Step3CCS

USMLE step 3 CCS cases list

• Step 3 CCS cases part 1

• Step 3 CCS cases part 2

• Unorganized list of CCS cases

Other step 3 CCS resources

• Asters Notes I

• Asters Notes II

• Asters Notes III

About step 3 exam

• Usmle step 3 CCS (clinical case study) is part of the [[USMLE
  Step 3]] exam.

• While it is half a day in a 2 day exam, it causes most of the anxiety associated with
  Step 3 exam for most test takers.

• A good understanding of the cases and the software used is essential to aid in the proper understanding of the exam.

List of USMLE step 3 CCS cases

• Here is a comprehensive list of CCS cases that can be edited and improved by Test takers.

Abbreviations

• See the full list of common medical abbreviations such as (yom = year-old male, yof = year old femal).

• If you find any mistakes, you can go ahead and edit the page! Part 2

CCS Acute Gout Attack

Step 1: keep foot elevated

Gout Signs and Symptoms

• Labs: CBC Basic metabolic panel, Uric acid, Stool guaic, UA with microsynovial fluid for light polarising micrograph, C&S, Gram stain, glucose, protein, cell count.

• X-RAY JOINT.

• 24 hour urine for UA

• Diet: low purine

• Medication: NSAIDs such as Motrin PO or Indomethacin Po for 2 days, then hypouricemic therapy: Probenicid increase until UA level falls below

• Allopuinol, after attack.

• symptomatic: Ranitidine bid.

• Meperidine or Vicodin

CCS Splenic Rupture

Diagnosis: splenic hematoma HPI 23 y/o male after MVA. step 1 ABC, PE focus Labs: serum glucose and rapid bedside glucose determination, CBC, serum chemistries, amylase, LFT's, UA, coagulation studies, blood type and match, ABG, blood ethanol, urine drug screens. Bedside U/S abdomen, Doppller abdomen (for unstable), CT abdomen(for stable) and emergent surgeon consult.

CT Spleen Rupture

• Chest X-Ray, supine & erect abdomen x-ray. Vital signs|Vital Signs]], Cardiac, and BP monitoring on bed side. Foley catheter and Urine output check. NPO, Ringer's lactate solution I.V before results from Lab. Transfer to ICU if patient is not stable. posted by raavii02good work up I would add surgical consult for repair also prefer NS as IVF rather than LR because in case he develops rhabdo.

• (MVA) NS is fluid of choice.

CCS AMI

HPI: 45 yom brought to the ER with excruciating stabbing pain on chest/inner arm for 20 min.

• No history of previous attack, but hypertensive c BP 190/ 96 when last taken.

• He is conscious but looks anxious. VS: temp-97, pulse-86/min, resp. rate-33/min,
  Step I : Emergent management: A, B, C, D- O2, IV access
  Step II : Focused PE: Heent/Neck, Chest/Lungs, Heart/Cv, Abdomen, Extremities
  Step III : Diagnostics: EKG, CXR, CK-mb, Troponin-I, CBC, Chem –7, Continuous cardiac monitoring

Myocardial infarction ECG

• Treatment: MONA
• NTG 0. 4mg s l
• Aspirin
• Morphine if patient is in pain
• ACE Inhibitor (Lisinopril)
• Depending on time since onset (if 3 h or less), consider t-PA if not contraindicated or cardiac cath.
• Consider NTG drip.
• Other antihypertensive you may consider is Labatelol or nipride( more severe cases).
• 
  Step IV: Changing pt’s location

Myocardial infarction

• Admit Pt. to CCU, if patient is symptomatic send to ward.

• Repeat cardiac markers

• D/C cardiac monitor after 24 hours if patient is stable

• When stable, consider sub-maximal exercise test all Pts. with MI should go home on B-blockers

• Check lipid profile

• Consult on healthy life style prior to discharge

• Make appointment to see him in about a week STEP V: Educate Pt’s family, Console patient, stop smoking, diet, exercise.

STEP VI: Final Diagnosis: AMI

CCS PID

• HPI 25 yoWF c/o lower abdominal pain.

Typical Sites for Pelvic Inflammatory Disease.

• PE: Pregnancy test CBC Chem7 Endocervical gram stain-for gram-negative intracellular diplococci

• Endocervical culture-for gonorrhea Endocervical culture or antigen test-for chlamydia Treatment: Outpatient, normally

Hospitalization recommended in the following situations:

• Uncertain Diagnosis

• Surgical emergencies cannot be excluded, e.g., appendicitis Suspected pelvic abscess Pregnancy Adolescent patient with uncertain compliance with therapy Severe illness.

• Cannot tolerate outpatient regimen

• Failed to respond to outpatient therapy Clinical follow-up within 72 hours of starting antibiotics cannot be arranged HIV-infectedGENERAL MEASURES Avoidance of sex until treatment is completed Insure that sex partners are referred for appropriate evaluation and treatment.

• Partners should be treated, irrespective of evaluation, with regimens effective against chlamydia and gonorrhea.

• SURGICAL MEASURES Reserved for failures of medical treatment and for suspected ruptured adnexal abscess with resulting acute surgical abdomen

• Inpatient treatment; Cefoxitin IV cefotetan IV (or other cephalosporins such as ceftizoxime, cefotaxime, and ceftriaxone) plus [[]]doxycycline orally or IV Therapy for 24 hours after clinical improvement and doxycycline continued after discharge for a total of 10-14 days Clindamycin plus gentamicin loading dose IV or IM Therapy for 24 hours after clinical improvement with doxycycline after discharge as above

• Outpatient treatment: ceftriaxone plus doxycycline orally for 10-14 daysOfloxacin orally for 14 days plus either clindamycin orally or metronidazole

PATIENT MONITORING Close observation of clinical status, in particular for fever, symptoms, level of peritonitis, white cell count

• Safe sex practices education-particularly for those who have had an episode of PID

CCS Depression

HPI: 40 yo executive man comes to the office with chief complaint of headache.Later he gives history of financial problem and starts crying.First pay attention to history for alcohol or recent drug use.

You should check HPI to see when these headaches started , is it recurrent? , is patient's energy level has change recently, etc.

R/O medical cause.

PE: complete

• Labs: CBC- possibly WNL chem-7 UA- WNL

• Alcohol and Urine Drug screening- need to rule out drug use.

TSH- probably WNL- rule out thyroid problem.if all above normal.

• depression index- response to 20 question indicates depression.

start antidepressant- if patient is obese use celexa otherwise any ssri would be fine.schd.

• psychotherapy (with psychiatrist) to augment medication.schd.

• patient for follow-up in 3 weeks.

CCS Spleen rupture

HPI 23 yom after MVA.ABC

• PE;focussed PE

• Labs: serum glucose and rapid bedside glucose determination CBC serum chemistries amylase LFTs Urinalysis, coagulation studies blood type and match ABG, blood ethanol urine drug screens.

• Bedside U/S, DPL(for unstable), CT(for stable) and emergent surgeon consult.

• Chest x-ray, supine & erect abdomen x-ray Abdominal sono(er) or abdominal CT

• Vital, Cardiac, and BP monitoring on bed side.

• Foley catheter and Urine output check.

• Ringer's lactate sol I.V before results from Lab.

• Transfer to ICU if patient is not stable.

CCS case of chron's disease

HPI 28 yof comes to office c/o diarrhea for several days.

Endoscopic image of Crohn's colitis showing deep ulceration in sigmoid colon.

• PE: Complete physical examination.

• Labs: CBC- check for leukocytosis Chem7

• Stool Guiac - positive for blood stool

• Stool culture- WNL

• Stool for ova and parasite- WNL

• Colonoscopy- biopsy- inflammatory process consistence with chron's diseas

• Treatment: mesalamineantidiarrhealreevaluate patient in couple days- patient diarrhea has improved.

• *Patient is feeling better.

• Follow up:see patient in 2 weeks

• Diagnosis: chron's disease

CCS case of Squamous cell Lung cancer

HPI 67 yof with 30 years history of smoking come to office c/o cough.

Histopathology of squamous-cell carcinoma of the lung

• PE: completeLabs: Pluse oxo

• CBC Chem 7 CXR- mass on left upper lobe

Biopsy- squamous cell carcinoma

• cell carcinomasurgical and onconlogy consult

• Diagnosis: squamous cell carcinoma of the lung

• You may ask how I am going to treat this patient.

• You probably won't have time to do any kind of treatment because when you make the diagnose case will end.

CCS case of asthma

HPI 5yo child with acute asthmatic attackNote vital signs: BP, Pulse, Resp.Rate, Temp.

An Asthma patient taking medication using an inhaler

• 
  Step I : Emergent management: A, B, C, D- O2 , broncodilaters MDI or nebulizer, depending on severity consider systemic corticosteroids.

• Step II : Physical Examination General appearance, HEET/Neck, Chest/Lung, Heart/CV

• Step III : Diagnostic investigations:O2 sat, PEF, CBC, Chem 7

• CXR

• ABG- should be considered in severe distress of when FEV1 <30% of predicted values after initial treatment.

• Treatment: Oxygen
• Beta 2 agonist with MDI or Nebulizer every 20 mins
• Methyprednisolone IV q6h for first 24-48 hours then inhaled steroids

• Step IV: Decision about changing patients location Discharge home if symptoms resolve quickly or FEV1 is greater than 70% of predicted or personal best.

Recommendation for hospitalization

• response to treatment is poor
• recent hospitalization for asthma
• failure of aggressive outpatient management
• previous life- threatening attack.
• If PEF or FEV1 is less than 50%
• arterial carbon dioxide tension is greater than 42
• If patient is confused of drowsy
• If no easy access to ERIf patient is discharge need to return to office within 5-7 days for follow up.

• Step V: Educate patient and family: Instruct patient/family to avoid factors that aggravate patients disease. Instruct on proper use of MDI

STEP VI: Final Diagnosis. Acute asthma attack

CCS case of Nortryptiline Toxicity

HPI 27 y male, depressed, and was found unconcious with a bottle of pill.

• Ensure ABCPE: Heent/Neck, skin, CV, Lung, ABD

• Labs: CBC Chem13 Puls ox EKG ABG drug level

• Treatment: Gastric lavage

• Activated charcoal with intermittent gastric suctioning

• Induce alkalinisation with NaHCo3 to maintain pH of 4.5 to 5.5

• If he is intubated hyperventilate to a PCo2 <35 and >25mmHg

• Foley's catheter placement

• If ECG normal and patient is asymptomatic, observe for 6 hrs in ER

• otherwise admit to ICU

• After Admission ECG should be normal for 24hrs to discharge for psychiatric disposition

CCS Sickle cell crisis

HPI 6 AAM was broght to your office because of pain he has a history of sickle cell disease.

Sickle cell anemia smear

• PE: Complete Physical examination

• Labs: Blood smear Hb electrophoresis. BUN & Creatinine LFTs, Electrolytes X-ray skeletal

• Treatment: pulse ox, O2, IV Fluid, morphine, type and cross, exchange blood transfusion hydroxyurea Penicillin V 125 mg bid up to age 3; then 250 mg bid up to age 5 folic acid

• Immunization: H.influenzae B vaccine and pneumoccal vaccines

• Aminocaproic acid for hematuria

• If recurrent CVA, chronic transfusion program

• Bone marrow transplation

• Eduation: Counsel

CCS case of community acquired pneumonia

HPI 64 Year old White female comes to your office c/o several days of productive cough.

• PE: complete

• Labs: CBC - leukocytosis with a left shift on differential Chem 7- hyponatremia and hypokalemia ABG - hypoxemia CX - blood cultures x 2, sputum culture and sensitivity

• Imaging: Chest x ray -(with lateral decubitus views if pleural effusion present)Lobar or segmental consolidation (air bronchogram)Bronchopneumonia Interstitial infiltrate Pleural effusion (free-flowing or loculated)

• Treatment: Outpatient oral azithromycin for mild case, inpatient for moderate to severe case such as hypoxemia, altered mental status, hypotension, significant co-morbid illness, and age extremes.

• Empiric antimicrobial therapy - oxygen, for patients with cyanosis, hypoxia, dyspnea, circulatory disturbances or delirium Electrolyte correction and fluid repletion Initial therapy community-acquired pneumonia requiring hospitalization a 3rd/4th generation cephalosporin or B-lactam/B-lactamase inhibitor plus macrolide, doxycycline, or fluoroquinolone OR a pneumococcal-active fluoroquinolone alone

• Patient monitoring: If outpatient therapy, daily assessment of the patient's progress, and reassessment of therapy if clinical worsening or no improvement in 48-72 hours

• Reduce risk factors where possible Annual influenza vaccine for high risk individuals, assess need for pneumococcal vaccine and haemophilus vaccination where appropriate.

CCS APKD

HPI: 32 y/o male for routine check up.

• PE: complete:LABORATORY CBC- Hematocrit - elevated in 5% of cases Urinalysis - may have hematuria and mild proteinuria Chem 7- Serum creatinine may be elevated Kidney U/S - stones usually calcium oxalate

• IMAGING Ultrasonography: > 5 cysts in the renal cortex or medulla of each kidney, in children, 2 or more cysts in either kidney CT scan-more sensitive 85% of patients can be detected by age 25

• Treatment: Outpatient-except for complicating emergencies (infected cysts require 2 weeks IV antibiotics then long-term oral antibiotics)

• GENERAL MEASURES: bed rest and analgesics for Pain

• ACTIVITY: Avoid contact activities that may damage enlarged organs.

• DIET: Low protein diet may retard progression of renal disease.

• PATIENT EDUCATION: Genetic counseling is critical

• Avoidance of nephrotoxic drugs

• Treatment: No drug therapy available for polycystic kidney disease

• Hypertension: - ACE inhibitors; avoid diuretics (possible adverse effects with cyst formation)

CCS Cystic Fibrosis

• HPI 7 month old child with fool smelling stools and recurrent episodes of bronchiolitis (cystic fibrosis)

Cystic fibrosis manifestations

• PE: General appearance, Heent/Neck, skin, chest/lung, heart/CV , Abdomen

• Labs: CBC Chem-13 sweat chloride test (Chloride level of >60mEq/dl dgn) CXR

• Pulmonary function tests

• ABG's Sputum culture & sensitivities of cultured organisms

• Treatment: Antibiotics (will not eradication colonized pathogens, but will improve quality of life)-iv for pulmonary infections (I/V B-lactam with anti-pseudomonal activity combined with tobramycin...choose combo therapy with 2 distinct mechanisms of action.

• Avoid quinolones in peds) albuterol/ipratropium bronchodilators

• Chest physiotherapy with postural drainage and percussion breathing exercise vigorous coughing/ISB exercise program

• Pain medication if needed

• Nutritional support: high calorie diet, PO pancreatic enzymes, ADEK vitamin supplement.

• Antibiotics: Use Anti-pseudomonal parenteral antibiotics

• -levofloxacin, ciprofloxacin

• -meropenem, imipenem

• -ceftazidime, cefepime

• -aztreonam

• -piperacillin

• -gentamicin, tobramycin (tobra more active)

CCS Child Abuse

• HPI 4 y/o boy brought to ER for evaluation by mom.

• ORDER Sheets skeletal survey Urinalysis CBC with differential PTPTT bleeding time

• opthalmologic consult (? ) for retinal hemorrhages

• CXR Electrolytes, serum Creatinine, Serum Blood Urea Nitrogen Bilirubin, Serum Total and Direct

• If sexual abuse considered, cultures of mouth, rectum /vag, urethra, VDRL

• ADMIT to WARD

• Diet: Full regular diet

• Social Worker Consult Child's Protective Agency report to local authorities (state protection agency)

• DISCHARGE: When the child gains his health, assure his safety and the hospital knows his destination.

CCS ATN

HPI:patient after MVA had developed decreased urine out put.o2 pulseo2 if need toLabs: CBCChem7UACPKTreatment:

• IVF with NS

• Diuresis with Lasix

• Sodium bicarb.Patient improves.

CCS ovarian cancer

C/cold lady with abdominal mass, ascities stable vitals or mild resp distress dur to pl.effusionLabs: CBC, Basic metabolic panel, UA ESR, LFT, fob, CXRabdominal u/sif mass positive ct for metastaislaproscpic biopsy of the mass- adeno/beginif adeno- debulking paracentesis if severe symptamatic lateral decubitus >10mm do thoracocentesis f/u her cbc and counsel

CCS Premature labor(Office)

• 26 y/o 32 weeks gestation presented with two 30 sec contractions in 10 minutes cervix 3 cm dilated.

• Effacement 70% .Transfer to Ward.Labs: CBC with differential.U/S for fetal size, position, placental location.Amniocentesis for equivocal fetal maturity Urinalysis, urine culture (urine obtained by catheter)Electrolytes, serum glucose, Treatment: bed rest, hydration If this fails tocolysis with mag.

• Sulfate/ ritodrine Glucocorticoids for lung maturity Note-(contraindications for tocolysis: ruptured membranes, cervical dilation>4 cm, effacement >80%, fetal death, fetal distress, IU infection, polyhydramnios, IUGR, erythroblastosis, sever maternal hypertension, maternal pulmonary, cardiac disorders, abruptio placenta, placenta previa).

CCS Trichomonas vaginitis (Office)

24 y/o female complaining vaginal discharge and itching.Labs: CBCChem7wet mount (saline and KOH) test to identify the organism DX of trichomonas: pruritus, fishy odor , gray or yellow-green discharge, PH>

• Treatmen: metronidazole 2gm x1 and treat parter.At discharge consult pt.

• For safe sex.

CCS Colon cancer

• History of present illness: 60 year old male presenting to office for regular checkup.

Colon cancer

• VITAL SIGNS- BP (N= 90-140/60-90), Pulse (N= 60-90, Mean- 72), RR (N= 12-20, Mean- 16), Temp.( N= 37C, 98.6F)Allergy: NKA
  Step I : Emergent management: A, B, C, D-Not needed
  Step II : Physical Examination Complete- General appearance, Skin, Lymph Nodes, HEET/Neck, Chest/Lung, Heart/CV, Abdomen, Genitalia, Extremities, Neuro.

• 
  Step III : Diagnostic investigations:

• CBC

• UA

• Chem-12

• Lipid profile

• Because of his age he needs Guiac stool, If positive followed by colonoscopy.

• result will show evidence of colon cancer.

• Liver function tests, Chest x-ray to look for metastatic disease.

• 
  Step IV: Decision about changing patients location

• After initial workup admit patient for elective surgery.

• Surgery consult.

• Get type and cross, CBC, Chem 12, EKG, CXR,PT, PTT, LFT, inform consent, NPO, and CEA level prior to surgery.

STEP V: Educate patient and family: After surgery patient should be evaluated every 3-6 months for 3-5 yrs with history, physical examination, fecal occult blood testing, liver function tests, and CEA determinations.

• Colonoscopy is performed within 6-12 months after operation to look for evidence of recurrence and then every 3-5 years.Step VI: Final Diagnosis: Colon Cancer

CCS turners syndrome

mother brings a 16 yr old girl with no menstruationor16 yr old for normal physical exam, menstruating no need of abc as it is a office visit for routine check up 2, physical- complete, you will get the webbed neck, widely spaced nipple, short stature, lack of breast development cbcsma 7uacxr- pulmonary hypoplasia ekg- coa, bp different in arms echo- coa, bicuspid aortic valve u/s abd- horeshoe kindney karyotype- xo reassurancef/u in 2 weeks in office if confirmed- < 12 yrs- growth hormone im injection+striods<12 yrs-e+p (hrt) counsel consult cardiology/urology/gyn(for streak ovary renoval)f/u in 4 weeks

CCS Alzheimer's Dementia

HPI: A 79 yof comes to your office complaining of forgetfulness. vital signs- BP (N= 90-140/60-90), Pulse (N= 60-90, Mean- 72), RR (N= 12-20, Mean- 16), Temp.( N= 37C, 98.6F)
Step

Alzheimer's disease brain comparison

• History and full PE Step

• labs: Allergy: NKADDX: Alzheimer’s dementia- Most common.Vascular dementia- 2nd Most common.Pick’s disease –3rd most common.Lewy body disease Huntington’s disease Parkinson’s diseaseHIV- Related dementia Head trauma related dementia StepI: Emergent management: A, B, C, D- Not needed.
  Step II : Physical Examination General appearance, Skin, Lymph Nodes, HEET/Neck, Chest/Lung, Heart/CV, Abdomen, Extremities, Neuro/Psych.

• 
  Step III : Diagnostic investigations: There are several diagnostic investigations for workup of dementia but H&P exam will narrow the list.

• MMSE

• CXR

• EKG

• CBC/D- To check for anemia.

• UA

• SMA-12- check for electrolyte abnormality

• TSH- to rule out thyroid problem.

• VDRL- To rule out syphilis 9.

• B12 level 10.

• BAL- guided by H&P1

• Urine Drug screening and heavy metals- guided by H&P 1

• HIV test – guided by H&P1

• CT – guided by H&P1

• LP- guided by H&P Initial Treatment: Not needed.

• 
  Step IV: Decision about changing patients location

• Some of the test you order may not be available right away, move patient home and schedule office appointment when all results are available.

• Need to see patient initially weekly then monthly.

• Treatment:

• When Diagnosis of Alzheimer is made by H&P and exclusion of other possible causes of dementia, start either Tacrine or aricept.

• Add Vitamin E – it has shown that may slow progression of Alzheimer

• Treat other complains that patient may have such as insomnia etc.Step V: Educate patient and family:

• Educate patient and family about the disease

• Console patient on driving restriction

• Educate patient on Living will.

• educate patient on exercise and Alzheimer support group.Step VI: Final Diagnosis: Alzheimer Dementia

CCS Hypothyroidism

(office visit) History of present illness: A 55 year old black woman with fatigue, weight gain, loss of lateral third of eyebrow, obese and other nonspecific signs/symptoms presented to office.

Note vital signs- BP (N= 90-140/60-90), Pulse (N= 60-90, Mean- 72), RR (N= 12-20, Mean- 16), Temp.( N= 37C, 98.6F) Allergy: NKA
Step I: Emergent management: A, B, C, D- Not needed.
Step II : Physical Examination Physical Examination General appearance, HEET/Neck, Heart/CV, Lymph Nodes, Skin, Chest/Lung, Abdomen, Extremities, Neuro.
Step III : Diagnostic investigations: CBC TSH (don't jump right away to whole thyroid function test as tsh is cost effective compared to whole thyroid pannel....if tsh comes abnormal then do whole thyroid pannekl). Thyroid Panel Chem 12 EKG – To rule out Cardiac disease.

• Patient with cardiac diseases should be started on low dose (25 Mcg) and monitored closely. lipid profile- patient is obese and at risk for CHD. Treatment: levothyroxine – Plasma TSH should be measured 2-3 months after initiation of therapy.
  Step IV: Decision about changing patients location Move patient home with follow-up appointment in 4 weeks. Stool guiac as part of yearly exam in this old pt. pap smear is due or have not been done.
  Step V: Educate patient and family: Advised patient on low cholesterol, low fat, and low na (high bp) diet, exercise program, etc. when 5min left screening warning, ordered repeat TSH in 4 weeks (to make sure, it is going down).
  Step VI: Final Diagnosis: Final Diagnosis: hypothyroidism 67 y o lady with HX of fatigue (Dyspeptic symptoms with weight loss) VITAL SIGNS- BP (N= 90-140/60-90), Pulse (N= 60-90, Mean- 72), RR (N= 12-20, Mean- 16), Temp.

• (N= 37C, 98.6F) Allergy: NKA

CCS Gastric Cancer

Step I: Emergent management: A, B, C, D-Not needed
Step II: Physical Examination Complete- General appearance, Skin, Lymph Nodes, HEET/Neck, Chest/Lung, Heart/CV, Abdomen, Genitalia, Extremities, Neuro
Step III: Diagnostic investigations:

• CBC (Iron Deficiency Anemia)

• Peripheral smear

• RI

• TSH

• chem-7

• Occult blood test stool (+++): because of her age she needs to go directly to:

• 
  Step IV: Decision about changing patient’s location Transfer Patient to Medical Ward (Colonoscopy is a hospital procedure) Emergent Lower colonoscopy and work based on the result (here will be -) Emergent upper endoscopy with cytologic brushing and biopsies (adeno cell Ca) LFT (metastasis) Abdominal CT for identifying distant metastases. Pre op workup such as blood type/cross match, CXR, EKG,PT, PTT, BT, start iron, Zantac. Consult Surgery/Oncology/: Message surgery will be available shortly DO interval/brief physical exam STEP V: Provide counseling from the list (Pt/family/advance directive) Case will end here
  Step VI: Final Diagnosis: Gastric Cancer

CCS Folic Deficiency Anemia(Office)

History of present illness: A 52 year old man come to office complaining fatigue.

• He has a history of drinking.Note vital signs- BP (N= 90-140/60-90), Pulse (N= 60-90, Mean- 72), RR (N= 12-20, Mean- 16), Temp.( N= 37C, 98.6F) Allergy: NKA
  Step I : Emergent management: A, B, C, D- Not needed.

• 
  Step II : Physical Examination General appearance, HEET/Neck, Heart/CV, Lymph Nodes, Skin, Chest/Lung, Abdomen, Extremities, Rectal, Neuro.

• 
  Step III : Diagnostic investigations: CBC/Diff (MCV > 110), Leukopenia, thrombocytopenia.Peripheral Smear- anisocytosis, poikilocytosis and macro-ovalocytes, hypersegmented neutrophils.RITSH (Ultrasensitive)Occult blood test (-)Chem 7LFT- LDH and bilirubin may be elevated Lipid profile- if patient has risk factor Order Folic acid (low/ B 12 level)- serum B12 and RBC folate levels.

• if level equivocal do Homocystine level.Initial Treatment: Start Folic Acid Continuous Multivitamin daily Message: pt is feeling better Do Interval History and physical exam
  Step IV: Decision about changing patients location Move patient home Schedule 1 week Refer for Substance abuse evaluation
  Step V: Educate patient and family: Quit Alcohol Quit Smoking Exercise program Advance directive Case will end here
  Step VI: Final Diagnosis: Folic Deficiency Anemia

CCS Erosive Gastritis

History of present illness: 55 yr old African American pt with history of Arthritis/chronic aspirin therapy presented to office with c/o fatigue
VITAL SIGNS- BP (N= 90-140/60-90), Pulse (N= 60-90, Mean- 72), RR (N= 12-20, Mean- 16), Temp.

• (N= 37C, 98.6F)

• Allergy: NKA
  Step I: Emergent management:

• A, B, C, D-Not needed

• 
  Step II: Physical Examination

• Complete- General appearance, Skin, Lymph Nodes, HEET/Neck, Chest/Lung, Heart/CV, Abdomen, Genitalia, Extremities, Neuro.

• 
  Step III: Diagnostic investigations:

• CBC (Normocytic Normochromic Anemia)

• TSH

• Chem-12

• Occult blood test stool (+++): because of his age he needs to go directly to:

• Colonoscopy (-) followed by endoscopy (++ for gastric ulcer, no evidence of malignancy)

• DC ASA

• Start Acetaminophen, Zantac

• from the counseling list: Quiet smoking

• from the counseling list Quiet alcohol

• Advanced directive

• 
  Step IV: Decision about changing patient’s location

• Home with 2 weeks follow up

• Pt comes feeling better

• Do Interval history and physical exam

• Repeat CBC only

• STEP V: Educate patient and family: and case will end here

• 
  Step VI: Final Diagnosis:

• Erosive Gastritis

CCS Transient Ischemic Attack

Transient Ischemic Attack (ED)History of present illness: Patient 54 years old with a hx of Hypertension, hypercholesterolemia, smoking and DM.

• wife brought her husband because he dropped a plate on the floor & he was unable to understand what she was saying, she asked him to write, he wrote couple of sentences that didn't make any sense, episode lasted few hrs.

• she brought her husband to ER.

• vital signs- BP (N= 90-140/60-90), Pulse (N= 60-90, Mean- 72), RR (N= 12-20, Mean- 16), Temp.( N= 37C, 98.6F)

• Allergy: NKADX: TIA Thrombotic or embolic strokeSubdural hematomaSeizure
  Step I : Emergent management: A, B, C, D- Not needed.

• 
  Step II : Physical Examination General appearance, HEET/Neck, Heart/CV, Lymph Nodes, Skin, Chest/Lung, Abdomen, Extremities, Neuro.Physical: BP 170/98 P 100A loud bruit was auscultated over left carotid, no murmurs, rubs or bruits were heard over pericardium.

• neuro was nonfocal.

• 
  Step III : Diagnostic investigations: Initial Test:

• CBC

• Chem-6

• CT- (remember CT takes about 2hrs, is this patient stable enough to send to CT(YES), are there any other tests(blood tests) you should do before you send him to CT.

• Think reason before you do a test, do not write all possible tests you could do.

• "Save cost, do less invasive tests, save time, be focused on that particular case, effective decisions.

• If CT questionable, MRI is more accurate.

• Why do you do a CT in this case? To rule out hemorrhage! Will the hemorrhage show in CT? , in which time phrase? Hemorrhage will show within 24 hrs, but infarcts will take few days.Why do you want to exclude hemorrhage?

• There is a carotids stenosis, neurological deficit we want to think, to give anticoagulation to this patient, if there is a hemorrhage he will bleed more with anti coagulation!Test results: after 2 hrs, remember patient is in YOUR care for TWO hrs now!

• CT: NEGATIVE

• Diagnosis: Considering , HX, physical, & the test you have done: this patient has 'expressive aphasia left temp, because the deficit lasted only few hrs it is TIA.

• TIA by definition, deficit lasting <24hrs.

• CT scan most of the time will not show any deficits in first 24 hrs.THere is a bruit on carotis, might represent a plaque that sent a small embolus to the brain.

• 
  Step IV: Decision about changing patients location Admit to wardFurther Diagnostic

Plan:

• Carotis doppler

• Angiography

• 24hrs Holter

• EchocardiogramResults;>70% stenosis77% stenosisno arrhythmiano valvular disease, no evidence of Thrombus

• Treatment Plan:

• Antiplatelet-Aspirin

• Heparin

• Vascular surgent consult for elective CEA- A Multidisciplinary Consensus Statement from the American Heart Association concluded that carotid endarterectomy is of proven benefit for symptomatic patients, including those with single or multiple TIAs or those who have suffered a mild stroke within a 6-month interval, who have stenosis of greater than 70% with a surgical risk of less than 6%.

• 100% stenosis ; NO CEA-causes hyperperfusionStep

• V: Educate patient and family: Stop smokingBetter BP control-(exercise, diet, Pharma.....)

• DM control(exrecise, diet, pharma) Continue aspirin or plavixStep VI: Final Diagnosis: Transit Ischemic Attack.

CCS Narcotic Overdose (ED)

History of present illness: 25-yr- lady brought in unconscious with bradycardia, hypotensive and pinpoint pupils classic case of narcotic overdose.Note vital signs- BP (N= 90-140/60-90), Pulse (N= 60-90, Mean- 72), RR (N= 12-20, Mean- 16), Temp.( N= 37C, 98.6F) Allergy: NKA

• 
  Step I : Emergent management: A, B, C, DA: Airway suction, Pulse Ox Q 1 hr or continueous monitoting, O2 B: Endotracheal intubation in O2 sat.

• does not improve with O2 nasal or PaO2<55, or PCO2>50, C: IV access (KVO), cardiac monitor, catheter Foley, finger stick glucose D: Drugs: thiamine, dextrose 50% and naloxone-all are IV bolus one time dose

• 
  Step II : Physical Examination General appearance, HEET/Neck, Heart/CV, Lymph Nodes, Skin, Chest/Lung, Abdomen, Extremities, Neuro.

• 
  Step III : Diagnostic investigations:

• B-HCG

• ABG

• CBC

• Chem 13

• PTT/PT

• EKG 12 lead

• CXR portable

• UA, UDS, BAL, Barbaturate level( level> 80-100 causes coma), blood aspirin and blood acetaminophen level.

• Initial Treatment: Order gastric lavage gets the result (which revealed pills fragments)Order Activated Charcoal Started naloxone drip, if evidence or BZD use, give flumazenil.Alkalinisation of the urine is useful with phenobarbital and barbital overdoseInterval HX on brief physical

• 
  Step IV: Decision about changing patients location Move patient to ICU Check lytes again DC Intubation if patient has improved DC NG Tube Cont cardiac/ox pulse 24 hrs DC NaloxonStep V: Educate patient and family: Psych consult (result will tell, the hx consistent with suicidal attempt)Order suicide precautionsMove pt to ward Basically the Psych ward DC IV line Start regular dietStart patient on Antidepressent
  Step VI: Final Diagnosis: Narcatic overdose

CCS Acute Pericarditis (ED Setting)

History of present illness: 45 year-old lady with substernal chest pain, Hx of previous URIOrders: O2, Iv Line (KVO) Cardiac monitoring, pulse monitoringPhysical Examination General Appearance, HEET/Neck, Extremities, Chest/Lung, Heart/CVDiagnostic Investigations: O2 saturationEKG (ST elevation in all leads)Cardiac enzymes, Troponin I (-)Chem 7 (WNL)CXR Portable (WNL)ABG (WNL)CBC

Treatment: Start ASA continuous (can use indomethacin or in severe cases corticosteroids)Next order in the ED ECHO (result was some fluid, but not severe)Next DC O2, MonitoreNext ReassuranceEducate patient and familyDC to home and F/U office.

• Final Diagnosis: Acute Pericarditis

CCS Solitary Pulmonary Nodule (office)

Solitary Pulmonary Nodule (office)History of present illness: 55 year-old smoker male with history of blood in the sputum Note vital signs- BP (N= 90-140/60-90), Pulse (N= 60-90, Mean- 72), RR (N= 12-20, Mean- 16), Temp.( N= 37C, 98.6F) Allergy: NKA
Step I : Emergent management: A, B, C, D- Not needed.

• 
  Step II : Physical Examination Complete Physical Examination

Step III : Diagnostic investigations: CBCChem 7Sputum: Gram stain.

• AFB, C&SPPDCXR PA/L Nodule in the R U Q LungSpirometry EKG Pulse OXNext order in the office Chest CT ( it will give you the size of the nodule

• 5 mg)Bronchoscopy and biopsy (result was SC Ca)Next consult surgeryOrder now LFT, Head CT, Blood type/cross match

Step IV: Educate patient and family: Stop smokingNext educate patient and family
Step V: Final Diagnosis: Solitary Pulmonary Nodule Case end here

CCS Active Tuberculosis

TB (Sudan immigrant Case): officeHistory of present illness: 55 yr old immigrant psychiatrist came in with classical symptoms of pulmonary TB Note vital signs- BP (N= 90-140/60-90), Pulse (N= 60-90, Mean- 72), RR (N= 12-20, Mean- 16), Temp.( N= 37C, 98.6F)Allergy: NKA
Step I : Emergent management: A, B, C, D- Not needed
Step II : Complete Physical Examination
Step III : Diagnostic investigations: Order the following:

Tuberculosis image 1

• CBC

• PPD

• Chem 12, LFT

• UA

• Sputum smears AFB

• Sputum TB culture and PCR test(result will be ready by PCR within 24 hrs)Now get the results of (AFB was negative.

Mantoux tuberculin skin test

• PCR came positive after couple days).Order CXR and the result was (upper apical infiltrate/cavity).Now you need to decide to admit or treat as an outpatient (remember hospitalization for the initial therapy of TB is not necessary in most patients
  Step IV: Decision about changing patients’ location Treatment plan:

• Notify the health dept.

• Start treatment with 4 drug regimen: INH, Rifampin, Pyrazinamide, and either Ethambutol or Streptomycin

• Weekly sputum smear and cultures and then monthly once they test negative.

• Ordered f/u appt with f/u sputum study.

• influenza/pneumonia vaccine, multivitamin

• HIV Test in all pts with TBStep V: Educate patient and family: Counseling and Education.

• 
  Step VI: Final Diagnosis: Active Tuberculosis

CCS G6PD

History of present illness: young boy present with pallor, jaundice and splenomegaly.

• Recent history of URI treat with Bactrim(sulfa).First note vital signs – make sure patient is stable.

• 
  Step I : Emergent management: Not needed.

• 
  Step II : Physical Examination General Appearance, skin, lymph nodes, HEENT/Neck, Chest/Lungs, Heart/Cardiovascular, Abdomen, extremities, Neuro.

• 
  Step III : Diagnostic investigations: HPI describe a patient with splenomegaly, anemia, and jaundice.

• Patient was treated with bactrim few days prior to presentation which makes you think of G6PD.

• Patient should be workup for anemia especially G6PD.

• CBC/D- will show Normochromic Normocytic Anemia

• Peripheral smear- Heinz bodies (bite cells) only seen on crystal violet staining of peripheral Smear.

• Will not be seen on wright-stained blood smear.

• reiculocyte index >3% (reticulocytosis)

• LFT- Serum bilirubin elevated

• Urinalysis- Hemoglobinuria

• Erythrocyte G6PD Assay- Low enzyme level.

• Type and cross- If hemoglobin is low- severe cases may need transfusionTreatment: Stop BactrimIv Access and IV fluid-NS
  Step IV: Decision about changing patients location Admit to wardContinue IV fluid until Diagnosis is established and patient has improved.If evidence of infection – Treat with non- sulfa drugsWhen patient is stabilized Cancel IV and Move patient home.Step V: Educate patient and family: Console patient on food and medications that can cause problem

• seek medical attention for any infection

• avoid food containing fava beans

• Medications including: acetanilid, dapsone, Bactrim, nitrofurantoin, sulfacetamide, sulfamethoxazole, sulfonamide, sulfapyridine doxorubicin, methylene blue, nalidixic acid, napthalene, phenazopyridine, phenylhydrazine, primaquine, quinidine, quinine, on ccs you may not have option to console patient for specific food or drug use, just select console patient!STEP VI: Final DiagnosisG6PD

CCS Panic Attack

History of present illness: A young man with Palpitation, pounding heart, anxiety come to ER for evaluation.Whenever a patient, regardless of age or risk factors, reports to an emergency room with symptoms of a potentially fatal condition i.e MI, a complete medical history must be obtained and a physical examination performed.

• DDX is numerous including: cardiovascular d/o, Pulmonary diseases such as asthma, Neurological diseases, endocrine disorders, Drug intoxication, Drug withdrawal such alcohol, and Anaphylaxis.VITAL SIGNS- make sure patient is stable- BP (N= 90-140/60-90), Pulse (N= 60-90, Mean- 72), RR (N= 12-20, Mean- 16), Temp.( N= 37C, 98.6F) Allergy: NKA
  Step I

Emergent management: Not needed.

• Unless respiratory distress is present.

• 
  Step II : Physical Examination General Appearance, skin, HEENT/Neck, Chest/Lungs, Heart/Cardiovascular, Abdomen, Neuro.

• 
  Step III : Diagnostic investigations: Following labs will eliminate any possible cause.

• With normal tests, panic attack is diagnosed.

• Presence of atypical symptoms such as vertigo, loss of bladder control and unconsciousness or the late onset of the first panic attack >45 years old require further evaluation.

• O2 SAT.

• Asthma, COPD.

• CBC- rule out anemia, Infection

• Chem 12- electrolyte abnormalities( glucose, Ca, BUN, Cr).

• TSH- Hyperthyroidism

• LFTs

• UA

• Urine Drug screening

• EKGTreatment: Usually not needed but can use Xanax 0.5mg once.

• 
  Step IV: Decision about changing patients location

• If All test results are Negative and patient is stable, Move patient home.

• Schedule office appointment

• If patient continues to have panic attacks at a later time/date, consider drug treatment with Benzodiazepines, SSRI, TCA, MOAIs, Treat for 8-12 months.

• Consider adding cognitive and behavior therapies as combination is superior than either one alone.

• SSRI are considered the initial drug of choice i.e sertraline.Step V: Educate patient and family: Avoid caffeine and medications that can cause panic attack including: yocon, pondimin, flumazenil, cholecystokinin, and isuprel.STEP VI: Final DiagnosisPanic Attack

CCS Tension pneumothorax

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CCS case of 65-year-old white man with chest pain

Pneumothorax CT

• YOU MAY HAVE TO DOWNLOAD THE TEST FROM THE USMLE'S WEBSITE, AND INSTALL THEM ON YOUR PC BEFORE YOU REVIEW THIS SOLUTIONCASE

• Case Introduction: Essential Facts• Patient is white, in mid-sixties• Has sharp, right-sided chest pain, accompanied by respiratory distress• He was brought to the emergency departmentCommentsThere is nothing that connects being white with having chest pain.

• This patient could have been of any racial origin and still present with these clinical features.

• However, the patient’s age will affect our choice of differential diagnoses.

• Chest pain in an older man is more likely to be of cardiac origin than the same pain in young patients.

• Possible differential diagnoses at this stage include• Pulmonary embolism (PE) because of chest pain, respiratory distress• Lobar pneumonia (chest pain, respiratory distress)• Tension pneumothorax (chest pain, respiratory distress)• Musculoskeletal chest pain (pain in a specific location)• Pleuritic chest pain• Cardiac pain (this is less likely, though possible.

• A patient with dextrocardia who develops myocardial infarction may have right-sided chest pain.

• However, since this test is based on clinical conditions commonly seen in practice, we are not going to be too concerned with this differential)Initial Vital signs|Vital Signs]]: Essential Facts• There is tachypnoea and tachycardia• Blood pressure is low• Temperature is normal• The patient is obese (BMI of 29)

• Comments Pneumonia as a cause of this patient’s chest pain is effectively ruled out because of the normal temperature.

• Still high on our list are PE, pneumothorax, and the other differentials listed above.

• Patient’s obesity will be addressed at a later time Initial History: Essential Facts• Chest pain began 10 minutes before arrival at the ER• This is the first episode of chest pain• Patient has had chronic lung diseases that may predispose to pneumothorax• Chest pain increases with respiration• He was not involved in strenuous activities immediately before the onset of chest pain Comments

• Although, this pain increases with respiration, a musculoskeletal cause is unlikely, going by the patient’s recent history.

• He is an accountant who suddenly developed an excruciating chest pain while at work.

• There is no recent history of chest trauma.Because of his long-standing history of asthma and emphysema, we will add emphysema to his differentials, since the latter can cause a measure of chest discomfort, especially if there is associated chronic obstructive pulmonary disease (COPD).

Tension-pneumothorax illustration of a tension pneumothorax showing deviated trachea and collapsed lung

• However, uncomplicated emphysema does not cause sudden sharp chest pain.It is time to perform the physical examination.

• Click the button labeled Interval

• History or PE and select • General Appearance• Chest/Lungs and • Heart/Cardiovascular We are interested in the general appearance (this is standard when interacting with most patients.

• You should always examine the patient’s general appearance).

• Moreover, because the primary complaint is in the chest region, we would naturally want to examine that area.

• Also, considering the patient’s age and the possibility that his heart might be the cause of his problems, we want to examine the heart as well.

• We cannot do more detailed examination of other systems because this is an emergency.

• Press OK to confirm your choice.History and Physical: Essential Facts• Patient is cyanotic and in marked respiratory distress• There is chest asymmetry, with hyper-resonance on right side.

• Breath sounds are also absent on that side• Cardiac examination essentially normal• Peripheral pulses present but weak• No pulsus paradoxus (a fall in pulse amplitude with quiet inspiration)

Comments: Notice the results of physical examination.

• We seem to have enough reason here to believe that this patient has tension pneumothorax.

• However, we would still like to confirm this with further tests.

• FAQ: Since this patient is in severe pain, and his vital signs are abnormal, why can’t we just go ahead and treat? Answer: Although this is a relative emergency, it is clear that we have enough reason to investigate the cause of the patient’s problems further before we initiate treatment.

• First, we can still measure his blood pressure (although this is low).

• There is no pulsus paradoxus.

• We are not going to waste time on nonessential investigations however.

• It is important to try and establish the cause of patient’s problems, if possible, before we initiate treatments.Now, let us write orders.

• If the result of the History and Physical is still visible, click OK to close it.

• Next, click the button labeled Write Orders or Review Chart.Next, click Order button at the bottom of the screen, and enter the following orders (one on each line): • Chest x-ray• Oxygen• Morphine•

• ECG Confirm the orders by clicking the Confirm Order button.

• For chest x-ray order verification, choose Chest x-ray, portable.

• Click OK.

Pleurisy and pneumothorax

• Urgency: stat. Note: Although, Chest X-ray PA/lateral may give you more detailed information, it takes more time.

• Moreover, the patient has to be wheeled to the X-ray department before the films can be taken.

• Portable chest x-ray can be done right there at the ER, and it takes very little time.For oxygen, choose Inhalation for route and Continuous for frequency.

• For morphine, choose Intravenous for route and Continuous for frequency.

• Note: morphine is almost always given through the intravenous route for most conditions.

• In any situation where you have need to use morphine, consider this fact.

• Don’t let the frequency that we chose mislead you.

• Continuous administration here means that it is given at fixed times (e.g. 6 hourly, 8-hourly, etc).For ECG order verification, choose ECG 12-lead; Urgency: stat.

• Now that we have initiated treatment, it is time to review that patient with the next available result.

• From our Order Sheet, we can determine that the result of the portable chest x-ray will be ready within 10 minutes.

• So let us advance the clock to that time.Click the button Obtain Results or See Patient Later at the top of the screen, and choose Review Patient with Next Available Result.

• The test result is displayed

• .Chest X-ray findings: Right tension pneumothorax

• Next, we are going to write more orders for this patient.

• Click the Order button at the bottom of your screen and type thoracentesis.

• Scroll to the bottom of the form and choose Thoracostomy tube.

• Confirm your choice.

• The result of this procedure is immediately displayed.

• When you click OK, the result of the 12-lead ECG will be displayed, showing essentially normal findings.It is now time to advance the clock, so we can re-evaluate our patient in 15 minutes.

• Click on the clock at the top of the screen and choose • Re-evaluate case In, then • type 15 in the Minutes box (you may also use the upward pointing arrow to do this).

• Click OK Now that our patient has been stabilized, we would like to perform an interval follow up before we admit him for further management.Towards the left side of the screen, click Interval History button, and choose • Interval Follow Up, • Chest/Lungs under the Physical Examination section The important findings this time are:

• • Patient is a smoker (for 45 years)• He has a positive family history of cardiac disease, hypertension, obesity, and stroke.

• • As noted earlier, the patient is obese (he has a body mass index of 29)• Patient does not engage in regular exercise (dyspneic after 1 minute of brisk walk)• The chest is now symmetricalSome of this information will come in handy when it is time to address the patient’s health maintenance issues.

• For now, we would like to send him to the intensive care unit.

• FAQ: Since the patient has been stabilized, why can’t we just admit him to the ward instead of the ICU? Answer: Under the British medical care system (and, incidentally, this is also true of many third world countries), we would have sent the patient to the ward.

• However, in the United States, patients like these are sent to the Intensive Care Unit.

• FAQ: Why can’t this patient be discharged home right away, since he has been relieved of his problems?

• Answer: he has a chest tube in place.

• The general consensus is that the chest tube should remain in place until we are sure it is no longer needed (i.e it does not show any bubbles in the water seal.) Even then, some hospitals prefer to clamp the tube and observe for some more time, before they remove the tube entirely.

• Click the Change Location button, and select Intensive Care Unit (ICU).

• Confirm move.

• Recorded vital signs are displayed (much better this time around).

• Click OK.We must now add more treatment for the patient.

• Click Order Sheet on the left side of the screen, and Order button at the bottom.

• Enter the following orders (one per line): • Albuterol (inhalation, continuous)• Atrovent (inhalation, continuous)• Advise patient, smoking cessation (routine, start now)• Advise patient exercise program (routine, start later)• Advise patient, weight reduction (routine, start later)Next, we are going to re-evaluate the patient in 1 day.

• Click the clock, and advance the next evaluation to 1 day.

• The dialog appears telling you you have five minutes more, and asking for the final diagnosis.

Final Diagnosis: Tension pneumothoraxEnd of case

CCS Cardiac Tamponade

History of present illness: A 59 year old man involved in MVA, chest impacts the steering wheel, comes in with distant heart sounds, dyspnea, obtundation.Vital signs- BP.

• Pulse, RR, Temp.This patient requires
  Step I with ABCD.With Steering wheel injuries one should be concern about fracture of sternum, ribs, trauma to lungs, spleen, Liver, and myocardial contusion.

CardiacTamponade

• This patient with distant heart sound give you the clue to possible pericardial effusion.

• Signs of cardiac tamponade include, the following: distended neck veins, decreasing blood pressure, narrowing pulse pressure, muffled heart sounds, pulses paradoxus, and equalization of hemodynamic pressures (CVP).

• 
  Step I : Emergent management: A, B, C, D- Supplemental oxygen , Cardiac monitoring, Intravenous access

• 
  Step II : Physical Examination General appearance HEET/Neck- check for distended neck JVD Heart/CV- Distant heart sound Chest/Lung, Abdomen, Extremities, Neuro.

• 
  Step III : Diagnostic investigations:

Pericardial effusion with tamponade

• EKG- electrical alternans

• CXR

• Echocardiography- the most sensitive and specific noninvasive test for the presence of fluid in the pericardium.

• Treatment:

• IV Fluid

• Pericardiocentesis

• If vital signs are lost in ER, an immediate thoracotomy is indicated.

• Consult for thoracotomy

• Presurgical workup- CBC, BMP, CXR,PT, PTT, EKG, Type and cross match, IV antibiotic.

• Urine drug screening

• BAL

• Step IV: Decision about changing patients location After surgery transfer patient to ICU and monitor EKG, repeat CXR and complete physical exam.When patient is table move to ward, then move home.

• Step V: Final Diagnosis: Cardiac Tamponade

CCS HEAD INJURY

HEAD INJURY

History of present illness: An 18 year old white male fell to the ground while playing soccer and was unconscious for 2 mints.

• He is complaining of headache but he cannot recall the incident.His friends state that after the time of injury, he has difficulty walking.VITAL SIGNS- Check vitals to make sure pt is hemodynamically stable.

• BP (N= 90-140/60-90), Pulse (N= 60-90, Mean- 72), RR (N= 12-20, Mean- 16), Temp.( N= 37C, 98.6F)Allergy: NKA DDX: 1)Concussion 2)Contusion 3)Epidural/Subdural Hematoma.

• 
  Step I : Emergent management: ABCD- if patient unstable O2, IV access
  Step II : Physical Examination Focus: Heent/Neck, chest/lungs Heart/CV, abdomen, Extremities, Neuro/Psych.

• 
  Step III : Diagnostic investigations:

• CBC

• chem-7

• Type and cross match

• Continuous monitoring of vital signs, oximetry, EKG

• Order CT SCAN of head without contrast.

• Move the clock and get results.

• If CT Scan shows epidural or subdural hematoma and patient is stable get Neurosurgical consult for Emergent Evacuation of the Hematoma.

• If patient is unstable due to increased intracranial pressure do #4 and start IV mannitol.

• If not effective then #6

• Intubate the pt.

• and hyperventilate to pCO2 of 35mm Hg
  Step IV: Decision about changing patients location

• Patient with Neurologic signs should have emergent surgery.

• Neurological check up every 1 hrs.

• Repeat CT after 24 hrs.

• If CT is Normal and patient is stable move home with office follow up in 5-7 days.STEP V: Educate patient and family: Patient with head trauma and initial normal CT should be informed to return to hospital Immediately if he develops Neurologic signs which requires Emergent CT.STEP VI: Final Diagnosis.Epidural Hematoma

CCS Pneumocystis Carinii Pneumonia with Candida Vaginitis

History of present illness: 40 year old homosexual female, cough and fever, vaginal itching.

• Note where the patient is on presentation, if she is in your office after initial work up, patient should be transferred to Ward or ICU (depending on presentation but most likely to ward).

• Unless the symptom are mild in that case treat patient in the office.

• VITAL SIGNS- will help you to determine if patient is stable or unstable.

• BP (N= 90-140/60-90), Pulse (N= 60-90, Mean- 72), RR (N= 12-20, Mean- 16), Temp.( N= 37C, 98.6F)Allergy: NKADDX- Pneumocystis pneumonia- Top of your list because of risk factor and OI at presentation.CytomegalovirusKaposi Sarcoma Legionellosis Lymphocytic Interstitial Pneumonia Mycoplasma Infections Nocardiosis Bacterial Pneumonia Fungal Pneumonia Viral Pneumonia Pulmonary Embolism Tuberculosis
  Step I : Emergent management: A, B, C, D- depending on presentation and assessment of O2 sat.

• if O2 sat is low.

• Start with one litter O2 and get IV access.

• 
  Step II : Physical Examination Any suspect HIV/AIDS patient should have a complete physical exam.

• General appearance, Skin, Lymph Nodes, HEET/Neck, Chest/Lung, Heart/CV, Abdomen, Genitalia, Extremities, Neuro.

• 
  Step III : Diagnostic investigations:

• O2 sat.- Pulse oximetry is obtained as part of the initial workup

• ABG- with signs of respiratory distress.(hypoxemia)

• LDH- Levels are noted to reflect disease progression.

• High levels during treatment indicate therapy failure and worse prognosis.

• CBC/with Diff, Chem-12

• CXR- The classic finding is diffuse central (perihilar) alveolar or interstitial infiltrates.

• Normal CXR is found in 5-10% of cases.

• Sputum- by-sputum induction for Wright-Giemsa stain or direct fluorescent antibody (DFA) for Pneumocystis if PCP is strongly suspected.

• If negative and PCP suspicion is high next step is bronchoalveolar lavage.

• HIV test- when you order a test like HIV that requires patient consent, it will tell you that patient consented to the test and result will be available in 7 days.

• CD4 count

• PCR assay

• Saline or KOH Vaginal secretion (wet mount).

• LFTs

• VDRL, Toxoplasma IGG, and hepatitis B and C serologies.

• Cervical papanicolaou Smear

• TB skin test.

Treatment

• IV fluid –NS (In moderate- severe cases).

• If suspicions is high for PCP start treatment with Bactrim-DS po bid for 14-21 days.

• If patient is hypoxic, start with Bactrim IV.

• Report positive result to Department of Health and Human services.

• 
  Step IV: Decision about changing patients location

• Mild-to-moderate disease refers to patients with milder symptoms and a nontoxic clinical appearance.

• They generally are not hypoxic and may even have a normal CXR.

• Outpatient oral therapy can be considered for these patients.

• Moderate-to-severe disease describes patients with severe respiratory distress, hypoxemia, and, often, a markedly abnormal CXR.

• Inpatient management with rapid Diagnosis and treatment is essential.

• Admit patient to ward for moderate to severe disease.

• (ICU if patient unstable).

• Mild cases should be managed outpatient.

• Discontinue IV fluid if patient is taking po and is not dehydrated.

• Continue Bactrim -

• Treat Vaginal candidiasis with antifungal such as nystatin, clotrimazole, miconazole vaginally.

• When Diagnosis of AIDS is established start Antiviral therapy with: A.

• 2 NRTIs + 1 or 2 PIs.

• B. 2 NRTIs + an NNRTI

• Vaccines: Influenza, Hepatitis A and B, Pneumococcal vaccine.

• when patient is stabilized cancel IV fluid, move patient to home with follow-up in your office in 5-7 days.

• Continue Bactrim and antifungal- discontinue antifungal when patient returns for follow –up unless symptoms still persist in that case consider changing antifungal.Step V: Educate patient and family:

• Educate patient on safe sex

• Educate patient on Medication compliance.

• Console patient on HIV support group.

• When you request this option it tells you arrangements for follow-up has been make.Step VI: Final Diagnosis: Pneumocystis Carinii Pneumonia (PCP) with Candida Vaginitis

CCS Sigmoid Volvulus

Abdominal radiography with a sigmoid volvulus in a 10 year old child.

• History of present illness: 63 years old man brought to Emergency Room complaining of colicky abdominal pain.When reading HPI note following: VITAL SIGNS- make sure patient is stable- BP (N= 90-140/60-90), Pulse (N= 60-90, Mean- 72), RR (N= 12-20, Mean- 16), Temp.( N= 37C, 98.6F)Allergy: NKADDX- Bowel obstruction, -carcinoma Pseudo-obstruction (ileus)Giant sigmoid diverticulum, Constipation

• 
  Step I : Emergent management: ABCD- Not needed

• 
  Step II : Physical Examination General appearance Abdomen- Examination reveals a tympanitic/distended abdomen, and a palpable mass may be present.

• Severe pain and tenderness suggests ischemia/perforation.

• Bowel sounds are usually absent.Rectal exam- Rectal examination shows only an empty rectal ampulla.

• Skin, Chest/Lung, Heart/CV, Extremities, Neuro.

• 
  Step III : Diagnostic investigations:

• CBC- Leukocytosis (in some cases Leukocytosis may be absent)

• Chem 7- to evaluate any electrolyte abnormality

CCS Colon cancer

• History of present illness: 60 year old male presenting to office for regular checkup.

Colon cancer

• VITAL SIGNS- BP (N= 90-140/60-90), Pulse (N= 60-90, Mean- 72), RR (N= 12-20, Mean- 16), Temp.( N= 37C, 98.6F)Allergy: NKA
  Step I : Emergent management: A, B, C, D-Not needed
  Step II : Physical Examination Complete- General appearance, Skin, Lymph Nodes, HEET/Neck, Chest/Lung, Heart/CV, Abdomen, Genitalia, Extremities, Neuro.

• 
  Step III : Diagnostic investigations:

• CBC

• UA

• Chem-12

• Lipid profile

• Because of his age he needs Guiac stool, If positive followed by colonoscopy.

• result will show evidence of colon cancer.

• Liver function tests, Chest x-ray to look for metastatic disease.

• 
  Step IV: Decision about changing patients location

• After initial workup admit patient for elective surgery.

• Surgery consult.

• Get type and cross, CBC, Chem 12, EKG, CXR,PT, PTT, LFT, inform consent, NPO, and CEA level prior to surgery.

STEP V: Educate patient and family: After surgery patient should be evaluated every 3-6 months for 3-5 yrs with history, physical examination, fecal occult blood testing, liver function tests, and CEA determinations.

• Colonoscopy is performed within 6-12 months after operation to look for evidence of recurrence and then every 3-5 years.Step VI: Final Diagnosis: Colon Cancer

• X-ray of Abdomen-

• Diagnosis of sigmoid volvulus can be made by using plain abdominal radiographic findings Plain radiographs show a markedly distended sigmoid loop, which assumes a bent inner tube or inverted U-shaped appearance, with the limbs of the sigmoid loop directed towards the pelvis.

• Also dilated gas-filled lumen, can result in a coffee bean–shaped structure; this is the coffee bean sign.

• If Diagnosis is questionable Barium Enema will confirm Diagnosis but is contraindicated in suspected perforation.

• Treatment: IV access- IV Fluid with LR

• GI consult- reason for consult, evaluation and decompression of possible sigmoid Volvulus.

• Sigmoidoscopy- decompression and untwisting of the sigmoid loop with placement of long soft tube
  Step IV: Decision about changing patients location
• Admit to ward
• Continue IV fluids
• Monitor patient for 2-3 days after decompression for persistent abdominal pain and bloodstained stools, signs that may herald ischemia and indicate the need for surgical intervention.

• Consult General surgery- Surgery is reserved for patients in whom tube decompression fails or for those in whom signs of ischemia are suggested.

• Surgery also has a role in an elective situation when the volvulus repeatedly recurs.

• After patient is stabilized, move patient home with office follow-up in 5-7 days.

• 
  Step V: Educate patient and family: Console patient to seek medical care if Nausea, Vomiting , Rectal bleeding or abdominal pain reoccur.Console on low fat, high fiber diet.

• STEP VI: Final Diagnosis Sigmoid Volvulus

CCS DKA vs Hyperosmolar state

• History of present illness: 25 yo woman, with abdominal discomfort and confusion (blood sugar over 600 mg/dL).Note vital signs: BP, Pulse, Resp.

• Rate, Temp.

• Check vitals to make sure pt is hemodynamically stable.

• Is there History of diabetes? (new onset ? )DDX: KDA vs hyperosmolar state
  Step I : Emergent management: A, B, C, D- IV acess followed by 0.9 NS ( pt.with hyperosmolar and hypotension from hypovolemia use NS otherwise ½ NS is prefered because of marked hyperosmolar state) , IV insulin
  Step II :

• Physical Examination General appearance, skin, HEENT/ Neck, Chest/Lung, Heart/ CV Abdomen, Neuro/Psych
  Step III : Diagnostic investigations:

• CBC

• Chem 12

• FSBS

• ABG

• UA

• ABG

• serum ketone

• Amylase and Lipase ( usually positive in abd.

• Cause)

• serum osmolality10.

• EKG1

• HGb A1cTreatment:

• Continue IV hydration with NS until blood sugar is around 250 mg% then consider D5 ½ NS.

• Change insulin to subq instead of IV.

• Monitor potassium , phosphate and Mag.

• And replace.

• 
  Step IV: Decision about changing patients location

• Patient need to admitted to ICU initially then to ward when stable

• After patient is stabilized investigate the cause if is still unclear.

• Discharge home with follow up visit

Step V: Educate patient and family: Educate patient on diabetic diet, exercise , signs of hypoglycemiaFinal Diagnosis: Key points in differentiation between DKA and Hyperosmolar is as follow DKA:

• hyperglycemia >250 Mg/dl

• Acidosis with blood PH<

• Serum bicarbonate <15 meq/dl

• serum positive for ketones

Hyperglycemic hyperosmolar state:

• Hyperglycemia >600 Mg/dl

• Serum osmolality >310 mosm/kg

• No acidosis; blood PH above 3

• Serum bicarbonate >15 meq/L

• Normal anion gap (<14 meq/L).

CCS Acute cholecystitis

Ultrasonography of cholecystitis

• History of present illness: Most likely a 42 year old female was having lunch developed abd pain with nausea and vomiting.

• Note: BP, P, RR, HR, quality of pain, duration of pain.

• DDX-

• Acute pancreatitis

• Ulcer

• Diverticulitis

• Pneumonia

• hepatic abscess

• hepatic tumors

• irritable bowel disease

• Non- ulcer dyspepsia

• Pancreatitis

• 
  Step I : Emergent management: Most likely not needed.

• 
  Step II : Physical Examination General appearance, Heent/Neck, skin, chest/lung, heart/CV , Abdomen

• 
  Step III : Diagnostic investigations:

• CBC w/diff.

• – (leukocytosis 12000- 15000) , Chem12, amylase, lipase, LFT (Ast, Alt, and GGt will be slightly elevated), fasting Lipid profile.

• Upright abdominal X-Ray ( 15% calcium stones)

• USG if questionable do Tc-99m-IDA (HIDA)- if USG shows no stone and HIDA is positive consider Acalculous cholecystitis.

• pregnancy test especially if result not clear or medication is to be given Treatment: For patient who are sick enough to be admitted.

• NPO

• IV Fluid

• demerol for pain

• Nasogastric suction
  Step IV: Decision about changing patients location

• If mild can be treated outpatient with low fat diet and actigall

• Admit If pain is >6 hour and showing toxicity, Jaundice, rigors, or requiring narcotics for pain.

• Admit to ward

• surgical consult- if no perforation or CBD obstruction

• If surgery is to be done prepare with CBC, chem7, CXR,PT, PTT, cross and match, EKG

• Antibiotics cefotetan, or clindamycin and gentamicin

• when patient stabilize discharge homeSTEP V: Educate patient and family: Avoid fatty meals, stop smoking, exercise

STEP VI: Final Diagnosis.Acute cholecystitis

CCS dysfunctinoal uterine bleeding

• History of present illness: A 14 yr AAF girl with profuse vaginal bleeding comes to ER.

• She had her menarche 3 months ago and had irregular bleeding since then.

• Note vital signs: BP, Pulse, Resp.

• Rate, Temp.

• Check vitals to make sure pt is hemodynamically stable.

• If patient unstable do step I.For any female with abnormal vaginal bleeding you should check:

• age of the patient

• Family history of bleeding disorder

• history of irregular cycles

• evidence of bleeding problem on physical exam i.e. petechia

Differential Diagnosis of vaginal bleeding

• dysfunctional uterine bleeding secondary to anovulation

Endometrial Intraepithelial Neoplasia (EIN)

• endometrial neoplasia

• endogenous source of estrogen i.e.

• granulosa cell tumor

• uterine myomas with submucous myomas

• hematologic disorders such as leukemia and idiopathic thrombocytopenia

• endometritis and endometrial polypsIn this 14 year old female with h/o irregular cycles and no other signs on physical exam you should think of DUB secondary to anovulation which usually occurs in extremes of reproductive age, menarch and perimenoposal women.

• 
  Step I:

• Emergent management: A, B, C, D- if patient stable move to step II

• 
  Step II: Physical Examination Do a focus PE: general, skin, chest/lung, heart, abd, genitalia, extremities
  Step III : Diagnostic investigations:

• Pregnancy test

• CBC- will show Hgb 7.0 – do cross and match if patient is hypotensive or symptomatic start IV access and consider NS

• Chem 12 (glucose included), coagulation profile, TSH, ESR

• Most likely in this case all test will be neg.

• except abnormal CBC.

• Treatment: This patient is bleeding profusely and her Hgb is 7.0 so start estrogen IV 25mg q4h x

• And Ferrous sulfate 325 mg. Po tid Bleeding should stop.

• Recheck CBC.

• 
  Step IV: Decision about changing patients location

• Move patient to ward because her Hgb is low.

• Repeat CBC following day and start OCP

• MVI one daily

• Continue ferrous sulfate 325 po tidIf patients Hgb is stable discharge patient home with office follow up in one weekConsult on safe sex.In office repeat CBC if has improved follow up in 3 weeks at that time you may D/C OCP and iron pills if you want to.

• ( 3 weeks of treatment is recommended with OCP).

• If patient desires you can continue OCP.Final Diagnosis: DYSFUNCTIONAL UTERINE BLEEDING

CCS Alzheimer Dementia

• History of present illness: A 79 year old female comes to your office complaining of forgetfulness.

• The first and most important initial evaluation of patient with dementia is History and Physical examination.

• Important clues such as onset, duration, etc..

• will narrow your Diagnosis and required investigating labs.Note vital signs- BP (N= 90-140/60-90), Pulse (N= 60-90, Mean- 72), RR (N= 12-20, Mean- 16), Temp.( N= 37C, 98.6F)Allergy: NKADDX: Alzheimer’s dementia- Most common.Vascular dementia- 2nd Most common.Pick’s disease –3rd most common.Lewy body disease Huntington’s disease Parkinson’s diseaseHIV- Related dementia Head trauma related dementia
  Step I : Emergent management: A, B, C, D- Not needed.

• 
  Step II : Physical Examination General appearance, Skin, Lymph Nodes, HEET/Neck, Chest/Lung, Heart/CV, Abdomen, Extremities, Neuro/Psych.

• 
  Step III : Diagnostic investigations: There are several diagnostic investigations for workup of dementia but H&P exam will narrow the list.

• MMSE

• CXR

• EKG

• CBC/D- To check for anemia.

• UA

• SMA-12- check for electrolyte abnormality

• TSH- to rule out thyroid problem.

• VDRL- To rule out syphilis

• B12 level10.

• BAL- guided by H&P1

• Urine Drug screening and heavy metals- guided by H&P 1

• HIV test – guided by H&P1

• CT – guided by H&P1

• LP- guided by H&P Initial Treatment: Not needed.

• 
  Step IV: Decision about changing patients location

• Some of the test you order may not be available right away, move patient home and schedule office appointment when all results are available.

• Need to see patient initially weekly then monthly.

Treatment

• When Diagnosis of Alzheimer is made by H&P and exclusion of other possible causes of dementia, start either Tacrine or aricept.

• Add Vitamin E – it has shown that may slow progression of Alzheimer

• Treat other complains that patient may have such as insomnia etc.Step V: Educate patient and family:

• Educate patient and family about the disease

• Console patient on driving restriction

• Educate patient on Living will.

• educate patient on exercise and Alzheimer support group.Step VI: Final Diagnosis: Alzheimer Dementia

CCS Chemotherapy Induced Neutropenia

History of present illness: A 50 year old lady with a history of chemotherapy post a successful breast surgery who came to the office with a low grade fever.Patient with history of chemotherapy and fever should make you think about possible infection secondary to immunocompromised status.

• First step is to get a good history and Physical exam.

• PE will help you eliminate any opportunistic infection.

• Note vital signs- BP (N= 90-140/60-90), Pulse (N= 60-90, Mean- 72), RR (N= 12-20, Mean- 16), Temp.( N= 37C, 98.6F)Allergy: NKA

• 
  Step I : Emergent management: A, B, C, D- Not needed.

• 
  Step II : Physical Examination Complete physical exam: General appearance Skin- check for skin lesions Breasts, Lymph Nodes, HEET/Neck- evidence of fungal infection.Chest/Lung- evidence of respiratory infection i.e.

• decreased Breath sound, rales, rhonchi.

• Lungs are the most frequent site of infection in Immunocompromised patients.Heart/CV, Abdomen Genitalia Rectal - look for evidence of fungal infection Extremities, Neuro/Psych.- mental status evaluation looking for meningism or focal deficits

• 
  Step III : Diagnostic investigations:

• CBC/D

• Peripheral blood smear

• Urinalysis, urine culture, sensitivity and Gram stain.

• Blood cultures

• stool culture

• Sputum Gram stain, AFB stain and cultures.

• If skin lesion present culture it

• LP- guided by H&P 9.

• CXR –check for infiltrates, lobar consolidation, cavitary lesions
  Step IV: Decision about changing patients location

• If any of the diagnostic test result is positive or patients' Temp. >38.5 C with Neutrophil count of less than 500 or three elevated Temp.

• >38 C in 24 hours , patient should be moved to ward and board- spectrum antibiotics should be started

• Neutropenic patient without fever can be monitored outpatient.

• Treatment:

• IV access

• Antibiotics- A.

• ceftazidime, carbapenems

B. Mezlocillin, piperacillin or azlocillin plus an aminoglycoside or third generation cephalosporin.

• Treat for 10-14 days or until Neutrophil count is >500.

• Consider use of Neupogen (G-CSF)
  Step V: Educate patient and family: Console patient to avoid people with cold/flu Console patient to seek medical help if a fever develops

Step VI: Final Diagnosis: Chemotherapy Induced Neutropenia

CCS breast mass

Breast cancer illustrations

• Breast mass work up: complete physical

• Mammography and Ultrasound(to determine cystic or solid)

• Fine needle aspiration if + then Biopsy

• Determine the receptors status

• CXR-LFT-CBC-Chem 7-Blood type/cross match-Pt/PTT/abdominal CT.

• EKG Consult surgery why? Breast Lumpectomy Consult oncology why ? evaluate for chem/hormon/radio therapy

• Counselling: Pt

• Counselling family: advance directive More steps:

• CT scan of brain with contrast/MRI

• Bone scan, alkaline PO4ase

• Liver USG if metastasis is suspected.

CCS Drug Toxicity: Benzo and barbiturate

50 yr women in er collapsed in work found with whisky no medication found, friend says taking something for sleep, not responding, breathing, VS stable.

• Step1 Order: Oxygen / PULSE OXYMETRY / iv access / IVF NS /Ekg monitor /catheter, foley endotracheal intubation (this pt's respiration is ok, no need of mechanical ventilation, but you need intubation for gastric lavage in obtunded pt)

• PE : Complete physical. Order : glucose, finger stick naloxone + Dextran + Thiamine (bolus) CBC / SMA 12 / UA /urine txicology BAL /ABG / CT head lFT blood level, aspirin/aceto ( not this case) gastric lavage charcoal, activated (good in both, repeat in 2-3 hrs) sodium bicarbonate (good in both) Interval H&P result : In benzo, flumazenil i/v In barbi, No specific antidote, continue...above RX Move to ICU' vitals q 1 hr Intake & output If pt.

• continue to detoreate consider charcoal hemoperfusion. cathartics >magnesium sulfate counsel family for advance directives consult psych> (suicide/depression)

CCS Drug Toxicity: Antidepressant

• depressed elderly pt in coma, respi dep..

• widened qrs on ekg..tca overdose.

• ensure ABC

• Order: ordered oxygen, iv access and gave triple combo (thiamine, dextrose 50% and naloxone-all are iv bolus) (Don't go first for physical exam in this case.

• Unconsciousness/unstable pt warrants urgent treatment)

• Do brief physical of 3min

• start her on normal saline,

• Labs: cbcd, SMA12 EKG 12 lead, cxr portable, pulse ox, ekg monitoring, UA urine drug screen, blood alcohol, blood aspirin and bl acetaminophen level,

• Rx: Gastric lavage.

• (which revealed pills fragments) Activated charcoal with intermittent gastric suctioning Induce alkalinisation with NaHCo3 to maintain pH of

• 45 to 55 If he is intubated hyperventilate to a PCo2 not< 25mmHg If ECG normal and patient is asymptomatic, observe for 6 hrs in ER otherwise admit into icu After Admission ECG should be normal for 24hrs to discharge for psychiatric disposition

• counsel to stop alcohol.

CCS Vaginal Bleeding

a 13 yo female came to office with mother with c/o increase amount fo bleeding and weakness..

• Period are heavy from last two time.

• C/o back pain and taking some NSAID.

• Feeling week and some pale.

• H/o of father bleed excessively in past during dental extraction.

• Two brothers are ok.

• My provisional Dig was VONWILLEBRAD DISEASE.

• I will briefly tell what I did and where I found problem with soft wear of CCS.

• 1) CBC, Preg teat, UA SMA

• pt, ptt

• 2) result shows anemia Hb 8, pt normal ptt slightly elevated and preg neg.PLT ok.

• I ordered BT , factor viii, Xi, von willebrand factor, transfer to hospital.

• Repeat Cbc in 2 hours.

• IVF, type and cross

• 3) BT was 17, I started DDAVP cryoprecipitate, transfuse one RBPC.

• 4) Pt ok in in next 6-8 hors bleeding reduced and feeling better.

• 5) could not DC pt but advised general counseling age appropriate and counseling to brothers, watch for bleeding in future, avoid ASP.

• etc

CCS MVA

A 45 yo male with MVA.

• No seat belt, steering broken, no loss of consciousness pt breathing ok, pain on chest bruised, conscious.

• My initial impressions was Cardiac tamponade or Aortic rupture. 1) Did ABC, IVF, oxygen, cervical spine precautions,

• 2) cbs, EKG, , Basic metabolic panel, pt , ptt, blood alcohol level, Chest X-Ray, X-ray extremities, spine, abd xray et, VS, m onitoring.

• Pain killer

• 3) chest X-ray sternal fracture, all ok, pt some SOB and distress,

• 4) Ct chest, called ortho,

• %0 orths said no intervention needed, Ct showed fluid in pericardial space

• 5) stat pericardiocentesis, admit to ICU, monitoring,

• 6) pt got better.

• Next day much better

• Again time is very short in CCS , I could not do repeat CT or DC pt.

• B/c when we orders so many thing its take time to see result and by the time case end.

• 7) Did some counseling, seat belt, age related and etc

CCS Black kid with pain

A 7 yo old black kid with pain, chest pain, fever, mild distress ( office ) pt know case of sickle cell disease and on prophylactic penicillin and had pnuemococcal vacine.

Sickle Cell Anaemia red blood cells in blood vessels

• 1) CBC Basic metabolic panel, UA chest X-ray , ul abdomen, LFTs, bilirubin, ivf, oxygen, meperidine.

• I did not order peripheral smear or Hb electrophoresis as knowing that its known case of SSD and we are going to see sickle cell. My prov Dig was SICKEL CELL CRISIS AND ACUTR=E CHEST SYNDROME

• 2) Hb 7, last was Transfer to hospital with continue oxygen , meperidine iv, ceftriaxone, IVF

• pt better next day.

• Dc iv meperidine, started PO ,

• 3) advised Hydroxyurea and hydration.

• Again it’s hard to keep track with time of soft wear and to understand when to dc drug or dc patient.

• 4) did some counseling with drug adherence, hydration Dc ceftriaxone and stated PO, was already on PNC and vaccine.

CCS dec urine output

A 35 you hispanic female, s/p repair of femur fracture, next day nurse said UOP 80 cc in last 8 hours.

• Pt ok but c/o some pian.

• Other exam ok.

• pT IS ON SOME CEPHALOSPORIN( PROBABLY CFOREXIME AND SOME PAON KILLER which was not apparent NSAID, was like phenylpyrazole? or Meperidine ( don't remember exactly).

• MY PROV DIAGNOSIS WAS ATN 1) did initial labs, Urine creatinine, urine eosinophil, urine sodium ( did not do FeNa).

• 2) there was granular cast an dno leukocyte, so I ruled out interstitial nephritis and urine NA was 4BUN 28 and cret

• 5 I was sure its renal Failure due to intrinsic problem and culprit is eigher cefalosporins or pain killer.

• I was not sure pain kille ris NASAID or not so i d/c cephalosporin.

• I am not sure I idi right or wring.

• I checked and it is not see cephalosporins cause ATN, they cause nephritis.

• 3) continue with Frusemide and fluid and some basic counseling

• Tried to counsel to avoid nephrotoxic but could not.

• Final Diagnosis I made ATN and Renal failure.

CCS 57 yo with cough

A 57 yo WM c/o mild cough , no other symptoms, no weight loss, h/o smoking but quit 3 years back, mild fever.

• Chest exam with decrease BR on left base

• My initial impression was b/w CAP or cancer

• 1) stared with simple test CBC, sputum gram stain.

• UA chest x-ray .eat,

• CBC with wbc high, net, chest xray with LFT lower consolidation and sputum with big amount of from pos cocci.

• I treat with Azithromycin, cough syrup and f/u in one week.

• also orders sputum c/s

• 2) did not get well in 10 week , c/o some blood in sputum..

• Did Ct chest and found mass at l lung.

• 3) request bronchoscope , consult oncologist and

• diagnose os Post obstructive Pneumonia and Lung cancer.

• By the time case finished.

CCS A 72 yo with mild progressive SOB

A 72 yo with mild progressive SOB, hx of HTN and MI , on enalapril , office, PND and otherwise ok.

• On exm am some b/l pitting edema and no JVP or other s/s of acute heart Failure or Pulmonary edem a. My prov diagnosis was Con hear failure sec to HTN or IHD

• 1) CBC, SMA

• cxr, ekg , echocard, lipid.etc as an out patiet.

• 2) results showed hypertrophy, axis dev, akinesia , EF was not given in report.

• 3)Next vist in 3 days, HCTZ and Digoxin, coucseeling few things, low sad, low choles, exercise, compliance with drug and f/u in 2 weeks.

• 4) pt was better, I checked SMA

• ( I did mistakes and forgot to see Dig level but there was no /s/ of toxicity) pt was better.

• 4) f/u in 4w, and 3 monts pt better.

• Final Diag CHF ( I did not add B blocker b/c was not sure about EF and he was already on ACE inhibitor.

• For got to add ASA too.

CCS a 45 yo IV drug abuser, fever, SOB, track marks

CCS a 45 yo IV drug abuser, fever, SOB, track marks

• My initial impression was Acute bac endocarditis ( like every one wil do)

• ivf, oxygen, orders initial test , Blood c/s, cxr, cbs, urine tox, hep panel , VDRL, etc

• 2) started on iv nafcillin and genata.

• 3) admitted to ICU ( I don’t know floor was better, let me know)/with cardiac monitoring.

• 4) did not get temp down next day.

• Cont AB and send another set of Blood c/s.

• consent for HIV test.

• orders Echo, showed, vegetation on TV.

• again its very hard to keep track of pt and what test to order here.

• its theoretically looks easy but soft wear is strange.

• May I did not do much practice, but I did practice.

• I could not see result of V Blood c/s in one week.

• Time was running.

• So I changes AB to Vanco and Genta b/a pt was still having fever.

• 5) did some counseling, safe sex, drugs etc etc, HIV test did not come back, Hepatitis and vdrl was negative. My Final Giag was Acute bacterial endocarditis, I did two important step like blood c/s and start AB before result which are life saving.

• I did know this is what USMLE want to see or to manage case entirely which was difficult for me.

• 4) in one week pt temp same

CCS 35 yo legal assistance female with non bloody diarrhea

CCS 35 yo legal assistance female with non bloody diarrhea weakness and pain in RLQ,

• My initial impression was, CROHNS disease

• 1) did usual lab after IVF.

• LFT, CBS, PT, stool ova nd parasite, c/s, smairon study, b12, FA

• 2) bi2 was low, iron very low anemic, mass on RLQ, abd series ok.

• 3) did barium ( upper GI) some time we can do colonoscopy or sigmoid, I chose to do Barium

• , admit to ward, NPO, TPN, B12, Iron,

• 4) barium neg , did colon scope showed ileum with cobble stone pattern no mucosa inflamed.

• 5) stated Masalamine and prednisone and all nutritional aids.

• 6) counseling few things, high fiber diet.

• and drug compliance and education.

• could not f/u or DC.

• It was chronic problem , to DC pt and f/u.

• B/c management takes time and every case finished in1-=20 minutes or earlier

• Final Diagnosis was Crohn's disease

• I mean I could not see how pt did and long term follow up.

• How much it is important in CCS.

CCS 45 yo female with discharge, itching

45 yo female with discharge/ itching came to office other wise healthy healthy and lst pap smear was 15 months back and normal

• My initial Impression was Bacterial vaginosis

• 1) did preg test, UA koh prep, wet mount smear, CBC

• 2) showed trichomonas and lot of clue celle

• 3) treated with Metronidazole

• 4) Pt was happy in next 10 days.

• 5) Scheduled Pap smear and mammogram in next month ( to get rid of infection.

• General counselling. Add more here... Recent CCS cases

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