CCS Cases Flashcards
Most common emergency Orders CCS Cases (before physical exam)
Pulse oximetry Oxygen IV access Normal Saline Cardiac Monitor BP Monitor ECG Ect
On CCS what orders need to be completed when admitting a patient.
Diet Activity IV access IV fluids Vitals (should be set)
On CCS what are important things to complete/consider prior to surgery
Need surgery consult NPO IV access (fluids if needed) PT/PTT Type and cross match ECG Cefazolin
On CCS case of meningitis what are big things not too miss
Antibiotics and lumbar puncture
Broad-spectrum antibiotics for PID
Cefoxitin plus doxycycline
Treatment of cystitis in Pregnancy
7-day course of Augmentin OR fosfomycin
May use nitrofuratoin but not until 2/3 trimester
Diagnostic tests for GI bleed
ESR Sigmoidoscopy Rectal biopsy (suspect UC) CBC with differential BMP Stool ova and parasites Stool for white cells Stool culture LFTs PT/INR PTT
Treatment of UC with mild proctitis
Topical therapy with 5-ASA compounds (mesalamine suppository)
Treatment of UC with moderate proctitis
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
Management of UC with severe proctitis
Hospital with IV fluids and electrolytes NPO, TPN IV steroids Consider BS antibiotics for fever, leukocytosis or sepsis Surgery for refractory cases
Managing diarrhea/cramps/mood in UC with bleeding
Loperamide (avoid in severe proctitis)
Anticholinergic agents for abdominal cramps
Antidepressants/anxiolytics for associated mood disorders
Methotrexate versus laparoscopy for ectopic pregnancy
MTX for stable patient with B-Hcg < 5,000, tubal mass <3.5 cm, and no fetal cardiac activity.
DVT prophylaxis recommendations for stroke patient who did not receive thrombolytics and are still in the hospital
If only receiving aspirin therapy patient should also started on intermittent pneumatic compression and low dose heparin
Diagnostic tests for diarrhea
CBC with diff. BMP TSH FOBT ESR Stool O&P Stool WBC Stool bact. culture 72-hour stool fat
Therapy for irritable bowel syndrome
Lactose free diet High fiber diet Loperamide Biofeedback Reassurance Relaxation exercise Patient counseling
Diagnostic test in depressed patient
CBC with diff
BMP
TSH
Vitamin B12
Diagnostic test UTI/Yeast infection
Vaginal pH Wet mount Gram stain, vagina GC, culture Chlamydia, culture U/A
When should NIPPV be started in a COPD exacerbation
PCO2 >45 or pH <7.30
Outpatient antibiotics for COPD exacerbation
TMP-SMZ or doxycycline
Inpatient antibiotics for COPD exacerbation
levofloxacin, ceftriaxone
Therapy for COPD exacerbation
Bronchodilators Steroids Antibiotics Counseling Influenzae vaccine Pneumococcal vaccine
Diagnostic test for foreign body aspiration
CXR-PA/lateral
X-ray neck
CBC
Rigid bronchoscopy
Empirical antibiotics for lower abdominal pain, cervical motion tenderness, or adenexal tenderness comparing inpatient versus outpatient
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
Patient with bleeding and prolonged PTT with normal PT
Deficiency of: factor VIII (Hemophilia A) factor IX (Hemophilia B) factor XI Von Willebrand's disease
Acquired causes:
antiphospholipid syndrome
heparin use
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
Treatment of aspiration pneumonia (not aspiration pneumonitis)
Clindamycin or ampicillin-sulbactam or amoxicillin-clavulanate
Medications for patient in hospital for unstable angina
Metoprolol
Simvastatin
Eptifibatide
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
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
What should be added prior to sending a patient with unstable angina for catheterization
GP IIB/IIIA (Eptifibatide)
Orders for patient with viral croup
CBC with diff, stat Neck x-ray, stat Humidified air Dexamethasone, oral Epinephrine, inhalation (moderate/severe)
Diagnostic tests for patient that present for suspected asthma exacerbation
Peak flow (PEFR) q hr ABG ECG CXR CBC BMP
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
Basic labs for clinic constipation patient
CBC
BMP
serum magnesium, phosphate, TSH, HgbA1c
FOBT
Preoperative antibiotics
Cefoxitin
ampicillin-sulbactam
cefazolin plus metronidazole
Broad spectrum antibiotics for bacterial arthritis
ceftriaxone with IV vancomycin
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
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
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)
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
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
Diagnostic tests for suspected pericarditis
CBC/CMP CXR Troponin/CK-MB ESR Blood cultures Echocardiography
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
Monitoring for patient with traumatic event (MVA)
Serial exam
H&H q6 hours (bleeding)
Urine Output (Foley catheter)
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
Initial therapy for gout including lifestyle changes
NSAIDs (indomethacin, naproxen) Low protein diet No alcohol No Smoking No aspirin
Management of Pneumocystis (PCP) pneumonia
Bactrim
PO2 < 70 and/or A-a O2 > 35 add oral steroids
Early treatment for patient with HIV
Early HAART (Efavirenz/Tenofovir/Emtricitabine)
Azithromycin if CD4 <50 for MAC prophylaxis
Preop antibiotic
Cefoxitin
ampicillin-sulbactam
cefazolin plus metronidazole
Preop antibiotics for bowel surgery
Ampicillin-sulbactam or piperacillin-tazobactam
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
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
Treatment for life altering menopausal symptoms
Oral estrogen (no uterus) Estrogen AND Progesterone with intact uterus
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
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
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
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
Acutely manic patient disposition
Should be hospitalized until patient has calmed down
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
Broad spectrum coverage for suspected bacterial meningitis
Ceftriaxone plus IV vancomycin
Add ampicillin if patient is immunocompromised
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
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
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
Why is dexamethasone added to patient treatment of suspected bacterial meningitis
Avoid neurologic sequelae of pneumococcal meningitis (is discontinue if not causative organism)
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)
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
New HIV diagnosis when is HAART therapy started
After any acute infection has resolved, DO NOT START during active infection
Labs suggestive of AIDS-related cryptococcal meningitis
CSF with mononuclear pleocytosis slightly elevated protein encapsulated yeast on Indian ink stain Positive CrAg
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
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
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
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
Routine test when thing autoimmune arthritis (polymyalgia rheumatica, RA, SLE, polymyositis)
CBC with diff, BMP ESR CXR ANA, RF, CPK (creatinine phosphokinase) TSH
Ddx of polymyalgia rheumatic
Diagnosis of exclusion once other conditions have been ruled out
Treatment for polymyalgia rheumatica
Steroids (low dose)
PPI for gastroduodenal protection
Calcium and vitamin D for osteoporosis prevention (Get baseline DEXA scan)
Cancer specific test for patient with suspected ovarian cancer
CA 125
Initial management for sigmoid volvulus
NPO with IV hydration, NG-tube
Consult GI; sigmoidoscopy followed by rectal tube placement
Intervention to help relieve symptoms in GI etiology and patient with emesis
NPO NG tube IV fluids Antibiotics Ketorolac Phenergan
Broad spectrum antibiotics for acute cholecystitis
Gram-neg and anaerobic organisms
piperacillin-tazobactam or 3 gen cephalosporin plus metronidazole (ceftriaxone + metro)
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
Orders for patient with acute bacterial rhinosinusitis
Augmentin
Acetaminophen
Normal saline solution, inhalation (irrigation)
Mometasone, topical steroid nasal
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
Main components of hyperosmolar / DKA treatment
Hydration Insulin Potassium Bicorbonate Phosphate
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
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
Key potassium points in DKA/Hyperosmolar
Indicated if K<5.3, no EKG changes, and normal renal function
Key bicarbonate therapy in DKA/Hyperosmolar
Controversial
Only when blood pH is <7.2
Key phosphate therapy in DKA/Hyperosmolar
Don’t replace
When to intubate unstable patient
O2 not improve with oxygen or PaO2 <55 or PCO2 >50 on ABG
Main orders of unconscious patient with suspected over
Suction airway, stat (Other orders) with possible intubation EKG (arrhythmias) CXR Finger stick glucose, stat
Initial treatment for suspected overdose patient
NG tube, gastric lavage, state
Activated charcoal, oral, one time
Naloxone, IV, stat
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
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
Treatment of patient with anemia secondary to intravascular hemolysis secondary to sulfa drug (Bactrim)
Normal saline
PRBC, transfuse, state
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
Treatment for failure to thrive child with suspected cystic fibrosis
Oxygen Augmenting Nebulized Albuterol, consider steroids Multivitamin tablets Chest physiotherapy D5NS, IV, continuous
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
Important labs seen in prerenal injury
FeNa <1
Spot urine sodium <20 meq/L
Disproportionate increase of BUN/Cr ratio >20:1
Important labs seen in intrinsic renal injury
FeNa>1
Spot urine sodium > 20 meq/L
Proportionate increase of BUN/Cr ratio <20:1
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
For gastroenteritis, what GI but do you treat and with what antibiotics
Campylobacter jejuni: Erythromycin
C. difficile: Metronidazole
Systemic salmonellosis: Ceftriaxone
Giardia: Metronidazole
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
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
Treatment for POCS
Low fat, low caloric diet Weight reduction Regular exercise OCPs (combined) Metformin if diabetic
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
Labs for newborn jaundice infant
Blood typing if not complete (infant and mother) Direct Coomb's test, stat CRP CBC Total and indirect bilirubin
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
Most likely ddx with pediatric patient with face, hand, and scrotal swelling
Nephrotic syndrome due to minimal change disease
Treatment of nephrotic syndrome
In Hospital: Prednisone, Albumin, and Laxis
No salt and high protein
Management SAH
Manage blood pressure if needed.
Once stable complete 4-vessel angiogram
Initial test for newly diagnosed hyperthyrodism
Radioiodine uptake
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
Treatment for lead poisoning
Increase calcium and iron multivitamin
if venous lead >45 mcg/dl Succimer (DMSA) chelation therapy, oral continuous
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
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
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
Broad spectrum antibiotic in infant with possible meningitis
cefoxitin plus ampicillin and dexamethasone is indication for H. influenza meningitis
How does meningitis antibiotics change as you get older
> 50 add ampicillin back again
Treatment if find Pseudomonas in LP
Ceftazidime
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
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
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
Treatment for TB
INH with Pyridoxine
Rifampin
Pyrazinamide
Ethambutol
Treatment of pleural effusion secondary to SLE
Trial of NSAIDs or glucocorticoids
Work-up for lupus picture with pleural effusion
CXR PT/IRN PTT Anti-Ds DNS Complement C3 Complement C4
Antibiotics for patient with sickle cell crisis
IV Cefuroxime and IV Axithromycin
Treatment for compression fracture
SPEP, (rule out myeloma) Naproxen Calcium carbonate Vitamin D Fosamax (alendronate) Calcium enriched diet
DEXA scan
Treatment toxic shock syndrome (tampon)
Clindamycin
H pylori infection treatment
Clarithromycin
Amoxicillin
PPI
