen,morphine, ranitidine foley catheter
Call OBGYN ----D&E
Just do medical Management in ICU- input/output ,pneumatic
2min: cbc esr bhcg papsmear rhogam
counsel contracetion , vacc
7-Incomplete abortion with heavy bleeding and acute PID.
Same as above naat gono/chlamy, hiv,vdrl hepatitis
Do cultures / IV Antibiotics ceftriaxone + azithromycin/ Call OBGYN, D&E
Just do medical Management in ICU
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8-Infected peripheral IV access
phy. Exam
iva (if central line, dc cental line and new central line)oxy/ vitals q1h/ (
ekg/fingerstick stat, acetominiphen
elevate arm ,cbc q12 bmp urine/ blood cult/urine cult/ remove iv line ) culture central line
esr, pt/ptt/
doppler of arm / xray of arm/ echo
(cath tip for c+s, gm stain, fungal cx not in software)
clinda + pipercill/tazobac(if admitted >48 hrs) / vancomycin +ceftriaxone
ward
bed rest iv nss
iv heparin if signs of cord-like thickening/bluish discoloration
when cx back:
iv naf for 2-3 days (until improvement)
dc zosyn and clinda
2 min: repeat cbc, chem in 3-4 days
counsel
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9-atrophic vaginitis
62 yr with vaginal itching clear discharge
painful intercourse (dd : atrophic vag/bacterial vagi/candidial vagi/ vulvar ca/cervicitis/tricho)
phy exam :vulvar erythema
mucus bleed during exam
cbc bmp urine ana. Vagina( culture wet prep,cytology,gonn, chlamydia, ph)
papmear
(may need emb colpo etc if finding in cervix or pap
if pap positive story goes further endocervical , ectocervical bx , colposcopy)
vaginal jelly for lubrication
estrogen cream
age related -counsel
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10-polycystic ovarian syndrome
21 yo f with beard, excessive hair ,weight gain, menstrual irregularity
darkening axillry thickened skin
dd (polycystic ovarian syndrome late cah adrenal tumour drug effects like minoxidil phenytoin
ovarian neoplasm cushing syndrome idiopathic hirsutism)
bhcg ,cbc ,bmp,urine
endocrine—tsh ,fsh ,lh, test, dhea, cortisol, prolactin 17 hydrox
pelvic us, blood glucose, lipid, papsmear
counsel weight loss, low fat diet send home
result: lh fsh ratio increase
insulin fasting glucose ratio increse
tx ocp/metformin/spirnolactone
fu 6 month-lh,fsh, lipid , HBa1c
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11-gono urethritis-male 21 m unprotected sex urethral discharge fever
burning sensation during urination office
Phy exam : comp. urethral discharge red urethra
suprapubic tender
(d/d-acute cystitis/epidymitis/nephrolithiasis/orchitis/prostitis/pyelonephritis
reiter's syndrome/urethritis—gono/chlymydia
office w/u
cbc bmp ua , urine culture, urethral gram stain
naat gonn/chlamy/vdrl/hiv/hepatitis
finding -- gram stain gram neg
culture awited
rx
azithromycin + ceftrixone
fu 4 week urethral culture
coun safe sex practice
treat patner
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12-AGN
office: 10 male with tea urine periorbit edema
had fever with hx of sore throat 3 wk back bp 140/85
dx
-cryoglobunemia /iga nephropathy/membranoprliferative gn/post streo gn
Nephritic/nephrotic
phy exam : complete
cbc bmp, urine anal, lft, lipid, 24 hour urine protein, ASO titer, Complement
orthostatic vitals, renal us, throat culture
low salt …..send home
results ua—proteinuria wbc cast, complement low rbc cast
office: interval /pe
Nephrology consult
nephritic: Lasix / captropril/ penicillin……..if nephrotic than steroids only if doest get better than add hctz and maybe albumin
fu 3 week: repeat urine anal,cbc
dietary consult
low sodium diet
fluid restriction
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13-BPH
office: 70 male night urin frequency urgency hesitancy terminal dribbling
double micturition weak stream
sensation of incomplete evacuation vita wnl
phy exam: prostate enlarged
cbc, bmp- ua urine culture/us prostate psa esr
send home
office rx finesteride/ prazosin which is a selecting short acting alpha blocker
urology consult
fu six month----for dre and psa , counsel
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14-acute psychotic disorder with mania… vital s -wnl
dd :mania/bipolar 1/stress/malingering/panic/schizophrenia/drug/delirium
phy exam -brief
cbc,bmp urine analysis, tsh ,head ct ,urine toxic. Bal, esr ,blood cult, depression index,lft ekg
Risperdal, lithium,
(restraints /lorazapam one time if agitated)
admit to ward:
psychiatry consult, suicide contract
psychotherpy
psychiatry consult
(monitor cbc with antipsychotic)
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15-spontaneous abortion
27 yr f lmp 6 week ago lower abdominal cramp and vag bleed
vitals tachy bp wnl …..dd : ectopic/abortion/cancer inflammation or cervicitis
normal menstration with dysmenorrhoea
er orders : iva ,pulse ox bp montor cardiac monitor vitals , morphine
phys exam : brief
cervix – open /blood in vault
bhcg trans vag us, cbc,bmp urine ana , blood culture, cervical culture ,gonorrhea,chlamy
blood type and group rh,pt ptt , fibrinogen, hb n hct q6
nss, npo, morphine ,pantoprazole ,cefazolin
result hb -9 no blood transfusion now pt is stable us -- fetus dead - fetal pole uterine pregnancy
ob/gyn consult : misoprostol ,D and E
admit to ward:, pneumatic compression
2 min screen folow up in 2 weeks monitor cbc ,bhcg
If rh neg …. Rhogam
counsel contraception
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16-malrotation VOLVULUS … 1 dy old m bilious vomi. ,poor feed lethargy ,rectal bleed
vitals 170 pulse 89 sat- er
dd: duodenal atresia/ intestinal atresia/ malrotation with volvulus
necrotising enterocolitis
er orders :iv aceess, nss , pulse ox , oxy,cardiac moni, bp monitor ,vitals
phy exam : brief
ng tube suction ,cbc ,bmp, urine ana. abg
lft,amylase upper gi series/abdominal xray+ abd us ,cxr/ barium enema
BLOOD C/S if fever
results: cbc leucocytosis-axr-airless rectum large gastric bubble- means some obstruction
iv bicarb if ph less than 7
sigmoidoscopy rectal tube if not relieved than surgery
pediatric surgery consult, pt ptt blood type , cefazolin, ranitidine, laparotomy
admit to ward
counsel parent
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17-child with rash/ Office W/U
ruleout drug reactin??
rule out lyme if suspected
Complete PE
CBC, stat /BMP, stat/ UA, urine culture
rapid strep, throat cult ,ESR, routine
blood culture/ culture of scraping from rash
CXR, stat EKG, 12 lead, stat
Neck x ray, stat
No aspirin
send the patient home and F/U in 4 days
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18-obesity in adolescent
Complete PE
vitals ,Measure Height Measure Weight
Calculate BMI -- you have to do this manually...not in the CCS software
cbc,BMP,urine ana, LFT Fasting Glucose, Fasting Lipid Profile
Serum TSH 24 hour urinary cortisol
Weight Loss diet
Counsel Patient for Exercise Program
Counsel Patient
Counsel Family
If the age of the PT is 2-7 years old and BMI with 95 percentile......or more without complication, the goal should generally be maintenance of baseline weight,
For children 2“7 years old with BMI at the 95th percentile or above and secondary complications, weight loss is indicated
For children older than 7 years with BMI between the 85th and 95th percentile, without complications, weight maintenance is an appropriate goal.
I guess this patient's BMI >95th percentile
Follow-up visit in 4 months
If no change...
Orlistat, po
Follow up in 6 weeks
If morbid obesity, BMI more than 45
Consider Bariatric surgery
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19-CTS secretary pain while typing …office
complete PE
Xray,cbc , bmp urine esr/ crp /tsh Rhem fact /ana
ca magnesium phos lipidb hcg, ibuprofen
fu 3 days
night splint-SPLINT EXTREMITY
nerve conduction study
rhematology counselling
another visit
carpal tunnel confirmed
another cou
3 month…….not better
ortho consult for surg
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20-teenager comes for a pre-employment
she is 5ft 2 inches and weighs 180 lbs. Bp 155/90
pt eats fast food..it is all about weight loss....
cbc bmp urinanalysis chest x ray
ekg, bp in both arm, abd us
for her bmi……lipid profile fasting/ FBS/ TSH/cortisol level
counselling life style -
low sodium low fat low cholesterol, exercise weight loss
calorie count and exercise
folow up three month
not better add hctz
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21-JRA
7 yr old girl with fever, rash and polyarthritis
PE: Complete
cbc bmp urine, cxr, ESR ANA Rhem F, ferritin
LFTs Xrays joint , blood culture ,throat culture, ekg echo d-dimers
PT/PTT ( if swelling do arthrocenthesis -synovial) start ibuprofen
send home..
Results: Cxr of joint erosion /ANA positive / RF normal BUN nad CR wnl
Tx cw ibuprofen + methotrexate add if erosions
opth consult eye exam q 3mths
Rheumatology consult
Physical therapy consult …EXERCISE
mvi, folic
Calcium supplements/ diet rich in calcium
Educate family
MRI and Dexa--?
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22-kawasaki disease
< 5yrs of age fever for more than 5 days, rash, conjunctival injection, cervical lympphadenitis, inflammation of lips and the oral cavity, redness and swelling of the hands and feet.
coronary arteries aneurysm…..unknown etiology.
iva,oxy, pulse ox vital q2 cardiac mon q1 ekg q12
PE ; complete
cbc q4 bmp urine an., cxr, lfts
Blood cult, urine cult, esr, LP csf culture
results: thrombocytosis elevated esr sterile pyuria
EKG=ST seg depression and T-wave flattening mild hypoalbuminemia
ORDER:
2-D echo Coronary angiogram....pediatric cardiology consult
IVIG + Aspirin ( untill pt is afebrile for several days)
d/c after 6-8 weeks if no signs of coronary involvement and practically indefinitely if there is a coronary problem.
Influenza vaccine before starting aspirin to prevent REYE'S Syndrome
if platelet count high than start wafarin
2min cbc /echo /esr on follow up in 4 week
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23-Osteomyelitis stable vitals
PE; complete..except breast, genitalia and rectal
* Orders: iva ,nss cbc q 12 bmp urine ana. Xary of leg, blood culture urine cult esr /crp q 6 hs
~Results...x-ray wnl... ESR 90.....
*Order
MRI or Bone scan( if MRI is... C/I)..........MRI more specific!
Bone Biopsy
Results ..... MRI= Mild destruction fo tibia... Bone Bx=GM shows neutrophils & Stph aureu grows on cxs!
* Admit to ward
diets
bedrest with bathrm privilages
cbc for day #2
Empiric coverage with ceft +vancomcin
follow up on esr, cbc in 2 weeks
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24-Hypoglycemia
27 yrs old female nurse found unresponsive, diaphoretic and tachy.Prior to this she was c/o headache and tremors. Pupils are wnl. PmHx is insignificant. Coming to ER
diffrential :Insulinoma/ Exogenous Insulin/ SU overdose /Prolonged fasting
Er- iva ,O2 pulse ox Vitals Q 1 HR Bp mon Cards ekg, accuch, finger stick neurocheck
thiamine naloxone suction airway
PE : HEENT, LUNGS, HEART AND ABDOMEN
*Result BS 50 and pupils are wnl
~ORDERS: nss dext 50 keterolac, bhcg cbc bmp, ua cxr lfts abg
C-peptide Insulin serum Insulin antibodies SU urine screen
bal Urine tox, abd ct, head ct
TSH Cortisol level
~PE: come back and finish the exam now.
* Interval histoyr...pt is a little awake
~Results: C-peptide rasied and SU urine tscreen +ve for glyburide!
~Order: Octreotide SC x 1 bolus
Transfere to ICU
Octreotide sc q 8hrs Accue check q 1hrs
NPO Urine output bedrest
cbc in AM bmp in AM
Psychiatyr consult, depression index ,suicide precaution , suicide contract , psychotherapy
If abd ct comes back + for Insulinoma
gastroenterology surgeon consul
Npo pt ptt blood type cefazolin omeprazole foley catheter
laparascopy
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25-Dilated cardiomyopathy
55 yr old pt presents w bilateral LE edema, sob on exerction, no cough. h/o drinking 5 quarts of wine every day. PE bibasilar wet crackles and evidence of moderate ascites!!!
Casuses of dialted CM
alcohol/ adriaamycin /radiation /viral myocarditis /amyloidosis /sarcoidosis/
hemochromatosis/ Thiamine deficiency
Er: head elevation iva pulse ox oxyg, cardiac, bp moni, vitals, ,
thiamine folic acid finger stick
PE ; COMPLETE
nss dextrose thiamine , Lasix , kcl ,morphine, cbc bmp q 2hrs urine ana, cxr, lft echo Cal Mag Phos
Amylase Lipase
PT PTT B12 FOLIC level BLOOD ALCOH utox
* Results : CXR=Enlarged heart w Kerley B llines + EKG= ST-T waves non-specific abnl
~ Admit to floor ~telemetry
~Order low salt diet fluid restriction Bedrest w bath rm privilages Hepari SC hb and hct
Foley
Strict Input and Output, Daily weights
CXR Q day BMP q day
~Result: echo shows dilated heart w EF 25%
Order cardiology consult iv carvedilol iv spirono iv lisino iv digi
Anticoagulation...consider in longterm .... if evidence of thrombosis
strict daily wt, i/o (foley for strict uo)
daily mvi, thiamine and folate (commonly deficient)
f/u in 1 wk with another bmp and ekg
~ 2Minute Screen
CARD REHAB/ ECHO-in 3 weeks and 3MONTHS
alcohol anonymous alcohol abstienance
lipid colonospcopy
Maybe you will have to manage the pt for 2-3 days in the simulated time...on the software...
but d/c home on ace, beta bxs, spironolactone, dig and lasix...with follow up in next 7-14 days... Of course change IV meds to PO before discharge.
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26-Down's Syndrome neonate
new born downs most probably presents with vomiting ( duoenal atresia)
Er: iva , pulse ox oxy abg card mon bp moni , ekg,vital npo NG Tube ranitidine nss
Brief physical
CBC ,BMP q6 ,urine ana ,CXR, abd xray (upper gi series) , abd us, blood cult urin culture
LFTs amylase lipase
Consult Pediatrics GI surgery
Transfer to icu
Preop orders: Blood type pt ptt cezolin foleys catheter input output
Laparascopy
Karyotype confirms Down's
2 min screen ECHO / audiometry / TSH / Opthamol / Genetics consult
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27-Preeclampsia
21 yr old at 33wks gestation, c/o facial and upper-extremity edema....
how will you proceed ER case
Er orders : Iva pulse ox ,nss, npo, oxy, cardiac mon bp moni vitals, neurocheck
brief physical exam
CBC,BMP, urine ana, blood culture,
LFTs pt,ptt blood typr n cross match UA
transvag USG, ca mg q 4 hrs phos level, fetal monitoring Doppler of fetus
DEXAMETH
MGSO4-IM than delivery depending gestation
Obgyn consult
IF SEVERE PRE-ecl- bp greater than 160/110
Im-MgSO4 stat-cont
IV hydralazine/labetalol stat-cont
Transfer to ward
foleys catheter urin output
complete bed rest
deliver the baby after “term-nvd with oxy
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28-Multiple Myeloma
Multiple Myeloma** patient presenting with Hypercalcemia
45 yr old male presents with abd pain and fatigue .,bone pain hypercalcemia in a pt who is presenting acutely..wife reports he has been acting a bit strange over the last few days....
Differential : 90% Primary Hyperparathyroidism Malignancy---
1-* Osteolytic Hypercalcemia due to Myeloma, Lymphoma, Breast carcinoma
2-*Humoral Hypercalcemia-PtHrP “ Sq Cell Cacinoma of lungs, head & neck, renal or bladder.
3-*Tumoral Calcitriol production is Hodgkins & Non Hodgkin Lymphomas.
ER: IVA, pulse oxy, oxy cardiac bp mon vitals ekg , npo morphine phenergen
Focused PE : General, HEENT , Heart , Lung, Abdomen, Extremities
Order: cbc, bmp urine analysis, chest xary, abd us
CA MG PHOS Lfts LIPASE
result :Crab
~*Results show Ca 13.5mg/dl Hb 8.7g/dl . Also BUN and Creatinine slightly Increased
~* EKG shows shortened QT Interval
Iv 0.9% NSS , Calcitonin - SC q 6-12 hours
IV Pamidronate Continuos (over 2-6 hours0
SPEP,UPEP, PTH ,VIT D level , 24 hr urinary calcium, CA MG PHOS 8hrs, bone scan
Seum alkaline phosphatase (to rule our Hyperparathyroidism & Paget disease)
~*Do Interval and Check for volume overload by focused Heart & lungs
Admit to Ward : Iron Enriched Diet, Ambulate at will ,Urine output, foleys cath
BMP daily, Sodium Docusate (stool softner)
Move the clock get results
~* Results show Bone X ray *Lytic Lesions.
~* Results show SPEP and UPEP *Positive
~* Results show PTH .*Normal
Order hematology consult,*Bone Marrow Biopsy
Consent for Procedure
biopsy result ~* which shows plasma cells in Bone Marrow
~*Call Oncology consult.chemotherapy consult.. Patient with Multiple Myeloma needs chemotherapy
~ORDER;
Mephalan , steroids ,lefunamide
Epogen** SC to fix his anemia----- erythropoietin
Fu with ca ,mg phos cbc in 1 week
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29-Hypercalcemia-office
30 yr old with hyper calcemia on routine tests with h/o renal stones some 2-3 yrs back. Serum calcium is 11.5 mg/dl.
PE complete except breast, rectal and genitalia
order: cbc, bmp urine ana calcium Mag Phos Lfts
PT PTT EKG CXR, abd us
home
Pt returns...do a small PE
Results show ca 11.5mmg/dl
ORDER;
PTH , vit d level,spep,upep
24 hr urinary calcium
Dexa Scan
pt home, call with results of the tests
Results show..PTH 23 mEq/ml
Ward : surgery consult…..preop for surgery..Parathyroidectomy..
f/u with ca mg phos pth in 1 week
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30-Hypercalcemia-ER
a 45 year old male presents with abdominal pain, wife reports he has been ating a bit strange over the last few days....
Er orders : iva, pulse oxi , oygen cardiac mon bp moni Ekg vitals , npo morphine phergen
Cbc bmp urine anal , cxr lft ca mg phos , abd us cxr
lft amyl,lipa , pt/ptt
full physical
Pth 24 hr urine . Ca spep/upep vit d level abdo ct
normal saline ,iv calcitonin
Iv pamidronate
bmp, ca, mg, phos q4h
consult surg if pth high surgery consult for parathoidectomy (blood type and cross match, npo, foley)
send home after 48 hr
2 min screen : f/u in 1 wk with cbc, bmp, ca, mg, phos, pth
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31-Multiple Sclerosis
24 yr F pt comes to your office with blurring of vision in L eye and weakness of right leg.
Past history of such weakness episode on R arm prior to 6 months.--ER
PE(complete)
fundoscopy shows blurring of disc margin, disc atrophy;
admit to ward
iva pulse npo nss vitals, cardiac monitor neurochecks , bhcg cbc bmp ua chest xray pt ptt
tsh cpk vit b12 mri brain and spine( shows demylinating lesions)
iv methyl prednisolone calcium vit d omeprazole
consult neurology consult opthal
LP, csf ( shows oligoclonal bands)
Interferon or Glatimer acetate start
baclofen for spasticity
if pain gabapentin
bladder hyperactivity oxybutinin
fatigue amantadine or flouxetine
urinary retention bethanecol
ocp
normal diet/urine output/ambulation at will
interval history and PE
symptom free-- on day3
follow up appointment; after 3 months MRI repeat
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32-HELLP
35 wks getation...bp 170/115, headache, scotoma, epigastic pain-ER
er orders: iva pulse ox oxy, cardiac mon ekg bp moni, vitals npo nss
MgSO4..IV Labetalol..IV DEXAmethasone.. IM
phy exam
Order :CBC BMP, urine ana , blood culture,lft.pt,ptt reteic count ,blood type fibrinogen
d-dimers Ca, Mg. Phos, trans vag us
Labor monitor , FETAL MONITOR
CULTURE-VAG,GONO,CHLAM
CONSULT OB
MONITOR BP,PLT,Urine ana,PT.PTT,BMP
type and cross 2 units of PRBCs FFp Platelet, monitor hb and hct
Admit to ICU...BED U OUT PNEU RANITIDINE-IV
PENICILLIN G-IV OXYTOCIN
NVD
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33-Endometrial Hyperplasia without Atypia
hx if imp for age, if she wants childbirth or contraception.
usually presents with abnormal heavy uterine bleed. (if very heavy: send to ER), lets assume here its moderate, no distress, pt now in office.
full PE
Order bhcg CBC BMP UA tsh lft pt ptt bleeding time pelvic us papsmear
obgyn consult ENDO BX
Call her again in 2 days:
if anemic, order FOBT, RETIC, PERI SMEAR, TIBC,. IRON, FERR
RESULTS ALL WNL. BX SHOWS HYPERPLASIA WITHOUT ATYPIA
OCP'S IF SHE DESIRES CONTRACEPTION
OR
MEDROXYPROGESTERONE ORAL FOR 14 DAYS IF NOT
FESO4 MVI
Call back in 14 days
IMPROVED BLEEDING: NO SYMPTOMS: CAN DC MEDROXY
IF PERSISTENT: CONTINUE MEDROXY FOR 6 MONTHS
Call in 1 month to check
2min screen
pap x1 yr
mammo
endo bx x6months
Colono
counsel
IF OLD PATIENT: SEVERE BLEEDING: HYSTERECTOMY
-------------------------------------------------------------------------------------
34-Gastric cancer
Weight loss , Abdominal pain , Nausea, presentation with Gastric obstruction
Dysphagia, Melena, Early satiety ,Ulcer-type pain to ER
ER orders : iva pulse ox, oxy ,cardiac mon,ekg vitals , NG Tube, IV Fluid, morphine
Iv phenegen
Phy.exam
Order: CBC, BMP, UA, CXR, EKG
XRAY-ABD-series, FOBT, LFT, lipase, amylase, Pt ptt, CA,MG,PHOS
FBS ALBUMIN, lipid
Pt once stable bit
Barium upper GI studies
CONSULT-GASTRO
ENDOSCOPY , BIOPSY-
Result,BX shows ADENO CA
ANEMIA-IRON STUDIES,VITB12
FESO4, VITA C
CT-CHEST,CT-ABD, colonoscopy
surgery consult ,blood type omeprazole cefazolin
ORDER: CONSULT-RADIO CONSULT-ONCO CONSULT-DIETICIAN
ADVANCE DIRECT
--------------------------------------------
35-TURP-HYPONATREMIA
Manifestations of the TURP Syndrome:
- acute hypo-osmolality - acute hyponatremia-congestive heart failure - pulmonary edema- hypertension – hypotension - solutee toxicity: hyperglycinaemia (glycine) hyperammonaemia (glycine
if detected intra-operatively bleeding points should be coagulated, surgery
terminated as soon as possible and iv.fluid should be stopped
Iva OXY VITALS CARDIO ekg BP MONIT OXY, abg
phy exam brief
CBC BMP UA CXR,foleys CULTURE-BLOOD/URINE
DC-NSS
DC-SX
FUROSEMIDE-IV-AFTER LOW Na
ICU BED NPO in/OUT PT PTT
CBC H and H blood TYPE
IF SEIZURE/confusion-
DIAZEPAM
3% NACL
-------------------------------------------------
36-testicular pain-acute unilateral, child--ER
testicular torsion, - the most dramatic and potentially serious of the acute processes
torsion of the appendix testis,-MC
epididymitis.
abrupt onset of severe testicular or scrotal pain.N,V
awaken with scrotal pain in the middle of the night or in the morning
VITALS-FEVER NO
IVA, OXYpulse ox CARDIO BP MONITOR,ekg, morphine , phenergen, vitals
P/E-
GENTAL,ABD”HORIZONT LEVEL
CREMESTERIC REFLEX-NEG
CBC BMP UA/culture, abd us , amylase ,lipase ,lft, surgery consult ,npo pt, ptt
Blood type cefazolin,
TRANSILLUMINATION
USS-SCROTUM--------TEST:TORSION
B/L ORCHEOPEXY
Orchiectomy is performed if the testicle is nonviable
IF FEVER+POSITIVE CREMESTER WITH NEG USS---ACUTE EPIDIDYMITIS
frequency, dysuria, urethral discharge “UTI
CULTURE
CHILD WTH UTI-CEPHALEXIN,BACTRIM
GONO- CEFTR+DOXY
scrotal support, rest
----------------------------------------------
37-hypertensive crisis with SAH 45 year old man with worst headache of life
Ischemic stroke or subarachnoid or intracerebral hemorrhage -- Intravenous labetalol Other first-line agents include transdermal nitroglycerin paste and intravenous nicardipine
nitroprusside should be considered second-line therapy
Sublingual nifedipine should be avoided
o Antihypertensive agents previously were advocated for an SBP greater than 160 mm Hg or diastolic BP (DBP) greater than 90 mm Hg.
o Keep systolic blood pressure 90-140 mm Hg before aneurysm treatment, then allow hypertension to keep systolic blood pressure less than 200 mm Hg
acute pulmonary edema -- Nitroprusside or nitroglycerin with a loop diuretic
Drugs that increase cardiac work (hydralazine) or decrease cardiac contractility (labetalol or other beta blocker) should be avoided
Angina pectoris or acute myocardial infarction - nitroprusside and nitroglycerin
Aortic dissection - beta blocker such as propranolol or labetalol. +/- Nitroprusside
Er iva nss pulse ox ,cardiac, mon, ekg bp mon, vitals,neurochecks, morphine , phenergen
Phy exam
cbc bmp q 4 urine anal cxr , esr CT head Noncontrast
Cardiac enzymes and troponin q8
Serum glucose lft , pt, ptt ,inr
Lipid profile, MRA of brain
Lumbar puncture if subarachnoid hemorrhage is suspected and head CT scan is negative for blood Electroencephalogram if seizures are suspected
Iv nimodipine , surgery consult npo blood type .foleys catheter , aneurysm repair,
Admit to Icu , pneumatic st, foley catheter bedrest urine input output
---------------------------------------------------------------
38-Hypertension-secondary
young man no risk factor 150/90 comes to office
Complete physical exam
cbc , bmp, urine cxr , ekg lft pt ptt inr
lipid tsh, urine drug screen , HBa1ccounsel low fat low salt diet exercise program
home
if sodium high potassium low normal anion gap
give KCL
office
aldesterone/rennin activity ratio
-24 aldosterone level (if high)
24 hr cortisol, metanephrine
abd/ct
spirinolactone
monitor BMp
home
ct-adrenal mass
ward
consent consult npo, pt,ptt,blood type , cefazolin foleys catheter
laparoscopic adrenalectomy
………………..
if cxr show cardimeg
rib notching-MRA go for coarctation
if ua proteinuria do ultrasound kidney mri kidney
do nephro consult do surgey consult
measure bp in both arm
beta-2 hctz-1 aci inh ccb
smoking obesity alcohol drug hx
coumsel call back
--------------------------------------------------------
39-fever unknown origin - adult
complete physical
cbc, bmp urine ana, cxr, blood cult/ urine cult/ sputum cult/esr lft pt ptt inr
(uds if pertinent)
lp/ csf if meningitis suspected or alter mental
ct if necessary
/ gyn consult -- if gyn cause
surgery if abscess
if lft increse …..hepatitis panel
if central lines line culture
if janeway osler roth spot or bacterial endo--echo
if throat pain can be pharyngitis or mono
atypical lypho in blood ,rapid strep test
if viral syndrome vdrl hiv
if leg pain or sob or pe suspected
vq scan later -doppler or low -d dimer
if no improve -
joint lymph node ry eye dry mouth …connective tissue panel
treat with abx iv saline
npo if sepsis suspected
surgical consult and ct if abscess
see the bllod cs report change the abx
no response you may have to add amphotericin
if herpes thing - add acyclovir
-----------------------------------------
40-septic shock ,fever shock tachy
low bp left lowe quadrant pain
iv access oxygen pulse /oxygen cardiac mon bp moin ekg vitals neurochecks abg
fingerstick, morphine phergen acetomino nss
focus pe
cbc, bmp urine anal, blood culture ( if endo order 3 cultures and echo )/urine culture cxr, esr, lft lipase, abd us
cefotaxime
genta
intake out put
foley
urine out put 1 hour
ct reort comes
surgical consult for drainage of abscess
oral cipro
------------------------------------------------------
41-Alcohol withdrawal
pt is a 30 yr old male coming with tachy, sweating, tremor, agitated
Er order :iva, pulse ox oxygen cardiac mon bp mon , ekg , fingerstick , vitals,neurochecks
(if agitated / psychosis) lorazepam im or Haldol ( possible soft restraints) aspiration precaution , thiamine n folic acid ( if give alcohol hx)
PE... real quick HEENT RESP CARDS
npo nss phergen
cbc bmp urine ana lft Blood alcohol level Urine toxicology
ABG amylase lipase PT PTT
Calcium serum Mag serum Phos serum
Thiamine IV Folic acid Iv
now come back and Complete the PE...what ever is left
librium q4 hr
transfere to ICU
seizure precaution
aspiration precaution
counselling
alcohol anonymous..alcohol rehab
-----------------------------------
42-retained placenta with profuse bleeding / endometritis
ER,3post op D, w fever and abd tenderness
iva , nss, pulse ox , acetaminophen, morphine , vitals
Complete PE
CBC q 12hrs , bmp , urine anal, cxr, blood cult, urine cult,cervical culture esr q 12 hrs, lft ,
pt,ptt blood type, fibrinogen, abd us
IV Ceftriaxzone + IV Clindamycin
Consult OBG, (If retained placenta than oxytocin DC for retained placental removal)
send the pt to medical ward: Bed rest NPO
----------------------------------------------------------------
43-Chronic renal failure
in office pt complaing of difficulty urination
complete Physical exam
cbc bmp ua cxr urine culture, abd us ,
ca, mg ,phos, pth vit d ekg, abg
if pt in emergency/ electrolyte abnormal send to ward
ward: iva , pulse ox urine out-put, calcium , vitamin d
and also pt ptt
and do blood typing
as there might be anaemia…iron studies …erythropoietin
transfusion if hb low or even dialysis if acidosis
correct electrolytes, renal diet nephrology consult
---------------------------------------------------------------------
44-Acute renal failure
80 yr old man comes to ER with n/v and maliase. PMhx is significant for Htn, DM and osteoarthritis. Pt is on NSAIDS, lisinopril. Also reports making very little urine over the last 24 hrs.
Er orders: iva nss pulse ox cardiac monitor ekg bp monitor vitals Q 2 hrs , acetominophen,
PE : General, heent, LUNGS, ABDOMEN
~ Orders:
CBC bmp q6 urine anal urine culture, chest xray , lft, pt ptt, ca, mg phos, abd us 24 urine creatnine level 24 urine protein , feNa , urine osmolality, eosnophils in urine
dc lisinopril and dc nsaids
Results..(.pH 7.29, PCO2 20, PO2 80). (BMP NA 138 & HCO3 12)
~Transfere to ward
bed rest FOLEYS, trict input/putput
(Urine NA ( NL IS LESS THAN & EQUAL TO 10) and Creatnine
24 hr Urine protien
eosinnophils in urine...(seen in allergic nephritis)
Renal USG ( if BPH...call urology consult))
Hgb A1c DAILY WEIGHTS
Accue check q 4 hrs Insulin sliding scale ( if need be )
BMP q 2-4 hrs
hopefully pt starts to improve after d/c nsaids and NSS infusion...
pre-renal RF treated with fluids...if no rsponse...IV lasix....
Dobutamine and dopamine (if heart failure)
---------------------------------------------
45-rape
Female pt complains of being raped
complete physical
vitals.. RAPE KIT.( not in soft ware )..
Bhcg cbc..bmp urine anal, urine culture
cervical smear/ culture , papsmear, KOH prep , gram stain , naat for chlam, gonn, hiv , vdrl hepatitis, depression index
LEVONORGESTREL..not in soft ware -oral(high dose estrogen) for 2days
Now STD prophylaxis:
Ceftriiaxone IM Azithromax PO
Probenecid Metonidazole for trichomonas
rape crisis consult, safety
Social services consult
Psych Consult?
------------------------------------------------------------
46- HUS
Er : iva pulse ox oxy cardiac bp mon vitals oxy ekg vitals
Phy exam
NPO CBC BMP UA, Culture, esr cxr , AXR acute series
Stool leuco, cultu, ova & para,
Lft , pt, ptt, hb n hct, ldh haptoglobin , reteic count , peripheral smear
peripheral smear blood type cross match
D-DIMER FIBRIN DEGRADATION PRODUCTS-fdp
results: come as low platelet
fragmented RBC
no FDP no D dimers
PT/PTT are normal K+ is elevated
tx: insulin , dextrose 50, nss keyexalate, hematology/ peads consult
transfer to ICU:
monitor pt,ptt bmp q 1 hrs than q4
If case doesn't improve plasmapheresis
***check for ldh inc. schisto in peripheral, retic increa
BUN & crea are in BMP
----------------------------------------------------------------------------
47-New onset DM-42 yr old c polydipsia & polyuria
DD- DM, DI, Factitious Disorder
since it is a clinic setting...no emergency..
Pe: complete
ORDERS:
cbc bmp, urine anal, cxr ekg, urine culture
abg, hba1c, lipid profile, lft
Finger stick BS 325mg/dL. DIAGNOSTIC DM
Admit to ward:
iva nss, accuchecks q2, vitals
serum/urine ketones, serum/urine osmolarity,
urine microalbumin.
UA-CULTURE
-ivf nss,
-sliding scale:bld glucose 100-200-do nothing
bld glucose 200-300-5u insulin
bld glucose 300-400-10u insulin
blood glucose q2h,
BMP-2h -vitals q4h,
foley's catheter for intake
output,1800 ADA
lisinopril if htn
-podiatry consult-endocrinology consult-ophthalmology consult
insulin and institute glipizide,
diabetic counsel:weight loss,diet,exercise,annual ophthalmologic exam,
foot care and protection,medication compliance,depression couseling,
home glucose monitoring
--------------------
48-Fever Unknown origin-child
INFANT-bac,HSV
Child-infect,connective
Cbc Ua Bmp
Culture-blood,urine,throat,cxr esr
Lft Lp-irritable, hiv , vdrl, ana rf, ct of abd
npo nss aceto,
Wbc scan-gallium/indium, pediatric consult
NO-emp..ABx…wait for results that start on abx.
--------------------------------------------------
49-Cervical cancer
physical exam complete
order: cbc bmp ua beta hcg, papsmear, cervical cult,wet mont , ph naat gonorrhea/chlamy
HIV ELISA VDRL
move the clock forward
if has come with chlamydial infection/ginorrhea treat that
call in 3 days (pap result comes in 3 days)
Colposcopy/ Endocervical curettage/ ectocervical biopsy
Gynecolgy consult
If cancer move clock for results
Surgery , oncology consults, radiology consult , cancer dx counsel
Ward : check for mets (ct of abd , ct of chest ,mammography, colonoscopy , bone scan , cystoscopy )
On Preop surgical orders
surgery
npo blood type cross match pt ptt phenergen, morphine ,cefazolin
Serum Iron with TIBC
reticulocyte count
interval history
TAH+BSO(If family done)
Gynecology consult
RADIATION/CHEMO-CISPLATIN
1. femur neck#--ER
2. Advanced maternal age with pregnancy with hx of bipolar office
3. Snake bite
4. HEPATIC ENCEPHALOPATHY
5. Post-op atelectasis.
6. Septic Abortion-
7. Incomplete abortion with heavy bleeding and acute PID.
8. Infected peripheral IV access
9. atrophic vaginitis
10. polycystic ovarian syndrome
11. gono
12. AGN
13. BPH
14. acute psychotic disorder
15. spontaneous abortion
16. malrotation
17. child with rash
18. obesity in adolescent
19. CTS
20. teenager comes for a pre-employment
21. JRA
22. kawasaki disease
23. Osteomyelitis
24. Hypoglycemia
25. Dilated cardiomyopathy
26. Down's Syndrome neonate
27. Preeclampsia
28. MM
29. Hypercalcemia-office
30. Hypercalcemia-ER
31. MS
32. HELLP
33. Endometrial Hyperplasia without Atypia
34. Gastric cancer
35. TURP-HYPONATREMIA
36. testicular pain-acute unilateral, child”ER
37. hypertensive crisis with SAH
38. Hypertension-secondary
39. fever unknown origin “ adult
40. septic shock
41. Alcohol withdrawal
42. retained placenta
43. Chronic renal failure
44. Acute renal failure
45. RAPE46. HUS 47. New onset DM-42 yr old c polydipsia & polyuria 48. Fever Unknown origin-child 49. Cx ca 50. Failure to Thrive
1-femur neck#--ER
Hx- 55 female post meno Exter. Rot. & shorten Right LL ,VS- stable
emerg.order: IVA oxy sat Pulse oxy cardiac monitor, vitals q1hr bp monitor EKG morphine
P/E general skin heent look for hematomaheart lung abd cns extr
Nss cbc q12hrs bmp q 12hrs ua x ray chest, hip(ap/lat) ,knee, fobt
Ca, phoph ,mg, PTH d-dimers
consent form
orthopedic consult ; reason hip fracture
surgery consult
interval+rest of exam
pre op surgery- npo cefazolin IV on time, pt ptt /inr q4hr
fobt blood type,crossmatch, omeprazole, hip replacemnet
admit to wd bed rest ,bathroom urine output foley
heparin sq- hb and hct q6
pneumatic stock surgery done-
calcium vit d
if shows patient improves,
discharged and f.u after 2wks
2min screen-f/u xray in 6weeks , vaccines
Counseling alendronate medicine comp
stop smoking limit alcohol seat belt
calcium rich diet
Age related
exa scan colonoscopy lipidmammography
-------------------------------------------------------
2-Advanced maternal age pregnancy with hx of bipolar
office: PE—complete
HCG (+ve) move clock 1 min , transvag
CBC ,BMP ,UA, urine culture, LFTs, lipid profile/ atypical antibody
blood type & cross type and Rh
pt/ptt
EKG, pap smear
gonorrhea/ chlymydia/ RPR/ Hep B antibody/ HIV ELISA rubella titer / toxo titer
pregnatal counseling/prenatal vitamins/ foic /iron
no smoking,/ no drugs / no alcohol, safe sex, seat belt, safety plan
follow up after 1 month in 1st trimester
2nd visit full physical
vital(BP check),Weight UA
Fetal heart monitoring, (fundal height)
do triple screen --serum HCG, AFP, estradiol [MS AFP], if high Amniocentesis
Triple marker screen-TRIPLE TEST repeat trans vag us
Valproic acid level
send her home..
2 min screen: counsel
Genetic counseling
Amniocentesis
Karotyping of the fetal amniocytes....cells found in the amniotic fluid
---------------------------------------------
3-Snake bite
ER Location
25 y young guy “ 30min after hx of snake bite.
Havenâ brought snake,
emerg. order- vitals q2hrs/hr IV Access NS Pulse oxi q2 hrs O2 Abg Cont BP moniter Cardiac moniter ekg (q1hr neuro q1hr
PE-(complete) shows local cellulitis, noticed 2 fang sites on his ankle Neuro xam shows drowsiness
Cbc q12 hrs bmp q12hr ua, cxr blood culture esr xray of ankle
pt ptt q6/ hb n hct q6 fibrinogen level,
Bleeding time,
Blood type and cross match.
Polyvalent snake antivenom -SNAKE
Shift to ICu
Foley Urine output NPO
interval hx+rest Ex Bedrest
Ranitidine cefazolin
Inj TT
If Neuroparalyis symptoms---- (Atropine + Neostigmine IV)
If devloping resp failure---- intubate and mech ventilation
----------------------------------------
4-HEPATIC ENCEPHALOPATHY
pt presented with altered state of mind... had h/o of cirrhosis of liver already. was given oxycodone my dentist following which he devleloped symptoms..HEP C cirrhosis
LOOK FOR-alkalosisi,low k,SBP,HIGH PROT diet,
ER- IV access, pulse oximetry, cont bp, cont cardiac moniter, neurochecks, vitaks, ekg ,fingers stick glucose Thiamine inj, naloxone
50% dxt
GPE( signs of cirrhosis, confused patient, asterixis)
npo/nss/dextrose /NGT suction (to look for variceal bleeding)
CBC Q 12HRS BMP Q 12 HRS, urine an ,cxr .NH3 Q 12HRS
LFT, PT, PTT, urine r/e, toxicology, blood alcohol level , ca Mg phos
URINE culture, BLOOD culture /esr, abd us, hepatitis profile
(pt marginally raised, lft deranged as for cirrhosis serum NH3 sky high)
GI consult
PARACENTESIS-SEND FLUID ascitic fluid anal
LEVOFLOXACIN----IF PARACENT+VE{>250CELL) CHANGE TO CEFTRIAXONE
Lactulose oral
spirnolactone
admit ICU
npo foley catheter, pneumatic stock, urine output, bed rest, continue thiamine, (HTN./ spironolactone
[Moniter PT/PTT/ cbc/bmp/ammo daily .)
shift to wards in 24 hrs or when better , Case usually ends after 6 hrs of pt getting better. propranolol to control portal diet salt restriction
ALCOHOL rehab AA, EGD, vaccines/hep
-----------------------------------------------------------------------------------------------
5-Post-op atelectasis. [after 36 hr of Surgery]...in ward
DD's were: Pneumothorax-PE- Pneumonia
pulse ox q1 oxygen, abg, cardiac monitor ekg vitals
phys exam: brief
CXR--it showed Atelactasis
cbc bmp urine ana / blood n urine culture, crp/esr,
d-dimers,fibrinogen, pt ,ptt
Removed the Foley Catheter and put a new one
IV clindamycin iv Acetaminophen
a)*Incentive Spirometry...chest physiotherapy
b)if chest xary normal d-dimers high……think PE
if stable (no hypo) :fobt , heparin
if unstable : tPA
cbc Q12 hb n hct Q6 pt,ptt/inr Q6
Pulmonary consult
CT ANGIOGRAM, dopplers
If started tpa than dc start heparin than warfarin
c) phy exam decrease breath sounds n jvd distention: needle thoacotomy
chest xray : tracheal deviation…tension pneumothorax
surgery consult , need thoracotomy,chest tube , repeat chest xray.
-----------------------------------------------
6-Septic Abortion-
Er orders , iva pulse ox oxg card mon ekg bp monitor, neurochecks npo abg
Phy exam : gen heent chest heart abd genital exam
bhcg q 12 hrs transvag us cbc q 12hrs bmp urine an /blood cult,urine cult, cervix cultures / esr,crp pt ptt,fibrinogen, lft,blood type and rh / Doppler for fetal heart
npo nss IV clindamycin and metronizadole, acetomin,phergen,morphine, ranitidine foley catheter
Call OBGYN ----D&E
Just do medical Management in ICU- input/output ,pneumatic
2min: cbc esr bhcg papsmear rhogam
counsel contracetion , vacc
7-Incomplete abortion with heavy bleeding and acute PID.
Same as above naat gono/chlamy, hiv,vdrl hepatitis
Do cultures / IV Antibiotics ceftriaxone + azithromycin/ Call OBGYN, D&E
Just do medical Management in ICU
--------------------------------------------------
8-Infected peripheral IV access
phy. Exam
iva (if central line, dc cental line and new central line)oxy/ vitals q1h/ (
ekg/fingerstick stat, acetominiphen
elevate arm ,cbc q12 bmp urine/ blood cult/urine cult/ remove iv line ) culture central line
esr, pt/ptt/
doppler of arm / xray of arm/ echo
(cath tip for c+s, gm stain, fungal cx not in software)
clinda + pipercill/tazobac(if admitted >48 hrs) / vancomycin +ceftriaxone
ward
bed rest iv nss
iv heparin if signs of cord-like thickening/bluish discoloration
when cx back:
iv naf for 2-3 days (until improvement)
dc zosyn and clinda
2 min: repeat cbc, chem in 3-4 days
counsel
---------------------------------------------------
9-atrophic vaginitis
62 yr with vaginal itching clear discharge
painful intercourse (dd : atrophic vag/bacterial vagi/candidial vagi/ vulvar ca/cervicitis/tricho)
phy exam :vulvar erythema
mucus bleed during exam
cbc bmp urine ana. Vagina( culture wet prep,cytology,gonn, chlamydia, ph)
papmear
(may need emb colpo etc if finding in cervix or pap
if pap positive story goes further endocervical , ectocervical bx , colposcopy)
vaginal jelly for lubrication
estrogen cream
age related -counsel
--------------------------------------------------------------------------------------------------------
10-polycystic ovarian syndrome
21 yo f with beard, excessive hair ,weight gain, menstrual irregularity
darkening axillry thickened skin
dd (polycystic ovarian syndrome late cah adrenal tumour drug effects like minoxidil phenytoin
ovarian neoplasm cushing syndrome idiopathic hirsutism)
bhcg ,cbc ,bmp,urine
endocrine—tsh ,fsh ,lh, test, dhea, cortisol, prolactin 17 hydrox
pelvic us, blood glucose, lipid, papsmear
counsel weight loss, low fat diet send home
result: lh fsh ratio increase
insulin fasting glucose ratio increse
tx ocp/metformin/spirnolactone
fu 6 month-lh,fsh, lipid , HBa1c
-----------------------------------------------------
11-gono urethritis-male 21 m unprotected sex urethral discharge fever
burning sensation during urination office
Phy exam : comp. urethral discharge red urethra
suprapubic tender
(d/d-acute cystitis/epidymitis/nephrolithiasis/orchitis/prostitis/pyelonephritis
reiter's syndrome/urethritis—gono/chlymydia
office w/u
cbc bmp ua , urine culture, urethral gram stain
naat gonn/chlamy/vdrl/hiv/hepatitis
finding -- gram stain gram neg
culture awited
rx
azithromycin + ceftrixone
fu 4 week urethral culture
coun safe sex practice
treat patner
------------------------------------------------------
12-AGN
office: 10 male with tea urine periorbit edema
had fever with hx of sore throat 3 wk back bp 140/85
dx
-cryoglobunemia /iga nephropathy/membranoprliferative gn/post streo gn
Nephritic/nephrotic
phy exam : complete
cbc bmp, urine anal, lft, lipid, 24 hour urine protein, ASO titer, Complement
orthostatic vitals, renal us, throat culture
low salt …..send home
results ua—proteinuria wbc cast, complement low rbc cast
office: interval /pe
Nephrology consult
nephritic: Lasix / captropril/ penicillin……..if nephrotic than steroids only if doest get better than add hctz and maybe albumin
fu 3 week: repeat urine anal,cbc
dietary consult
low sodium diet
fluid restriction
---------------------------------------
13-BPH
office: 70 male night urin frequency urgency hesitancy terminal dribbling
double micturition weak stream
sensation of incomplete evacuation vita wnl
phy exam: prostate enlarged
cbc, bmp- ua urine culture/us prostate psa esr
send home
office rx finesteride/ prazosin which is a selecting short acting alpha blocker
urology consult
fu six month----for dre and psa , counsel
----------------------------------------------------
14-acute psychotic disorder with mania… vital s -wnl
dd :mania/bipolar 1/stress/malingering/panic/schizophrenia/drug/delirium
phy exam -brief
cbc,bmp urine analysis, tsh ,head ct ,urine toxic. Bal, esr ,blood cult, depression index,lft ekg
Risperdal, lithium,
(restraints /lorazapam one time if agitated)
admit to ward:
psychiatry consult, suicide contract
psychotherpy
psychiatry consult
(monitor cbc with antipsychotic)
----------------------------------------------------
15-spontaneous abortion
27 yr f lmp 6 week ago lower abdominal cramp and vag bleed
vitals tachy bp wnl …..dd : ectopic/abortion/cancer inflammation or cervicitis
normal menstration with dysmenorrhoea
er orders : iva ,pulse ox bp montor cardiac monitor vitals , morphine
phys exam : brief
cervix – open /blood in vault
bhcg trans vag us, cbc,bmp urine ana , blood culture, cervical culture ,gonorrhea,chlamy
blood type and group rh,pt ptt , fibrinogen, hb n hct q6
nss, npo, morphine ,pantoprazole ,cefazolin
result hb -9 no blood transfusion now pt is stable us -- fetus dead - fetal pole uterine pregnancy
ob/gyn consult : misoprostol ,D and E
admit to ward:, pneumatic compression
2 min screen folow up in 2 weeks monitor cbc ,bhcg
If rh neg …. Rhogam
counsel contraception
-----------------------------------------------------------
16-malrotation VOLVULUS … 1 dy old m bilious vomi. ,poor feed lethargy ,rectal bleed
vitals 170 pulse 89 sat- er
dd: duodenal atresia/ intestinal atresia/ malrotation with volvulus
necrotising enterocolitis
er orders :iv aceess, nss , pulse ox , oxy,cardiac moni, bp monitor ,vitals
phy exam : brief
ng tube suction ,cbc ,bmp, urine ana. abg
lft,amylase upper gi series/abdominal xray+ abd us ,cxr/ barium enema
BLOOD C/S if fever
results: cbc leucocytosis-axr-airless rectum large gastric bubble- means some obstruction
iv bicarb if ph less than 7
sigmoidoscopy rectal tube if not relieved than surgery
pediatric surgery consult, pt ptt blood type , cefazolin, ranitidine, laparotomy
admit to ward
counsel parent
-------------------------------------------------
17-child with rash/ Office W/U
ruleout drug reactin??
rule out lyme if suspected
Complete PE
CBC, stat /BMP, stat/ UA, urine culture
rapid strep, throat cult ,ESR, routine
blood culture/ culture of scraping from rash
CXR, stat EKG, 12 lead, stat
Neck x ray, stat
No aspirin
send the patient home and F/U in 4 days
--------------------------------------------------------
18-obesity in adolescent
Complete PE
vitals ,Measure Height Measure Weight
Calculate BMI -- you have to do this manually...not in the CCS software
cbc,BMP,urine ana, LFT Fasting Glucose, Fasting Lipid Profile
Serum TSH 24 hour urinary cortisol
Weight Loss diet
Counsel Patient for Exercise Program
Counsel Patient
Counsel Family
If the age of the PT is 2-7 years old and BMI with 95 percentile......or more without complication, the goal should generally be maintenance of baseline weight,
For children 2“7 years old with BMI at the 95th percentile or above and secondary complications, weight loss is indicated
For children older than 7 years with BMI between the 85th and 95th percentile, without complications, weight maintenance is an appropriate goal.
I guess this patient's BMI >95th percentile
Follow-up visit in 4 months
If no change...
Orlistat, po
Follow up in 6 weeks
If morbid obesity, BMI more than 45
Consider Bariatric surgery
-------------------------------------------------------------------------------
19-CTS secretary pain while typing …office
complete PE
Xray,cbc , bmp urine esr/ crp /tsh Rhem fact /ana
ca magnesium phos lipidb hcg, ibuprofen
fu 3 days
night splint-SPLINT EXTREMITY
nerve conduction study
rhematology counselling
another visit
carpal tunnel confirmed
another cou
3 month…….not better
ortho consult for surg
--------------------------------------------------------------------------------
20-teenager comes for a pre-employment
she is 5ft 2 inches and weighs 180 lbs. Bp 155/90
pt eats fast food..it is all about weight loss....
cbc bmp urinanalysis chest x ray
ekg, bp in both arm, abd us
for her bmi……lipid profile fasting/ FBS/ TSH/cortisol level
counselling life style -
low sodium low fat low cholesterol, exercise weight loss
calorie count and exercise
folow up three month
not better add hctz
-------------------------------------------------------------------
21-JRA
7 yr old girl with fever, rash and polyarthritis
PE: Complete
cbc bmp urine, cxr, ESR ANA Rhem F, ferritin
LFTs Xrays joint , blood culture ,throat culture, ekg echo d-dimers
PT/PTT ( if swelling do arthrocenthesis -synovial) start ibuprofen
send home..
Results: Cxr of joint erosion /ANA positive / RF normal BUN nad CR wnl
Tx cw ibuprofen + methotrexate add if erosions
opth consult eye exam q 3mths
Rheumatology consult
Physical therapy consult …EXERCISE
mvi, folic
Calcium supplements/ diet rich in calcium
Educate family
MRI and Dexa--?
--------------------------------------------------------
22-kawasaki disease
< 5yrs of age fever for more than 5 days, rash, conjunctival injection, cervical lympphadenitis, inflammation of lips and the oral cavity, redness and swelling of the hands and feet.
coronary arteries aneurysm…..unknown etiology.
iva,oxy, pulse ox vital q2 cardiac mon q1 ekg q12
PE ; complete
cbc q4 bmp urine an., cxr, lfts
Blood cult, urine cult, esr, LP csf culture
results: thrombocytosis elevated esr sterile pyuria
EKG=ST seg depression and T-wave flattening mild hypoalbuminemia
ORDER:
2-D echo Coronary angiogram....pediatric cardiology consult
IVIG + Aspirin ( untill pt is afebrile for several days)
d/c after 6-8 weeks if no signs of coronary involvement and practically indefinitely if there is a coronary problem.
Influenza vaccine before starting aspirin to prevent REYE'S Syndrome
if platelet count high than start wafarin
2min cbc /echo /esr on follow up in 4 week
---------------------------------------------------------------------
23-Osteomyelitis stable vitals
PE; complete..except breast, genitalia and rectal
* Orders: iva ,nss cbc q 12 bmp urine ana. Xary of leg, blood culture urine cult esr /crp q 6 hs
~Results...x-ray wnl... ESR 90.....
*Order
MRI or Bone scan( if MRI is... C/I)..........MRI more specific!
Bone Biopsy
Results ..... MRI= Mild destruction fo tibia... Bone Bx=GM shows neutrophils & Stph aureu grows on cxs!
* Admit to ward
diets
bedrest with bathrm privilages
cbc for day #2
Empiric coverage with ceft +vancomcin
follow up on esr, cbc in 2 weeks
--------------------------------------------------------------------------
24-Hypoglycemia
27 yrs old female nurse found unresponsive, diaphoretic and tachy.Prior to this she was c/o headache and tremors. Pupils are wnl. PmHx is insignificant. Coming to ER
diffrential :Insulinoma/ Exogenous Insulin/ SU overdose /Prolonged fasting
Er- iva ,O2 pulse ox Vitals Q 1 HR Bp mon Cards ekg, accuch, finger stick neurocheck
thiamine naloxone suction airway
PE : HEENT, LUNGS, HEART AND ABDOMEN
*Result BS 50 and pupils are wnl
~ORDERS: nss dext 50 keterolac, bhcg cbc bmp, ua cxr lfts abg
C-peptide Insulin serum Insulin antibodies SU urine screen
bal Urine tox, abd ct, head ct
TSH Cortisol level
~PE: come back and finish the exam now.
* Interval histoyr...pt is a little awake
~Results: C-peptide rasied and SU urine tscreen +ve for glyburide!
~Order: Octreotide SC x 1 bolus
Transfere to ICU
Octreotide sc q 8hrs Accue check q 1hrs
NPO Urine output bedrest
cbc in AM bmp in AM
Psychiatyr consult, depression index ,suicide precaution , suicide contract , psychotherapy
If abd ct comes back + for Insulinoma
gastroenterology surgeon consul
Npo pt ptt blood type cefazolin omeprazole foley catheter
laparascopy
-------------------------------------------------------------------------------------------
25-Dilated cardiomyopathy
55 yr old pt presents w bilateral LE edema, sob on exerction, no cough. h/o drinking 5 quarts of wine every day. PE bibasilar wet crackles and evidence of moderate ascites!!!
Casuses of dialted CM
alcohol/ adriaamycin /radiation /viral myocarditis /amyloidosis /sarcoidosis/
hemochromatosis/ Thiamine deficiency
Er: head elevation iva pulse ox oxyg, cardiac, bp moni, vitals, ,
thiamine folic acid finger stick
PE ; COMPLETE
nss dextrose thiamine , Lasix , kcl ,morphine, cbc bmp q 2hrs urine ana, cxr, lft echo Cal Mag Phos
Amylase Lipase
PT PTT B12 FOLIC level BLOOD ALCOH utox
* Results : CXR=Enlarged heart w Kerley B llines + EKG= ST-T waves non-specific abnl
~ Admit to floor ~telemetry
~Order low salt diet fluid restriction Bedrest w bath rm privilages Hepari SC hb and hct
Foley
Strict Input and Output, Daily weights
CXR Q day BMP q day
~Result: echo shows dilated heart w EF 25%
Order cardiology consult iv carvedilol iv spirono iv lisino iv digi
Anticoagulation...consider in longterm .... if evidence of thrombosis
strict daily wt, i/o (foley for strict uo)
daily mvi, thiamine and folate (commonly deficient)
f/u in 1 wk with another bmp and ekg
~ 2Minute Screen
CARD REHAB/ ECHO-in 3 weeks and 3MONTHS
alcohol anonymous alcohol abstienance
lipid colonospcopy
Maybe you will have to manage the pt for 2-3 days in the simulated time...on the software...
but d/c home on ace, beta bxs, spironolactone, dig and lasix...with follow up in next 7-14 days... Of course change IV meds to PO before discharge.
----------------------------------------------------------------------
26-Down's Syndrome neonate
new born downs most probably presents with vomiting ( duoenal atresia)
Er: iva , pulse ox oxy abg card mon bp moni , ekg,vital npo NG Tube ranitidine nss
Brief physical
CBC ,BMP q6 ,urine ana ,CXR, abd xray (upper gi series) , abd us, blood cult urin culture
LFTs amylase lipase
Consult Pediatrics GI surgery
Transfer to icu
Preop orders: Blood type pt ptt cezolin foleys catheter input output
Laparascopy
Karyotype confirms Down's
2 min screen ECHO / audiometry / TSH / Opthamol / Genetics consult
-----------------------------------------------------------------------------------------
27-Preeclampsia
21 yr old at 33wks gestation, c/o facial and upper-extremity edema....
how will you proceed ER case
Er orders : Iva pulse ox ,nss, npo, oxy, cardiac mon bp moni vitals, neurocheck
brief physical exam
CBC,BMP, urine ana, blood culture,
LFTs pt,ptt blood typr n cross match UA
transvag USG, ca mg q 4 hrs phos level, fetal monitoring Doppler of fetus
DEXAMETH
MGSO4-IM than delivery depending gestation
Obgyn consult
IF SEVERE PRE-ecl- bp greater than 160/110
Im-MgSO4 stat-cont
IV hydralazine/labetalol stat-cont
Transfer to ward
foleys catheter urin output
complete bed rest
deliver the baby after “term-nvd with oxy
---------------------------------------------------------------------------
28-Multiple Myeloma
Multiple Myeloma** patient presenting with Hypercalcemia
45 yr old male presents with abd pain and fatigue .,bone pain hypercalcemia in a pt who is presenting acutely..wife reports he has been acting a bit strange over the last few days....
Differential : 90% Primary Hyperparathyroidism Malignancy---
1-* Osteolytic Hypercalcemia due to Myeloma, Lymphoma, Breast carcinoma
2-*Humoral Hypercalcemia-PtHrP “ Sq Cell Cacinoma of lungs, head & neck, renal or bladder.
3-*Tumoral Calcitriol production is Hodgkins & Non Hodgkin Lymphomas.
ER: IVA, pulse oxy, oxy cardiac bp mon vitals ekg , npo morphine phenergen
Focused PE : General, HEENT , Heart , Lung, Abdomen, Extremities
Order: cbc, bmp urine analysis, chest xary, abd us
CA MG PHOS Lfts LIPASE
result :Crab
~*Results show Ca 13.5mg/dl Hb 8.7g/dl . Also BUN and Creatinine slightly Increased
~* EKG shows shortened QT Interval
Iv 0.9% NSS , Calcitonin - SC q 6-12 hours
IV Pamidronate Continuos (over 2-6 hours0
SPEP,UPEP, PTH ,VIT D level , 24 hr urinary calcium, CA MG PHOS 8hrs, bone scan
Seum alkaline phosphatase (to rule our Hyperparathyroidism & Paget disease)
~*Do Interval and Check for volume overload by focused Heart & lungs
Admit to Ward : Iron Enriched Diet, Ambulate at will ,Urine output, foleys cath
BMP daily, Sodium Docusate (stool softner)
Move the clock get results
~* Results show Bone X ray *Lytic Lesions.
~* Results show SPEP and UPEP *Positive
~* Results show PTH .*Normal
Order hematology consult,*Bone Marrow Biopsy
Consent for Procedure
biopsy result ~* which shows plasma cells in Bone Marrow
~*Call Oncology consult.chemotherapy consult.. Patient with Multiple Myeloma needs chemotherapy
~ORDER;
Mephalan , steroids ,lefunamide
Epogen** SC to fix his anemia----- erythropoietin
Fu with ca ,mg phos cbc in 1 week
-------------------------------------------------------------------------------------------
29-Hypercalcemia-office
30 yr old with hyper calcemia on routine tests with h/o renal stones some 2-3 yrs back. Serum calcium is 11.5 mg/dl.
PE complete except breast, rectal and genitalia
order: cbc, bmp urine ana calcium Mag Phos Lfts
PT PTT EKG CXR, abd us
home
Pt returns...do a small PE
Results show ca 11.5mmg/dl
ORDER;
PTH , vit d level,spep,upep
24 hr urinary calcium
Dexa Scan
pt home, call with results of the tests
Results show..PTH 23 mEq/ml
Ward : surgery consult…..preop for surgery..Parathyroidectomy..
f/u with ca mg phos pth in 1 week
---------------------------------------------------------------
30-Hypercalcemia-ER
a 45 year old male presents with abdominal pain, wife reports he has been ating a bit strange over the last few days....
Er orders : iva, pulse oxi , oygen cardiac mon bp moni Ekg vitals , npo morphine phergen
Cbc bmp urine anal , cxr lft ca mg phos , abd us cxr
lft amyl,lipa , pt/ptt
full physical
Pth 24 hr urine . Ca spep/upep vit d level abdo ct
normal saline ,iv calcitonin
Iv pamidronate
bmp, ca, mg, phos q4h
consult surg if pth high surgery consult for parathoidectomy (blood type and cross match, npo, foley)
send home after 48 hr
2 min screen : f/u in 1 wk with cbc, bmp, ca, mg, phos, pth
----------------------------------------------------------------------------
31-Multiple Sclerosis
24 yr F pt comes to your office with blurring of vision in L eye and weakness of right leg.
Past history of such weakness episode on R arm prior to 6 months.--ER
PE(complete)
fundoscopy shows blurring of disc margin, disc atrophy;
admit to ward
iva pulse npo nss vitals, cardiac monitor neurochecks , bhcg cbc bmp ua chest xray pt ptt
tsh cpk vit b12 mri brain and spine( shows demylinating lesions)
iv methyl prednisolone calcium vit d omeprazole
consult neurology consult opthal
LP, csf ( shows oligoclonal bands)
Interferon or Glatimer acetate start
baclofen for spasticity
if pain gabapentin
bladder hyperactivity oxybutinin
fatigue amantadine or flouxetine
urinary retention bethanecol
ocp
normal diet/urine output/ambulation at will
interval history and PE
symptom free-- on day3
follow up appointment; after 3 months MRI repeat
------------------------------------------------------
32-HELLP
35 wks getation...bp 170/115, headache, scotoma, epigastic pain-ER
er orders: iva pulse ox oxy, cardiac mon ekg bp moni, vitals npo nss
MgSO4..IV Labetalol..IV DEXAmethasone.. IM
phy exam
Order :CBC BMP, urine ana , blood culture,lft.pt,ptt reteic count ,blood type fibrinogen
d-dimers Ca, Mg. Phos, trans vag us
Labor monitor , FETAL MONITOR
CULTURE-VAG,GONO,CHLAM
CONSULT OB
MONITOR BP,PLT,Urine ana,PT.PTT,BMP
type and cross 2 units of PRBCs FFp Platelet, monitor hb and hct
Admit to ICU...BED U OUT PNEU RANITIDINE-IV
PENICILLIN G-IV OXYTOCIN
NVD
------------------------------------------------------------------
33-Endometrial Hyperplasia without Atypia
hx if imp for age, if she wants childbirth or contraception.
usually presents with abnormal heavy uterine bleed. (if very heavy: send to ER), lets assume here its moderate, no distress, pt now in office.
full PE
Order bhcg CBC BMP UA tsh lft pt ptt bleeding time pelvic us papsmear
obgyn consult ENDO BX
Call her again in 2 days:
if anemic, order FOBT, RETIC, PERI SMEAR, TIBC,. IRON, FERR
RESULTS ALL WNL. BX SHOWS HYPERPLASIA WITHOUT ATYPIA
OCP'S IF SHE DESIRES CONTRACEPTION
OR
MEDROXYPROGESTERONE ORAL FOR 14 DAYS IF NOT
FESO4 MVI
Call back in 14 days
IMPROVED BLEEDING: NO SYMPTOMS: CAN DC MEDROXY
IF PERSISTENT: CONTINUE MEDROXY FOR 6 MONTHS
Call in 1 month to check
2min screen
pap x1 yr
mammo
endo bx x6months
Colono
counsel
IF OLD PATIENT: SEVERE BLEEDING: HYSTERECTOMY
-------------------------------------------------------------------------------------
34-Gastric cancer
Weight loss , Abdominal pain , Nausea, presentation with Gastric obstruction
Dysphagia, Melena, Early satiety ,Ulcer-type pain to ER
ER orders : iva pulse ox, oxy ,cardiac mon,ekg vitals , NG Tube, IV Fluid, morphine
Iv phenegen
Phy.exam
Order: CBC, BMP, UA, CXR, EKG
XRAY-ABD-series, FOBT, LFT, lipase, amylase, Pt ptt, CA,MG,PHOS
FBS ALBUMIN, lipid
Pt once stable bit
Barium upper GI studies
CONSULT-GASTRO
ENDOSCOPY , BIOPSY-
Result,BX shows ADENO CA
ANEMIA-IRON STUDIES,VITB12
FESO4, VITA C
CT-CHEST,CT-ABD, colonoscopy
surgery consult ,blood type omeprazole cefazolin
ORDER: CONSULT-RADIO CONSULT-ONCO CONSULT-DIETICIAN
ADVANCE DIRECT
--------------------------------------------
35-TURP-HYPONATREMIA
Manifestations of the TURP Syndrome:
- acute hypo-osmolality - acute hyponatremia-congestive heart failure - pulmonary edema- hypertension – hypotension - solutee toxicity: hyperglycinaemia (glycine) hyperammonaemia (glycine
if detected intra-operatively bleeding points should be coagulated, surgery
terminated as soon as possible and iv.fluid should be stopped
Iva OXY VITALS CARDIO ekg BP MONIT OXY, abg
phy exam brief
CBC BMP UA CXR,foleys CULTURE-BLOOD/URINE
DC-NSS
DC-SX
FUROSEMIDE-IV-AFTER LOW Na
ICU BED NPO in/OUT PT PTT
CBC H and H blood TYPE
IF SEIZURE/confusion-
DIAZEPAM
3% NACL
-------------------------------------------------
36-testicular pain-acute unilateral, child--ER
testicular torsion, - the most dramatic and potentially serious of the acute processes
torsion of the appendix testis,-MC
epididymitis.
abrupt onset of severe testicular or scrotal pain.N,V
awaken with scrotal pain in the middle of the night or in the morning
VITALS-FEVER NO
IVA, OXYpulse ox CARDIO BP MONITOR,ekg, morphine , phenergen, vitals
P/E-
GENTAL,ABD”HORIZONT LEVEL
CREMESTERIC REFLEX-NEG
CBC BMP UA/culture, abd us , amylase ,lipase ,lft, surgery consult ,npo pt, ptt
Blood type cefazolin,
TRANSILLUMINATION
USS-SCROTUM--------TEST:TORSION
B/L ORCHEOPEXY
Orchiectomy is performed if the testicle is nonviable
IF FEVER+POSITIVE CREMESTER WITH NEG USS---ACUTE EPIDIDYMITIS
frequency, dysuria, urethral discharge “UTI
CULTURE
CHILD WTH UTI-CEPHALEXIN,BACTRIM
GONO- CEFTR+DOXY
scrotal support, rest
----------------------------------------------
37-hypertensive crisis with SAH 45 year old man with worst headache of life
Ischemic stroke or subarachnoid or intracerebral hemorrhage -- Intravenous labetalol Other first-line agents include transdermal nitroglycerin paste and intravenous nicardipine
nitroprusside should be considered second-line therapy
Sublingual nifedipine should be avoided
o Antihypertensive agents previously were advocated for an SBP greater than 160 mm Hg or diastolic BP (DBP) greater than 90 mm Hg.
o Keep systolic blood pressure 90-140 mm Hg before aneurysm treatment, then allow hypertension to keep systolic blood pressure less than 200 mm Hg
acute pulmonary edema -- Nitroprusside or nitroglycerin with a loop diuretic
Drugs that increase cardiac work (hydralazine) or decrease cardiac contractility (labetalol or other beta blocker) should be avoided
Angina pectoris or acute myocardial infarction - nitroprusside and nitroglycerin
Aortic dissection - beta blocker such as propranolol or labetalol. +/- Nitroprusside
Er iva nss pulse ox ,cardiac, mon, ekg bp mon, vitals,neurochecks, morphine , phenergen
Phy exam
cbc bmp q 4 urine anal cxr , esr CT head Noncontrast
Cardiac enzymes and troponin q8
Serum glucose lft , pt, ptt ,inr
Lipid profile, MRA of brain
Lumbar puncture if subarachnoid hemorrhage is suspected and head CT scan is negative for blood Electroencephalogram if seizures are suspected
Iv nimodipine , surgery consult npo blood type .foleys catheter , aneurysm repair,
Admit to Icu , pneumatic st, foley catheter bedrest urine input output
---------------------------------------------------------------
38-Hypertension-secondary
young man no risk factor 150/90 comes to office
Complete physical exam
cbc , bmp, urine cxr , ekg lft pt ptt inr
lipid tsh, urine drug screen , HBa1ccounsel low fat low salt diet exercise program
home
if sodium high potassium low normal anion gap
give KCL
office
aldesterone/rennin activity ratio
-24 aldosterone level (if high)
24 hr cortisol, metanephrine
abd/ct
spirinolactone
monitor BMp
home
ct-adrenal mass
ward
consent consult npo, pt,ptt,blood type , cefazolin foleys catheter
laparoscopic adrenalectomy
………………..
if cxr show cardimeg
rib notching-MRA go for coarctation
if ua proteinuria do ultrasound kidney mri kidney
do nephro consult do surgey consult
measure bp in both arm
beta-2 hctz-1 aci inh ccb
smoking obesity alcohol drug hx
coumsel call back
--------------------------------------------------------
39-fever unknown origin - adult
complete physical
cbc, bmp urine ana, cxr, blood cult/ urine cult/ sputum cult/esr lft pt ptt inr
(uds if pertinent)
lp/ csf if meningitis suspected or alter mental
ct if necessary
/ gyn consult -- if gyn cause
surgery if abscess
if lft increse …..hepatitis panel
if central lines line culture
if janeway osler roth spot or bacterial endo--echo
if throat pain can be pharyngitis or mono
atypical lypho in blood ,rapid strep test
if viral syndrome vdrl hiv
if leg pain or sob or pe suspected
vq scan later -doppler or low -d dimer
if no improve -
joint lymph node ry eye dry mouth …connective tissue panel
treat with abx iv saline
npo if sepsis suspected
surgical consult and ct if abscess
see the bllod cs report change the abx
no response you may have to add amphotericin
if herpes thing - add acyclovir
-----------------------------------------
40-septic shock ,fever shock tachy
low bp left lowe quadrant pain
iv access oxygen pulse /oxygen cardiac mon bp moin ekg vitals neurochecks abg
fingerstick, morphine phergen acetomino nss
focus pe
cbc, bmp urine anal, blood culture ( if endo order 3 cultures and echo )/urine culture cxr, esr, lft lipase, abd us
cefotaxime
genta
intake out put
foley
urine out put 1 hour
ct reort comes
surgical consult for drainage of abscess
oral cipro
------------------------------------------------------
41-Alcohol withdrawal
pt is a 30 yr old male coming with tachy, sweating, tremor, agitated
Er order :iva, pulse ox oxygen cardiac mon bp mon , ekg , fingerstick , vitals,neurochecks
(if agitated / psychosis) lorazepam im or Haldol ( possible soft restraints) aspiration precaution , thiamine n folic acid ( if give alcohol hx)
PE... real quick HEENT RESP CARDS
npo nss phergen
cbc bmp urine ana lft Blood alcohol level Urine toxicology
ABG amylase lipase PT PTT
Calcium serum Mag serum Phos serum
Thiamine IV Folic acid Iv
now come back and Complete the PE...what ever is left
librium q4 hr
transfere to ICU
seizure precaution
aspiration precaution
counselling
alcohol anonymous..alcohol rehab
-----------------------------------
42-retained placenta with profuse bleeding / endometritis
ER,3post op D, w fever and abd tenderness
iva , nss, pulse ox , acetaminophen, morphine , vitals
Complete PE
CBC q 12hrs , bmp , urine anal, cxr, blood cult, urine cult,cervical culture esr q 12 hrs, lft ,
pt,ptt blood type, fibrinogen, abd us
IV Ceftriaxzone + IV Clindamycin
Consult OBG, (If retained placenta than oxytocin DC for retained placental removal)
send the pt to medical ward: Bed rest NPO
----------------------------------------------------------------
43-Chronic renal failure
in office pt complaing of difficulty urination
complete Physical exam
cbc bmp ua cxr urine culture, abd us ,
ca, mg ,phos, pth vit d ekg, abg
if pt in emergency/ electrolyte abnormal send to ward
ward: iva , pulse ox urine out-put, calcium , vitamin d
and also pt ptt
and do blood typing
as there might be anaemia…iron studies …erythropoietin
transfusion if hb low or even dialysis if acidosis
correct electrolytes, renal diet nephrology consult
---------------------------------------------------------------------
44-Acute renal failure
80 yr old man comes to ER with n/v and maliase. PMhx is significant for Htn, DM and osteoarthritis. Pt is on NSAIDS, lisinopril. Also reports making very little urine over the last 24 hrs.
Er orders: iva nss pulse ox cardiac monitor ekg bp monitor vitals Q 2 hrs , acetominophen,
PE : General, heent, LUNGS, ABDOMEN
~ Orders:
CBC bmp q6 urine anal urine culture, chest xray , lft, pt ptt, ca, mg phos, abd us 24 urine creatnine level 24 urine protein , feNa , urine osmolality, eosnophils in urine
dc lisinopril and dc nsaids
Results..(.pH 7.29, PCO2 20, PO2 80). (BMP NA 138 & HCO3 12)
~Transfere to ward
bed rest FOLEYS, trict input/putput
(Urine NA ( NL IS LESS THAN & EQUAL TO 10) and Creatnine
24 hr Urine protien
eosinnophils in urine...(seen in allergic nephritis)
Renal USG ( if BPH...call urology consult))
Hgb A1c DAILY WEIGHTS
Accue check q 4 hrs Insulin sliding scale ( if need be )
BMP q 2-4 hrs
hopefully pt starts to improve after d/c nsaids and NSS infusion...
pre-renal RF treated with fluids...if no rsponse...IV lasix....
Dobutamine and dopamine (if heart failure)
---------------------------------------------
45-rape
Female pt complains of being raped
complete physical
vitals.. RAPE KIT.( not in soft ware )..
Bhcg cbc..bmp urine anal, urine culture
cervical smear/ culture , papsmear, KOH prep , gram stain , naat for chlam, gonn, hiv , vdrl hepatitis, depression index
LEVONORGESTREL..not in soft ware -oral(high dose estrogen) for 2days
Now STD prophylaxis:
Ceftriiaxone IM Azithromax PO
Probenecid Metonidazole for trichomonas
rape crisis consult, safety
Social services consult
Psych Consult?
------------------------------------------------------------
46- HUS
Er : iva pulse ox oxy cardiac bp mon vitals oxy ekg vitals
Phy exam
NPO CBC BMP UA, Culture, esr cxr , AXR acute series
Stool leuco, cultu, ova & para,
Lft , pt, ptt, hb n hct, ldh haptoglobin , reteic count , peripheral smear
peripheral smear blood type cross match
D-DIMER FIBRIN DEGRADATION PRODUCTS-fdp
results: come as low platelet
fragmented RBC
no FDP no D dimers
PT/PTT are normal K+ is elevated
tx: insulin , dextrose 50, nss keyexalate, hematology/ peads consult
transfer to ICU:
monitor pt,ptt bmp q 1 hrs than q4
If case doesn't improve plasmapheresis
***check for ldh inc. schisto in peripheral, retic increa
BUN & crea are in BMP
----------------------------------------------------------------------------
47-New onset DM-42 yr old c polydipsia & polyuria
DD- DM, DI, Factitious Disorder
since it is a clinic setting...no emergency..
Pe: complete
ORDERS:
cbc bmp, urine anal, cxr ekg, urine culture
abg, hba1c, lipid profile, lft
Finger stick BS 325mg/dL. DIAGNOSTIC DM
Admit to ward:
iva nss, accuchecks q2, vitals
serum/urine ketones, serum/urine osmolarity,
urine microalbumin.
UA-CULTURE
-ivf nss,
-sliding scale:bld glucose 100-200-do nothing
bld glucose 200-300-5u insulin
bld glucose 300-400-10u insulin
blood glucose q2h,
BMP-2h -vitals q4h,
foley's catheter for intake
output,1800 ADA
lisinopril if htn
-podiatry consult-endocrinology consult-ophthalmology consult
insulin and institute glipizide,
diabetic counsel:weight loss,diet,exercise,annual ophthalmologic exam,
foot care and protection,medication compliance,depression couseling,
home glucose monitoring
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48-Fever Unknown origin-child
INFANT-bac,HSV
Child-infect,connective
Cbc Ua Bmp
Culture-blood,urine,throat,cxr esr
Lft Lp-irritable, hiv , vdrl, ana rf, ct of abd
npo nss aceto,
Wbc scan-gallium/indium, pediatric consult
NO-emp..ABx…wait for results that start on abx.
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49-Cervical cancer
physical exam complete
order: cbc bmp ua beta hcg, papsmear, cervical cult,wet mont , ph naat gonorrhea/chlamy
HIV ELISA VDRL
move the clock forward
if has come with chlamydial infection/ginorrhea treat that
call in 3 days (pap result comes in 3 days)
Colposcopy/ Endocervical curettage/ ectocervical biopsy
Gynecolgy consult
If cancer move clock for results
Surgery , oncology consults, radiology consult , cancer dx counsel
Ward : check for mets (ct of abd , ct of chest ,mammography, colonoscopy , bone scan , cystoscopy )
On Preop surgical orders
surgery
npo blood type cross match pt ptt phenergen, morphine ,cefazolin
Serum Iron with TIBC
reticulocyte count
interval history
TAH+BSO(If family done)
Gynecology consult
RADIATION/CHEMO-CISPLATIN