CCS

Question 1

DVT

Answer 1

• Immediately after PE: Doppler US (+), LMWH/UFH(if renal failure) + Warfarin + Percocet
• CBC, CMP, FOBT, PT/PTT/INR, D-dimer
• Bed rest –> ambulate once swelling is down
• Monitor: Platelet count 3-5 days after LMWH started (r/o HIT), PTT - D/C LMWH once PTINR is 2-3 for 24 hrs.

Question 2

Pulmonary Embolism

Answer 2

D/C OCPs

PICAPregPEN: Pulse Ox, Ox, IV access, Cardiac/BP monitoring, ABG, EKG

Physical Exam

Imaging: CXR, Spiral-CT or V/Q scan
Heart: cardiac enzymes, ABG
B: FOBT, CBC, CMP, D-dimer, PTT/PT/INR
U:
Sx: Percocet for pain

Treat: Heparin/LMWH + Warfarin

Monitor: PLT CT (LMWH), PTTq6 (UFH), INR (warfarin)

Admit to Ward:Bed rest, Normal diet

Question 3

PERC (PE Rule-out Criteria)

Answer 3

PERC (PE Rule-out Criteria)

• Age <50
• HR <100
• Pulse Ox >95%
• No unilateral leg swelling
• No hx of DVT
• No estrogen use
• No surgery/trauma past 4 weeks

Question 4

How to use Heparin

Answer 4

UFH/LMWH + WF for about 5 days until INR is 2-3 for 24 hrs. Then d/c UFH/LMWH.

LMWH for preferred stable patients with normal creatinine
UFH is preferred in UNSTABLE patients, Chronic renal, pt’s about to undergo thrombolytic therapy

If allergic to Heparin (HIT) –> STOP HEPARIN, do “-ban” “-rudin” . Confirm with Serotonin Release Assay

IVC filter if recurrent DVT/PE while on WF OR bleeding

Question 5

Fatigue/Colon Cancer

Answer 5

EKG

ESR, FOBT, CBC, CMP, TSH, Lipid panel, UA, ANA

• *CEA**
• *CXR, Abdominal CT**

Colonoscopy: Mechanical Bowel Prep, Polyethylene Glycol
TX: Iron tablet

Consult: Surgery, Oncology

Pre-Op orders: NPO, IV Metro/Cipro 1x, PTT/PT/INR, Type and Cross
Surgery: Hemicolectomy.

Monitor: CEA

Question 6

Lithium Pre-labs

Answer 6

CBC, CMP (BUN, calcium), TFTs, B-hCG
EKG (if >40)

When treating for mania, keep in mind:
ANA
HIV
Dexamethasone suppression test
EEG
CT/MRI head

Question 7

Bacterial Meningitis

Answer 7

Blood cultures –> Antibiotics —> Head CT –> LP

Empiric therapy: Ceftriaxone + Vanc
if Immunocompromised or Age >50: + Ampicillin

After Culture:
If S. pneumoniae: + Dexamethasone (dec. risk of deafness)

Gram(+) cocci: Ceftriaxone + Vanc
Gram (-) cocci: Ceftriaxone
Gram (+) bacilli: Ampicillin + Gentamicin
Gram (-) Bacilli: Ceftriaxone + Gentamicin

Question 8

Cryptococcal Meningitis

Answer 8

Physical Exam –> ER

CBC, CMP
Blood culture, Serum Cryptococcal antigen
HIV Elisa, Head CT

Lumbar Puncture, CSF protein/glucose/gram-stain/cell count. CSF cryptococcal antigen, India Ink, fungal culture. CSF AFB stain, bacterial antigen, culture.

Once you get (+) result –> Amphotericin B (IV, cont..) Flucytosine (PO, cont…) - for 2 weeks

—-> Transfer patient to WARD

d/c meds after 2 weeks and start Fluconazole for maintenance therapy (PO, for 2 months or years)

Question 9

HSV Encephalitis

Answer 9

Pulse ox, O2,
IV access, Normal saline

Head CT/MRI, CXR
CBC, CMP, blood cultures
UA, Uculture
PTT/PT/INR

LP (PGG, FC, CS): protein, glucose, gram stain, fungal stain, culture/sens,
PCR HSV, bacterial antigen, CSF culture

Phenergan IV
Acetaminophen IV

Elevate head
NPO
Bed rest

(initial CSF shows “pink fluid” aka blood in csf, and lymphocytic pleocytosis) –> Immediately start Acyclovir IV!!!
—-> transfer to Ward

Advance to get PCR results, (+) for HSV
Advance q12 hrs to request interval hx + focused exam
Patient improves, case ends

Question 10

Giant Cell Arteritis (Temporal Arteritis)

Age >50
New onset Headache

Temporal artery tenderness/decreased pulsations

Elevated ESR/CRP

Biopsy shows necrotizing vasculitis/granulomas

Answer 10

PE —> ER/ward

CBC, CMP
Blood culture
ESR (>50), CRP
UA, UCulture
**CXR, CT Head

Biopsy (temporal A.)**

TX: before results:
Prednisone (oral, cont.)
Aspirin (oral, cont.) - dec risk of blindness/tia/stroke
Calcium + Vit D (oral cont.)

Monitor:
CBC, ESR, DEXA

Question 11

Ovarian Torsion

Answer 11

CBC, CMP
UA
Preg test
Pelvic US

IV access, NS
Morphine IV
Phenergan IV

NPO, PTT/PT/INR

Gyn Consult

Laparoscopy

Question 12

50 yo F

Distended Abdomen

Answer 12

CBC, CMP, UA, Pelvic US

Abd CT, CXR
CA-125
PT/PTT/INR, type and cross
Colonoscopy, MMG, PAP, ECG
Gyn Consult

NPO
IV Access, NS
Cefazolin + LMWH (SQ) + Pneumatic compression
TAH-BSO via Laparotomy

Question 13

Bowel Obstruction (Sigmoid Volvulus)
Stable Vitals

Answer 13

CBC, CMP
Abd XR
UA

NPO
IV access, IV D5N5 1/2NS w/ KCl
NG Tube (any time you think there is a block)
IV analgesics (morphine, continuous)
IV Cefazolin + Metronidazole
PT/PTT/INR, Type & Cross

Gastroconsult
Sigmoidoscopy + Rectal Tube
or Elective Laparotomy

Question 14

RUQ pain

+ Fever

Answer 14

PE first (hemodynamically stable)

CBC, CMP
Amylase, Lipase
Blood cultures!
Abd XR, Abd US

NPO
IV access, NS
NG Tube
IV Abx (Ceftriaxone + Metronidazole OR Piperacillin-Tazobactam)

—-> Admit to Ward<—–

Bedrest w/ bathroom privledges

Surgical consult: PT/PTT/INR, Type & Cross

• If low surgerical risk: Cholecystectomy (elective/emergent)
• If high surgical risk: Cholecystostomy

Question 15

Facial Pain + Rhinorrhea

32 yo M
Vitals stable
Purulent nasal discharge, maxillary tenderness, fullness in tympanic membrane.

Answer 15

TX:

• Augmentin for 1 week
• If allergic Doxycycline or Levo/Moxi (Respiratory FQ)
• Acetaminophen
• Mometasone (topical, cont.)
• Normal saline solution (Inhalation, cont.)

DO NOT ORDER CT/MRI!

Question 16

AAA

Answer 16

Emergency Orders: IV access, IV fluids, BP monitor

CBC, CMP,
NPO

D/C Metoprolol, Aspirin
Bedrest
IV Morphine (cont..)
IV Phenergan (cont..)

Surgery:
PTT/PT/INR, Type & Cross, IV cefazolin (1x)

Unstable (SBP<90) –> Vascular surgery consult IMMEDIATELY, Surgical intervention ASAP

Stable (SBP>90) —> Confirmatory test: US/CT Abd, Vascular consult, Surgery

=== Aneurysmectomy

Question 17

Intussusception (Peds)

Answer 17

PE

CBC, CMP (r/o bowel necrosis/acidosis(
US Abd, XR Abd (must! r/o perforations)

IV access, NS
IV morphine 1x
IV phenergan 1x
NG tube

Barium enema stat!
If complicated (hemodynamic instability, perforation, bowel necrosis, prescence of pathological lead point, multiple unsuccessful reductions)--\> Laparatomy