Step 3 CCS

Question 1

Case:

25F w/ dysuria, urgency, and burning, + suprapubic ttp. Afebrile, hemodynamically stable. No vaginal discharge, no flank pain. Sexually active with husband, does not use contraception. LMP 24 days ago. Smoker.

Answer 1

Emergency orders (before PE): none

PE: general, chest/lung, CV, abdominal, genital exam

Order:

• UA,
• qualitative beta-hCG
• Ucx (with repeat in 1-2 weeks after initial to confirm eradication)
• then advance clock to see lab results

Orders:

• pregnancy counseling
• prenatal vitamins, Iron, Folate
• Nitrofurantoin for 7 days (oral, continuous) (or augmentin if allergic)

Now - change location to “home”, schedule appt in 2 weeks, confirm move

Final orders:
- Urine cx at 2 week clinic visit to confirm clearance

Primary dx: uncomplicated acute cystitis and pregnancy

Question 2

DKA

Answer 2

STAT: None

PE: Gen, HEENT, CV, chest, abd ext

Initial orders:
Pulse Ox, O2
IV, IV NS
Cardiac monitor, EKG
ABG
POC glucose
—-
CBC, BMP
Amylase, Lipase,
IV ins, Serum Osm, Ketones
bHCG, UA
—–
SX: phenergan

TRANSFER: admit to ICU

• VS
• A- bed rest,
• D- NPO
• *-** In/Out **- UOP
• Labs:HbA1c, IV KCl, Phos**

MONITOR:

• BMP q2-4 hr
• ABG q2 hr x2

Orders after results:

• Stop NS and give 1/2 NS after 4 hr.s, add K as needed,
• d/c IV insulin, fluids and heart monitor and go with NPH, regular insulin, diabetic diet
• Final orders: F/u in 10 days
• Counseling: Diabetic teaching, education, foot care, home glucose monitoring, no alcohol, no smoking, safe sex, no drugs, regular exercise, seat belts

Question 3

What is the treatment for uncomplicated cystitis? If Allergic?

What is the treatment for complicated cystitis?

What is the tx for cystitis in pregnancy? If allergic?

Answer 3

Uncomplicated cystitis:

• 3 days of TMP-SMZ;
• 3 days of FQ (Cipro) if allergic.

Complicated
- 7 days of TMP-SMZ

Pregnant

• 7 days of Nitrofurantoin
• 7 days of Augmentin if allergic

Question 4

Case: 24F w/ n/v and amenorrhea x 7 weeks, previously normal cycles. No medical problems, but smokes.

Answer 4

Emergency orders (before PE): none

Exam: complete PE

Order:
- Urine beta-hCG qualitative (serum or urine), STAT Clock: Advance to obtain result (positive)

Order:

• TVUS
• Routine prenatal labs: blood type and Rh type, atypical antibody titer, CBC with diff, BMP, pap smear, UA, ucx, rubella antibodies, RPR, hep B surface antigen, HIV (ELISA), chlamydia
• Treat: prenatal vitamins, iron sulfate, folic acid,
• Counseling (prenatal, listeria and toxo precautions, childbirth classes, breastfeeding, quit smoking and alcohol)
• Change location to “home” - schedule appt in 4 weeks (until week 28, then every two weeks until week 36, then every week), review test results, pelvic u/s confirms pregnancy
• Dx: pregnancy

Question 5

What is Chadwick’s sign?

Answer 5

bluish discoloration of the vulva/vagina; demonstrates pregnancy

Question 6

Case:

28M presents to the office with one week of BRBPR and colicky abdominal pain. No sick contacts, no recent travel, no systemic sx’s. Hemodynamically stable. He has an older brother with UC, and he is a smoker.

Answer 6

Emergency orders: none

PE: general, skin, HEENT/neck, chest/lung, CV, abdominal, rectal, extremities/spine

Labs:
CBC, CMP
Bleeding: PT/INR, PTT, BT
Diarrhea: FEBCOW (Stool Fat, ESR, Blood/FOBT, Culture, Ova/parasites, WBCs)

Location: change to “home”

Clock: schedule appt in a week, and advance to obtain results - note elevated ESR!

Treat
- Diarrhea: Loperamide
-

Order:
Sigmoidoscopy, Rectal bx

Clock: advance to obtain results - UC dx confirmed -

Location: change back to “office”

Treat:
Topical 5-ASA (mesalamine),
Loperamide, Dicyclomine (antispasmodic)
Dietary consult, counseling

Location: change to “home”
Clock: schedule appt in 2 weeks - Final orders: none Dx: UC, mild case involving rectum and sigmoid colon

Question 7

Case:

26F presents to the office with lower abdominal pain, nausea, slight vag bleeding. LMP 7 weeks ago. Sexually active. Hx of PID x 2.

Afebrile, hemodynamically stable.

Answer 7

Emergency orders: none

PE:

Order:
- urine or serum qual beta-hCG

Advance clock to “next available result” - positive Preg -
Location: change to “ward”

Order:
V- q1
A- bedrest
Diet- NPO
I- IV access, IV normal saline
DVT ppx?

UO
Sx

I-TVUS
L- CBC, BMP Quant serum beta, type and cross, blood group and Rh, CBC with diff, PT/PTT, BMP, LFTs, cervical gonococcal and chlamydia cultures - all should be “stat” - Clock: advance clock to see transvag u/s (tubal mass) and quant beta (2000), Rh+

C: OB/GYN consult, MTX, morphine

• Clock: advance to get OB recommendations
• Order: cancel “NPO, vitals, IV access, normal saline, and complete bedrest” - Order: rest at home, counseling - Location: change to “home” - Clock: appt in 4 days (for repeat serum beta) - Final orders: none Dx: ectopic pregnancy

Question 8

When do you give MTX for an ectopic? When do you perform a lap?

Answer 8

MTX - beta < 5000, tubal mass < 3.5cm, no fetal cardiac activity laparoscopy - beta > 5000, tubal mass > 3.5cm, with fetal cardiac activity

Question 9

Case: 27F presents to the office with 3 months of alternating diarrhea and constipation, colicky abdominal pain relieved by defecation, and 3 days of non-bloody diarrhea containing mucus. No sick contact, no travel, no weight loss, no systemic sx’s.

Answer 9

• Emergency orders: none - Exam: normal - Orders: CBC, BMP, ESR, TSH, FOBT, stool for ova/parasites/white cells/culture, 72-hr stool fat, pap smear - all “routine” - Location: change to “home” - Clock: schedule appt in one week, see normal results - Location: “office”, request interval/f/u - Order: lactose-free diet, high fiber diet, loperamide, biofeedback, reassurance, relaxation, exercise, pt counseling, advise to drive with seat belt - Location: change to “home” - Clock: schedule appt in 2 weeks - Final orders: none Dx: IBS

Question 10

40F presents to the office with feelings of worthlessness, fatigue, insomnia, anhedonia, poor appetite, inability to concentrate, and feelings of guilt and hopelessness x 2 months. Sx’s have forced her to take a leave of absence from work.

Answer 10

• Emergent orders: none - PE: normal - Order: TSH, CBC with diff, BMP, vitamin B12 - “routine”, also fluoxetine, oral, continuous, and counseling (suicide contract, medication compliance, regular exercise, pt education) - Location: change to “home” - Clock: schedule appt in 10 days, see all normal lab results - Exam: interval f/u, general - Location: change to “home” - Clock: schedule appt in 14 days - Final orders: none Dx: major depression

Question 11

39F presents to the office c/o thick, white vaginal discharge, also vulvar pruritus x 1 week. She finished abx for a UTI one week ago. PMH includes asthma, on inhaled betamethasone and albuterol. LMP 25 days ago. Afebrile, hemodynamically stable.

Answer 11

• Emergency orders: none - PE: vulvar erythema and edema, + thick, adherent white curd-like discharge with white patches along the vaginal walls - Orders: measure vag pH, wet mount, UA, gram stain - vagina, pap smear, GC culture, chlamydia culture - Clock: advance by 20 minutes to see pH and wet mount - Order: miconazole, vaginal, continuous, counseling - safe sex, no alcohol, patient education - Location: change to “home” - Clock: schedule appt in 2 weeks, see other labs that are normal - Final orders: none Dx: candida

Question 12

How do candida, BV, and trich differ in terms of vaginal pH?

Answer 12

< 4.5 (normal) –> candida; > 4.5 –> Bacterial Vaginosis or Trichimoniasis (treat partner too!)

Question 13

What is the tx for BV? Do you have to treat the partner?

Answer 13

PO or topical flagyl; NO need to treat partner

Question 14

What is the tx for trich? Do you have to treat the partner?

Answer 14

Tx = flagyl 500mg BID for 7 days OR 2gm single dose; yes, you have to treat the partner

Question 15

Case: 75M presents to the office with gradual onset of forgetfulness, difficulty with activities of daily living and money management, wandering behavior, and paranoia. He has no other medical problems. Non alcoholic. Eats well. + fam hx of dementia. Afebrile, hemodynamically stable.

Answer 15

• Emergent orders: none - PE: cognitive impairment c/w dementia, normal thyroid, no focal neuro deficits, no rigidity, no tremors - Orders: head CT, vit B12, TSH, CBC, BMP, LFTs - “routine” - Location: change to “home” - Clock: schedule appt in 3-7 days, see normal lab results - Order: donepezil (oral, continuous), vitamin E (oral, continuous), olanzapine (oral, continuous), counseling (of pt and family, cognitive rehab, OT, support groups, ensuring good nutrition and med compliance, no driving, medic alert bracelet, advanced directives) - Location: change to “home” - clock: schedule appt in 6 weeks - Final orders: none Primary dx: Alzheimer’s disease

Question 16

What 3 types of medications should you give to pts with Alzheimer’s to slow progression of the disease?

Answer 16

cholinesterase inhibitors (i.e. donepezil, rivastigmine, galantamine), NMDA receptor antagonist (memantine), vitamin E

Question 17

Case: 65M w/ hx of smoking and COPD presents to the ED with progressively worsening SOB and wheezing. + worsening cough productive of yellow sputum. Vital signs stable. + one previous hospitalization for COPD exacerbation, medication = inhaled albuterol.

Answer 17

• Emergency orders: elevate head of bed, cardiac monitor, pulse ox, oxygen, IV access - PE: moderate resp distress, accessory muscle use, inc AP chest diameter, dec breath sounds, diffuse rhonchi and wheezing, prolonged expiration. No peripheral edema, no JVD. - Orders: PEFR q1hr, CXR - PA and lateral, ABG, EKG, CBC, BMP, albuterol nebulizer - continuous. all “stat” (if you’re in the ED, it’s stat!) - Clock: advance by 30 minutes - see low PEFR, low o2 sat, abnormal CXR - Order: ipratropium nebs, IV methylprednisolone, oral or IV abx (if oral - bactrim or doxy; if IV - levofloxacin, moxifloxacin, ceftriaxone, cefotaxime) - Clock: advance by 4 hours, pt improves - Location: transfer to “ward” - Orders: as pt improves, convert steroids from IV to PO, convert albuterol and ipratropium from nebs to MDI, if PaO2 55 or SaO2 88% –> d/c on home O2 - Final orders: Counseling - smoking cessation, flu vaccine, pneumococcal vaccine Dx: COPD exacerbation

Question 18

Case: 40F presents to the office complaining of a mobile, painless mass in the upper outer quadrant of the L breast discovered 2 months ago on self-exam. The mass does not vary with menses, there is no nipple discharge, she denies systemic sx’s, and there is no family hx of breast cancer. + 10 pack year smoking hx.

Answer 18

• Emergency orders: none - PE: general, breast, lymph node, HEENT/neck, chest/lung, CV, abdominal - Order: “routine” mammography, FNA - Location: change to “home” - Clock: schedule return appt in 1 week, see dx of fibroadenoma on mammography and FNA - Exam: interval f/u - Order: reassurance, counseling - pt counseling, contraception advise, safe sex, smoking cessation, limit alcohol intake, safety plan, seat belt use, regular exercise; pap smear - Location: change to “home” - clock: schedule appt in 4 months - Final orders: none Dx: fibroadenoma of L breast

Question 19

Case: 45M w/ hx of HTN and noncompliance with medications presents to the ED with nausea, vomiting, blurred vision, and headache, found to have BP of 230/140. No chest pain, no focal neuro deficits. + 25 pack-year smoking hx.

Answer 19

• Emergency orders: IV access, oxygen, pulse ox, cardiac monitor, BP monitor - PE: general, HEENT/neck, chest/lung, CV, abdominal, ext/spine, neuro/psych - Order: “stat” - 12-lead EKG, head CT, CBC, BMP, UA, CXR-PA - Clock: advance clock to see head CT results, will see all lab results - BUN/creat elevated; CT neg for hemorrhage; LVH on EKG - Order: Nitroprusside, IV, continuous; arterial line - Location: change to “ICU” - Order: NPO, complete bed rest, monitor urine output - Clock: advance 15 minutes to reevaluate the patient; see that BP has improved - Clock: advance clock to check BP every 30-60min until BP is under control and pt is sx-free - Location: once a 25% drop in BP is achieved, transfer to “ward”, d/c arterial line, change to PO anti-hypertensive - Location: change to “home” - Final orders: lipid profile, routine; counseling (medication compliance, smoking cessation, exercise, limit alcohol intake, low salt diet) Dx: hypertensive emergency

Question 20

What is the first-line tx for hypertensive urgency/emergency? Name two alternatives.

Answer 20

first-line - IV nitroprusside alternatives - IV labetalol, IV nicardipine

Question 21

What is the overall BP lowering goal in hypertensive urgency/emergency?

Answer 21

you want to lower diastolic BP to 100-105mmHg within 2-6 hours, (or until total drop in BP is less than 25% of original value)

Question 22

Case: 7-month-old male presents to the ED with a hx of sudden and dramatic onset of respiratory sx’s. He had peanuts in his vicinity before he developed sx’s. His respiratory rate is 55, and he has severe cough and stridor. No hx of allergies, no personal or family hx of asthma. He was previously healthy.

Answer 22

• Emergency orders: oxygen, pulse ox, IV access - PE: general, HEENT/neck, chest/lung, CV - Orders: CXR-PA/lateral, X ray neck, CBC - all stat - Clock: advance to obtain all results - neck X-ray negative (so croup is less likely), CXR demonstrates inflated lungs - Order: bronch, stat; pulm consult, stat (reason: confirmation and removal of aspiration body - Clock: advance to get bronch result - foreign body found in airway and removed; then advance clock to reevaluate the pt; then request interval f/u and focused exam until pt’s sx’s are resolved - Order: counsel parents - Location: change to “home”, schedule appt in 1-2 weeks - Final orders: none dx: foreign body aspiration

Question 23

Case: 25M w/ no PMH presents to the ED with palpitations, chest tightness, shortness of breath, sweating, nausea, anxiety, and a fear of dying that began abruptly 30 minutes ago while the patient was at work. He is afebrile and hemodynamically stable with borderline tachycardia.

Answer 23

• Emergency orders: IV access, O2, pulse ox, cardiac monitor, EKG, glucose level - all “stat” - PE: general, HEENT/neck, heart, lungs, abdomen, extremities - all normal, except for an anxious, diaphoretic, and tachycardic young man. - Clock: advance to obtain ECG results - tachycardia without ST wave abnormality. note normal o2 sat - Order: cbc, bmp, TSH, CXR, UA, Utox, cardiac enzymes, alprazolam - sublingual - one time; all “stat” - Clock: set to see results - all normal except for slightly low bicarb (2/2 hyperventilation from panic attack). also cannot see TSH. patient has improved. - PE: psych, also repeat general, CV, and lung exam - Order: cancel pulse ox, o2, and cardiac monitor. reassure. counseling (no caffeine, no nicotine, no alcohol, patient counseling) - Clock: change location to “home”, schedule appt in 2 weeks, end case. - Final orders: none Dx: acute episode of panic attack

Question 24

Case: 65M presents to the ED with complaints of R hand weakness and difficulty speaking which had lasted a few hours, and resolved entirely before arrival in the ED. + smoking with 30 pack-year hx. Takes enalapril, simvastatin, and metformin for HTN, HL, and type2 DM.

Answer 24

• Emergency orders: IV access, o2, Pulse ox, cardiac monitor, EKG, glucose - “stat” - PE: general, CV, resp, neuo - loud bruit over L carotid. - Order: cbc, bmp, head CT - “stat” - Clock: advance to see above results; head CT is neg for hemorrhage - Order: ASA, continuous - Location: Change location to “ward” - Order: diabetic diet, ambulate at will, glucometer glucose q8hr, carotid doppler, cardiac monitor, echo, MRI head, MRA head, HbA1c, lipid profile - all “stat” - Clock: advance to get carotid doppler results - > 70% L ICA stenosis; echo shows no thrombus. - Order: vascular surg consult - for CEA for >70% L carotid artery stenosis and TIA - Clock: advance to get consult recommendation - Order: cancel diabetic diet, order pre-op stuff (PT/INR, PTT, NPO, cefazolin - IV one-time, CEA (carotid endarterectomy) - Clock: advance to get CEA result - Final orders: pt counseling (no smoking, no alcohol, regular exercise, diabetic diet, med compliance, better BP control, DM control) Dx: transient ischemic attack

Question 25

What are the indications and contraindications to carotid endarterectomy?

Answer 25

indications: symptomatic pts with 70-99% stenosis, and CEA is of greatest clinical benefit if done within 14 days of the last symptomatic event. Contraindications: 100% carotid stenosis, previous stroke with persistent neuro sx’s, poor surgical candidate

Question 26

What pre-op abx do you give prior to a carotid endarterectomy?

Answer 26

cefazolin, 1g IV, one time

Question 27

Case 15: 22F presents to the ED with lower abdominal and pelvic pain, worsened by movement and intercourse, along with fever, chills, nausea, vomiting, and vaginal discharge. LMP 3 weeks ago. Medications = OCP. She has unprotected intercourse with her boyfriend. She is febrile and tachycardic to 102.

Answer 27

• Emergency orders: IV access, o2, pulse ox, cardiac monitor - PE: general, skin, lymph node, HEENT?neck, chest/lung, cardiovascular, abdominal, rectal, genital - cervical motion tenderness, bilateral adnexal tenderness, mild purulent discharge at the os; extremities/spine - Order: CBC, BMP, upreg, cervical gram stain and G and C cultures, UA, ucx + sensitivity, ESR, blood cultures, PAP smear, HIV, VDRL or RPR - all place “stat” if possible - Clock: advance to obtain results of cervical gram stain - note negative upreg and gram neg diplococci on gram stain (gonococcus) - Order: IV cefotixin, IV doxy, morphine IV - one time, phenergan IV - continuous, acetaminophen - IV continuous, normal saline, NPO, bedrest with bathroom privileges - Location: change to “wards” - Order: IV cefotixin, IV doxy, morphine IV - one time, phenergan IV - continuous, acetaminophen - IV continuous, normal saline, NPO, bedrest with bathroom privileges - Clock: advance 12 hours, request interval follow up and abdominal/genital exam, see pt clinically improving - Order: cancel phenergan, morphine, NPO, bedrest; order normal diet, ambulate at will - Clock: advance 12 hours, request interval follow-up and abdominal/genital exam, see pt continuing to improve - Order: doxycycline, PO, continuous. counseling - treat partners, patient counseling, contraception counseling, medication compliance, safe sex counseling, smoking cessation. Cancel IVF, IV cefoxitin, IV doxy, vitals - Location: change to “home”, set f/u appt in 7 days - Final orders: none Dx: acute PID

Question 28

What is the inpatient tx for PID? Outpatient?

Answer 28

Inpatient - IV cefoxitin + IV doxy Outpatient - IM ceftriaxone + doxy PO x 14 days

Question 29

Case 16: 5M presents to the peds office with his mom because of continued oozing 2 days after a tooth extraction. The boy is well-developed and hemodynamically stable. He has no known medical problems, but his maternal uncle has hemophilia.

Answer 29

• Emergency orders: none - PE: complete - exam shows oozing at the site of tooth extraction - Order: CBC, BMP, PT, PTT, bleeding time, LFTs - stat - Clock: advance to see results of PTT and PT; see PTT elevated at 50 seconds (control < 28 seconds); everything else within normal limits - Location: change to ER - Order: level of factor VIII, level of factor IX, level of factor XI - Clock: advance to see results of factor assays; see factor VIII level of 3% of normal, confirming dx of hemophilia A - Order: purified monoclonal recombinant factor VIII - Clock: advance clock by 20 minutes, for interval f/u and HEENT exam - see pt’s bleeding has stopped - Order: PTT, stat, factor VIII, plasma - Clock: advance to obtain results, see PTT is decreased and factor VIII level has increased - Clock: reevaluate the case every 1-2 hours until PTT/factor VIII are within the normal range - Order: counseling - genetics, pt, and family counseling, encourage pt to avoid aspirin and contact sports. genetics consult, routine. - Location: change to “home”, schedule f/u appt in 1 week - Final orders: none Primary dx: hemophilia A

Question 30

Case 17: 60M presents to the ED with sudden-onset severe substernal chest pain that began at rest, radiates to the jaw and shoulder, and is accompanied by shortness of breath and nausea. Hemodynamically stable. + 2 month hx of stable angina. + smoker, HTN, positive fam hx of heart disease.

Answer 30

• Emergency orders: oxygen, IV access, cardiac monitor, continuous BP monitor, pulse ox, EKG - 12 lead, asa, nitro - sublingual, one time - stat - PE: focused - general, HEENT/neck, chest/lung, cardiovascular, abdominal, genital, rectal, extremities/spine - Clock: advance to see EKG results - ST depressions and T wave inversion, no ST elevations - Order: rectal - FOBT, metoprolol, IV, one time - to decrease HR to 60-70 - Clock: advance to see FOBT results - negative - Order: heparin IV continuous, PTT q6hrs, CBC with diff, BMP, LFTs, CK-MB and trop q8hrs, portable CXR-PA, PT/INR - Clock: advance to see enzymes - negative (suggesting unstable angina), interval f/u - partial relief from chest pain - Location: change to “ICU” - Order: consult cards - for unstable angina, catheterization. Order GP IIB/IIIA inhibitors - eptifibatide IV continous, NPO, bedrest, urine output, metoprolol PO continuous, simvastatin PO continuous, echo stat, lipid panel - Clock: advance 1 hour to obtain consultant’s recommendations, interval f/u - pt’s chest pain resolved - Order: cardiac cath routine, coronary angioplasty routine - Clock: advance to obtain procedure results - Final orders: counseling - pt counseling, smoking cessation, limit alcohol, exercise program, medication compliance, relaxation techniques, diet - low sodium, diet - low cholesterol, order d/c meds: asa, metoprolol, statin, sublingual nitro, clopidogrel. set up f/u appt in 2-6 weeks. Dx: unstable angina

Question 31

Case 18: 16-month-old M brought to the ED by his mother because of a progressive barking cough and noisy breathing over the past 10 hours. Sx’s preceded by a runny nose that began 2 days ago, and he seems to have a sore throat. Vaccinations are up to date, he has not ingested any foreign objects, and his appetite is good. Vital signs on presentation reveal a low-grade fever and are otherwise normal.

Answer 31

• Emergency orders: pulse ox, o2 - PE: complete (except rectal and genital), note stridor at rest however satting 99% on RA - Order: IV access, CBC with diff, neck XR, CXR, dexamethasone PO continuous, cool humidified mist, epi nebulized continous (child has stridor at rest, qualifying his croup as moderate-severe; otherwise you could go without the epi) - Clock: advance one hour to see results, note elevated white count with predominance of neutrophils, steeple sign on neck XR without evidence of foreign body on CXR, interval f/u - pt’s symptoms persist - Clock: advance 1 hours for interval f/u and focused exam, see pt improving - Clock: advance 4 hours, see pt improved - Order: cancel o2, epi, humidified air; counsel parent - Location: change to “home”, f/u in 24 hours Dx: viral croup

Question 32

Case 19: 36M w/ hx of asthma presents to the ED with shortness of breath, wheezing, and cough. Last asthma exacerbation was 1 year ago, he has never been hospitalized for asthma, + smoker. + Tachypneic and tachycardia.

Answer 32

• Emergency orders: pulse ox- 90% on room air, o2, IV access, head elevation, cardiac monitor - PE: General, HEENT, chest/lungs, heart, abdomen, extremities - moderate respiratory distress, accessory muscle use, inspiratory and expiratory wheezes, hyperresonance, equal air entry bilaterally, tachycardia - Order: Peak expiratory flow rate, ABG, CXR, CBC, BMP, EKG - 12 lead, albuterol nebulized continuous, methylpred IV continuous - Clock: advance 45 minutes for interval f/u and general/lung exam, pt still in respiratory distress - Order: ipratropium bromide nebulizer continous - Clock: advance every hour for 3 hours for interval f/u, general/lung exam and repeat PEFR, pt not improving. - Location: change to “ward” - Order: albuterol nebulized continuous, methylpred IV continuous, NPO, complete bedrest, normal saline, peak flow q2hrs - Clock: reevaluate q2-4 hours for 24 hours interval f/u, see pt improving - Location: change to “home” - Final orders: counseling - smoking cessation and asthma care, cancel NPO, complete bed rest, and cardiac monitor, order normal diet and ambulate at will Dx: acute exacerbation of asthma

Question 33

Case 20: 62M with hx of DM2, HTN, and HL presents to the office with 6 weeks of constipation. He also complains of abdominal distension after meals, and eats a diet that consists of mostly red meat. Medications = metformin, glipizide, lisinopril, ASA, and simvastatin. Hemodynamically stable. No weight loss or change in stool caliber. Had colonoscopy 12 years ago.

Answer 33

• Emergency orders: not in distress, so nothing - PE: complete, including rectal and abdominal - distended and tympanic abdomen and rectal vault containing hard stool - Order: CBC, BMP, mag, phos, TSH, FOBT, HbA1c, microalbumin, colonoscopy - all “routine”, counseling - high fiber diet, oral hydration, low salt diet, low fat diet, exercise program. + metamucil (psyllium) PO continous. - Location: change to “home” - Clock: schedule appt in 1 week, pt’s sx’s improve - Final orders: none Primary dx: chronic constipation

Question 34

Case 21: 9M brought to the office by his mom with fever, nausea, vomiting, anorexia, and periumbilical abdominal pain. Febrile to 101.1.

Answer 34

• Emergency orders: none - PE: general, skin, HEENT/Neck, Chest/lung, cardiovascular, abdominal, genital, rectal, extremities/spine - notable for RLQ ttp, palpation of LLQ worsens RLQ pain - Location: transfer to ER - Order: IV access, IV NSS 0.9%, CBC with diff, BMP, LFTs, FOBT, UA, abdominal US, abdominal XR, NPO, PT/INR/PTT - all “stat”, morphine IV continuous, Phenergan IV continuous - Clock: advance to see results of u/s - leukocytosis, fecalith and inflamed appendix - Order: cefoxitin IV one-time (pre-op abs), general surgery consult - Clock: advance clock to obtain surgeon’s recs - Order: lap appendectomy - Location: admit to ward - Clock: advance to next available result, appy is performed. reevaluate in 4-8 hours, then case ends - Final orders: cancel NPO and IV access, order normal diet, also counsel parent and patient Primary dx: acute appendicitis

Question 35

Case 22: 40M previously healthy presents to the office with fever/chills x 2 days, also a swollen, painful L knee x last night. He walks with a limp, has a fever of 102.3. No trauma. Family hx of RA, no fam hx of gout.

Answer 35

• Emergency orders: none - PE: extremities - erythematous, tender, swollen left knee with limited range of motion - Location: change to ER - Order: IV access, o2, pulse ox, cardiac monitor, CBC, BMP, ESR, blood cx’s, knee XR, joint aspiration - send fluid for cell count and differential, gram stain, culture and sensitivity, and microscopy (to look for crystals), vanc and ceftriaxone IV continuous, NPO, morphine IV continous, acetaminophen PO one time, type and screen, PT/INR, PTT, IV NSS 0.9% - Clock: advance to see results - synovial fluid analysis: 120000 with 85% neutrophils, lower glucose, decreased viscosity, absence of crystals, + gram pos cocci in clusters - Order: consult, orthopedic surgery, reason: septic knee, also cancel IV ceftriaxone with the gram stain results of GPC - Clock: advance to see recs - Order: arthroscopy stat - Location: change to “ward” - Clock: advance clock to have procedure performed - Order: cancel NPO, order normal diet - Clock: advance clock to reevaluate pt in 6-12 hours, case will end - Final orders: counsel patient Dx: septic arthritis of the L knee

Question 36

What empiric abx should you start when considering a septic joint? How should you change it if the gram stain shows gram pos cocci? What about gram neg bacilli?

Answer 36

empiric: IV 3rd gen cephalosporin (i.e. ceftriaxone) + IV vanc gram pos cocci: if MRSA –> IV vanc x 4-6 weeks, if MSSA –> IV nafcillin for 2 weeks then 2-4 more weeks of PO abx gram neg bacilli: IV 3rd gen cephalosporin x 14 days, then 14 days PO abx

Question 37

What is the most common cause of non-gonococcal arthritis in adults?

Answer 37

Staph aureus

Question 38

Case 23: 16F presents to the office complaining of irregular and heavy menstrual bleeding. Her menses were regular since the age of 13 until 2 months prior to presentation. She is sexually active, has no systemic sx’s, and is hemodynamically stable.

Answer 38

• Emergency orders: none - PE: genital, complete - Order: urine preg, CBC, TSH, serum prolactin, PT/INR, PTT, pap smear - Location: change to home, arrange for f/u in 1 week - Clock: advance to see results, all normal except for mild anemia - Order: OCP - low estrogen low progesterone continuous, iron sulfate oral continuous, counseling (med compliance, safe sex, regular exercise, seat belt use) - Location: send patient home, schedule an appointment in 3 months, case will end - Final orders: none Dx: DUB

Question 39

Case 24: 3 month old male is brought to the clinic by his mother with runny nose, noisy breathing, low-grade fever, emesis containing mucus, and poor feeding. The boy has older siblings who have had a “cold” in the past week. The boy is healthy, vaccines UTD. Low-grade fever and tachypnea.

Answer 39

• Emergency orders: pulse ox - 91% on room air, o2 - PE: good hydration status, edematous nasal mucosa, profuse clear rhinorrhea, nasal flaring, mild subcostal retractions, hyperinflated lungs, b/l diffuse expiratory wheezing and rhonchi - Location: change to ER - Order: CBC, BMP, CXR, ABG, UA/ucx, acetaminophen rectal one time, albuterol nebulized continuous, IVF, nasotracheal suctioning, IV access, cardiac monitor - Clock: advance to see results - leukocytosis with lymphocyte predominance, hyperinflated lungs, pO2 61 - Clock: advance 1 hour, no improvement - Order: epi inhalation one time - Clock: advance clock one hour to reevaluate the patient, patient improved - Location: change to “ward” - Order: change frequency of pulse ox to q8hrs - Clock: advance q8hrs until pt has been there for 24 hours, pt remains stable - Order: cancel all inpatient orders, parent counseling - Location: change to home, schedule an appt in 1-2 weeks, case ends - Final orders: none Dx: bronchiolitis

Question 40

Case 25: 47M w/ hx of HTN presents to the ED with a one-day hx of sharp, retrosternal chest pain worsened by inspiration and relieved by leaning forward. He experienced a flu-like illness one week ago, and has been febrile over the past 2 days. Febrile to 101.6, normal HR and BP.

Answer 40

• Emergency orders: IV access, pulse ox - 98%, o2, cardiac monitor, BP monitor, EKG - diffuse ST elevation - PE: cardiac - note pericardial friction rub - Order: CBC, BMP,CKMB and trop I, CXR, blood cx’s, ESR, ibuprofen PO continuous, colchicine PO continuous - Clock: advance to see results, ESR elevated, CBC shows lymphocytosis, cardiac enzymes reveal elevated CK with normal troponin. - Location: change to ward - Order: general diet, ambulate at will, echo routine, reassurance, IV NS - Clock: advance to see echo result - pericardial effusion but no tamponade - Clock: advance until sx’s improve - Order: patient counseling, d/c inpatient orders - Location: change to “home”, schedule f/u appt in 2 weeks, case ends - Final orders: none Dx: acute pericarditis

Question 41

Case 26: 34F presents to the ER with severe LUQ pain and nausea following a motor vehicle crash. She never lost consciousness, last meal 3 hours ago, LMP 4 weeks ago. She drinks alcohol daily and has taken part in a drug rehab program in the past. Tachycardic.

Answer 41

• Emergency orders: IV access, IV access, O2, cardiac monitor, BP monitor, pulse ox, 2L NS, c-spine immobilization - PE: awake, alert, oriented, multiple skin abrasions. No crepitation ro instability over the rib cage. + steering wheel-shaped contusion and severe ttp LUQ. - Order: CBC, BMP, LFTs, amylase, lipase, PT/INR, PTT, ABG, type and cross, blood ethanol, UA, upreg, utox, EKG, FAST scan, CXR, abdominal CT, chest CT, pelvis XR, spine XR, NPO, morphine IV, UOP, foley catheter, phenergan IV continuous, surgery consult (trauma) - Clock: advance to see results, note subcapsular splenic hematoma on abdominal CT - Location: change to “ward” - Order: serial H and Hs, serial exams, cancel “c spine immobilization” - Clock: keep advancing q4-6 hours, once stable for 24 hours can d/c home with f/u appt in 1-2 weeks - Location: change to “home” - Final orders: counseling (avoid contact sports, no alcohol, no smoking, seat belt use) Dx: subcapsular splenic hematoma

Question 42

Case 27: 40y/o construction worker presents to the ED with pain and swelling of the RLE x 3 days, s/p work-related laceration. No discharge from the lac. Last tetanus 3 years ago. Febrile to 103.1 and tachycardic.

Answer 42

• Emergency orders: IV access, o2, pulse ox, cardiac monitor, BP monitor - PE: 2cm lac on the R shin that is very tender and surrounded by diffuse erythema and edema. - Order: CBC, BMP, LFTs, ESR, CRP, blood cx’s, clinda IV, lactic acid, X-ray RLE, morphine IV continuous - Clock: advance to see results of everything but blood cx’s, note leukocytosis with left shift, soft tissue swelling of the R leg, mildly elevated ESR, neg blood cx’s - Location: change to “ward” - Order: IV NS, bedrest with bathrrom privileges, leg elevation, general diet, PO analgesia, PO antipyretics, daily CBC - Clock: continue to request interval hx and focused exam daily until improvement noted - Order: cancel inpatient orders, start clinda oral continuous, provide counseling (medication compliance) - Location: send patient home - Clock: schedule a f/u appt in 1-2 weeks, case ends - Final orders: none Dx: cellulitis

Question 43

Case 28: 43M presents to the office with severe pain and swelling of the R great toe that began acutely 2 days ago and worsened overnight. He walks with a limp and denies fever, morning stiffness, rashes, or hx of tick bites. He has not suffered trauma to the joint. He is a smoker and consumes alcoholic beverages on the weekends.

Answer 43

• Emergency orders: none - PE: erythematous, tender, swollen R first metatarsophalangeal joint with limited ROM - Order: CBC, BMP, PT/INR, PTT, ESR, CRP, serum uric acid, X-ray of toe, arthrocentesis with synovial fluid analysis (cell count and diff, gram stain, culture and sensitivity, viscosity, microscopy) - Order: indomethacin PO continuous, counseling (avoid asa, avoid diuretics, avoid excessive amounts and alcohol and purine rich foods, weight loss through diet and exercise, medication compliance, no smoking) - Location: change to “home”, schedule f/u appt in 1-2 weeks, note results of synovial fluid analysis: wbc count of 10,000 with 57% neutrophils, normal glucose, decreased viscosity, needle-shaped, negatively birefringement monosodium urate crystals. Patient improves. Case ends. - Final orders: none Dx: acute gout

Question 44

Case 29: 29F presents to the office with progressive shortness of breath over the past 2 weeks. + dry cough, intermittent low-grade fevers, and 15-lb weight loss. + alcohol on weekends, has 3 sexual partners in the past 2 years, uses depo for contraception. + low-grade fever and low BMI.

Answer 44

• Emergency orders: pulse ox - 93% - PE: cachexia, generalized lymphadenopathy, scattered rhonchi and crackles in both lungs - Location: change to “ER” - Order: IV access, pulse ox, o2, cardiac monitor, CBC, BMP, LFTs, ABG, UA, utox, upreg, CXR, EKG - Clock: advance to see results - note PaO2 of 68 on ABG, lymphopenia, monocytosis, and eosinophilia on CBC, bilateral interstitial infiltrates on CXR - Order: bactrim PO continuous, prednisone PO continuous, blood cx’s - Location: change to “ward” - Order: bedrest with bathroom privileges, general diet, IV NS, sputum PCP stain, serum LDH, HIV by ELISA, blood G6PD - Clock: advance to see results - PCP positive, high LDH (374), positive HIV - Order: western blot test for HIV, CD4 count, HIV viral load - Clock: advance daily for interval hx, focused exam, and pulse ox until pt’s sx’s improve - Order: influenza vaccine, pneumococcal vaccine, efavirez PO continuous, tenofovir PO continuous, emtricitabine PO continuous, counseling (medication compliance, no alcohol, safe sex, HIV support group, patient counseling), cancel inpatient orders - Location: change to “home” - Clock: schedule an appt in 3-6 weeks, case ends - Final orders: none Primary dx: PCP pneumonia

Question 45

Case 30: 55M presents to the office c/o profound fatigue and anorexia for the past few weeks. + night sweats and a 15-lb weight loss. He is a smoker and drinks alcoholic beverages on the weekends. He has never had a colonoscopy. VS wnl.

Answer 45

• Emergency orders: none - PE: skin and conjunctival pallor - Order: CBC, BMP, LFTs, iron studies, CXR, FOBT, UA - Location: change to “home”, set up repeat appt in 1 week, see normocytic normochromic anemia, also microscopic hematuria on UA - Order: CT abd/pelvis w/ contrast - Location: change to “home”, set up repeat appt in 1 week, see 4x5cm R renal mass without involvement of the renal capsule, renal vein, or IVC. - Location: change to “ward” - Order: NPO, IV access, ambulate as needed, IVF, chest CT (for staging), surgery consult, onc consult, pre-op orders - Clock: advance to see chest CT results, demonstrate no mets - Order: abx prophy (cefazolin) IV one time, nephrectomy - Clock: advance to have procedure performed - Clock: reevaluate the case q12-24 hours and request interval hx and focused exam until pt is ready for discharge, case ends - Final orders: cancel NPO, order regular diet, counseling (no smoking, no alcohol, cancer dx) Dx: renal cell carcinoma

Question 46

Case 31: 45M brought to the ED with sudden onset of severe burning epigastric pain, nausea, vomiting, malaise. He has a long hx of intermittent epigastric discomfort and is taking ibuprofen for tension headaches. Febrile, VS otherwise normal.

Answer 46

• Emergency orders: IV access, IVF, o2, pulse ox, cardiac monitor, BP monitor, EKG - PE: diaphoresis, absent bowel sounds, rigid and extremely tender abdomen with rebound tenderness - Order: CBC, BMP, LFTs, PT/INR, PTT, type and cross, lactate, amylase, lipase, FOBT, blood cx’s, UA, upright abdominal series, morphine IV continuous, acetaminophen IV continuous, cancel ibuprofen from home med list - Clock: advance to see upright abdominal series - note leukocytosis with left shift on CBC, also free air under the diaphragm on XR - Order: surgery consult (perf peptic ulcer with peritonitis), NG tube, zosyn/flagyl IV continuous, IV phenergan continuous, IV pantoprazole continuous, bedrest, NPO, urine output - Location: change to “ward” - Clock: advance to get consult recs - Order: laparotomy, stat - Clock: advance the clock to have the procedure performed, see surgical repair of the perf duodenum (simple patch closure) is done, then reevaluate the case q4-8hrs, case ends. - Final orders: counseling (no smoking, pt counseling), clear liquid diet, cancel NPO Dx: perf duodenal ulcer

Question 47

Case 32: 13F brought to the office because of short stature. Her height is below the 5th percentile. In addition, she lacks secondary sexual characteristics and has not yet experienced menses. Her parents are of normal height. VS normal.

Answer 47

• Emergency orders: none - PE: webbed neck, low occipital hairline, widely spaced nipples, shield-shaped chest, tanner stage I breast and genital development. - Order: karyotype analysis, serum FSH, serum LH - Location: change to “home”, schedule f/u appt in 1 week, note 45 XO-karyotype, high FSH and LH - Order: fasting glucose, BMP, UA, lipid profile, serum TSH, renal US, pelvic US, echo, skeletal survey, hearing test, GH therapy SQ continuous, estrogen-progesterone therapy PO continuous, vit D therapy PO continuous, calcium PO continuous, dietary consult (Turner syndrome with growth failure), psych consult (estimate IQ), counseling (regular diet, regular exercise, med complicance, parent counseling) - Location: send patient home - Clock: schedule appt in 1-2 weeks, above test results return, case ends. - Final orders: none Dx: turner syndrome

Question 48

Case 50: 34M comes to the office with 3 days of increasing R facial pain associated with purulent rhinorrhea, nasal congestion, maxillary toothache, and cough. He has no significant past medical hx, denies any other sx’s, and has never experienced such pain in the past. VS normal.

Answer 48

• Emergency orders: none - PE: purulent nasal discharge, ttp R maxillary area, normal dentition - Order: amoxicillin PO continuous, ibuprofen PO continuous, decongestants PO continuous, nasal irrigation, counseling (medication compliance, oral hydration) - Location: change to “home”, f/u in 1 week, patient improves, case ends. - Final orders: none Dx: acute bacterial sinusitis

Question 49

Case 38: 45-y/o overweight woman presents to the ED with one day hx of pleuritic, L-sided chest pain. She has been generally healthy and takes OCPs for menstrual abnormalities. She smokes 1 pack of cigarettes per day and has a family hx of CAD. VS show tachypnea and borderline tachycardia.

Answer 49

• Emergency orders: IV access, o2, pulse ox - mild hypoxemia, cardiac monitor, BP monitor, EKG - no abnormalities - PE: tachypnea - Order: CBC, BMP, LFTs, ABG, cardiac enzymes, UA, upreg, utox, CXR, CTA - Clock: advance to see results - CTA shows PE - Order: PT/INR, PTT, heparin, d/c OCPs - Location: change to “ward” - Order: complete bedrest, NPO, IVF, pulse ox q4 hours - Clock: advance q8hrs until pt improving - Order: warfarin - Clock: continue to advance daily, until INR 2-3, patient improves - Order: cancel inpatient orders, case ends Final orders: counseling (no smoking, med compliance, med side effects) Primary dx: PE