Cases Flashcards by Judas Kelley

Case 4: 26 y/o F w/ lower abd pn, nausea, vag bleed, LMP 7wks ago. 2 episodes PID. AF and HDS.
DDX?

Ectopic pregnancy
Spontaneous abortion
Molar pregnancy
Adnexal torsion
PID
Appendicitis
pyelonephritis

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Case 4: Suspected ectopic pregnancy. What PE? (8)

ABD
GENITAL

General
Heent
Lung
Cv
Rectal
Extremities

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Case 4: Suspected ectopic pregnancy. PE - LLQ tenderness, blue vulva, blood ooze from os, slightly enlarged uterus, and left adnexal tenderness.

What test to order after PE? (1) What next?

1) B-HCG, urine or serum qualitative

Advance clock to get result

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Case 4: Suspected ectopic pregnancy. + pregnancy test. Pt gets increased abd pn, shock, or bleeding. What should be done next?

Transfer pt from office to ward

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Case 4: Suspected ectopic pregnancy. Orders now that the pt is on the ward? (5-for status if HDUS, 9 for dx and management, total 14)

STAT:

1) NPO
2) vitals Q1 hr
3) IV access
4) IV NS 0.9%
5) Complete bedrest

6) Quantitative B-HCG
7) TVUS
8) Type and cross
9) Rh status
10) CBC w/ diff
11) PT/PTT
12) BMP
13) LFT
14) Cervical GC/CT cx

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Case 4: Suspected ectopic pregnancy. Orders placed on the ward. Next action?

Advance time to get TVS and quant B-HCG

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Case 4: Suspected ectopic pregnancy.

TVUS - adnexal mass, absence of IUP
B-HCG - 2000
Rh +

What do these results mean? Different result scenarios and management

1) B-HCG >1500 and IUP. Tx for abnl pregnancy
2) B-HCG > 1500 and no IUP. Ectopic suspected, but not confirmed. Repeat test in 2 days
3) B-HCG <1500, no IUP. Repeat test in 2-3 days
4) B-HCG >1500 and adnexal mass = ectopic

If any are Rh - they must receive RH immunoglobulin

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Case 4: Suspected ectopic pregnancy. BHCG 2000 and adnexal mass. Next orders? (3)

1) OB/Gyn consult
2) MTX
3) Morphine

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Case 4: Suspected ectopic pregnancy. Orders placed after results show ectopic. Next step?

Advance to get OB/GYN recs

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Case 4: Suspected ectopic pregnancy. OB makes recs. Next orders (7), and location?

Cancel

1) NPO
2) vitals Q1 hr
3) IV access
4) NS
5) Complete bedrest

6) Rest at home
7) Counseling for ectopic

Send home

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Case 4: Suspected ectopic pregnancy. Sent home, Final move?

Set follow up appt in 4 days

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Case 5: IBS

Orders - 1st set (10) and 2nd set (8)

1) CBC
2) BMP
3) TSH
4) FOBT
5) ESR
6) Stool O&P
7) Stool cx
8) Stool for WBC
9) 72 hr stool fat
10) Pap smear

11) Lactose free diet
12) high fiber diet
13) loperamide
biofeedback
14) reassurance
15) relaxtion
16) exercise
17) Pt counseling
18) Drive w/ seatbelt

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Case 6: Major depressive disorder. Orders 1st set (6). Follow up and actions?

1) CBC
2) BMP
3) TSH
4) Vitamin B12
5) Fluoxetine
6) Counsel

FU in 10 days
Interval FU. General and neuro/psych PE

FU again in 14 days

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Case 7: Candida vulvovaginitis. Orders before (7) and after (2)?

1) Vaginal pH
2) Wet mount
3) Vaginal gram stain
4) Pap smear
5) GC culture
6) Chlamydia culture
7) U/A

8) Miconazole, vaginal, continuous
9) Counsel safe sex

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Case 8: Alzheimer’s dementia.
1st set of orders (6)
2nd set (4)

1) CBC
2) BMP
3) LFT
4) TSH
5) Vitamin B12
6) Head MRI or CT

7) Donepezil
8) olanzapine
9) Vitamin E
10) Counsel
FU in 6 weeks

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Case 9: COPD exacerbation

1st set of orders prior to PE (5)? PE?

1) Elevate head of bed
2) Pulse oximetry
3) Oxygen
4) IV access
5) Cardiac monitor

General, HEENT, Chest, CV, Abd Ext

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Case 9: COPD exacerbation

Stat orders after PE (7, 1 is for txmnt)?

1) Peak expiratory flow rate (PEFR) Q1 hr
2) CXR
3) ABG
4) ECG
5) CBC
6) BMP
7) Albuterol nebulizer, continuous

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Case 9: COPD exacerbation. Advance 30 minutes after first dx test results. New orders (3)?

1) Ipratropium nebulizer
2) IV methyl prednisone
3) Oral or IV abx, Outpt - doxycycline or TMP-SMX, Inpt - CTX or levofloxacin

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Case 9: COPD exacerbation. Add new meds and advance by 4 hrs. Case ends. Final recs(3)?

1) Counsel
2) Flu vaccine
3) Pneumococcal vaccine

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Case 10: Fibroadenoma. Focused or full PE? Orders after PE (2), next move?

Focused PE - including breast and lymph

1) Mammography
2) FNAB

Send home. FU in 1 wk

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Case 10: Fibroadenoma. Come back to clinic. 4 things to do, 3 orders? Next step?

Interval FU

Reassurance
Pap smear
Counsel

Send home FU in 4 weeks

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Case 11: Hypertensive emergency. Before PE, orders (5)?

1) IV access
2) pulse oximetry
3) oxygen
4) bp monitor
5) cardiac monitor

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Case 11: Hypertensive emergency. Orders after PE (6)?

1) 12 lead ECG
2) Head CT
3) CBC
4) BMP
5) UA
6) CXR-PA

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Case 11: Hypertensive emergency. Advanced to get CT results. Next orders (2 and one move)?

1) Nitroprusside, IV, continuous
2) Arterial line

3) Move to ICU

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Case 11: Hypertensive emergency. After move to ICU. Next orders (3)?

1) NPO 2) Complete bed rest 3) Monitor urine output Advance 15 minutes, bP improves

Case 11: Hypertensive emergency. Advance clock every 30-60 min to get improvement. Final orders (2)

1) Lipid profile | 2) Counsel

Case 12: Foreign body aspiration. Orders before PE (3)?

1) Pulse oximetry 2) Oxygen 3) IV access

Case 12: Foreign body aspiration. After focused PE. Next orders (3)?

1) CXR 2) Neck XR 3) CBC advance to obtain results

Case 12: Foreign body aspiration. After dx tests result. Next orders (2)?

1) Bronchoscopy stat | 2) Pulm medicine consult - confirm and remove FBA

Case 12: Foreign body aspiration. After bronchoscopy. Next moves?

Interval FU and focused exam

Case 12: Foreign body aspiration. Pt sxs resolve. Next order?

Counsel parents Send home FU in 1-2 wks

Case 13: Panic attacks. Initial orders before PE (6)?

1) Pulse ox 2) oxygen 3) Iv access 4) ECG 5) Cardiac monitor 6) Glucometer glucose

Case 13: Panic attacks. Orders after PE and advancing clock to get results (7 for dx, 1 for txmnt)?

1) CBC 2) BMP 3) TSH 4) CXR 5) UA 6) urine tox 7) cardiac enzymes 8) Alprozalam, sublingual once

Case 13: Panic attacks. advance to obtain results. Now pt has improved. Next steps

Interval FU Psych Chest and CV

Case 13: Panic attacks. After improvement and interval FU. Next orders(3-cancel, 5 related to counseling)?

1) Cancel pulse ox 2) Cancel oxygen 3) Cancel cardiac monitor 4) Reassure pt 5) Counsel pt 6) No ETOH 7) No caffeine 8) No nicotine

Case 14: TIA. 1st orders after PE (5)?

1) IV access 2) CBC 3) BMP 4) ECG 5) Head CT non-contrast

Case 14: TIA. Head CT is negative. Next order?

ASA, continuous Transfer to wards

Case 14: TIA. Orders after transfer to ward (10)?

1) MRI Head 2) MRA Head 3) Carotid doppler 4) Echo 5) Cardiac monitor 6) Glucometer glucose Q8hr 7) HgbA1c 8) Lipid profile 9) Ambulate at will 10) Diabetic diet

Case 14: TIA. Got doppler and echo results. Next order?

Vascular consult, CEA for >70% carotid artery stenosis and TIA

Case 14: TIA. Get consult recs. Next orders (6)?

1) Cancel diabetic diet 2) NPO 3) Cefazolin 4) PT/INR 5) PTT 6) Carotid endartectomy

Case 15: PID. 1st set of orders after PE (14)?

1) Iv access 2) CBC 3) BMP 4) B-HCG 5) cervical gram stain 6) gonorrhea culture 7) chlamydia culture 8) UA 9) Urine culture 10) HIV Elisa 11) ESR 12) VDRL 13) Pap smear 14) Blood culture

Case 15: PID. 2nd set of orders after Bhcg, gram stain results, and transfer to ward (8)?

1) Cefoxitin, IV 2) Doxycyline, IV 3) Morphine, IV one time 4) Phenergan 5) APAP, IV 6) NS 7) NPO 8) bedrest w/ bathroom

Case 15: PID. Advanced by 12-24 hrs to get improvement w/ interval FU and abd and genital exams. Next set of new and cancelled orders (Cancel 4 and add 2)?

Cancel 1) Phenergan 2) Morphine 3) NPO 4) Bedrest 5) Normal diet 6) ambulate at will

Case 15: PID. Advance 12-24 hrs a 2nd time w/ clinical improvement. New orders (2 new, cancel 4)?

1) Doxycycline oral 2) Counsel Cancel 3) IVF 4) Cefoxitin 5) IV doxy 6) vital signs Send home. FU in 1 wk

Case 16: Hemophilia A. 1st orders?

1) CBC 2) BMP 3) LFT 4) Bleeding time 5) PT 6) PTT

Case 16: Hemophilia A. Prolonged PTT and normal PT. Next move?

Transfer to ER or ward

Case 16: Hemophilia A. Orders after arrival to ED or ward (3)?

1) Factor VIII 2) Factor IX 3) Factor XI

Case 16: Hemophilia A. Low factor VIII, next order and moves?

1) Factor VIII therapy advance by 20 mins Interval FU and HEENT. Stopped bleeding

Case 16: Hemophilia A. Pt stopped bleeding

1) PTT stat 2) Factor VIII Advance to obtain results

Case 16: Hemophilia A. PTT decreased and Factor VIII improved. Next step?

Reeval every 1-2 hrs, checking PTT and Factor VIII until normal

Case 16: Hemophilia A. PTT and Factor VIII are normal. Next orders (3)?

1) Consult genetics 2) No ASA 3) Counsel avoid contact sports Send home, Fu in 1 wk

Case 17: Unstable angina. Emergency orders before PE (8, 2 are monitoring)?

1) Pulse ox 2) oxygen 3) IV access 4) ECG 5) ASA 6) Nitroglycerin 7) Continuous BP monitor 8) Cardiac monitor

Case 17: Unstable angina. Focused PE and ECG show ST depressions. Next 2 orders?

1) FOBT | 2) Metoprolol one time

Case 17: Unstable angina. Ask for next available result. FOBT negative. Next 6 orders?

1) Heparin 2) PTT Q6 hrs 3) CBC 4) BMP 5) Cardiac enzymes Q8hr 6) Portable CXR -PA

Case 17: Unstable angina. Advance to get enzymes are not elevated. Next move and next orders (11)?

Move to ICU 1) Metoprolol, continuous, oral 2) Simvastatin, oral 3) Eptifibatide, IV 4) NPO 5) bedrest 6) ECG, 12 lead 7) Echo 8) cardiology consult - cardiac cath 9) Lipid panel 10) LFT 11) urine output

Case 17: Unstable angina. REeval in 1hr. Cards recs and CP resolved. Next 2 orders?

1) cardiac cath routine | 2) Coronary angioplasty, routine

Case 17: Unstable angina. Obtain cath results. Last orders(8-counsel, continue 5 meds)?

1) Counsel pt 2) smoking cessation 3) limit eTOH 4) Exercise 5) Medication compliance 6) relaxation technique 7) Low sodium diet 8) Low fat diet FU in 1-2 wks Continue 1) ASA 2) Metoprolol 3) simvastatin 4) Nitroglycerin 5) clopidogrel

Case 18: Viral croup. Orders before PE (2)? | Orders after PE(5)?

1) Pulse ox 2) oxygen 1) CBC 2) Neck XR 3) Humidified air 4) Dexamethasone, oral, continuous 5) Epinephrine, inhaled

Case 18: Viral croup. Case progression after putting in txmnts?

Interval FU and focused exam every 1-2 hrs. Send home after 3-4 hrs of being stable. Cancel O2, epi, humidified air Counsel parents

Case 19: Asthma exacerbation. Orders prior to PE (5)?

1) oxygen 2) pulse ox 3) iv access 4) elevate head 5) cardiac monitor

Case 19: Asthma exacerbation. Orders after PE (8)?

1) PEFR 2) Albuterol nebulizer 3) prednisone oral or IV methylprednisolone 4) ABG 5) ECG 6) CXR 7) CBC 8) BMP

Case 19: Asthma exacerbation. Interval FU and exam after 1 hr. Still in distress. Next order? Eval timing and move?

1) Ipratropium neb Re-eval q1hr for 3 hrs Transfer to ward

Case 19: Asthma exacerbation. After transfer to ward, orders (4)?

1) PEak flow Q2hr 2) NPO 3) NS 4) Bed rest Re-eval every 2-4 hrs. Improve. Counsel

Case 20: Chronic constipation. Orders after PE (1 for txmnt, 9 others)?

1) FOBT 2) TSH 3) CBC 4) BMP 5) Mg 6) Phos 7) HgbA1c 8) Colonoscopy 9) Metamucil (psyllium oral) 10) counsel Send home w/ FU in 1 wk

Case 21: Acute appendicitis. First move and first orders after PE (15, 2 imaging, 2 txmnt)?

Transfer to ER 1) Iv access 2) NS 3) abd US 4) Abd XR 5) CBC 6) BMP 7) LFT 8) FOBT 9) UA 10) NPO 11) PT/INR 12) PTT 13) Morphine, IV, continuous 14) Phenergan, IV, continuous

Case 21: Acute appendicitis. Orders after getting dx results (2)? Consult comes back next order?

1) Cefoxitin, IV, one time 2) Consult General surgery 3)Lap appy

Case 21: Acute appendicitis. Following procedure. Next move and FU? 2 final orders and 2 canceled

Admit to ward RE-eval case 4-8 hrs after surgery Cancel NPO and IV 1) Normal diet 2) counsel parents and pt