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Old 09-23-2009
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Star 50 star ccs cases

found this on another forum so thought of sharing here


. femur neck#--ER

2. Advanced maternal age

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. RAPE

46. 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
P/E
general
skin
heent look for hematoma
heart
lung
abd
cns
extr

Orders

IVA
oxy sat
Pulse oxy
cardiac monitor
bp monitor
EKG
nss
cbc
bmp
ua

pt
ptt
inr
fobt
blood type,crossmatch
Ca,phoph,pth,mg
x ray –chest,hip(ap/lat) ,knee
morphin-pain
consent form
orthopedic consult ; reason hip fracture

admit to wd
interval+rest ex
cefazolin IV on time
npo
bed rest ,bathroom
urine output
foley
ranitidine
cbc/d
bmp/d
h&H
ptt-4h
heparin sq
pneumatic

surgery done-
post-sx
morphi
ambulate early
calcium
vit d
if shows patient improves,

discharged and f.u after 2wks

Counseling
mobilization
exercise
alendronate
medicine comp
stop smoking
limit alcohol
seat belt
calcium rich diet
Dexa scan
colonoscopy
lipid
mammography

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

2-Advanced maternal age
office:
PE--complete.
urine HCG (+ve)

CBC
BMP
UA
urine culture
LFTs
lipid profile
blood type & cross
type and Rh
pt/ptt
EKG
pap smare
USG trans vaginal
mammography
gonorrhea
chlymydia
RPR
Hep B antibody
HIV ELISA
toxo
rubella titer

Educate patient pregnancy
pregnant mother counseling
no smoking, safe sex, seat belt, safety plan
diet (high calory,High protein)
iron oral
folic acid oral
multi vitamins-prenatal

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
Valproic acid level

send her home..

counsel about the vit and folic and RATED SEX

further diagnostic plan
continue Valproic acid
Genetic counseling
Genetic Sonogram
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.
Haven’t brought snake,

order-
vitals/hr
IV Access
NS
Pulse oxi
O2
Abg
Cont BP moniter
Cardiac moniter
cbc
bmp
ua
pt
ptt
Bleeding time
ECG
CXR
Blood type and cross match.
Foley
Urine output
NPO

PE-(complete)
shows local cellulitis, noticed 2 fang sites on his ankle Neuro xam shows drowsiness
order-
Polyvalent snake antivenom -SNAKE
Shift to ICU
interval hx+rest Ex
Bedrest
Vitalsq2h
Pulse Oximetry q2h
Neuro exam q2h
Monitor Bleeding time, PT, PTT, Platelet counts (Can develop DIC)
H&H-6h
Ranitidine
Inj TT
Ampicillin/Cloxacillin IV
ABG q8h
cbc/24
Bmp/24

If Neuroparalyis symptoms---- (Atropine + Neostigmine IV)
If devloping resp failure---- intubate and mech ventilation

D/C ASV when Bleeding time/PT/PTT parameters normal and neuro symptoms subside,
D/c IV antibiotics; make oral
When pt ok—to wd Later send home
counselling
-----------------
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
routine (IV access, pulse oximetry, cont bp, cont cardiac moniter)
fingers stick glu
Thiamine inj
50% dxt

NGT suction (to look for variceal bleeding)
EKG
CXR
CBC, BMP, S.NH3
NPO
NSS

GPE( signs of cirrhosis, confused patient, asterixis)

LFT, PT, PTT, urine r/e, toxicology, blood alcohol level ,Mg
URINE culture
BLOOD culture
(pt marginally raised, lft deranged as for cirrhosis serum NH3 sky high)

admit ICU

urine output, bed rest, continue thiamine and dextrose normal saline drip,

propranolol to control portal HTN./ spironolactone

PARACENTESIS-SEND FLUID

LEVOFLOXACIN----IF PARACENT+VE{>250CELL) CHANGE TO CEFTRIAXONE

.Lactulose oral
[ampicillin po or neosporin po/ neomycin]
enemas to evacuate stool

Moniter PT/PTT/ cbc/bmp/ammo daily .

Pt improves –ADD diet salt restriction

.shift to wards in 24 hrs or when better

Case usually ends after 6 hrs of pt getting better.

rehab

5-Post-op atelectasis.

[after 36 hr of Surgery]...
DD's were:
Pneumothorax
PE
Pneumonia

CXR--it showed Atelactasis

It is one of the first cause of Fever, High WBC and shortness of breath...

So..

I did..blood culture
Removed the Foley Catheter and put a new one
UA culture
And Started..
IV Antibiotics
Acetaminophen Per Rectal

And Incentive Spirometry...

Patient become stable...I transferred him to Inpatient Unit..

----------------
6-Septic Abortion-

Do cultures
IV Antibiotics
Call OBGYN
When patient is accepeted by OBGYN for D&E

Just do medical Management in ICU

7-Incomplete abortion with heavy bleeding and acute PID.

Do cultures
IV Antibiotics
Call OBGYN
When patient is accepeted by OBGYN for D&E

Just do medical Management in ICU
--------------

8-Infected peripheral IV access

iva (if central line, dc cental line and new central line)
oxy
vitals q1h (qday when stable temp)
cardiac monitor (risk of septic shock)
fingerstick stat
b-hcg
cbc stat
bmp stat

focused pe

pt/ptt stat
ua/uc+s
blood cx
cxr
esr
crp
xray site
doppler arm
remove iv line
cath tip for c+s, gm stain, fungal cx
clinda + zosyn (if admitted >48 hrs)
tylenol
ekg
2 d echo

full pe
elevate arm
bed rest
iv nss
iv heparin if signs of cord-like thickening/bluish discoloration
(new iv access already done in beginning to give empiric abx)

when cx back:
iv naf for 2-3 days (until improvement)
dc zosyn and clinda
in this case do not worry abt dc'ing patient or po meds and patient has iv line for a reason.

5 min:
repeat cbc, chem in 3-4 days
counsel
screen
----------------
9-atrophic vaginitis

62 yo
vaginal itching
clear discharge
painful intercourse

vulvar erythema
mucus bleed during exam

dd

atrophic vag
bacterial vagi
candidial vagi
vulvar ca
cervicitis
tricho

office work up

cbc cmp lipid profile as a health maintainance exam-safer to do bu no credit

wet prep
trich
gono
chly
pap
may need emb colpo etc if finding in cervix or pap

if pap positive story goes further
otherwise
cou

vaginal gelly for lubrication
local hrt
estrogen cream

follow up as needed

-----------------
10-polycystic ovarian syndrome

21 yo f
beard
excessive hair
weight gain
menstrual irregularity
darkening axillry thickened skin
normal vitals

dd

polycystic ovarian syndrome
congenital late onset adrenal hyperplasia
adrenal tumour
drug effects like minoxidil phenytoin
ovarian neoplasm
cushing syndrome
idiopathic hirsutism

cbc lft

bmp

endocrine--dhea

lh fsh ratio

prolactin

tsh

dhea

testerone

blood glucose

insulin level

serum 17 hydroxyprogesterone

us pelvis

result - testerone increse

lh fsh ratio increase
insulin fasting glucose ratio increse

urine pregnancy test -do it anyway --
rx
ocp
exercise
metformin
spirolactone
smoking cesation

fu 6 month

----------------
11-gono-male

21 m
unprotected sex
urethral discharge fever

sickness
burning sensation during urination
o/e

urethral discharge
red urethra
suprapubic tender

d/d

-acute cystitis
epidymitis
forign body
nephrolithiasis
orchitis
prostitis
pyelonephritis
reiter's syndrome

urethritis
--gono
chlymydia

office w/u
ua culture urethral gram stain

urethral discharge for gono
chlymydia
vdrl
cbc

finding -- gram stain gram neg
culture awited

rx
azithromycin 1 gram stat

ceftrixone 250 mg stat

coun safe sex practice
smoking
alcohol
safe driving
drug

culture --
fu 4 week
pt coun

treat patner

-------------
12-AGN

10 m
tea urine
priorbit edema
had fever with hx of sore thrat 3 wk bak

bp 140/85
ankle edema

dx
-cryoglobunemia
iga nephropathy
membranoprliferative gn
post streo gn

er work
cbc chem 8
ua
no need of cs he does not have fever

24 hour urine protein
aso titer
complement -low

ua--proteinuria
wbc cast
rbc cast

rx

lasix
captropril
penicillin

office work up
us renal
throat culture
office rx

furosemide
captropril
nephrology consult -

fu 3 week
family couns
dietary consult
low sodium diet
fluid restriction
seat belt

----------
13-BPH
70m sono need of pregnancy test?

night urin
frequency urgency hesitency
terminal dribbling
double micturation
weak stream
sensation of incomplete evacuation

vita wnl
prostate normal but enlarged

office
cbc
bmp-urea creatinine normakl
ua
cs

us prostate
psa
esr
residual urinary volume

rx
finesteride
prazocin which is a selecting short acting alpha blocker


second visit

urology consult
urodynamic study


fu six month
for dre and psa

dietary consult
seat belt smoking
alcohol
patient counseling
-----------

14-acute psychotic disorder

dd
mania
bipolar 1
stress
malingering
panic
scizophrenia
drug
delirium

vital s -wnl

so pe

meds-
olazapine
valproic acid
we should give a antipsychotic and mood sabliser- lithium or valproic acid

order-cbc bmp no need of lft pt ptt order tsh uds no need of ua no need of ekg xray cardiac enzymes

do psychotherpy
psychiatry consult

coun med compliance
suicide contract
regular exercise
patient education

send home
appointment - one week

agin exam

if not allright -vdrl hiv sle

ect can be given

monitor cbc with antipsychotic
-------------
15-spontaneous abortion

27 yo f
lmp 6 week ago
lower abdominal crmp
vag bleed

cervix - open
blood in vault
vitals tachy bp wnl
dd

ectopic
abortion
polyp
cancer inflammation or cervicitis

normal menstration with dysmenorrhoea

er work up
cbc
pregnancy test
qualitative
then quantiatative
us
blood group rh

iv saline
no cervix tenderness - no pap gono cz now

hb -9 no bllod transfusion now pt is stable

us -- fetus dead - fetal pole uterine pregnancy

gyn consult for d and c
d and c

admit to ward

iv saline
pneumatic compression
methylprednisolone
doxy
cbc folow up

grief counselling
counsel pt rebirth control

follow up 3 week

-------
16-malrotation VOLVULUS

1 dy old m bilious vomi
poor feed
lethargy
rectal bleed

oe-

distension
170 pulse
89 sat

dd

duodenal atresia
intestinal atresia
malrotation with volvulus
meconium plug

necrotising enterocolitis

will do gi series to r/o duodenal
will do plain xray
will r/0 infections

transfer to er
iv aceess
iv normal saline

o2
abg
cbc
bmp
lft
abdominal xray
cxr
BLOOD C/S if fever
abg-metabolic acidosis- means something in the intestine

cbc leucocytosis-
axr-airless rectum
large gastric bubble- means some obstruction


rx as intestinal obst
rx--NPO
ng tube suction

iv bicarb if ph less than 7

pediatric surgery consult

ward -

upper gi sries -
barium enema
ng tube suction


upper gi -- bird beak
corkscrew proximal jejunum

barium enema cecum in RUQ


rx ng tube suction
iv normal saline bmp


fu 48 hours

family counselling

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

17-child with rash

ruleout drug reactin??
rule out lyme if suspected

Office W/U
Complete PE
CBC, stat
BMP, stat
Pulse oximetry
ESR, routine
blood culture
UA, urine culture
CXR, stat
EKG, 12 lead, stat
Neck x ray, stat
culture of scraping from rash
No aspirin

send the patient home and F/U in 4 days

-------------
18-obesity in adolescent

Complete PE

Measure Height
Measure Weight
Calculate BMI -- you have to do this manually...not in the CCS software

cbc
BMP
LFT
Fasting Plasma Glucose
Fasting Lipid Profile
Serum TSH
UA
24 hour urinary cortisol

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

so,

Weight Loss diet
Counsel Patient for Exercise Program
Counsel Patient
Counsel Family


Follow-up visit in 4 months

If no change...

Sibutramine or Orlistat, po
Follow up in 6 weeks
If morbid obesity, BMI more than 45

Consider Bariatric surgery
-------------
19-CTS

pe

xray

cbc
esr
crp
tsh
ra
ana
ca
magnesium
bmp
lipid
hcg


fu 3 days
night splint-SPLINT EXTREMITY
nerve conduction study
nsaid

usual 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....


bmp show no Potasium drop
abdominal exam ...no striae.... PE does not point towards high cortisol
for her BP

do urinanalysis
chest x ray
ekg
bmp

for her bmi
lipid profile fasting
FBS
TSH
cbc

follow up one week

bp in both arm
counselling life style -
low sodium low fat low cholesterol

weight mange
oreder calorie count and exercise
folow up three month

better

not better add hctz

it is not secondary hypertension bmp normal no cushing no coarctation

----------------
21-JRA

7 yr old girl with fever, rash and polyarthritis
PE: Complete

Order:
cbc ( stat )
bmp or may be just BUN and Creatinine (stat)
ESR
ANA
RF
UA
LFTs
Xrays of the joints involved
PT/PTT ( if planning to do arthrocenthesis )
athrocenthesis can be done as well....

CULTURE-URINE/BLOOD/THROAT
Tylenol
CXR
12 Lead EKG
Echo
d-dimers and fibrinogen ( i do not know the indication ..maybe coz it's a vasculitis)

will pretend the child does not have a high fever...so send him home. see in next 4-5 days with the lab results..

Results:
Cxr of joint without erosive changes...( so no methorexate)
ANA positive
such pts get eye involvement, thus eye exam q 3mths
RF positive
BUN nad CR wnl
ASPIRIN
MTX-SECOND LINE

Interval hx: improved

Order

Rheumatology consult
Eye consult
Physical therapy consult
EXERCISE
Med compliance
Multi-Vits
Calcium supplements/ diet rich in calcium
Educate family
MRI and Dexa--?
then do RATED SEX...mneumonic counsellin...whatever is applicable


22-kawasaki disease.....

< 5yrs of age
fever, 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.

PE ; complete

Orders:

pulse ox
oxygen
cbc
bmp
lfts
esr
ua
12 lead ekg
bld cxs
LP
Urine cx
CXR
IVA

results:
thrombocytosis
elevated ESR
sterile pyuria
EKG=ST seg depression and T-wave flattening
mild hypoalbuminemia

ORDER:
2-D echo
Coronary angiogram....maybe???
Aspirin ( untill pt is afebrile for several days)
IVIG
Consult Peads Cardiologist (like Dr. Fisher says on CCS always Consult; it wont harm U)
should continue 3-5mg/kg/day, 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

MMR and Varicella to be delayed till 11 months
INTERVAL HX: PT HAS DEFERVESCED

I do not know what to do now....maybe...

ORDER:
d/c home on aspirin
f/u in 7 days
cbc on follow up may be in 30 days to look for platelets
esr follow up
repeat ECHO. 6-8 weeks out

counselling...


23-Osteomyelitis

PE; complete..except breast, genitalia and rectal

* Orders:
admit

iv acess
iv saline
blood cs
urine ua and cs

cbc
bmp
pt
ptt
ESR
C-reactive protiens
X-ray of the involved leg

~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 Oxacillin & Cipro ...OR.... Ofloxacin & ceftriaxone....treatment for 6 -12 wks....IV...
Gram negative osteomyelitis treated with Cipro orallay.

* 5 minute screen

RATED SEX
age appropriate tests...

-----------------
24-Hypoglycemia
27 yrs old female nurse found unresponcsive, daiphoretic and tachycardic. Prior to this she wa sc/o headache and tremors. Pupils are wnl. PmHx is insignificant.

diffrential includes

Insulinoma
Exogenous Insulin
SU overdose
Prolonged fasting

O2
pulse ox
IVA
Vitals Q 1 HR
BP
Cards
ekg
CXR
Accuecheck
Beta Hcg urine
thiamine
dextrose 50
naltrexone- if pupil constricted

then iv infusion-5%dex

~PE : HEENT, LUNGS, HEART AND ABDOMEN

*Result BS 50 and pupils are wnl

~ORDERS:
cbc
bmp
cal
mag
phos
lfts
UA
abg
C-peptide
Insulin serum
Insulin antibodies
Bld alcohol level
Urine tox
SU urine screen
TSH
Cortisol level
Lipid panel

~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

do ct/ABD to see insulinoma

gastroenterology surgeon consult for surgey

* Interval Hx and VItals: improving

~Orders:
Transfere to ICU
Octreotide sc q 8hrs
Accue check q 1hrs
NPO
Urine output
teds
bedrest
cbc in AM
bmp in AM
Psychiatyr consult

* Interval History/vitals check...

* improved.. d/c npo, bedrest and octreotide and dextrose.when BS in the range of 85-90
* Move to the ward....

~ "5 MINUTE SCREEN"
PAP
Rated SEX ..whatever is applicable
screening (mamo if age >40)
colono if age>50
counsel (I select as many counsellings for all patients as poss)
diet consult
suicide contract if OD
resched visit in another 4 wks
f/u in 2 weeks after the discharge...


================================================== =====
If insulinoma is suspected..then CT abdomen or USG abdomen..
DEBULKING i.e surgery is the treatment then.....

anyone still feels the need to add something...lol...be my guest..
this is an exhausting one, for sure!



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
hemachromatosis
Thiamine deficiency

~ Order: put thme in as STAT
O2
Pulse OX
EKG
CXR
Cards
Vitals q 2
CBC
BMP
IVA
Fingerstick

PE ; COMPLETE
Cal
Mag
Phos
Lfts
Amylase
Lipase
UA
PT
PTT
lipid
tsh
e cho
B12
FOLIC
BLOOD ALCOH
HEAD ELEV

* Results : CXR=Enlarged heart w Kerley B llines + EKG= ST-T waves non-specific abnl

~ Admit to floor ~

~Order
IVA
Low Na diet
Bedrest w bath rm privilages
TEDS
Hepari SC
Lasix IV
KCL
MORPHI
Foley
Strict Input and Output
Daily weights
Cardiac Echo ...now!
CXR Q day
BMP q day

* interval hx...pt hope meds will help

~Result: echo shows dilated heart w EF 25%

~Order

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)
bed rest
low salt diet
fluid restriction

statin if abn lipids
cards consult

D/C ALCOHOL
ACE receptor blockers for those who cannot tolerate ACEI

when stable:
dc all iv meds-->po—day3
f/u in 1 wk with another bmp and ekg
echo in 2-3 wks
screen
counsel
dietician consult

~ 5 Minute Screen
alcohol anonymous
alcohol abstienance
lipid
colonospcopy
Rated SEX
RPT ECHO-3MONTHS
CARD REHAB

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 befor discharge


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


26-Down's Syndrome neonate

new born downs most probably presents with vomitting ( duoenal atresia)

telemetry

Pulse oxy
IVA
iv one fourth normal saline
oxygen
BP monitoring
Cardiac MONITOR
NPO
NGT
IV metoclopramide stat

Brief physical

ABG
CBC
BMP
CXR
EKG
AXR acute series
USG abd
UA
urin culture
LFTs
amylase
lipase

USG confirms the Diagnosis
Consult Pediatrics GI surgery

Transfer to ICU

vitals Q 1 hr
NPO
Urin out put
karyotyping
BP check
electrolytes

Karyotype confirms Down's

ECHO
audiometry
TSH

Genetics consult
-------------------------------------

27-Preeclampsia

21 yr 0ld at 33wks gestation, c/o facial and upperextremity edema....
how will you proceed

pulse oxy
IVA
BP monitor
Cardiac Monitor

brief physical


CBC
BMP
LFTs
blood typr n cross match ( if not done already)
pt/ptt
UA
Obtretical USG
DEXAMETH
MGSO4-IM[deli/labo]

IF SEVERE PRE-ecl- Im-MgSO4 stat-cont
IV hydralazine stat-cont

ECL IV MgSO4 stat-cont
IV hydralazine stat-con

Urin creatinine ( it will be included in UA I guess)

Transfer to ward

interval hx-check-neuro
pulse oxy Q 2hrs
Vitals Q 2 hrs
urin output
bp check
complete bed rest
serum Mg Q 4 hrs-if give
Urin 24 hr uric acid
FHR monitoring
fetal doppler
OB consult

observe for 24 hrs
pt gets better


deliver the baby after –term-nvd with oxy


------------------------
28-MM

Multiple Myeloma** patient presenting with Hypercalcemia

CCS: hypecalcemia in a pt who is presenting acutely...... lets say a 45 year old male presents with abdominal pain, wife reports he has been acting a bit strange over the last few days.... how would you proceed.... Presented in emergency.!

Differential will be following:
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.

~ORDERS:
Iv Access
Pulse oximetry
Oxygen inhalation continuous
Vitals x 1hr

Focused PE : General, HEENT , Heart , Lung, Abdomen, Extremities
~ORDERS:
cbc- ----- Stat
bmp ------Stat
calcium--- Stat
Mag ---Stat
Phos ---Stat
Lfts ---Stat
UA ---Stat
EKG ---Stat
CXR ---Stat

Move the clock get the result
~*Results show Ca 13.5mg/dl
~*Results show Hb 8.7g/dl . Also BUN and Creatinine slightly Increased
~* EKG shows shortened QT Interval

~ORDER;

Iv 0.9% Saline Continuous
Salmon Calcitonin - SC q 6-12 hours
Or IV Pamidronate Continuos (over 2-6 hours0
PTH assay
24 hr urinary calcium
Sulfosalicylic Acid Test (to detect ~*Bence Jones Protein… coz Normal urine dipsticks will not detect light chain)
Seum Protein Electrophoresis
Urine Protein electrophoresis
Seum alkaline phosphatase (to rule our Hyperparathyroidism & Paget disease)
Serum Ferritin
TIBC
Serum Iron
Ultrasound of Abdomen (to rule out Renal carcinoma)

~*Do Interval and Check for volume overload by focused Heart & lungs

~ORDER;

If Volume overload then give
Iv Furosemide One time only

*******Patients feels better so move the patient to Ward
~ORDER;

Vitals q 2 hours
Iron Enriched Diet
Ambulate at will
Urine output
BMP daily
Sodium Docusate (stool softner)
Calcium Daily
Bone Xrays

Move the clock … get results
~* Results show Bone X ray *Lytic Lesions.
~* Results show SPEP and UPEP *Positive
~* Results show PTH .*Normal”

Order *Bone Marrow Biopsy
Consent for Procedure
Move the clock …Get the biopsy result ~* which shows “Plasma cells” in Bone Marrow

~*Call Oncology consult... Patient with Multiple Myeloma needs chemotherapy
~ORDER;
Chemotherapy ---Vincristine, Adriamycin, Dexamaethasone.

Hopefully case ends here
5 minute screen
do all the counselling
and age appropriate test.

Epogen** SC to fix his anemia----- erythropoietin


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




29-Hypercalcemia-off ice

30 yr old with hyper calcemia on routine tests with h/o renal stones some 2-3 yrs bcak. Serum calcium is 11.5 mg/dl.

PE complete except breast, recal and genitalia

~ORDERS:
cbc
bmp
calcium
Mag
Phos
Lfts
PT
PTT
UA
EKG
CXR

send the pt home..call him when all the lab result return!

Pt returns...do a small PE
Results show ca 11.5mmg/dl

ORDER;
PTH assay
24 hr urinary calcium
Dexa Scan

pt home, call with results of the tests

Results show..PTH 23 mEq/ml

Call general surgery consult...parathyroidectomy.....
as pt fulfills 2 criteria for undergo parathyroidectomy + age less than 50 and h/o Renal stones..

Hopefully case ends here

5 minute screen
do all the counselling
and age appropriate test.

-------------------------
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....

iva
pulse oxi stat
vitals q1h
cardiac monitor
cxr
abdo usg
cbc stat
bmp stat
ca, mg, phos stat
ua stat
amylase stat
lipase
lfts
tsh
pt/ptt
morphine iv

full physical

npo
sr. pth
24 hr ur. ca
spep/upep
vit d level
abdo ct
normal saline iv
furosemide iv
calcitonin

if better:
tt ward

vitals q4h
bmp, ca, mg, phos q4h
consult surg if pth for parathoidectomy (blood type and cross match, npo, foley)

dc all iv's
alendronate

send home after 48 hr
f/u in 1 wk with cbc, bmp, ca, mg, phos, sr. pth

5 min screen:
colono
counsel
f/u in 4 wks with same labs

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



31-MS

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

Pregnancy test
cbc
bmp
ua
tsh
vit b12
pt/ptt

mri brain and spine( shows demylinating lesions)
iv methyl prednisolone

consult neurology
consult opthal
LP( shows oligoclonal bands)

neuro check-2h

baclofen for spasticity
if pain gabapentin
bladder hyperactivity oxybutinin
fatigue amantadine or flouxetine
urinary retention bethanecol
Contracpetive

normal diet/urine output/ambulation at will
r/w after 12 hrs
interval history and PE

symptom free-- on day3

d/c IV methyl pred
Fasting blood sugar
cbc
bmp
calcium
vitaminD

Interferon or Glatimer acetate start
counsel patient
contraception
oral predni
vacc-influ
eye consult

follow up appointment; after 3 months MRI repeat

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

32-HELLP

35 wks getation...bp 170/115, headache, scotoma, epigastic pain-ER


pulse ox
Oxygen
cardiac monitors
Bp continous
IV access
NS
NPO

MgSO4..IV
Latetalol..IV
DEXAmethasone.. IM

P/E

Admit to ICU...

BED
U OUT
PNEU
RANITIDINE-IV

CBC
BMP
Ca, Mg. Phos
LFTs----------------CONSULT OB
PT/PTT
Retic
FSPs
D-Dimers
UA
USS-PELV
Labor monitor
FETAL MONITOR
CULTURE-VAG,GONO,CHLAM

MONITOR—BP,PLT,UA-PROTEIN,PT.PTT,BMP

type and cross 2 units of PRBCs
FFP
Platelet

PENICILLIN G-IV
OXYTOCIN
NVD

5MIN
H&H
ORAL DIET
PT
PTT
OMEPRA
BF
PAP
LFT


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

CBC
BMP
UA
LFTS
B-HCG
TSH
PT/PTT
BLEEDING TIME
PAP
ENDO BX
USG-PELVIS-ENDO THICKNESS

Call her again in 2 days:
if anemic, order FOBT, RETIC, PERI SMEAR, TIBC, SR. IRON, FERR

RESULTS ALL WNL. BX SHOWS HYPERPLASIA WITHOUT ATYPIA


CYCLIC-
MONOPHASIC 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

5 min screen:
pap x1 yr
mammo
endo bx x6months
Colono
counsel

IF OLD PATIENT: SEVERE BLEEDING: HYSTERECTOMY


--------



34-Gastric cancer

Weight loss , Abdominal pain , Nausea, presntation was Gastric obstruction
Dysphagia, Melena, Early satiety ,Ulcer-type pain

NPO
NG Tube
IV Fluid
Vitals
Iva
Pulse oxy
ABG
CARDIAC MONITOR

CBC
BMP
UA
CXR
EKG
XRAY-ABD-series

P/E

FOBT
LFT
LIP ID
FBS
PT
PTT
ALBUMIN
CA,MG,PHOS
AMYLASE
LIPASE
PHENERGAN
MORPHINE

WD

OUTPUT
Barium upper GI studies
CONSENT
CONSULT-GASTRO
ENDOSCOPY
BIOPSY-NO OPTIONIN SOFTWARE
COLONOSCOPY

ENDOSCOPY,BX
ADENO CA

ANEMIA-IRON STUDIES,VITB12
FESO4, VITA C

CT-CHEST
CT-ABD
PT
PTT
TYPE

NEXT ORDER

CONSENT
CONSULT –GASTRO-SX
CONSULT-RADIO
CONSULT-ONCO
CONSULT-DIETICIAN

ADVANCE DIRECT
--------------------------------------------


35-TURP-HYPONATRE MIA

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


OXY
VITALS
CARDIO
BP MONIT
OXY

FOLEY
CULTURE-BLOOD/URINE
CBC
BMP
UA
EKG
CXR

DC-NSS
DC-SX
FUROSEMIDE-IV-AFTER LOW Na


ICU

BED
NPO
OUT
PT
PTT
CBC
HandH
TYPE
ABG
PULSE OXY

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
OXY
CARDIO
BP MONITOR

CBC
BMP
UA/culture

PHENERGAN
MORPHIN

P/E-
GENTAL,ABD�� �HORIZONT LEVEL
CREMESTERIC REFLEX-NEG

NPO
TRANSILLUMINATION
USS-SCROTUM--------TEST:TORSION

CX R
amylase
lipase
LFTs
PT
PTT
TYPE
CONSULT-PED SX
Cefazolin
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-hype rtensive crisis with SAH

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

Noncontrast brain CT or brain MRI
Electrocardiogram
Complete blood count including platelets
Cardiac enzymes and troponin
Electrolytes, urea nitrogen, creatinine
Serum glucose
Prothrombin time and international normalized ratio (INR)
Partial thromboplastin time
Oxygen saturation
Lipid profile

Lumbar puncture if subarachnoid hemorrhage is suspected and head CT scan is negative for blood Electroencephalogram if seizures are suspected
------------------------------------

38-Hypertension-secondary

youn g man no risk factor

cbc
bmp
lft
pt
ptt inr
lipid
tsh
ua
uds
cxr
ekg
FBS

home

if sodium high potassium lo normal anion gap

give KCL

office
go for aldesterone/rennin activity ratio
if high-24 aldosterone level
spiranolactone
abd/ct
monitor BMp

home
ct-adrenal mass

ward

consent
consult
pt
ptt
type
npo
laparoscopic adrenalectomy
--------------------------------
if cxr show cardimeg

rib notching-MRA

go for coarctation

if ua proteinuria

do ultrasound kidney
mara kidney

do nephro consult
do surgey consult


measure bp in both arm

start meds

beata-2
hctz-1
acei
ccb
smoking
obesity
alcohol
drug hx

coumsel
call back

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


39-fever unknown origin - adult


h pe

cbc
bmp
lft

pt ptt inr

cxr

ekg

ua

uds if prtinent

blood culture

urine cs
sputum

lp 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 lad

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

treatwith

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 normal saline
iv access
oxygen
pulse oxy
later abg

focus pe

cbc
lft
pt ptt
ua uds
urine culture
blood culture times two

ct abdomen and pelvis with contreast
lactic acid
cxr
echo if bacterial endocarditis suspected--later in floor if he does not improve
can do cardiac enzyme to rule out cardio shock
amylase lipase
xray abdomen - do or dont do because yo do ct anyway

start abx
cefotaxime
genta
intake out put
foley
urine out put 1 hourly

pt get bette -continue

ct reort comes
surgical consult for drainage of abscess

better

dc with cipro
-------------------------------
41-Alcohol withdrawal

tachy,sweating,tremor,agitated

iva
o2
pULSE OX
cARDS MONITORS
bP
Accue check

PE... real quick
HEENT
RESP
CARDS

Labs... STAT..
npo
nss
cbc
bmp
lfts
Blood alcohol level
Urine toxicology
ABG
amylase
lipase
PT
PTT
Thiamine IV
Folic acid Iv
Calcium serum
Mag srum
Phos serum


now come back and Complete the PE...what ever is lfet

librium
transfere to ICU

seizure precaution
aspiration precaution


5 minute screen
counselling
RATED SEX...
alcohol anonymous..
-----------------------------------

42-retained placenta

(ER,3post op D, w fever and abd tenderness)


Pulse Oxymetry
IV Access
IV NSS

Complete PE

CBC with Diff
PT/PTT
Blood Grouping and Cross Match
LFTs
UA and CS
Blood Cultures
Cervical Cultures and gram staining

IV Ceftriaxzone
IV Clindamycin

Consult OBG, for retained placental removal

send the pt to medical ward:

Bed rest
NPO

Vitals Q4H
----------------------------------

43-Chronic renal failure


in office


take complete physical exam

order
vitals
cbc
bmp
ua
cxt
abd ultra sound
abg
ekg
serum lipids
serum albumin
serum calcium
phosphate
vitamin D
pth
lft

if pt in emergency

then we do iva and also see the urnie output

check phosphate lever

and also pt ptt
and do blood typing
as tehre might be anaemia

so we mite need transfusion

or even dialysis if acidosis

calcium

tratment is diet

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

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.



PE : General, heent, LUNGS, ABDOMEN

~ Orders:

iva
nss
pulse ox
vitals Q 2 hrs
cards
ABG
Accue check
ekg and cxr
CBC
BMP
Cal
Mag
Phos
UA
Urine cxs
LFTs
tylenol

~PE: come back and complete the rest of the exam now...

*!* Results..(.pH 7.29, PCO2 20, PO2 80). (BMP NA 138 & HCO3 12)

~Transfere to ward

~Order

low potassium diet/diabetic diet
bed rest with bathroom privilages

d/c NSAIDS
d/c Lisinopril

FOLEY
Strict input/putput
Teds

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)

~famous 5 minute screen
RATED SEX...what ever is applicable.

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

45-rape

complete physical

orders:
maybe one ste of vitals..
RAPE KIT...
cbc..for baseline
UA
pregnancy test..beta HCG urine
cervical smear
KOH prep
Hanging drop
cervical gram stain and culturegonorrhoe DNA probe testing
Chlamydia DNA probe testing

morning after pill..i think it is LEVONORGESTREL-oral(high dose estrogen) for 2days
Now STD prophylaxis:
Ceftriiaxone 125 mg IM
Azithromax 1gm PO
Probenecid
Metonidazole 2gm po for trichomonas

add vdrl
rape crisis consult
cervical sample for chlamy and gonorr
elisa for HIV
Hep B surface antigen

Social services consult
Psych Consult?
----------------

46- HUS

ER
Focused PE

IVA
NSS
Oxygen
pulse oxymetry
Monitor Blood Pressure

NPO
CBC
BMP
UA, Culture
AXR acute series
Stool leuco, cultu, ova & para
peripheral smear
ldh
haptoglonin
in/output
pt/inr
pt/ptt
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

treatment with keyexalate

Once stable transfer to ICU
monitor BP
cbc
check BMP again every 1 hr till K+ normalizes followed by every 4hrs
pt/ptt
supporitve for now.
consult hema pediac
counsel pat/fam

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
ca, mg, phos
UA
12ekg
ABG
lipid profile
cxr
HgbAIC
lft

Finger stick BS 325mg/dL.—DIAGNOSTIC DM

Admit to inpx service

monofilament skin test,
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 (accucheck or finger stick) q2h,
BMP-2h
-vitals q4h,
Activity prn,
foley's catheter for intake
output,1800 ADA (55-60% cho,less tham 30% fat,15-20% protein,vitamins,minerals,H20),

lisinopril and other anti HTN (if HTN)
-podiatry or chiropody consult
-endocrinilogy consult
-ophthalmology consult

-If insulin 100-200,dc insulin and institute glipizide,
dc ivf
-counsel:weight loss,diet,exercise,
annual ophthalmologic exam,
foot care and protection,medication compliance,
depression couseling,
family counseling,medication side effect counseling,annual health maintenance and flu vaccine couseling.
-follow-ups.


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


48-Fever Unknown origin-child

INFANT-bac,HSV
Child-infect,connective

Cbc
Ua
Bmp
Cu lture-blood,urine,throat
Lft
Ana
Rf
Esr
Cxr
Lp-irritable

Ppd
Hiv
Syph

Ct-abd

Wbc scan-gallium/indium

NO-emp..ABx
--------------------------------------- -----------

49-Cervical cancer

physical exam

cbc
bmp
ua
urine beta hcg
gonorhea probe
chlamydia probe
wet mount
vaginal ph
HIV ELISA
VDRL
pap

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 curretage(its there in the software but asks for Gynecolgy consult)
Gynecology consult(No Endocervical biopsy on the software so can ask for that also on the Gynec consult)

Move the clock forward

Call her in a week

colpo-cx ca

Interval history
Admit to ward

Bed rest with bathroom previleges
cxr
lft
pelvic ex
IVP
CSYTOSCOPY
SIGMOIDOSCOPY
abdominal ct
pelvic ct
bone scan

RADIO-CONS
oncology consult
ekg 12 leads
blood type cross match
pt
ptt
Serum Iron with TIBC
reticulocyte count



interval history

TAH+BSO(If family done)
Gynecology consult
RADIATION/CHEMO-CISPLATIN

patient education
no smoking
no alcohol
supportive psychotherapy
Iron enriched diet

50-Failure to Thrive

2yr - below 5th percent


If severe malnutrition/abuse---Hospitalization

dd-
low intake
abuse
chd
infection
endo
genetical

Hx+EX

Head,neck,weight
Cbc
Bmp
Ua
Cxr
Fobt
Lft
Culture-stool/urine
Folic
Vit b12
Stool-ova/fat/

--
HIV
PPD
TSH
Sweat test
Galactose-----

---
Caloric count
Nutrient supp
Cons-dietician
Social service


F/u-q week
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  #2  
Old 09-23-2009
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Default

woow
I kept scrolling and scrolling down and this post never finish
how reliable is this info!
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  #3  
Old 09-23-2009
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Default :)


hahaha i think it is pretty short for 50 cases..bt i think it covers some vital stuff u that cud help u for sure while working wid uw stuff!!!
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  #4  
Old 11-27-2010
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Thumbs Up Thanks!

thanks so much for the post! much appreciated.
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  #5  
Old 09-02-2011
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Default 100 important USMLE STEP 3 CCS cases

that's helpful

this is a list of dr.red 100 important CCS cases , i think it will help
http://www.slideshare.net/usmlegalaxy , in this see the dr.red pdf CCS cases
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  #6  
Old 11-11-2011
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WOW!!! I am speechless. And Thanks.
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  #7  
Old 01-19-2013
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This is very useful.
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  #8  
Old 09-01-2014
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Default obesity in adolescent

was just doing obesity in adolescent and isn't orlistat or phentermine not approved for age less than 18 years..? great effort though
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  #9  
Old 4 Weeks Ago
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Default

Really appreciated!
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