The Ultimate USMLE Step 3 CCS Review solutions/ The Efficient USMLE Step 3 CCS Review /Comprehensive USMLE STEP 3.

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The Ultimate USMLE Step 3 CCS Review solutions/ The Efficient USMLE Step 3 CCS Review /Comprehensive USMLE STEP 3. Case 1: 25F w/ dysuria, urgency, and burning, + suprapubic ttp. Afebrile, hemodynami... cally stable. No vaginal discharge, no flank pain. Sexually active with husband, does not use contraception. LMP 24 days ago. Smoker. 1. Emergency orders 2. Physical Exam 3. Diagnostic tests 4. Therapy 5. Location 6. Final order 7. Dx ✅- 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 (oral, continuous), 7-day course of nitrofurantoin (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 Primary dx: uncomplicated acute cystitis and pregnancy What is the treatment for uncomplicated cystitis?. What if they're allergic to that abx? What is the treatment for complicated cystitis? What is the tx for cystitis in pregnancy, and what if they're allergic to that abx? ✅- - Uncomplicated cystitis --> 3 days of TMP-SMX: 3 days of fluoroquinolone if allergic. - Complicated --> 7 days of TMP-SMX - Pregnant --> 7 days of nitrofurantoin; 7 days of augmentin if allergic Case 2: 24F w/ n/v and amenorrhea x 7 weeks, previously normal cycles. No medical problems, but smokes. 1. Emergency orders 2. Physical Exam 3. Diagnostic tests 4. Therapy 5. Location 6. Final order 7. Dx ✅- - Emergency orders (before PE): none - Exam: complete PE - Order: beta-hCG, qualitative (serum or urine), as STAT - Clock: advance to obtain result (positive) - Order: transvag u/s, then 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, 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 What is Chadwick's sign? ✅- bluish discoloration of the vulva/vagina; demonstrates pregnancy Case 3: 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. 1. Emergency orders 2. Physical Exam 3. Diagnostic tests 4. Therapy 5. Location 6. Final order 7. Dx ✅- - Emergency orders: none - PE: general, skin, HEENT/neck, chest/lung, CV, abdominal, rectal, extremities/spine - Orders: CBC with diff, BMP, stool for ova and parasites, stool for white cells, stool for bacterial culture, LFTs, PT/INR, PTT, ESR - Location: change to "home" - Clock: schedule appt in a week, and advance to obtain results - note elevated ESR! - Order: sigmoidoscopy, rectal bx - Clock: advance to obtain results - UC dx confirmed - Location: change back to "office" - Order: 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 Case 4: 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. 1. Emergency orders 2. Physical Exam 3. Diagnostic tests 4. Therapy 5. Location 6. Final order 7. Dx ✅- - Emergency orders: - PE: demonstrates LLQ abd ttp, bluish discoloration of the vulva, blood oozing from a closed os, slightly enlarged uterus, L adnexal tenderness - Order: urine or serum qual beta-hCG - advance clock to "next available result" - positive upreg - location: change to "ward" - Order: NPO, vitals q1hr, IV access, IV normal saline, complete bedrest, quant serum beta, transvag u/s, 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+ - Order: 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 When do you give MTX for an ectopic? When do you perform a lap? ✅- MTX - beta < 5000, tubal mass < 3.5cm, no fetal cardiac activity laparoscopy - beta > 5000, tubal mass > 3.5cm, with fetal cardiac activity Case 5: 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. 1. Emergency orders 2. Physical Exam 3. Diagnostic tests 4. Therapy 5. Location 6. Final order 7. Dx ✅- - 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 Case 6: 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. 1. Emergency orders 2. Physical Exam 3. Diagnostic tests 4. Therapy 5. Location 6. Final order 7. Dx ✅- - 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 Case 7: 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. 1. Emergency orders 2. Physical Exam 3. Diagnostic tests 4. Therapy 5. Location 6. Final order 7. Dx ✅- - 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 How do candida, BV, and trich differ in terms of vaginal pH? ✅- < 4.5 (normal) --> candida; > 4.5 --> BV or trich What is the tx for BV? Do you have to treat the partner? ✅- PO or topical flagyl; NO need to treat partner What is the tx for trich? Do you have to treat the partner? ✅- Tx = flagyl 500mg BID for 7 days OR 2gm single dose; yes, you have to treat the partner Case 8: 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. 1. Emergency orders 2. Physical Exam 3. Diagnostic tests 4. Therapy 5. Location 6. Final order 7. Dx ✅- - 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 What 3 types of medications should you give to pts with Alzheimer's to slow progression of the disease? ✅- cholinesterase inhibitors (i.e. donepezil, rivastigmine, galantamine), NMDA receptor antagonist (memantine), vitamin E Case 9: 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. 1. Emergency orders 2. Physical Exam 3. Diagnostic tests 4. Therapy 5. Location 6. Final order 7. Dx ✅- - 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 Case 10: 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. 1. Emergency orders 2. Physical Exam 3. Diagnostic tests 4. Therapy 5. Location 6. Final order 7. Dx ✅- - 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 Case 11: 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. 1. Emergency orders 2. Physical Exam 3. Diagnostic tests 4. Therapy 5. Location 6. Final order 7. Dx ✅- - 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 What is the first-line tx for hypertensive urgency/emergency? Name two alternatives. ✅- first-line - IV nitroprusside alternatives - IV labetalol, IV nicardipine What is the overall BP lowering goal in hypertensive urgency/emergency? ✅- 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) Case 12: 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. 1. Emergency orders 2. Physical Exam 3. Diagnostic tests 4. Therapy 5. Location 6. Final order 7. Dx ✅- - 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 Case 13: 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. 1. Emergency orders 2. Physical Exam 3. Diagnostic tests 4. Therapy 5. Location 6. Final order 7. Dx ✅- - 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 Case 14: 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. 1. Emergency orders 2. Physical Exam 3. Diagnostic tests 4. Therapy 5. Location 6. Final order 7. Dx ✅- - Emergency orders: None - 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 What are the indications and contraindications to carotid endarterectomy? ✅- 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 What pre-op abx do you give prior to a carotid endarterectomy? ✅- cefazolin, 1g IV, one time 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. 1. Emergency orders 2. Physical Exam 3. Diagnostic tests 4. Therapy 5. Location 6. Final order 7. Dx ✅- - 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, 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 continuous , 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 What is the inpatient tx for PID? Outpatient? ✅- Inpatient - IV cefoxitin + IV doxy Outpatient - IM ceftriaxone + doxy PO x 14 days 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. 1. Emergency orders 2. Physical Exam 3. Diagnostic tests 4. Therapy 5. Location 6. Final order 7. Dx ✅- - 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 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. 1. Emergency orders 2. Physical Exam 3. Diagnostic tests 4. Therapy 5. Location 6. Final order 7. Dx ✅- - 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 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. 1. Emergency orders 2. Physical Exam 3. Diagnostic tests 4. Therapy 5. Location 6. Final order 7. Dx ✅- - 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 hjmidified 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 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. 1. Emergency orders 2. Physical Exam 3. Diagnostic tests 4. Therapy 5. Location 6. Final order 7. Dx ✅- - 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 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. 1. Emergency orders 2. Physical Exam 3. Diagnostic tests 4. Therapy 5. Location 6. Final order 7. Dx ✅- - 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 Case 21: 9M brought to the office by his mom with fever, nausea, vomiting, anorexia, and periumbilical abdominal pain. Febrile to 101.1. 1. Emergency orders 2. Physical Exam 3. Diagnostic tests 4. Therapy 5. Location 6. Final order 7. Dx ✅- - 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 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. 1. Emergency orders 2. Physical Exam 3. Diagnostic tests 4. Therapy 5. Location 6. Final order 7. Dx ✅- - 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 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? ✅- 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 What is the most common cause of non-gonococcal arthritis in adults? ✅- Staph aureus 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. 1. Emergency orders 2. Physical Exam 3. Diagnostic tests 4. Therapy 5. Location 6. Final order 7. Dx ✅- - 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 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. 1. Emergency orders 2. Physical Exam 3. Diagnostic tests 4. Therapy 5. Location 6. Final order 7. Dx ✅- - 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 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. 1. Emergency orders 2. Physical Exam 3. Diagnostic tests 4. Therapy 5. Location 6. Final order 7. Dx ✅- - 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 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. Tachycardia. 1. Emergency orders 2. Physical Exam 3. Diagnostic tests 4. Therapy 5. Location 6. Final order 7. Dx ✅- - 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 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 tachycardia. 1. Emergency orders 2. Physical Exam 3. Diagnostic tests 4. Therapy 5. Location 6. Final order 7. Dx ✅- - 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 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. 1. Emergency orders 2. Physical Exam 3. Diagnostic tests 4. Therapy 5. Location 6. Final order 7. Dx ✅- - 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 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. 1. Emergency orders 2. Physical Exam 3. Diagnostic tests 4. Therapy 5. Location 6. Final order 7. Dx ✅- - 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, 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 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. 1. Emergency orders 2. Physical Exam 3. Diagnostic tests 4. Therapy 5. Location 6. Final order 7. Dx ✅- - 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 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. 1. Emergency orders 2. Physical Exam 3. Diagnostic tests 4. Therapy 5. Location 6. Final order 7. Dx ✅- - 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 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. 1. Emergency orders 2. Physical Exam 3. Diagnostic tests 4. Therapy 5. Location 6. Final order 7. Dx ✅- - 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 Case 33: 65M presents to ED c/o LLQ abdominal pain, fever, n/v. Hx of chronic constipation x10 years, HTN, hypercholesterolemia. Meds include HCTZ, simvastatin, & ASA. Vitals reveal temp of 100.6 and are otherwise normal. 1. Emergency orders 2. Physical Exam 3. Diagnostic tests 4. Therapy 5. Location 6. Final order 7. Dx ✅- - Emergency orders: none - PE: - Order: CBC w/ diff, blood cx, BMP, UA, AXR, abd CT, IV access, NPO (all as STAT) - Order NS (IV, cont), ampicillin-sulbactam (IV, cont), morphine (IV, cont), phenergan (IV, cont) - Advance clock to get CT results, note leukocytosis - Change location to ward - Order: bed rest w/ bathroom privileges, SCDs - Advance clock to reevaluate q 12-24hrs until clinical improvement noted - Cancel: NPO, vitals, IV and infusions - Order: percocet (PO, cont), flagyl (PO, cont), cipro (PO, cont), advance diet, counsel high fiber diet, med compliance, med S/Es, regular exercise - Send patient home w/ follow up 2-6 weeks - Final orders: none Dx: acute diverticulitis Case 34: 4M brought to ED after having fallen down stairs. Mom's bf was babysitting at the time. Boy has right side chest pain and is withdrawn and apprehensive, vitals WNL. 1. Emergency orders 2. Physical Exam 3. Diagnostic tests 4. Therapy 5. Location 6. Final order 7. Dx ✅- - Emergency orders: none - PE: Full PE - Order: CBC w/ diff, PT/PTT/INR, bleeding time, CXR, pulse ox (all STAT) - Advance clock to obtain test results (note rib fx) - Order: ibuprofen (PO, cont), chest PT (stat), reg diet, CPS consult (stat), psych consult (routine), parent counseling - Admit patient to ward - Advance clock to get CPS recommendations, reeval in 12-24 hrs - Final orders: none Dx: child abuse Case 35: 52F presents to office w/ insomnia, intermittent hot flashes, and vaginal dryness. Also has amenorrhea for 12 months. Vitals WNL. 1. Emergency orders 2. Physical Exam 3. Diagnostic tests 4. Therapy 5. Location 6. Final order 7. Dx ✅- - Emergency orders: none - PE: full PE - Order: counsel (exercise, high calcium diet, low salt diet, med compliance, med SEs, HRT), estrogen-progesterone therapy (PO, cont), vit D (PO, cont), calcium (PO, cont) - Consider ordering: Pap, mammo, colonoscopy (routine) - Send patient home w/ follow up 3-6 weeks - Final orders: none Dx: menopause Case 36: 46M truck driver presents w/ 3 day hx of increasing pain & swelling of RLE. Denies trauma and has no PMH. Smokes 1-2ppd, job entails long periods of immobility. Vitals reveal low grade fever and are otherwise normal. 1. Emergency orders 2. Physical Exam 3. Diagnostic tests 4. Therapy 5. Location 6. Final order 7. Dx ✅- - Emergency orders: none - PE: focused - Transfer patient to ED - Order: LE doppler US, CBC, BMP, D-dimer (all as STAT) - Advance clock to get results - Order: PT/PTT/INR, FOBT - Advance clock to get results - Order: enoxaparin (SC, cont), warfarin (PO, cont), percocet (PO, cont), counsel (med compliance, med SEs, no smoking) - Send patient home w/ f/u next day - Daily interval f/u, focused exam, PT/INR until therapeutic, repeat CBC on day 3 - Final orders: none Dx: DVT Case 37: 45F overweight presents to ED w/ 1 day hx of pleuritic, left-side chest pain. Generally healthy and takes OCPs for menstrual abnormalities. Smokes 1ppd and has FHx of CAD. Vitals show tachypnea & borderline tachycardia. 1. Emergency orders 2. Physical Exam 3. Diagnostic tests 4. Therapy 5. Location 6. Final order 7. Dx ✅- - Emergency orders: pulse ox, O2, IV access, EKG, cardiac monitor (STAT) - PE: focused - Advance clock for EKG - Order: CBC w/ diff, CXR, cardiac enzymes, D-dimer, ABG, pulse ox q2h (STAT) - Advance clock to get results - Cancel: OCPs - Order: PTT q6h, BMP, spiral chest CT (STAT) - Order: heparin (IV, cont) or if Cr is normal, lovenox (SC, cont) - Advance clock for CT result - Admit patient to ward - Order: complete bed rest, reg diet, INR daily, CBC daily, warfarin (PO, cont) - Reevaluate q24hrs: interval f/u & focused PE, daily lab review for therapeutic INR, monitor platelets - Cancel: O2, pulse ox, cardiac monitor, BP monitor - Final orders: counsel (no smoking, med compliance, med SEs) Dx: Pulmonary Embolism Case 38: 57M comes to office c/o fatigue & anorexia x2 months. No other symptoms. Drinks alcohol occasionally and is a smoker. Vitals WNL. 1. Emergency orders 2. Physical Exam 3. Diagnostic tests 4. Therapy 5. Location 6. Final order 7. Dx ✅- - Emergency orders: none - PE: full PE - Order: CBC w/ diff, BMP, LFTs, ESR, TSH, FOBT, colonoscopy (routine), polyethylene glycol (PO, once) - Send patient home w/ f/u in 1-2 weeks - On return, request interval hx & do focused PE - Admit patient to ward - Order: abd CT, CXR, CEA, UA, EKG, PT/PTT/INR, oncology consult, surgery consult, counsel (cancer dx), iron sulfate (PO, cont) - Advance clock to get results - Order: NPO, IV access, NS, flagyl (IV, once), cipro (IV, once), hemicolectomy - Advance clock to get result - Reevaluate q12-24hrs & request interval f/u until patient ready for d/c - Order: pain meds if needed - Final orders: cancel NPO, order reg diet, no smoking, no alcohol Dx: colon cancer Case 39: 28M brought to ED for agitation & insomnia. Over last 2 weeks, he has had high energy level, exercising excessively, and made a large donation to his church. He also claims he is the state governor. 1. Emergency orders 2. Physical Exam 3. Diagnostic tests 4. Therapy 5. Location 6. Final order 7. Dx ✅- - Emergency orders: none - PE: focused PE - Order: CBC w/ diff, BMP, TSH, urine tox screen (all STAT), olanzepine (IM, cont) - Admit patient to ward - Advance clock to get results - Order: lithium (PO, cont), psych consultation (STAT), suicide contract - Advance to get psych recommendations - Reevaluate - Reevaluate to get TSH - Final orders: psychotherapy (routine), counsel (med compliance, med SEs, suicide contract, reg exercise, patient education) Dx: Bipolar I, acute manic episode Case 40: 46M brought to ED w/ 2 day hx of fever, body aches, severe headache, and AMS. Denies sick contacts. Has a hx of HTN and takes HCTZ. Vitals show high grade fever and borderline tachycardia. 1. Emergency orders 2. Physical Exam 3. Diagnostic tests 4. Therapy 5. Location 6. Final order 7. Dx ✅- - Emergency orders: none - PE: focused PE - Order: pulse ox q2h, CBC w/ diff, BMP, CXR, UA, blood cx, urine output q2h, head CT (all STAT) - Order: O2, NPO, head elevation, complete bedrest, IV access, IVF (cont), ceftriaxone (IV, cont), vancomycin (IV, cont), dexamethasone (IV, cont), phenergan (IV, cont), acetaminophen (IV, cont), cancel HCTZ - Advance clock for CT - Order: LP w/ CSF analysis - Advance clock for LP - Admit patient to ward - Reevaluate q 8-12h w/ interim f/u and focused PE until clinical improvement noted - Cancel: NPO, O2, pulse ox, urine output - Order: low salt diet, OOB to chair - Reevaluate q 12-24h - Final orders: counsel Dx: bacterial meningitis Case 41: 35M presents to office w/ worsening headaches, malaise, & nausea for 2 weeks. Reports feeling subjectively warm and having intermittent diarrhea along with an unintentional 30lb weight loss. Is a smoker, drinks alcohol on weekends, hx of multiple sexual partners without using barrier contraception. Has not seen a doctor in 10 years. Vitals show low grade fever & low BMI. 1. Emergency orders 2. Physical Exam 3. Diagnostic tests 4. Therapy 5. Location 6. Final order 7. Dx ✅- - Emergency orders: none - PE: full PE - Transfer patient to ED - Order: CBC w/ diff, BMP, blood cx, serum cryptococcal antigen, HIV ELISA, head CT (all STAT) - Advance clock for CT - Order: LP w/ CSF analysis, CSF india ink, CSF fungal culture, CSF culture, CSF AFP (all STAT) - Advance clock for india ink - Order: amphotericin B (IV, cont), flucytosine (PO, cont) - Transfer patient to ward - Reevaluate w/ interval f/u & focused PE for response to treatment - D/c amphotericin & flucytosine after 2 weeks and order fluconazole (PO, cont) - Consider ordering: HIV western blot, CD4 count, HIV viral load - Order: counseling - Send patient home w/ f/u in 1-2 months - Final orders: none Dx: cryptococcal meningitis Case 42: 30F brought to ED w/ 3 day hx of fever, headaches, and AMS. Also has impaired memory and hallucinations. No PMH, no meds, and no sick contacts. Vitals show low grade fever and are otherwise normal. 1. Emergency orders 2. Physical Exam 3. Diagnostic tests 4. Therapy 5. Location 6. Final order 7. Dx ✅- - Emergency orders: none - PE: focused PE - Order: pulse ox q4h, CBC w/ diff, BMP, CXR, UA, blood cx, urine cx, PT/PTT/INR, head CT, LP w/ CSF analysis (all STAT) - Order: NPO, O2, head elevation, complete bedrest, IV access, IVF (cont), phenergan (IV, cont), acetaminophen (IV, cont) - Advance clock for results - Do not wait for culture and PCR results - Order: acyclovir (IV, cont) - Admit patient to ward - Advance clock for PCR results - Reevaluate q 12-24hrs w/ interval f/u and focused PE - Final orders: counsel Dx: HSV encephalitis Case 43: 67M presents to office w/ a 3 month hx of frequent headaches and scalp pain over the right temporal area. Also has low grade fevers, fatigue, anorexia, and 15 lb weight loss. Recent colonoscopy and PSA were WNL. PMH includes diet-controlled hypercholesterolemia and HTN tx w/ HCTZ. Vitals WNL. 1. Emergency orders 2. Physical Exam 3. Diagnostic tests 4. Therapy 5. Location 6. Final order 7. Dx ✅- - Emergency orders: none - PE: full PE - Transfer patient to ED/ward - Order: CBC w/ diff, BMP, ESR, UA, urine cx, blood cx, CXR, and head CT (all STAT) - Advance clock to get results - Order: temporal artery biopsy (routine), prednisone (PO, cont), ASA (PO, cont), pantoprazole (PO, cont), calcium (PO, cont), vitamin D (PO, cont), counsel (med compliance) - Send patient home w/ f/u in 2-4 weeks - Interval hx & focused PE - Order: ESR, CBC, DEXA scan (routine) - Send patient home w/ f/u in 2-4 weeks - Final orders: none Dx: Temporal arteritis Case 44: 62F presents to office w/ pain and stiffness in hips and shoulders for past 6 months. Stiffness lasts 1-2 hours each morning. Also has fatigue and poor appetite, but no weight loss. Last colonoscopy was WNL. On metformin for DM2. Vitals WNL. 1. Emergency orders 2. Physical Exam 3. Diagnostic tests 4. Therapy 5. Location 6. Final order 7. Dx ✅- - Emergency orders: none - PE: full PE - Order: CBC w/ diff, BMP, ESR, CRP, ANA, RF, TSH, CPK, CXR (routine) - Send patient home w/ f/u in 4-7 days - Request interval hx & focused PE - Order: prednisone (PO, cont), calcium (PO, cont), vitamin D (PO, cont), counseling (med compliance) - Send patient home w/ f/u in 2-4 weeks - Request interval hx & focused PE - Order: ESR, CRP, CBC, and DEXA (routine) - Send patient home w/ f/u in 2-4 weeks - Final orders: none Dx: polymyalgia rheumatica Case 45: 20F presents to ED w/ sudden onset sharp RLQ pain worsening over the last 3 hours. Pain associated w/ nausea & vomiting. Denies fever, diarrhea, constipation, urinary sx, or vaginal discharge. LMP 2 weeks ago, only medication is OCPs. Vitals show tachycardia and are otherwise normal. 1. Emergency orders 2. Physical Exam 3. Diagnostic tests 4. Therapy 5. Location 6. Final order 7. Dx ✅- - Emergency orders: none - PE: focused PE - Order: CBC w/ diff, BMP, UA, urine HCG, pelvic US (all STAT), IVF (cont), morphine (IV, cont), phenergan (IV, cont) - Advance clock to get results - Order: gyn consult, PT/PTT/INR, NPO, bedrest (all STAT) - Transfer patient to ICU/ward - Advance clock for gyn recommendations - Order: laparoscopy (STAT) - Advance clock for procedure - Order: reg diet, cancel NPO - Reevaluate q 12-24hrs w/ interim f/u & focused PE, pain management - Final orders: counsel Dx: simple ovarian cyst w/ torsion Case 46: 53F comes to office w/ expanding abdominal girth for 1 week. Also has early satiety, anorexia, and fatigue for 5 weeks. Denies other symptoms. No PMH and no medications. Never had a colonoscopy. Pap smear 4 years ago was WNL. Menopause at age 51. Vitals WNL. 1. Emergency orders 2. Physical Exam 3. Diagnostic tests 4. Therapy 5. Location 6. Final order 7. Dx ✅- - Emergency orders: none - PE: full PE - Order: CBC w/ diff, BMP, LFTs, UA, pelvic US (routine) - Send patient home w/ f/u in 1-2 weeks - Request interval hx & focused PE - Order: abd CT, CA 125, CXR, colonoscopy, mammogram, EKG, PT/PTT/INR, type & screen, gyn consult, counsel (cancer dx) (routine) - Send patient home w/ f/u in 4-7 days - Transfer patient to ward - Order: NPO, IV access, cefazolin (IV, once), LMWH (SC, cont), SCDs, IVF (cont), TAH-BSO by laparotomy (routine) - Advance clock for procedure - Order: reg diet, oncology consult, cancel NPO - Reevaluate q12-24hrs w/ interval hx & focused PE until ready for discharge, pain management - Final orders: no smoking, no alcohol Dx: ovarian cancer Case 47: 72M presents to ED w/ colicky abdominal pain, nausea, bloating, and constipation. Nursing home resident w/ PMH of schizophrenia. No hx of abdominal surgeries. Last colonoscopy WNL. Vitals WNL. 1. Emergency orders 2. Physical Exam 3. Diagnostic tests 4. Therapy 5. Location 6. Final order 7. Dx ✅- - Emergency orders: none - PE: focused PE - Order: CBC w/ diff, BMP, UA, AXR (all STAT), IV access, NPO, IVF (cont) - Advance clock to get results - Order: GI consult (STAT), NGT, morphine (IV, cont) - Advance clock for GI recommendations - Order: flexible sigmoidoscopy (STAT), rectal tube, complete bed rest - Transfer patient to ward - Reevaluate q8-12h - Final orders: counsel, preoperative abx as appropriate, PT/PTT/INR, elective laparotomy Dx: sigmoid volvulus Case 48: 43F presents to ED w/ 8 hour hx of RUQ abdominal pain associated w/ n/v. Similar attack 1 year ago that resolved spontaneously in hours. PMH significant for tubal ligation. Vitals show fever of 101.7 and are otherwise normal. Mildly obese (BMI 30.1). 1. Emergency orders 2. Physical Exam 3. Diagnostic tests 4. Therapy 5. Location 6. Final order 7. Dx ✅- - Emergency orders: none - PE: focused PE - Order: CBC w/ diff, BMP, LFTs, amylase, lipase, blood cx, AXR, abd US (all STAT), IV access, NPO, NGT, IVF (cont), piperacillin-tazobactam (IV, cont), ketorolac (IM, cont), phenergan (IV, cont) - Advance clock to get results - Transfer patient to ward - Order: bed rest w/ bathroom privileges, general surgery consult, PT/PTT/INR, type & screen - Reevaluate q8-12h, monitor vitals - Order: laparoscopic cholecystectomy (when afebrile) - Advance clock for procedure - Reevaluate q12-24h until patient ready for discharge - Final orders: counsel Dx: acute cholecystitis Case 49: 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. 1. Emergency orders 2. Physical Exam 3. Diagnostic tests 4. Therapy 5. Location 6. Final order 7. Dx ✅- - 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 rhinosinusitis Case 50: 74M presents to ED w/ sudden onset severe abdominal pain radiating to back. Accompanied by nausea & diaphoresis. Denies fever, chest pain, diarrhea, constipation, or urinary sx. Ex-smoker, drinks occasionally. PMH of HTN, HLD, previous MI. Meds include ASA, metoprolol, simvastatin, & nitroglycerin PRN. Vitals show borderline tachycardia and borderline hypotension. 1. Emergency orders 2. Physical Exam 3. Diagnostic tests 4. Therapy 5. Location 6. Final order 7. Dx ✅- - Emergency orders: IV access, BP monitor, cardiac monitor, EKG, pulse ox, O2 - PE: focused PE - Order: cancel metoprolol & ASA, IVF (cont), morphine (IV, cont), phenergan (IV, cont), CBC w/ diff, BMP, abd US, PT/PTT/INR, type & screen, NPO, bedrest, vascular surgery consult (all STAT) - Transfer patient to ICU - Advance clock for US results - Order: cefazolin (IV, once), repair AAA (STAT) - Advance clock for procedure - Order: reg diet, cancel NPO - Reevaluate q8-12 hours - Final orders: counsel Dx: AAA Case 51: 10 month M brought to ED due to sudden onset intermittent crying spells during which he is irritable and draws legs to abdomen. Between attacks, he is comfortable & sleepy. Had some episodes of emesis. Sx were preceded by URI 1 week ago that has resolved. Vaccines up to date, vitals WNL. 1. Emergency orders 2. Physical Exam 3. Diagnostic tests 4. Therapy 5. Location 6. Final order 7. Dx ✅- - Emergency orders: none - PE: focused PE - Order: NPO, IV access, IVF (con), IV analgesics (once), IV antiemetics (once), NGT, CBC w/ diff, BMP, AXR, abd US, surgery consult (all STAT) - Advance clock to get results - Order: barium enema (STAT) - Advance clock for procedure - Admit patient to ward - Order: complete bed rest, urine output - Reevaluate q3-4h - Final orders: counsel parent Dx: intussusception Common orders (office) ✅- CBC BMP Lipids LFT UPreg Common orders (ED) ✅- IV access IVF Pulse ox Cardiac/BP monitor Oxygen CBC BMP EKG Glucose UPreg Hypertensive emergency - Immediate orders? - Exam? - Initial orders? - Orders after results? - Final orders? ✅- - Immediate: IV, pulse ox, O2, cardiac monitor, BP monitor - Exam: Gen, HEENT, chest, CV, abd, extremities, neuro - Initial: EKG, head CT, CBC, BMP, UA, CXR - Result orders: IV nitroprusside, A line, transfer to ICU with NPO, bed rest, monitor UOP, check BP q15 minutes - Final: Lipid profile, counseling Uncomplicated acute cystitis and pregnancy - Immediate orders? - Exam? - Initial orders? - Orders after results? - Final orders? ✅- - Immediate orders: None - Exam: Gen, chest, CV, abd, genital - Initial orders: bHCG, UA, consider pap, lipid profile, STD screening - Orders after results: Nitrofurantoin, UCx, PNV, couseling - Final orders: Appt in 2 weeks, repeat UCx Pregnancy - Immediate orders? - Exam? - Initial orders? - Orders after results? - Final orders? ✅- - Immediate orders: None - Exam: Complete - Initial orders: bHCG, pelvic US, prenatal labs (blood type and Rh, atypical antibody, CBC, BMP, pap smear, U/A, UCx, rubella, RPR, HBsAg, HIV, chlamydia, gonorrhea) - Orders after results: PNF, iron sulfate, folic acid, prenatal counseling - Final orders: F/u in 4 weeks Mild ulcerative colitis - Immediate orders? - Exam? - Initial orders? - Orders after results? - Orders after dx confirmed? - Final orders? ✅- - Immediate orders: None - Exam: Gen, skin, HEENT, chest, CV, abd, rectal, extremities - Initial orders: ESR, CBC, BMP, stool studies, LFTs, PT/INR, PTT , return in 1 week - Orders after results: Sigmoidoscopy, rectal bx - Orders after dx confirmed: Mesalamine, loperamide, dicyclomine, dietary consult, counseling - Final orders: F/u in 2 weeks, ESR to monitor Ectopic pregnancy - female is bleeding - Immediate orders? - Exam? - Initial orders? 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