CCS Cases Flashcards
1
Q
Most common emergency Orders CCS Cases (before physical exam)
A
Pulse oximetry Oxygen IV access Normal Saline Cardiac Monitor BP Monitor ECG Ect
2
Q
On CCS what orders need to be completed when admitting a patient.
A
Diet Activity IV access IV fluids Vitals (should be set)
3
Q
On CCS what are important things to complete/consider prior to surgery
A
Need surgery consult NPO IV access (fluids if needed) PT/PTT Type and cross match ECG Cefazolin
4
Q
On CCS case of meningitis what are big things not too miss
A
Antibiotics and lumbar puncture
5
Q
Broad-spectrum antibiotics for PID
A
Cefoxitin plus doxycycline
6
Q
Treatment of cystitis in Pregnancy
A
7-day course of Augmentin OR fosfomycin
May use nitrofuratoin but not until 2/3 trimester
7
Q
Diagnostic tests for GI bleed
A
ESR Sigmoidoscopy Rectal biopsy (suspect UC) CBC with differential BMP Stool ova and parasites Stool for white cells Stool culture LFTs PT/INR PTT
8
Q
Treatment of UC with mild proctitis
A
Topical therapy with 5-ASA compounds (mesalamine suppository)
9
Q
Treatment of UC with moderate proctitis
A
Oral therapy with 5-ASA compounds (sulfasalazine, mesalamine, olsalazine)
Steroids are added when 5-ASA compounds faile to induce remission
Immunomodulators (azathioprine, 6-MP) for refractory cases
10
Q
Management of UC with severe proctitis
A
Hospital with IV fluids and electrolytes NPO, TPN IV steroids Consider BS antibiotics for fever, leukocytosis or sepsis Surgery for refractory cases
11
Q
Managing diarrhea/cramps/mood in UC with bleeding
A
Loperamide (avoid in severe proctitis)
Anticholinergic agents for abdominal cramps
Antidepressants/anxiolytics for associated mood disorders
12
Q
Methotrexate versus laparoscopy for ectopic pregnancy
A
MTX for stable patient with B-Hcg < 5,000, tubal mass <3.5 cm, and no fetal cardiac activity.
13
Q
DVT prophylaxis recommendations for stroke patient who did not receive thrombolytics and are still in the hospital
A
If only receiving aspirin therapy patient should also started on intermittent pneumatic compression and low dose heparin
14
Q
Diagnostic tests for diarrhea
A
CBC with diff. BMP TSH FOBT ESR Stool O&P Stool WBC Stool bact. culture 72-hour stool fat
15
Q
Therapy for irritable bowel syndrome
A
Lactose free diet High fiber diet Loperamide Biofeedback Reassurance Relaxation exercise Patient counseling
16
Q
Diagnostic test in depressed patient
A
CBC with diff
BMP
TSH
Vitamin B12
17
Q
Diagnostic test UTI/Yeast infection
A
Vaginal pH Wet mount Gram stain, vagina GC, culture Chlamydia, culture U/A
18
Q
When should NIPPV be started in a COPD exacerbation
A
PCO2 >45 or pH <7.30
19
Q
Outpatient antibiotics for COPD exacerbation
A
TMP-SMZ or doxycycline
20
Q
Inpatient antibiotics for COPD exacerbation
A
levofloxacin, ceftriaxone
21
Q
Therapy for COPD exacerbation
A
Bronchodilators Steroids Antibiotics Counseling Influenzae vaccine Pneumococcal vaccine
22
Q
Diagnostic test for foreign body aspiration
A
CXR-PA/lateral
X-ray neck
CBC
Rigid bronchoscopy
23
Q
Empirical antibiotics for lower abdominal pain, cervical motion tenderness, or adenexal tenderness comparing inpatient versus outpatient
A
Inpatient:
IV cefoxitin plus IV or PO doxycycline
Outpatient: Ceftriaxone IM (one dose) plus doxycycline PO x 14 days
May add metronidazole for suspected BV, Trich, pelvic abscess or recent gynecologic instrumentations
24
Q
Patient with bleeding and prolonged PTT with normal PT
A
Deficiency of: factor VIII (Hemophilia A) factor IX (Hemophilia B) factor XI Von Willebrand's disease
Acquired causes:
antiphospholipid syndrome
heparin use
25
Treatment of a patient with bleeding and diagnosed with hemophilia
Purified monoclonal recombinant factor VIII (Hem A) or factor IX (Hem B)
Desmopressin and antibibrinolytic agents
26
Treatment of aspiration pneumonia (not aspiration pneumonitis)
Clindamycin or ampicillin-sulbactam or amoxicillin-clavulanate
27
Medications for patient in hospital for unstable angina
Metoprolol
Simvastatin
Eptifibatide
28
Important orders for hospital patient with unstable angina
```
NPO, bedrest, 12 lead ECG, urine output
Metoprolol
Simvastatin
Echocardiography
Cardiology consult, stat (cardiac catheterization)
Eptifibatide
Lipid panel, LFTs
```
29
Counseling for unstable angina
```
Smoking cessation
Limit alcohol
Exercise program
Medication compliance
Relaxation techniques
Diet, low sodium
Diet, low cholesterol
Follow-up at 2-6 weeks
```
30
What should be added prior to sending a patient with unstable angina for catheterization
GP IIB/IIIA (Eptifibatide)
31
Orders for patient with viral croup
```
CBC with diff, stat
Neck x-ray, stat
Humidified air
Dexamethasone, oral
Epinephrine, inhalation (moderate/severe)
```
32
Diagnostic tests for patient that present for suspected asthma exacerbation
```
Peak flow (PEFR) q hr
ABG
ECG
CXR
CBC
BMP
```
33
Under what criteria should a asthma exacerbation be admitted to floor
Admit for PEFR (peak expiratory flow rate) <40% predicted at 4 hours
Consider admission for PEFR 40-70% at 4 hours
Discharge to home for PEFR >70% at 4 hours
34
Basic labs for clinic constipation patient
CBC
BMP
serum magnesium, phosphate, TSH, HgbA1c
FOBT
35
Preoperative antibiotics
Cefoxitin
ampicillin-sulbactam
cefazolin plus metronidazole
36
Broad spectrum antibiotics for bacterial arthritis
ceftriaxone with IV vancomycin
37
Antibiotics with septic knee with gram stain showing gram-positive cocci
MRSA: IV vancomycin x 4-6 weeks
MSSA: IV cefazolin for 2 weeks than 2-4 more weeks of oral antibiotics
38
Antibiotics with septic knee with gram stain showing gram-negative bacilli
IV 3 generation cephalosporin (ceftriaxone x 14 days), then 14 days of oral antibiotics
39
Initial labs in patient (pediatric or adult) with abnormal uterine bleeding
```
Urine pregnancy test
Serum TSH
Serum prolactin
CBC with diff
PT/INR
PTT
```
Consider biopsy (perimenopausal women), pelvic ultrasound (obese/PCOS), LFTs (liver disease)
40
What OCP to start on patient present with dysfunctional uterine bleeding
Hgb 10-12:
- Absence of active bleeding: Progestin-only OCPs
- Presence of active bleeding (combination OCPs, low progesterone, low estrogen)
Hgb < 10:
- Hormonal therapy: Combination OCPs with high estrogen if stable; IV estrogen if unstable
41
Treatment for idiopathic or viral pericarditis
NSAIDs while patient is symptomatic (steroids if resistant)
Colchicine for 3 months
Avoid NSAIDS (other than aspirin) in post-MI pericarditis
42
Diagnostic tests for suspected pericarditis
```
CBC/CMP
CXR
Troponin/CK-MB
ESR
Blood cultures
Echocardiography
```
43
Routine orders in ER trauma patient
```
CBC with diff
BMP
LFTs
Serum amylase/lipase
UA
ABG
PT/INR/PTT
Blood type and cross
Ethanol
Urine tox screen
Urine Hcg
12 lead ECG
Chest and Spin x-ray
Abdominal CT
Urine output
```
44
Monitoring for patient with traumatic event (MVA)
Serial exam
H&H q6 hours (bleeding)
Urine Output (Foley catheter)
45
Diagnostic tests in patient with suspected gout
```
CBC with diff
BMP
PT/IRN
PTT
ESR
Serum uric acid
X-ray of the foot/toes
Synovial fluid analysis
```
46
Initial therapy for gout including lifestyle changes
```
NSAIDs (indomethacin, naproxen)
Low protein diet
No alcohol
No Smoking
No aspirin
```
47
Management of Pneumocystis (PCP) pneumonia
Bactrim
PO2 < 70 and/or A-a O2 > 35 add oral steroids
48
Early treatment for patient with HIV
Early HAART (Efavirenz/Tenofovir/Emtricitabine)
Azithromycin if CD4 <50 for MAC prophylaxis
49
Preop antibiotic
Cefoxitin
ampicillin-sulbactam
cefazolin plus metronidazole
50
Preop antibiotics for bowel surgery
Ampicillin-sulbactam or piperacillin-tazobactam
51
Once Turner syndrome is confirmed what other screening that need to be completed.
```
BMP, fasting glucose, serum TSH
Serum FSH and LH
UA
Echocardiogram
renal and pelvic ultrasound
skeletal survey
Hearing test
```
52
Therapy for Turner syndrome
Growth hormone (height <5%) and anabolic steroids (oxandrolone)
Estrogen replacement (12-13 yr old)
Age >13 begin with combination estrogen and progestin until menopause
Vitamin D and calcium (osteoporosis)
Dietary and Psychiatry consult (IQ)
Ophthalmology consult
Ob/Gyn consult
Exercise
53
Treatment for life altering menopausal symptoms
```
Oral estrogen (no uterus)
Estrogen AND Progesterone with intact uterus
```
54
Initial treatment of patient with suspected PE
High suspicion just start patient on heparin (LMWH [Lovenox] or UFH)
When confirmed add warfarin until therapeutic
IVC filter for patient with contraindication to anticoagulation
thrombolytic therapy for hemodynamically unstable patients
55
Additional diagnostic studies and labs for patient with new ddx of colon cancer prior to surgery
```
Abdominal CT
CXR, ECG
CEA
UA, PT, PTT/INR
Blood type and crossmatch
Consult: Blood, surgery, oncology
```
56
Important surgery orders for patient undergoing surgery for colon cancer
```
NPO
Pre-operative CEA
Pre-colonoscopic MBP
Polyethylene glycol
Pre-op antibiotics
Hemicolectomy
Oncology consult
Surgery consult
Counseling: cancer diagnosis, smoking, alcohol
```
57
Acute therapy for actively manic patient
Evaluate for suicidal ideation and obtain a suicide contract
First-line pharmacotherapy: Atypical antipsychotic (olanzapine or risperidone) and a mood stabilizer (lithium, valproate, or carbamazepine); if very mild mania may start with mood stabilizer
Alternative is clonazepam and mood stabilizer
ECT for life threatening acute mania
58
Acutely manic patient disposition
Should be hospitalized until patient has calmed down
59
Diagnostic testing for suspected acute bacterial meningitis
Blood cultures, CBC, lumbar puncture with CSF analysis
Indications for head CT prior to LP: papilledema, focal neurologic deficit, obtundation, history of CNS disease, recent seizure, or immunocompromised
60
Broad spectrum coverage for suspected bacterial meningitis
Ceftriaxone plus IV vancomycin
Add ampicillin if patient is immunocompromised
61
If a head CT is considered for possible bacterial meningitis, what is the order of orders where timing is important
Blood cultures -> antibiotics -> head CT -> LP
62
How wound antibiotics be adjusted pending gram stain of LP (ceftriaxone and vancomycin)
Eg:
- Gram-positive cocci
- Gram-negative cocci
- Gram-positive bacilli
- Gram-negative bacilli
Gram-positive cocci: Ceftriaxone and vancomycin
Gram-negative cocci: ceftriaxone only
Gram-positive bacilli: IV Ampicillin plus IV gentamycin
Gram-negative bacilli: Ceftriaxone plus IV gentamicin
63
In bacterial meningitis, how is pneumococcal meningitis treated somewhat differently
Add dexamethasone, thus always add dexamethasone in bacterial meningitis and then discontinue if pneumococcal meningitis is excluded
64
Why is dexamethasone added to patient treatment of suspected bacterial meningitis
Avoid neurologic sequelae of pneumococcal meningitis (is discontinue if not causative organism)
65
Diagnostic testing for suspected AIDS-related CNS infection
Should be thinking cryptococcosis
Serum CrAg (cryptococcal antigen)
Head CT/MRI before LP
HIV screening by ELISA (then confirmation with Western blot)
66
LP orders for suspected AIDS-related CNS infection
```
LP
cell count
glucose
protein
gram stain
bacterial antigen
culture
CrAg
Indian ink stain
fungal culture
AFB
```
67
New HIV diagnosis when is HAART therapy started
After any acute infection has resolved, DO NOT START during active infection
68
Labs suggestive of AIDS-related cryptococcal meningitis
```
CSF with
mononuclear pleocytosis
slightly elevated protein
encapsulated yeast on Indian ink stain
Positive CrAg
```
69
Treatment for AIDS-related cryptococcal meningitis
IV amphotericin B plus oral flucytosine for 14 days (discontinue with clinical improvement)
Then high dose fluconazole for 8-10 weeks with HAART treatment
Maintenance therapy fluconazole
70
In patient who continue to have symptoms and recent ddx of AIDS-related cryptococcal meningitis
Repeat LP dailyuntil OP <200 mm H2O or >50% reduction
If high ICP persists despite daily LP, consider lumbar drain or ventricular shunt
71
Additional medication for Giant cell arteritis (vasculitis)
Steroids (IV if vision loss)
Aspirin (prevent blindness, TIA, or stroke)
PPI
Calcium plus vitamin D (prevent osteoporosis), should obtain baseline DEXA scan
72
Diagnostic testing with suspected giant cell arteritis (vasculitis)
```
CBC, BMP
Blood culture
UA, urine culture
ESR, CRP
CXR (looking for possible aneurysm - will need surveillance)
temporal artery biopsy
Head CT
```
73
Routine test when thing autoimmune arthritis (polymyalgia rheumatica, RA, SLE, polymyositis)
```
CBC with diff, BMP
ESR
CXR
ANA, RF, CPK (creatinine phosphokinase)
TSH
```
74
Ddx of polymyalgia rheumatic
Diagnosis of exclusion once other conditions have been ruled out
75
Treatment for polymyalgia rheumatica
Steroids (low dose)
PPI for gastroduodenal protection
Calcium and vitamin D for osteoporosis prevention (Get baseline DEXA scan)
76
Cancer specific test for patient with suspected ovarian cancer
CA 125
77
Initial management for sigmoid volvulus
NPO with IV hydration, NG-tube
Consult GI; sigmoidoscopy followed by rectal tube placement
78
Intervention to help relieve symptoms in GI etiology and patient with emesis
```
NPO
NG tube
IV fluids
Antibiotics
Ketorolac
Phenergan
```
79
Broad spectrum antibiotics for acute cholecystitis
Gram-neg and anaerobic organisms
piperacillin-tazobactam or 3 gen cephalosporin plus metronidazole (ceftriaxone + metro)
80
Timing for main management for suspected acute cholecystitis
Labs and diagnostic test
Admit
Supportive therapy (Bowel rest, analgesic, antibiotics)
Reassess 24-48 hours later
Clinical improvement have patient undergo elective cholecystectomy during same hospital admission (not stat)
Discharge 1-2 days after hospitalization
81
Orders for patient with acute bacterial rhinosinusitis
Augmentin
Acetaminophen
Normal saline solution, inhalation (irrigation)
Mometasone, topical steroid nasal
82
Management of intussusception
After ultrasound and abdominal XRAY to rule out perforation or ischemia
NG tube, fluid, analgesics, antiemetic
nonoperative reduction under fluoroscopic or sonographic guidance using hydrostatic (CONTRAST ENEMA, saline enema) or pneumatic pressure
Following procedure observe 12-24 hours
Surgery for complicated
83
Main components of hyperosmolar / DKA treatment
```
Hydration
Insulin
Potassium
Bicorbonate
Phosphate
```
84
Key hydration points in DKA/Hyperosmolar
Start with NS with urine output monitoring
When patient improve, stable BP, and good UP change to 1/2 NS
When glucose levels approach 250 mg/dl fluid is changed to 5-10% dextrose in water
85
Key insulin points in DKA/Hyperosmolar
Initial bolus 0.1 U/kg body weight followed by continue infusion of 0.1 U/Kg per hour
When glucose levels approach 250 mg/dl fluid is changed to 5-10% dextrose in water
86
Key potassium points in DKA/Hyperosmolar
Indicated if K<5.3, no EKG changes, and normal renal function
87
Key bicarbonate therapy in DKA/Hyperosmolar
Controversial
Only when blood pH is <7.2
88
Key phosphate therapy in DKA/Hyperosmolar
Don't replace
89
When to intubate unstable patient
O2 not improve with oxygen or PaO2 <55 or PCO2 >50 on ABG
90
Main orders of unconscious patient with suspected over
```
Suction airway, stat
(Other orders) with possible intubation
EKG (arrhythmias)
CXR
Finger stick glucose, stat
```
91
Initial treatment for suspected overdose patient
NG tube, gastric lavage, state
Activated charcoal, oral, one time
Naloxone, IV, stat
92
Suggestive labs for hemolytic cause of jaundice (exposure to sulfa drugs)
Normal LFT
Elevated indirect bilirubin
Anemia with bite cells (G6PD) on peripheral smear, if seen order G6PD blood, quantitative, stat
93
Routine labs for suspected hemolytic cause of jaundice
Reticulocyte count, stat (elevated more suggestive)
Serum haptoglobin
LDH (elevated in intravascular hemolysis)
UA
Type and cross
94
Treatment of patient with anemia secondary to intravascular hemolysis secondary to sulfa drug (Bactrim)
Normal saline
| PRBC, transfuse, state
95
Diagnostic work up for child with failure to thrive and family history of cystic fibrosis
```
Sputum gram stain, stat
Sputum culture and sensitivity, stat (Type sputum C&S)
Blood cultures, stat
CBC, BMP
CXR, Sinus XRAY
FEV1
Sweat chloride, routine
72-hour fecal fat estimation, routine
```
96
Treatment for failure to thrive child with suspected cystic fibrosis
```
Oxygen
Augmenting
Nebulized Albuterol, consider steroids
Multivitamin tablets
Chest physiotherapy
D5NS, IV, continuous
```
97
Orders (specific to condition) for patient admitted to hospital for acute heart failure
```
Low-salt, low-cholesterol, diabetic diet (if diabetic)
Fluid restriction (I/O's)
Daily weights
Lasix and KCL (as long as giving Lasix)
DVT prophylaxis Echocardiogram, routine
```
98
Important labs seen in prerenal injury
FeNa <1
Spot urine sodium <20 meq/L
Disproportionate increase of BUN/Cr ratio >20:1
99
Important labs seen in intrinsic renal injury
FeNa>1
Spot urine sodium > 20 meq/L
Proportionate increase of BUN/Cr ratio <20:1
100
Patient hospitalized with prerenal AKI but urinary output not responding to fluids, next step
start Lasix to increase UO
if secondary to heart failure could start dobutamine
101
For gastroenteritis, what GI but do you treat and with what antibiotics
Campylobacter jejuni: Erythromycin
C. difficile: Metronidazole
Systemic salmonellosis: Ceftriaxone
Giardia: Metronidazole
102
What are the biochemical abnormalities in PCOS
High serum androgens, estrone, LH (with normal FSH)
Normal estradiol
Impaired glucose tolerance
Elevated total and free serum testosterone
103
Orders for a patient with obesity, hirsutism, and irregular menstrual perids
```
beta-HCG
Serum testosterones total and free
Serum DHEAS
Serum prolactin
24-hour urine cortisol
24-hour urine 17-ketosteroids
Serum TSH, LH, FSH
Pelvic ultrasound
Glucose tolerance test
```
104
Treatment for POCS
```
Low fat, low caloric diet
Weight reduction
Regular exercise
OCPs (combined)
Metformin if diabetic
```
105
Additional ER orders for confused alcoholic
```
IV thiamine followed by IV 50% glucose
IV folic acid
Blood glucose, stat
Lorazepam
Seizure and aspiration precautions
Severe confusion LP
```
106
Labs for newborn jaundice infant
```
Blood typing if not complete (infant and mother)
Direct Coomb's test, stat
CRP
CBC
Total and indirect bilirubin
```
107
When should infant phototherapy be considered during when 25-48 hours old
12 mg/dl
greater than 25 mg/dl, then exchange transfusion and intensive phototherapy
108
Most likely ddx with pediatric patient with face, hand, and scrotal swelling
Nephrotic syndrome due to minimal change disease
109
Treatment of nephrotic syndrome
In Hospital: Prednisone, Albumin, and Laxis
No salt and high protein
110
Management SAH
Manage blood pressure if needed.
Once stable complete 4-vessel angiogram
111
Initial test for newly diagnosed hyperthyrodism
Radioiodine uptake
112
Treatment for hyperthyrodism
Methimazole and atenolol (anxiety, tachy, tremor)
Stop med 4 days prior and then radioiodine, x1 (make sure not pregnant first)
FU 2-4 months
113
Treatment for lead poisoning
Increase calcium and iron multivitamin
if venous lead >45 mcg/dl Succimer (DMSA) chelation therapy, oral continuous
114
Thoughts if patient present fie nails more curved longitudinally and base of nail bed fluctuant
Hypertrophic osteoarthropathy and may be related with squamous and adenocarcinoma of the lungs
115
Work-up for patient with suspected lung cancer
Spiral CT scan of the chest
| Bronchoscopy with BAL with cytology, gram stain, culture, AFB smear, and fungal cultures
116
Additional work-up for a patient who diagnosed with small cell lung cancer following bronchoscopy
```
PFT, LFT
Serum calcium
CT abdomen/pelvis
MRI brain with and without contrast
Bone scan
Consult oncology and radiation oncology
```
117
Broad spectrum antibiotic in infant with possible meningitis
cefoxitin plus ampicillin and dexamethasone is indication for H. influenza meningitis
118
How does meningitis antibiotics change as you get older
>50 add ampicillin back again
119
Treatment if find Pseudomonas in LP
Ceftazidime
120
Broad spectrum antibiotic for chemotherapy induced neutropenia
cefepime and add vancomycin if patient does not improve after 2-3 days
amphotericin B should be considered at 5-7 days of neutropenia
Can stop antibiotics 4-5 days after afebrile and ANC is >500
121
Infective endocarditis initial antibiotic treatment
IV vancomycin and gentamicin
Then appropriate sensitivities with IV antibiotic through central line placement for 4-6 weeks with documented cure
122
Treatment rhabdomyolysis due to prolonged immobilization
Initially NS
Start 1/2NS with mannnitol and soda biocarbonate added to it
Correct magnesium, phosphorus PRN
Monitor CPK for improvement
123
Treatment for TB
INH with Pyridoxine
Rifampin
Pyrazinamide
Ethambutol
124
Treatment of pleural effusion secondary to SLE
Trial of NSAIDs or glucocorticoids
125
Work-up for lupus picture with pleural effusion
```
CXR
PT/IRN
PTT
Anti-Ds DNS
Complement C3
Complement C4
```
126
Antibiotics for patient with sickle cell crisis
IV Cefuroxime and IV Axithromycin
127
Treatment for compression fracture
```
SPEP, (rule out myeloma)
Naproxen
Calcium carbonate
Vitamin D
Fosamax (alendronate)
Calcium enriched diet
```
DEXA scan
128
Treatment toxic shock syndrome (tampon)
Clindamycin
129
H pylori infection treatment
Clarithromycin
Amoxicillin
PPI
