Usmle Step 3 CCS cases part 2

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Case 01: Acute Cystitis

LocationLocation: Office Presenting complaint: A 25-year old white female presents with burning micturition. Vitals: Pulse: 80/min, B.P: 130/80 mm Hg, Temp:990F, R.R:14/min, Height: 67 inches (167.5 cm), Weight: 79 Kg (173.8 lbs). HPI: A 25-year-old personal secretary at a local office presents with the complaints of three days of burning micturition, urgency, and frequency. She had to pass urine 10 times yesterday. She also complains of suprapubic discomfort. There is no vaginal discharge, fever, hematuria, or flank pain. She has no previous history of STD or UTI. ROS is unremarkable. She has no known allergies. Medications: None. SH: She is a personal secretary at a local office.

She has been married for five years and has no children. She has been smoking 10 cigarettes for the last seven years and drinks alcohol on weekends. She is sexually active in a monogamous relation with her husband. They have not been practicing contraception. Her last menstrual period was 3 weeks ago. How do you approach this case? This young female has dysuria. Her dysuria may be due to acute pyelonephritis, acute cystitis, acute pelvic inflammatory disease, acute urethritis, or acute cervicitis. You should come up with the differential diagnosis of a dysuria in a young woman. Now, perform a focused physical examination on this patient. Order physical examination: Abdominal Pelvic exam Here are the findings: Suprapubic tenderness present Normal Pelvic examination No Urethral and vaginal discharge No costovertebral angle tenderness Small discussion: This is probably a straightforward case of acute cystitis. The patient has no systemic signs of infection. So, she probably does not have acute pyelonephritis. A patient with pyelonephritis usually presents with a history of fever, chills, and flank pain. For acute uncomplicated pyelonephritis, oral ciprofloxacin for out-patients or IV ceftriaxone for hospitalized patients is appropriate therapy. The duration of treatment is usually 14 days. This patient is in a monogamous relationship with her husband and there is no history of vaginal discharge, so conditions like acute urethritis, cervicitis or acute PID are highly unlikely. A single oral dose of azithromycin or a 7-day course of doxycycline can be administered for chlamydial genital tract infections. For gonococcal genital tract infections, a single IM injection of ceftriaxone is the treatment of choice. Begin therapy for acute cystitis after confirming the diagnosis of acute cystitis by demonstrating pyuria on urine analysis. Cultures are generally not required for acute uncomplicated cystitis. Treatment with 3-day TMP-SMZ is appropriate.

The most important part of this case is whether your order pregnancy test or not. This patient is not using contraception and her LMP was 3 weeks ago. She might be a pregnant from the past 5-7 days. So, order serum pregnancy test before prescribing antibiotics. ORDERS: Urine analysis, routine Serum pregnancy test, stat RESULT: Serum pregnancy test is positive

Urine appearance Turbid/ yellow
pH 5.6 (normal 4.1-8.0)
Specific Gravity 1.016 (normal 1.003-1.030)
Bilirubin Negative
Ketones Negative
Glucose Negative
Blood Negative
Leukocyte Esterase Positive
Nitrite Positive
Protein Negative
Microscopic Analysis:

Epithelial cells -
Bacteria 20-30/hpf
RBC/WBC Casts -
WBC 30-40/hpf
RBC 3/hpf
Crystals -
Mucus -

Review order: Oral Amoxicillin continuous (for 7 days) Followup for prenatal assessment Prenatal vitamin Consider counseling about the following: Smoking cessation Limit alcohol Regular exercise Use of seat belt Medication compliance Patient education Primary Diagnosis: Uncomplicated acute cystitis and Pregnancy Treatment of uncomplicated cystitis: Normal healthy women a 3 day TMP-SMZ Diabetic women, symptoms for >7 days, recurrent UTI, >65 yrs age group a 7 day TMP-SMZ Pregnancy a 7-day amoxicillin; if the patient is allergic to penicillin – 7-day nitrofurantoin

Case 02: Alzheimers

LocationLocation: office Presenting complaint: A 75-year-old white male presents with forgetfulness. Vitals: Pulse:75/min, B.P:110/75, Temp:98.6 F, R.R:16/min, Height:72 inches (180 cm), Weight:65kg (143 lbs). HPI: A 75-year-old white male is brought to the outpatient clinic by his son with the complaint of forgetfulness for the last two years. He reports that his forgetfulness was mild initially but it has gradually worsened and now he cannot continue his routine activities of daily life. He has also developed paranoid features and accuses his son of mixing poison in his food. He eats and sleeps well, does not take any recreational drugs, smoke or drink alcohol. He has been sexually inactive since the death of his wife 15 years ago. There is no history of CAD or stroke. An older sister has a history of dementia. He has no known allergies. He takes docusate for constipation. FH: Father died of MI at 68 and mother died of breast cancer at 55. His rest of the ROS are unremarkable. How to approach this case? This patient has presented with progressive memory loss, which is most likely due to dementia. Complete physical examination to detect some occult/atypical medical illness should be performed. Neurological examination is of special consideration, which may help us detect focal neurologic deficits due to stroke; rigidity or tremors due to Parkinson’s disease. Patient with Alzheimer’s does not present with motor deficits. Perform the physical examination: General HEENT/Neck Neuropsychiatric examination Chest/lung examination Heart/CVS examination Abdominal examination Rectal examination Genital examination Lymph node examination Extremities Skin Results of the physical examination:

    GeneralThe patient is alert but appears poorly groomed.
    HEENT Thyroid gland is normal, no other abnormality found. 
    Abdominal examinationWNL
    Rectal examinationNormal sphincter tone and prostate; brown colored stools 
    with no evidence of occult blood; no palpable masses. 
    Chest/lungsWNL 
    CVSWNL 
    Lymph node examination No lymphadenopathy 
    Neuropsychiatric examinationOn Mini-mental state examination he can’t 
    spell ‘world’ backwards, calculate, copy designs, recall objects or follow 
    3-stage commands.

Discussion:

The major dementia syndromes include Alzheimer’s disease, Parkinson’s and Lewy 
body dementia, vascular dementia, frontal lobe dementia, and reversible 
dementia.

DSM-IV criteria for the diagnosis of Alzheimer’s disease:

  Gradual impairment of cognitive function resulting in social or occupational 
  dysfunction; 
  Impaired recent memory with one or more of the following: impaired executive 
  function, impaired visual processing, impairment of skilled motor 
  activities; 
  Absence of other psychiatric, neurologic or systemic diseases; 
  Occurrence of deficits not exclusively in the setting of delirium 
Vascular dementia is suggested by the presence of abrupt onset of symptoms 
with stepwise deterioration, focal neurologic findings on examination, and 
presence of infarcts on CT scan. 
If dementia is due to Parkinson’s disease, typical features like rigidity, 
tremor and bradykinesia will be evident. The recurrent graphic visual 
hallucinations and delusions are the most characteristic feature of associated 
dementia. 
In frontal lobe dementia there is impairment of executive function, behavior 
is disinhibited, and cognitive function is normal or minimally abnormal. These 
patients don’t have insight of their problem. 
Many causes of dementia are reversible and they include the followings: 
medication induced; metabolic disorders like vitamin B12 deficiency, thyroid 
problems, hyponatremia, hypercalcemia; alcohol related; hepatic, and renal 
dysfunction; normal pressure hydrocephalus, and CNS disorders like tumors and 
hematomas. 
The American Academy of Neurology recommends routine non contrast CT/MRI of 
the head, vitamin B12 level, and TSH level in all patients with dementia. 
There are no clear evidence to support or refute ordering "routine" laboratory 
studies such as a CBC, BMP. and LFTs. Screening for neurosyphilis is done only 
when there is high index of suspicion. Test for HIV should be considered in a 
high-risk patient, but it is not a routine part of investigations.

Thus, we will order the following tests Order routine: CBC with differential, routine BMP (Na, K, Cl, Co2, BUN, Cr, Blood glucose, Ca), routine LFTs Serum TSH Serum B12 Serum folic acid Non-contrast CT scan of head Result of Labs: CBC WBC counts of 12,000/micro-L with 85% neutrophils

    BUN 11 mg/dL 
    Serum creatinine 0.7 mg/dL 
    Blood glucose 110mg/dL 
    Serum calcium 9.5 mg/dL 
    Serum TSH Normal 
    Serum electrolytes Na is 140 meq/L, K is 4.0 meq/L, Cl is 100 meq/L. 
    LFTs WNL 
    CT scan of head Moderate to severe cortical atrophy

So based on the history, examination and lab results, the most likely diagnosis in this patient is Alzheimer’s disease.

Order review: Oral Donepezil, continuous (As cholinesterase inhibitors can improve cognitive function in patients with AD) Oral olanzapine, continuous for treatment of delusions in AD, atypical antipsychotics are preferred. The older low potency typical neuroleptics like chlorpromazine are highly sedating, and have anticholinergic side effects (May worsen memory). High potency neuroleptics like haloperidol are associated with high incidence of extra pyramidal side effects.

Counsel patient: Advance directives Alzheimer’s support group Patient education Family counseling about safety plan regarding cooking, driving, and falls. Supportive care SSRI (Fluoxetine) antidepressants if depression is present Buspirone if patient has anxiety Temazepam is the drug of choice if the patient has sleep problems. Do not use short acting sedatives like triazolam as they exacerbate mental confusion. Primary Diagnosis: Alzheimer’s disease

Case 03: Unstable Angina

Case 04: Antenatal Care Case 05: Ulcerative Colitis Case 06: Irritable Bowel Syndrome Case 07: COPD Case 08: Depression Case 09: Hypertensive Emergency Case 10: Foreignbody Aspiration Case 11: Breast Lump Case 12: DKA Case 13: Narcotic Poisoning Case 14: TIA Case 15: PID Case 16: G6PD Case 17: Cystic Fibrosys Case 18: Ectopic Pregancy Case 19: Hemophilia Case 20: Asthma Case 21: Constipation Case 22: CHF Case 23: ARF Case 24: DUB Case 25: Croup Case 26: Gastroenteritis Case 27: Appendicitis Case 28: Bronchiolitis Case 29: Septic Arthritis Case 30: Acute Pericarditis Case 31: Cellulitis Case 32: Splenic Rupture Case 33: PCP Case 34: Renal Cell Carcinoma Case 35: Candida Vaginitis Case 36: HTN Office Management Case 37: Turners Syndrome Case 38: Acute Diverticulitis Case 39: Child Abuse Case 40: Perforated PU Case 41: PCOD Case 42: Menopause Case 43: Alcohol Withdrawal Case 44: Carcinoma Colon Case 45: Infant Jaundice Case 46: Nephrotic Syndrome Case 47: Child Pneumonia Case 48: Child Intoxication Case 49: Pulmonary Embolism Case 50: Gout Case 51: Headache Case 52: Hyperthyroidism Case 53: Lead Poisoning Case 54: Lung Cancer Case 55: Meningitis Case 56: DVT Case 57: Ovarian Cancer Case 58: Sigmoid Volvulus Case 59: Febrile Neutropenia Case 60: Acute Cholecystitis Case 61: Infective Endocarditis Case 62: Atrial Fibrillation Case 63: Pericardial Tamponade Case 64: Acute Pancreatitis Case 65: Hepatitis A Case 66: UGI Bleed Case 67: LGI Bleed Case 68: Complete Heart Block Case 69: Rhabdomyolysis Case 70: Pneumonia Case 71: TB Case 72: Acute prostatitis

1)LocationLocation: Office Presenting complaint: A 25-year old white female presents with burning micturition. Vitals: Pulse: 80/min, B.P: 130/80 mm Hg, Temp:990F, R.R:14/min, Height: 67 inches (167.5 cm), Weight: 79 Kg (173.8 lbs). HPI: A 25-year-old personal secretary at a local office presents with the complaints of three days of burning micturition, urgency, and frequency. She had to pass urine 10 times yesterday. She also complains of suprapubic discomfort. There is no vaginal discharge, fever, hematuria, or flank pain. She has no previous history of STD or UTI. ROS is unremarkable. She has no known allergies. Medications: None. SH: She is a personal secretary at a local office.

She has been married for five years and has no children.  She has been smoking

10 cigarettes for the last seven years and drinks alcohol on weekends. She is sexually active in a monogamous relation with her husband. They have not been practicing contraception. Her last menstrual period was 3 weeks ago. How do you approach this case? This young female has dysuria. Her dysuria may be due to acute pyelonephritis, acute cystitis, acute pelvic inflammatory disease, acute urethritis, or acute cervicitis. You should come up with the differential diagnosis of a dysuria in a young woman. Now, perform a focused physical examination on this patient. Order physical examination: Abdominal Pelvic exam Here are the findings: Suprapubic tenderness present Normal Pelvic examination No Urethral and vaginal discharge No costovertebral angle tenderness Small discussion: This is probably a straightforward case of acute cystitis. The patient has no systemic signs of infection. So, she probably does not have acute pyelonephritis. A patient with pyelonephritis usually presents with a history of fever, chills, and flank pain. For acute uncomplicated pyelonephritis, oral ciprofloxacin for out-patients or IV ceftriaxone for hospitalized patients is appropriate therapy. The duration of treatment is usually 14 days. This patient is in a monogamous relationship with her husband and there is no history of vaginal discharge, so conditions like acute urethritis, cervicitis or acute PID are highly unlikely. A single oral dose of azithromycin or a 7-day course of doxycycline can be administered for chlamydial genital tract infections. For gonococcal genital tract infections, a single IM injection of ceftriaxone is the treatment of choice. Begin therapy for acute cystitis after confirming the diagnosis of acute cystitis by demonstrating pyuria on urine analysis. Cultures are generally not required for acute uncomplicated cystitis. Treatment with 3-day TMP-SMZ is appropriate.

     Urine appearance Turbid/ yellow 
     pH 5.6 (normal 4.1-8.0) 
     Specific Gravity 1.016 (normal 1.003-1.030) 
     Bilirubin Negative 
     Ketones Negative  
     Glucose Negative 
     Blood Negative 
     Leukocyte Esterase Positive 
     Nitrite Positive 
     Protein Negative

Microscopic Analysis:

     Epithelial cells - 
     Bacteria 20-30/hpf 
     RBC/WBC Casts - 
     WBC 30-40/hpf 
     RBC 3/hpf 
     Crystals - 
     Mucus -

2) LocationLocation: office Presenting complaint: A 75-year-old white male presents with forgetfulness. Vitals: Pulse:75/min, B.P:110/75, Temp:98.6 F, R.R:16/min, Height:72 inches (180 cm), Weight:65kg (143 lbs). HPI: A 75-year-old white male is brought to the outpatient clinic by his son with the complaint of forgetfulness for the last two years. He reports that his forgetfulness was mild initially but it has gradually worsened and now he cannot continue his routine activities of daily life. He has also developed paranoid features and accuses his son of mixing poison in his food. He eats and sleeps well, does not take any recreational drugs, smoke or drink alcohol. He has been sexually inactive since the death of his wife 15 years ago. There is no history of CAD or stroke. An older sister has a history of dementia. He has no known allergies. He takes docusate for constipation. FH: Father died of MI at 68 and mother died of breast cancer at 55. His rest of the ROS are unremarkable. How to approach this case? This patient has presented with progressive memory loss, which is most likely due to dementia. Complete physical examination to detect some occult/atypical medical illness should be performed. Neurological examination is of special consideration, which may help us detect focal neurologic deficits due to stroke; rigidity or tremors due to Parkinson’s disease. Patient with Alzheimer’s does not present with motor deficits. Perform the physical examination: General HEENT/Neck Neuropsychiatric examination Chest/lung examination Heart/CVS examination Abdominal examination Rectal examination Genital examination Lymph node examination Extremities Skin Results of the physical examination:

     GeneralThe patient is alert but appears poorly groomed.
     HEENT Thyroid gland is normal, no other abnormality found. 
     Abdominal examinationWNL
     Rectal examinationNormal sphincter tone and prostate; brown colored stools 
     with no evidence of occult blood; no palpable masses. 
     Chest/lungsWNL 
     CVSWNL 
     Lymph node examination No lymphadenopathy 
     Neuropsychiatric examinationOn Mini-mental state examination he can’t 
     spell ‘world’ backwards, calculate, copy designs, recall objects or follow 
     3-stage commands.

Discussion:

 The major dementia syndromes include Alzheimer’s disease, Parkinson’s and Lewy 
 body dementia, vascular dementia, frontal lobe dementia, and reversible 
 dementia.

DSM-IV criteria for the diagnosis of Alzheimer’s disease:

   Gradual impairment of cognitive function resulting in social or occupational 
   dysfunction; 
   Impaired recent memory with one or more of the following: impaired executive 
   function, impaired visual processing, impairment of skilled motor 
   activities; 
   Absence of other psychiatric, neurologic or systemic diseases; 
   Occurrence of deficits not exclusively in the setting of delirium 
 Vascular dementia is suggested by the presence of abrupt onset of symptoms 
 with stepwise deterioration, focal neurologic findings on examination, and 
 presence of infarcts on CT scan. 
 If dementia is due to Parkinson’s disease, typical features like rigidity, 
 tremor and bradykinesia will be evident. The recurrent graphic visual 
 hallucinations and delusions are the most characteristic feature of associated 
 dementia. 
 In frontal lobe dementia there is impairment of executive function, behavior 
 is disinhibited, and cognitive function is normal or minimally abnormal. These 
 patients don’t have insight of their problem. 
 Many causes of dementia are reversible and they include the followings: 
 medication induced; metabolic disorders like vitamin B12 deficiency, thyroid 
 problems, hyponatremia, hypercalcemia; alcohol related; hepatic, and renal 
 dysfunction; normal pressure hydrocephalus, and CNS disorders like tumors and 
 hematomas. 
 The American Academy of Neurology recommends routine non contrast CT/MRI of 
 the head, vitamin B12 level, and TSH level in all patients with dementia. 
 There are no clear evidence to support or refute ordering "routine" laboratory 
 studies such as a CBC, BMP. and LFTs. Screening for neurosyphilis is done only 
 when there is high index of suspicion. Test for HIV should be considered in a 
 high-risk patient, but it is not a routine part of investigations.

     BUN 11 mg/dL 
     Serum creatinine 0.7 mg/dL 
     Blood glucose 110mg/dL 
     Serum calcium 9.5 mg/dL 
     Serum TSH Normal 
     Serum electrolytes Na is 140 meq/L, K is 4.0 meq/L, Cl is 100 meq/L. 
     LFTs WNL 
     CT scan of head Moderate to severe cortical atrophy

So based on the history, examination and lab results, the most likely diagnosis in this patient is Alzheimer’s disease.

3) LocationLocation: Emergency room Vitals: Pulse: 80/min; B.P: 145/90 mm Hg; Temp: 98.8 F; R.R: 16/min; Height: 72 inches (180 cm); Weight: 72 Kg (158.4 lbs) . CC: Severe chest pain HPI: A 60-year old white male comes to E.R with a two- hour history of severe central chest pain that began while relaxing on the couch at home. The patient denies any exertional activity prior to the onset of symptoms. The pain is constant, 9/10 in severity, crushing in quality, and radiates to the left side of the jaw and left shoulder. There is associated nausea without vomiting. Over the past two months he has experienced several episodes of exertional chest pain while at work. The pain is usually relieved with rest. He did not seek any medical attention thinking that the pain was work related muscle spasms. Medical problems include hypertension for which he has been taking hydrochlorothiazide the past 10 years. He has no known allergies. FH: His father died of MI when he was 55. Mother is 85 yrs old and healthy. SH: He has been married for 34 years and has two sons. He is not sexually active. He has a 30-pack per year smoking history. He drinks moderate amounts of alcohol on weekends, but denies the use of recreational drugs. He is a truck driver. ROS: Denies headaches, vision changes, tinnitus, or vertigo. Denies muscle tenderness, joint pain, stiffness, or weakness. Rest of ROS is unremarkable. How to approach this case? This patient has come to the ED with chest pain of recent onset which has many causes and some of them may cause sudden death. Therefore, all such patients should be transported to ED immediately. Oxygen, IV access, cardiac monitoring, and EKG need to be done as soon as possible. Aspirin is given if MI is likely.

Therefore, we should order the following: Order: Continuous supplemental oxygen Oral Aspirin Sublingual nitroglycerin 0.4 mg every 5 minutes x 3 as needed for chest pain Continuous pulse-oximetry Intravenous access Continuous cardiac monitoring Continuous BP monitoring EKG, 12 Lead, stat

The history and physical examination complemented by selected tests such as chest X-ray, EKG, cardiac enzymes allow the physician to accurately diagnose most causes of chest pain, especially CAD. Therefore, we will also do the following Physical Exam: General appearance HEENT/Neck Heart examination Lung examination Abdomen Rectal exam (As this patient may require Heparin for CAD) Musculoskeletal (for possible DVT) Order: Chest X-ray, PA, portable, stat Cardiac enzymes, CK-MB and troponin-T, stat and every 8 hours x 2, Results:

     Chest/lungsThe chest wall is normal.  The diaphragm and chest move equally 
     and symmetrically with respiration.  No abnormality is detected on 
     percussion and auscultation. 
     CVSNormal S1 and S2. No murmurs, rubs, gallop, or extra sounds.  Pulses 
     are normal. There is no jugular venous distension.  Blood pressure is 
     equal in both arms. 
     EKGNormal sinus rhythm with 3 mm ST depression and T wave inversion in 
     lead II, III and AVF. 
     Pulse oximetryShows O2 saturation of 96% on 2-lit nasal cannula & 92% on 
     room air. 
     Cardiac enzymes and CXRPending 
     Cardiac monitorNo change of vitals from the time of admission. 
     Heme occultNegative

Patient is still complaining of pain. His history, CAD risk factors such as smoking, HTN, family history, and the EKG findings of T wave inversion suggest the diagnosis of either unstable angina or non-Q wave infarction. In cases of unstable angina, troponins or CK-MB are not elevated but they are elevated in cases of non-Q wave infarcts. However, even in cases of non-Q wave infarcts, troponins levels may not be detectable at initial presentation. We will start heparin and anti-ischemic therapy in this patient. Order review: Shift to ICU PTT/PT stat IV heparin, continuous with every 6 hours PTT or Enoxaparin Q12 hours without frequent PTT monitoring IV nitroglycerin, continuous (blood pressure should be monitored as hypotension may develop) IV Metoprolol 5mg x 3 (5 minutes apart) Bed rest, complete NPO, as this patient may require emergency catheterization Input and output charts CBC with differential, stat and daily to monitor heparin-induced thrombocytopenia Basic metabolic panel (BMP), stat and daily Results: Cardiac enzymes are within normal limits. Discussion: The guidelines for the management of USA/NSTEMI are:

 Bed rest with continuous ECG monitoring in patients with ongoing rest pain.  
 NTG, sublingual, followed by intravenous administration, for the immediate 
 relief of ischemia. 
 Aspirin should be given as early as possible. Clopidogrel is used in patients 
 who are unable to take ASA because of allergic reactions or major 
 gastrointestinal intolerance. 
 Pulse oximetry and/or ABG 
 Supplemental oxygen for patients with cyanosis or respiratory distress 
 IV Morphine when the chest pain is not immediately relieved with NTG or when 
 acute pulmonary congestion and/or severe agitation is present.  
 IV beta-blocker followed by a oral dose provided there are no 
 contraindications. The goal of the treatment is to bring the heart rate down 
 to 60-70/min. If there are any contraindications for beta blockers and the 
 patient is having continuous or frequently recurring, a nondihydropyridine 
 calcium antagonist (e.g., verapamil or diltiazem) can be used as initial 
 therapy in the absence of severe LV dysfunction or other contraindications.  
 Routine use of ACEI to all patients with USA/NSTEMI is a class II 
 recommendation. However, an ACEI is used when hypertension persists despite 
 treatment with NTG and a beta-blocker, in patients with LV systolic 
 dysfunction and in diabetic patients. 
 Anticoagulation with LMWH or intravenous unfractionated heparin should be 
 added to antiplatelet therapy with ASA and/or clopidogrel. Enoxaparin is the 
 best studied of all. Heparin should be given for at least 2 days. 
 A platelet GP IIb/IIIa antagonist (Tirofiban or eptifibatide) should be 
 administered, in addition to ASA and heparin, to patients in whom 
 catheterization and PCI are planned.  
 Early invasive therapy is indicated for high-risk patients with UA. Patients 
 with refractory ischemia, recurrent symptoms, ST segment depression, and 
 hemodynamic instability are at high risks. These patients should be referred 
 for angiography and revascularization. In the absence of these findings, 
 either an early conservative or an early invasive strategy in hospitalized 
 patients without contraindications for revascularization. 
 Role of statin therapy is conflicting. However, in the acute setting the 
 mechanism of benefit from statin therapy probably involves anti-inflammatory 
 effects rather than the lipid lowering. The other added benefit is, studies 
 have shown that the long term compliance is better if the statins are started 
 before the discharge. 
 Thrombolytic therapy is not indicated in the treatment of USA/NSTEMI and 
 should not be used.

Order review: Shift to ward and continue the above treatment. Repeat 12 lead EKG Order fasting lipid panel LFTs (for baseline before you start statins) Trans thoracic echocardiography Cardiac catheterization Obtain TSH if the patient has abnormal lipids especially elevated triglycerides.

Order review: Aspirin, continuous Sublingual nitroglycerin, continuous as needed Atenolol, oral, continuous Parvastatin, continuous Patient education Cessation of cigarette smoking Limit alcohol Exercise program Medication compliance Relaxation techniques Low sodium diet Follow up visit at two to six weeks Diagnosis: Unstable angina @2002-2003 All Rights Reserved

4) LocationLocation: Office Presenting complaint: A 24-year-old married female presents with nausea and vomiting Vitals: Pulse:82/min, Temp:98.6 F,R.R:15/min, B.P:130/70 mm Hg,Height:162cm, Weight:62 kg (136.4lbs) HPI: A 24-year-old Asian female presents with complaints of nausea and vomiting for the last several days. She feels more nauseated in the morning and also complains of breast pain. Her last menstrual period was 7 weeks ago and before that her menstrual periods have always been regular with a 28-29 day cycle. She was married 8 months ago, is sexually active with her husband, and has never been pregnant. The patient denies abdominal pain, fever or vaginal discharge. She has been a one pack per day smoker since her teenage years. She is not on any medications, does not drink or use recreational drugs. The patient migrated to the United States 5 years ago and does not recall her vaccination history. There is no history of sexually transmitted disease, but she has never been tested for STDs. Recently, she has been experiencing some constipation, other wise her bowel and bladder functions are regular. She is doing well at her office where she works as a secretary and has no emotional stresses. ROS are unremarkable.

     Hospitalization/ProceduresNever 
     Other Medical ProblemsNone            
     AllergiesNone   
     Current MedicationsNone   
     VaccinationsSee HPI 
     Family HistoryFather is healthy at 55; mother is healthy at 45. Maternal 
     grandmother died of breast cancer at 60. She has one older sister who is 
     healthy. 
     Social historySee HPI 
     Recreational historyAttending social events and watching movies

How to approach this case? This young sexually active female has presented with nausea, vomiting and amenorrhea, which are most likely due to pregnancy. Therefore do complete physical examination, which should include abdominal, breast and genital examination to look for signs of pregnancy and order a pregnancy test.

Here are the results: Breast examination: Mild breast tenderness bilaterally. Abdominal examination: Normal Pelvic examination: Bluish discoloration of vulva and vagina present; no vaginal discharge; no vaginal or cervical lesions, uterus is globular and soft; no adnexal masses or adnexal tenderness noted. Rest of the examination is within normal limits. Labs: Urinary beta-HCG, routine

The "gold standard" for diagnosis of pregnancy is the detection of the beta subunit of human chorionic gonadotropin (hCG) by immunologic techniques in blood or urine. When performed in a clinical laboratory, the sensitivity and specificity for both blood and urine pregnancy tests are between 97 and 100 percent. Results: Urinary beta-HCG: positive Discussion: There are many signs of pregnancy, which can be grouped into presumptive, probable and positive categories. Presumptive signs are associated with skin and mucous membrane changes. The dark discoloration of vulva and vagina noted in this woman is called Chadwick’s sign. Probable signs are associated with changes in uterus. Globular shape and softer consistency of uterus is one of the probable signs. Positive signs of pregnancy are the detection of fetal heart sounds and the recognition of fetal movements. Doppler techniques enable us to detect fetal heart sounds as early as 9 weeks of gestation while the stethoscope can detect at 16 weeks. Recognition of fetal movements by an observer is possible at 20-24 weeks. Positive pregnancy testing coupled with findings on history and examination is suggestive of pregnancy. Next, confirm her pregnancy by ultrasound and start antenatal care. Ultrasound will also help us determine gestational age. A standard panel of laboratory tests should be obtained on every pregnant woman at the first prenatal visit. Additional testing of women at risk for specific conditions can augment this panel. The initial laboratory tests recommended by the American College of Obstetricians and Gynecologists are Blood type Antibody screen Rhesus type CBC with differential Basic metabolic panel Pap smear Rubella status Syphilis screen Urinary infection screen Hepatitis B surface antigen HIV counseling and testing Chlamydia Additional laboratory tests commonly performed in at-risk individuals include: Gonorrhea Tuberculosis Red cell indices to screen for thalassemia Hemoglobin electrophoresis to detect hemoglobinopathies (e.g. sickle cell, thalassemias) Hexosaminidase A Cystic fibrosis carrier testing Serum phenylalanine level Toxoplasmosis screen Hepatitis C antibodies

The first prenatal visit is a good time to discuss the patient's responsibilities and the expected course of pregnancy and delivery. Patients should be given information regarding the general plan of management for the pregnancy. Number and frequency of prenatal visits

 Recommendations for nutrition, weight gain, regular exercise (limited), rest, 
 and sexual activity 
 Routine pregnancy monitoring 
 Listeria precautions 
 Toxoplasmosis precautions 
 Abstinence from alcohol, cigarettes, and illicit drugs 
 Information on the safety of commonly used nonprescription drugs 
 Recommendation to continue wearing seat belts during pregnancy 
 Potential problems related to plans for travel, work outside of the home, or 
 hobbies 
 Childbirth classes and breastfeeding recommendations 
 Confidentiality issues

Therefore, we will do order the following in this patient Order Routine: Blood type and antibody screen Atypical antibody titer CBC with differential Basic metabolic panel Pap smear Rubella antibodies RPR Urinalysis Urine culture and sensitivity Hepatitis B surface antigen, serum Anti-HIV by ELISA, serum Transvaginal ultrasound Chlamydia, culture cervix Medications: Vitamin, prenatal, oral Iron sulfate, oral Folic acid, oral (0.4 mg) High calorie diet Regular moderate exercise Patient education Smoking cessation Safety plan Safe sex No illegal drug use No alcohol Drive with seat belt Follow up in 4 weeks

U/A and Urine culture are very important because 5-10 % of pregnant patients may have asymptomatic bacteriuria and untreated patients may develop pyelonephritis.

Follow up visits: Every 4 weeks until 28 weeks Every 2 weeks between 28 to 36 weeks Every week between 36 to delivery Follow up visits: Complete physical examination Wt. Measurement Vitals especially BP Complete urinalysis Fundal measurement Fetal heart rate (110—160/min=N) measurement Glucose screening: In the United States all pregnant women will get 50 gm 1 hr glucose tolerance test between 24-28 wks gestational age. Results >135 is abnormal. If the patient has risk factors, she should be screened at 1st prenatal visit.

Indications for glucose screening on 1st prenatal visit: Age> 25years Obesity Family History of DM Previous infant Wt > 400 gm Previous still born Previous congenitally deformed child Recurrent spontaneous abortions Advise from 2nd Trimester: Promotion of breast-feeding Childbirth classes Danger signs of pregnancy Preterm labor education Primary Diagnosis: Pregnancy @2002-2003 All Rights Reserved

5) LocationLocation: Office C.C: A 28-year-old white male presents with bleeding per rectum. Vitals: Pulse:76/min, B.P:120/70 mm Hg, Temp:98.5 F, R.R:16/min, Height:72 inches (180 cm), Weight:72 Kg (158.4 lbs). HPI: A 28-year-old white male presents with the complaint of having blood per rectum (BRBPR) for a week. His stools are streaked with blood. They are loose, watery, and contain mucus. He has mild colicky pain and a feeling of incomplete evacuation after defecation. He denies any history of nausea, vomiting, fever, weight loss, recent travel, or ill contacts with diarrheal illness. He has been smoking 20 cigarettes a day for the last seven years. He drinks alcohol occasionally and does not use illegal drugs. ROS are unremarkable. He has never been admitted to the hospital. He is not on any medications. He has no allergies. FH: Mother died at the age of 60 due to MI. An older brother has ulcerative colitis. Father is alive and healthy at the age of 65. SxH: Sexually active with his wife. He is a restaurant manager. Approach to the patient:

 Differential diagnosis of rectal bleeding include ulcerative colitis, Crohn's 
 disease, infectious colitis, medication induced (NSAIDs, antibiotics), 
 radiation colitis, ischemic colitis, internal hemorrhoid, anal fissure etc. 
 The common infections include Campylobacter, Escherichia coli 0157:H7, 
 Salmonella, Shigella etc. Consider CMV infections and Kaposi's sarcoma in an 
 immunocompromised patient. C.difficle can sometimes present with bleeding per 
 rectum. It should be considered in all patients who have been on antibiotics. 
 NSAIDs can exacerbate the underlying IBD. 
 Whenever there is visible rectal bleeding in adults an evaluation, either in 
 an inpatient or outpatient setting is necessary depending on the degree of 
 risk. Low risk patients (e.g. self limited rectal bleeding in an otherwise 
 healthy young patient is most likely due to an internal hemorrhoid) can be 
 followed as outpatient. 
 High risk patients, such as those with acute abdomen, hemodynamic instability, 
 or persistent bleeding need to be resuscitated and hospitalized. GI consult 
 should be obtained as soon as possible. After assessing the stability of the 
 patient, the next step is to determine the source of the bleeding. When the 
 left colon is the source, the blood is usually bright red. Dark maroon 
 bleeding or blood mixed with stool is probably from the right colon. Some 
 times the source of the hematochezia is upper GI (in about 11% of patients) 
 and therefore nasogastric lavage should be done in all cases to rule out an 
 upper GI source.  
 In this patient, who is clinically stable, there is no need for resuscitation. 
  This patient is stable, and he is a potential candidate to have ulcerative 
 colitis.  So he needs a complete physical examination including rectal.

Results of your exam: Complete physical examination is unremarkable except rectal examination, which is significant for blood stained stool. This patient is most likely suffering from ulcerative colitis based on his presenting complaints, family history and findings on examination. However, other similar conditions need to be ruled out. Discussion: Typical history coupled with characteristic findings on endoscopy establish the diagnosis of UC, which is confirmed by a biopsy. The presence of ulcerative colitis, in a first-degree relative, is an extremely important clue. Flexible sigmoidoscopy documents the extent of inflammation as well as establishes the diagnosis. Colonic biopsy is particularly helpful when the findings on sigmoidoscopy are equivocal. A barium enema can confirm the diagnosis but is usually not necessary. Colonoscopy is usually not required unless the diagnosis is uncertain. The other problem with colonoscopy is it can cause perforation in a severely ill patient with extensive disease. Order Routine: CBC with differential, routine BMP, routine Stool examination for ova and parasites Fecal leukocytes Stool bacterial culture Liver function tests PT, PTT Flexible Sigmoidoscopy Rectal biopsy Results of labs: CBC with differential, an BMP are within normal limits. Stool for ova and parasites is negative. Stool bacterial culture shows normal flora. LFTs are within normal limits. PT, and PTT are within normal limits. Sigmoidoscopy, and rectal biopsy are consistent with the diagnosis of ulcerative colitis involving the rectum, and distal sigmoid colon. Management of ulcerative colitis: Treatment depends on the severity and extent of the disease.

 Topical therapy with 5-ASA compounds is the treatment of choice (not steroid 
 enemas) for mildly active proctitis or proctosigmoiditis. They are very 
 effective in inducing and maintaining remission.  For proctitis, 5-ASA 
 suppositories are used and enemas are recommended for proctosigmoiditis. 5-ASA 
 enemas are significantly superior in inducing remission and have less side 
 effects compared with steroid enemas.  Although the symptomatic improvement 
 will be seen within a few days, treatment should be continued for at least 
 four to six weeks.  Doses should be tapered off during this time as complete 
 healing takes place. 
 Oral therapy with sulfasalazine or with newer 5-aminosalicylates is the 
 treatment of choice for moderately active proctosigmoiditis. Newer 
 5-aminosalicylates like mesalamine are more costly but have fewer side 
 effects. Folic acid supplementation should be given to patients on 
 sulfasalazine. Steroids are used when these 5-aminosalicylates compounds fail 
 to induce remission. Steroids should not be used for maintenance of remission. 
 Immunomodulator drugs like azathioprine or 6-MP are used when patient becomes 
 steroid dependent or he is refractory to steroids. 
 Patients with severe disease need to be hospitalized and resuscitated with IV 
 fluids and electrolytes. They are kept NPO and given parenteral nutrition. 
 It’s very important to monitor the patient for complications that might 
 develop. Abdominal examination, vital signs, and plain abdominal films are 
 used for this purpose. IV steroids are the most important treatment modality.  
 Role of antibiotics is controversial in this patient population. However, many 
 physicians consider giving broad spectrum antibiotics if the patient has 
 fever, leukocytosis, or any indication of sepsis. Surgery is considered for 
 refractory cases. 
 Antidiarrheal agents like loperamide may be used for symptomatic treatment of 
 diarrhea, and anticholinergic agents for abdominal cramps. Antidiarrheal 
 agents need to be avoided in severely ill patients. 
 Antidepressants or anxiolytics may be required in some cases. Dietary 
 counseling is important in all cases.

ORDER REVIEW: 5-ASA suppositories Loperamide, prn Dicyclomine, prn Diet and nutrition consult Counsel about cessation of cigarette smoking and injury prevention PRIMARY DIAGNOSIS: Ulcerative colitis, mild case involving rectum and distal sigmoid colon @2002-2003 All Rights Reserved

6) LocationLocation: Office Presenting complaint: A 28-year-old man presents with two months of abdominal pain, and altered bowel. Vitals: Pulse:72/min, B.P:130/75 mm Hg, Temp:98.70F, R.R:17/min, Height:70 inches (175 cm), Weight:70 Kg (154 lbs) HPI: A 28-year-old white male presents with the complaints of abdominal pain and altered bowel habits for the last three months. The pain is colicky in nature. It is located in the lower abdomen. The pain does not radiate, is 5/10 in severity, worsens postprandially, and relieves with defecation. For the last three months he has been suffering with diarrhea alternating with constipation. For the last three days, he has been having diarrhea. Stools contain mucus but not blood. Symptoms occur during the day and do not interfere with his sleep or work. His weight and appetite are normal. He is not taking any prescribed or recreational drugs. He smokes 10 cigarettes per day for the last 10 years and drinks alcohol only on weekends. He is currently sexually active with his wife and always uses condoms. He has no other medical problems or known allergies. He is not on any medications. FH: No H/O IBD or colon cancer in the family. SH: Married for 5 years and has a 2 year old daughter. Works at a local university. ROS are unremarkable. How to approach this case? This patient has alternating diarrhea and constipation. This may be due to infectious causes like amebiasis or giardiasis, which are very rare. Irritable bowel syndrome is another possible cause. Bowel obstruction may present with alternating diarrhea and constipation. Colon cancer may also present in this manner, but is unlikely in a 28 year old with no family history of bowel cancer.

Order: A complete physical examination, including rectal, is appropriate in this setting. Results: Completely normal physical examination Now, order the following: CBC with differential, routine Serum TSH, routine BMP, routine (diarrhea is associated with electrolyte abnormalities) FOBT Stool examination for ova and parasites Stool for white cells Stool cultures 24-hour stool collection 24-hour fecal fat estimation Results of labs: WBC count is 8,000/micro-L, hemoglobin is 15.6g/dL, and platelet count is 200,000/micro-L Serum TSH is 1 micro-U/L BMP is normal FOBT is negative Stool does not contain any ova, parasites, or white cells. Stool culture – No growth 24 hour fecal fat is WNL. Order review: Counsel the patient Reassurance Lactose free diet High fiber diet Loperamide, orally, PRN Counseling about cessation of cigarette smoking, limitation of alcohol intake, safe sex practices, and driving with seat belt Follow up visit in 2 weeks Discussion: Clinical features: Irritable bowel syndrome is a diagnosis of exclusion. Abdominal pain and altered bowel habits are the most characteristic features of this entity. Abdominal pain is crampy, located in lower abdomen, aggravated by stress, and relieved by defecation. Patients with IBS have diarrhea, constipation or diarrhea alternating with constipation. Stools contain mucus but no blood. Clinical features that suggest disease other than IBS include fever, weight loss, bloody diarrhea, large volume diarrhea, nocturnal diarrhea, nocturnal pain, anorexia and anemia. Diagnosis: When a clinical presentation is typical of IBS, only a few investigations are ordered. They include CBC and routine chemistry panel in all; thyroid hormones, and stool for ova, parasites, and leukocytes in patients with diarrhea; and flexible sigmoidoscopy in patients over 40, and in patients who have persistent diarrhea. When all the fore mentioned studies are normal, symptomatic treatment is started and patient is reevaluated after 4-6 weeks. If symptoms progress, more detailed studies are warranted. Treatment: A lactose free diet and high fiber diet are considered. A diet that produces gas is discouraged. Anticholinergic drugs for abdominal pain and loperamide for diarrhea are given on a 'as needed basis'. Prokinetic drugs may be used for constipation. Benzodiazepines are used only in cases of acute situational anxiety. Behavioral treatment is a consideration for patients who have some sort of stressor. PRIMARY DIAGNOSIS: IBS @2002-2003 All Rights Reserved

LocationLocation: Emergency room Presenting complaint: A 65-year-old male presents with a chief complaint of severe breathlessness . Vitals: Pulse: 88/min , regular, B.P: 120/70 mm Hg, Temp: 100.5 F, R.R: 25/min , Height: 72 inches (180 cm), Weight: 72 Kg (158.4 lbs). HPI: A 65-year-old white male, with a two-year history of COPD, presents to the ER with an acute onset of severe breathlessness, wheezing, and chest tightness. He also states that his cough has become more severe the past two days and the sputum production has increased in quantity and become yellowish. Other complaints include fever and malaise. He denies any chest pain and does not use supplemental oxygen at home. He continues to smoke 2-5 cigarettes/day. He does not drink alcohol or use illegal drugs. He has no allergies. His current medications are albuterol 2 puffs as needed for SOB. He has no other medical problems. Vaccinations are up to date. He was admitted once in the hospital for exacerbation of COPD. REVIEW OF SYSTEMS:

     Skin No complaints                    
     HEENT No vision changes, epistaxis, or sore throat          
     Musculoskeletal Easily fatigued, chronic left knee pain                  
     Cardio respiratory Frequent productive cough, wheeze, and dyspnea 
     Genitourinary No history of STD or UTI. 
     Neuropsychiatric Not asked      
     Abdominal Occasional heartburn, denies nausea, vomiting, or diarrhea

How to approach this case? Based on his history, this is most likely an exacerbation of COPD.

 Features suggestive of COPD exacerbation include increase in the severity of 
 dyspnea, and a change in the color and quantity of sputum. To assess the 
 severity of exacerbation, ABGs and pulmonary function tests are performed. 
  CXR is done to rule out disorders that mimic COPD exacerbation. ECG is done 
 to detect RVH, arrhythmia and ischemia. CBC is performed to detect 
 polycythemia or bleeding. Serum chemistry may point towards some metabolic 
 cause of COPD exacerbation. Sputum gram staining, culture, and sensitivity are 
 indicated when COPD exacerbation with a purulent sputum fails to respond to 
 empiric antibiotic treatment. 
 PaO2 of < 60 mm Hg and/or SaO2 <90 on room air indicates respiratory failure. 
 PaO2 <50 mm Hg, PaCO2 >70 mm Hg, and pH <7.30 indicate a life-threatening 
 respiratory failure and requires mechanical ventilation with ICU management. 
 A PEF <100 L/min or an FEV1 <1.00 L also indicates a severe exacerbation.

Start with the physical examination: General HEENT Neck Heart examination Lungs examination Abdomen Extremities Results of your examination: The patient is in obvious respiratory distress, sitting upright and using his accessory muscles of respiration. Increased AP diameter of chest, decreased air entry on both sides, and generalized bilateral rhonchi and wheezing. Heart exam: Regular rate, and rhythm,; loud P2 but no murmurs. There is no edema, calf tenderness, or Jugular venous distension. Rest of the examinations is within normal limits. Routine Orders: Sit upright (Head elevation) Pulse-oxy, stat and continuous Supplemental oxygen continuous Intravenous line capped Connect cardiac monitor FEV1, stat and every hour PEFR, stat and every hour EKG, 12 lead, stat CXR, PA, lateral, stat ABG, stat Lab results: PEFR: 0.9L/min FEV1: 0.85L Oxygen saturation: 86% on room air and 94% on 2-litre oxygen via nasal cannula CXR shows hyperinflation of both lung fields and a small infiltrate on the right lower lobe EKG is within normal limits. Start treatment: Nebulized albuterol Nebulized ipratropium Prednisone, IV Levofloxacin (preferred) or amoxicillin, oral, continuous CBC, with differential, stat BMP, stat Lab results: ABG: • pH: 7.38 • PaO2: 53 • PaCO2: 53 mm Hg CBC shows WBC count of 12,000/micro-L with 8% bands. BMP are normal Patient is feeling better and his pulmonary function has improved now after 4 hours of therapy. Review orders: Shift to floor/ward Ambulate as tolerated Input and output chart Vitals Q 4 hours Regular diet Serum theophylline levels if patient is on theophylline Pulmonary toilet (suction upper airway): If the patient is having lot of secretions and is unable to clear them Diuretics are given in cases of cor pulmonale Phlebotomy (> 50 hematocrit) Low sodium diet in cases of cor pulmonale Discontinue the cardiac monitor if the patient's vitals are stable and the acute episode is over DISCUSSION:

 Pharmacological agents used to treat acute exacerbation of COPD include 
 inhaled beta-adrenergic agonists, inhaled anticholinergics, antibiotics, and 
 steroids. 
  Inhaled beta-adrenergic agonists like albuterol are the main stay of 
 treatment for acute exacerbation of COPD and are given via a nebulizer or MDI.

  Anticholinergic bronchodilators like ipratropium are sometimes used along 
 with beta-agonists when more bronchodilation is required. 
 Even though there is no clear evidence, parenteral corticosteroids may be used 
 in hospitalized patients for severe exacerbation. 
 Methylxanthines like theophylline are used for patients who fail with inhaled 
 bronchodilators. It may improve dyspnea, airway function, mucociliary 
 clearance, and central respiratory drive. However, theophylline has narrow 
 therapeutic window and may cause tachyarrhythmias.  
 Antibiotics are indicated when COPD exacerbation is caused by infection. 
 Empiric treatment is done with levofloxacin, amoxicillin, TMP-SMZ or 
 doxycycline. Gram staining and culture of sputum is required in refractory 
 cases. 
 Adequate oxygenation must be maintained by giving supplemental oxygen with 
 goal arterial oxygen tension of >55-60 mmHg and the oxygen saturation of above 
 88-90%. 
 Noninvasive positive pressure ventilation (NIPPV) should be tried initially in 
 selected patients with respiratory failure. However, it is contraindicated in 
 patients with hemodynamic instability (eg, hypotension, serious cardiac 
 arrhythmias). Criteria to use NIPPV include moderate to severe dyspnea, PaCO2 
 of > 45 mmHg or pH of < 7.35 or RR of >25/minute.

Review order: Patient is asymptomatic and his pulmonary function tests have reached his personal best after 2 days of inpatient therapy. Discharge: Send the patient home Follow-up visit at 2 weeks Smoking cessation Alcohol, advice the patient to limit intake Counsel patient, no illicit drugs Patient education Oxygen therapy at home (when PaO2 is less than 55 mm Hg or SaO2 is less than 88 percent, oxygen therapy and cessation of cigarette smoking improves prognosis) Oral amoxicillin/Levofloxacin for total of 10 days D/C nebulization of albuterol and ipratropium (Switch to metered dose inhalers) Ipratropium inhalation, as needed Albuterol inhalation, as needed Influenza vaccine Pneumococcal vaccine Primary diagnosis: Acute exacerbation of COPD

8) LocationLocation: office Presenting complaint: A 40-year-old female with complaints of insomnia, easy fatiguability, and feelings of worthlessness presents to the outpatient medicine clinic. Vitals: Pulse:75/min, B.P:110/75mm Hg, Temp:98.6 F, R.R:16/min, Height:72 inches (180 cm), Weight:55kg (121 lbs). HPI: A 40-year-old female comes to the clinic with the complaint of insomnia, easy fatiguability, and feeling worthless. She states that she has been “feeling low” for the last two months. She no longer finds pleasure in any of her normal activities. She can’t sleep. There is loss of appetite. Her weight has decreased by 20 pounds in two months. The patient has feelings of guilt, hopelessness, and inability to concentrate. She is finding it difficult to continue her job as a librarian and has decided to take a leave of absence. Prior to the onset of symptoms, she was doing well, both at home and in the office. She is married, has two children, and her husband is very loving. Because of her lack of interest in sex, they have been sexually inactive for the past two months. Generally, the patient has always been in good health. She doesn’t smoke, drink alcohol, or use drugs. She has a history of cluster headaches. Her last cluster headache was six years ago. ROS are unremarkable. FH: Mother is 65 and has HTN. Father is 70 and healthy. Vaccinations are up-to-date. She is not on any medications. She has no known allergies. How do you approach this case? This patient has classic clinical features of depression. A number of medical conditions may present with depression, including stroke, diabetes, dementia, cancer, hypothyroidism, chronic fatigue syndrome (see Fatigue below), fibromyalgia, systemic lupus erythematosus (SLE), coronary heart disease, corticosteroid use, anxiety and panic disorders, hypercalcemia, Sjögren's syndrome, increased bone loss, and seizure disorders in older adults. Perform a complete physical and psychiatric examination. An assessment of the presence of suicidal ideation is essential in all depressed patients. Physical examination: Complete physical examination Results of PE: General: Well developed, well nourished, middle aged female, in no acute distress. HEENT, lungs, heart, abdomen, and the rectal exam is completely normal. No lymph nodes palpable. Neuro/psychiatric examination: Neurological examination is non-focal. She is alert and oriented though her speech is somewhat slow. She expresses feelings of worthlessness and lack of energy. She denies having delusions or hallucinations. There are no suicidal ideations. Her cognitive functioning is normal. How would you approach this patient? In cases of depression, limited laboratory testing that may help rule out associated disorders includes measurement of thyroid function (TSH), serum electrolytes/basic metabolic panel, folate, vitamin B12, and an electrocardiogram. Other tests may be ordered based on the findings of history and physical examination include:

 ANA when SLE is suspected 
 HIV testing and VDRL in cases of high risk sexual behavior 
 Urine and blood toxicology screening in cases of suspected substance abuse 
 Dexamethasone suppression test for suspected Cushing’s disease 
 Cosyntropin stimulation test for suspected Addison’s disease

Order review: In this case, no associated medical illness is suspected based on history and examination. Routine Orders: CBC with differential, routine BMP, routine Serum TSH, routine 12 Lead EKG, routine Serum B 12, routine Serum folate, routine Result of Labs: EKG: normal rate, rhythm and axis, no evidence of ischemia or hypertrophy. Serum TSH: 1microU/mL BMP: Na is 140 meq/L, K is 4.0 meq/L, Cl is 100 meq/L; calcium, CO2, BUN, creatinine, B 12 and Folate are normal. Discussion: Based on the history and examination, this patient is likely suffering from major depression. There are four major types of depression: adjustment disorder with depressed mood; depressive disorders; bipolar disorders; and mood disorders secondary to illness and drugs. These need to be differentiated from grief and bereavement, which are normal responses to a loss.

The DSM-IV criteria for major depression: At least five of the following symptoms should present for a period of two-weeks. One of the symptoms must be depressed mood or loss of interest. The symptoms should not be the result of an organic factor or substance. The disturbance should not occur within 2 months of the loss of a loved one.

   Depressed mood most of the day 
   Markedly diminished interest or pleasure in almost all activities nearly 
   every day (anhedonia) 
   Significant weight loss or weight gain 
   Insomnia or hypersomnia 
   Psychomotor agitation or retardation 
   Fatigue or loss of energy nearly every day 
   Feelings of worthlessness and/or excessive or inappropriate guilt  
   Impaired concentration or indecisiveness  
   Suicidal ideation 
 A history of a prior manic episode in addition to these criteria suggests the 
 diagnosis of bipolar disorder. 
 Dysthymia is defined as mild, chronic depression which lasts for at least two 
 years or longer. It is characterized by poor appetite, insomnia, low energy or 
 fatigue, low self-esteem, impaired concentration, and anhedonia. Long-term 
 psychotherapy is frequently helpful. 
 Mild to moderate major depression is treated with either psychotherapy or 
 pharmacotherapy. Patients with moderate to severe depression should be treated 
 initially with either pharmacotherapy or ECT.   
 SSRIs are the drugs of choice. Patients should have a follow-up appointment at 
 least every one to two weeks for six to eight weeks during the initiation 
 phase of treatment.  Patients with severe depression should be seen weekly.  
 Less severely ill patients should be seen every 2 weeks. 
 Patients with associated anxiety symptoms and difficulty sleeping should be 
 offered a short acting benzodiazepine like lorazepam for 1-2 weeks with 
 tapering doses. 
 Patients with suicidal behavior and severe functional impairment should be 
 admitted in the hospital and treated with ECT.

When to obtain a psychiatry consultation? Psychiatric consultation is needed

 When the first line medication produce no improvement in 6-8 weeks period 
 Patients with severe suicidal ideation 
 Patients with associated psychiatric or medical or substance abuse disorders

When to add antipsychotics? If the patient experiences the associated psychotic symptoms with depression, a small dose of atypical antipsychotics like resperidol can be added.

 As this patient has moderate to severe depression and she does not reveal any 
 history of suicidal ideation, psychotic symptoms and anxiety, we can treat her 
 with antidepressants alone.

Order review: Oral, fluoxetine Counsel patient

 Suicide contract 
 Seat belt use 
 Patient education

LocationLocation: Emergency room Presenting complaint: A 55-year-old male presents with recent onset confusion, blurry vision and headache. Vitals: Pulse:75/min, B.P:215/150 mm Hg, Temp:98.8 F, R.R: 16/min, Height:72 inches (180 cm), Weight:72 Kg (158.4 lbs) HPI: A 55-year-old white male comes to the E.R with a 2-hour history of confusion, blurred vision, headache, nausea, one episode of vomiting, and breathlessness. He was doing his routine office job when symptoms developed. The headache started this morning, was 1-2/10 in severity but now it is 6-7/10. He denies weakness, sensory disturbances, dysphasia, dysarthria, leg swelling, chest pain or palpitations. Bowel and bladder functions are intact. Diagnosed 5 years ago with hypertension, he was prescribed atenolol, however he is poorly compliant. There is no history of DM, CAD or hyperlipidemia. He has a 25-pack-year smoking history and rarely drinks alcohol. He has no known allergies. FH: Mother is 80 and is hypertensive, father died of MI at 65. One brother is diabetic. Sh: Married 30 years, has two sons and one daughter. He is a business executive. SxH: he is sexually active with his wife and does not use condoms. ROS are unremarkable. How to Approach this case: This hypertensive male presents with recent onset of confusion, blurred vision and headache. He is most likely suffering from hypertensive encephalopathy, a hypertensive emergency. Other possible causes include subarachnoid hemorrhage, intra-parenchymal brain hemorrhage, acute MI or migraine. Hypertensive emergency or hypertensive crisis is characterized by very high blood pressure with impairment of end organs like CNS, heart or kidney. CNS manifestations include confusion, blurring of vision, headache, weakness and fatigue. CVS involvement results in congestive heart failure, angina, MI or aortic dissection. Renal manifestations are hematuria and/or proteinuria and impaired renal function. Immediate examination is crucial in this patient, Order: General Neuropsychiatric HEENT Neck CVS Lungs Abdominal Extremities Order: Intravenous line, capped Nasal oxygen, continuous Pulse oxymetry, stat and continuous Continuous cardiorespiratory monitoring Continuous BP cuff 12 Lead EKG, stat Bed rest, complete NPO Results: Patient is disoriented and neurological examination is otherwise non-focal. Fundoscopy shows arteriolar narrowing and AV nicking. There is mild papilledema, and soft exudates. There is no neck stiffness. CVS examination is significant for S4 gallop. Lungs are clear to auscultation bilaterally. Abdominal examination is normal. Extremities show no evidence of edema.

Before starting treatment, rule out the possibility of stroke. Treating high BP is detrimental in patients with stroke especially those who with increased intracranial pressure, i.e. papilledema. First order CT scan of the head without contrast. STAT Order: CT scan of head without contrast (to look for edema, hemorrhage, infraction)

Results: CT is negative for stroke. Pulse oxy is 97% on 2 lit. Vitals are same as before. 12 lead EKG has evidence of Left ventricular hypertrophy. Now start treatment: IV nitroprusside, (monitor the patient for hypotension) After starting treatment, order basic labs to assess the end organ involvement. CBC with differential, stat (for microangiopathic hemolytic anemia) BMP, stat (for possible renal involvement) Urinalysis, stat (for possible renal involvement) CXR-PA view, stat (to look for the evidence of pulmonary edema) Order review: BP is under control and patient is symptom free. Always check the BP frequently (in the exam) as continuous infusion of nitroprusside can cause hypotension and try to wean nitroprusside and add an oral agent. Shift the patient to the medicine floor/ward D/C cardiac monitor, oxygen, pulse oxy Vitals Q 4 hours Oral atenolol, continuous Allow ambulation Low salt diet Once the blood pressure is controlled with oral antihypertensive agents, the patient can be sent home with the following orders Order review: Fasting lipid profile Patient education Home BP monitoring Regular exercise Regular follow-ups Smoking cessation Alcohol, advice patient to limit intake Seat belt use No illegal drugs Discussion:

 Diastolic blood pressure of more than 120 is considered as hypertensive 
 crisis. The presence of end organ damage further classifies it as hypertensive 
 emergency and lack of end organ damage classifies it as hypertensive urgency. 
 The most common cause of hypertensive crisis is inadequately treated essential 
 hypertension. The other common causes include renovascular hypertension and 
 renal parenchymal diseases and rarely form pheochromocytoma or primary 
 hyperaldosteronism.  
 Careful physical exam to differentiate hypertensive urgency form emergency 
 should be done. The main components of the exam are funduscopy, CVS, CNS and 
 BP in both upper extremities and at least one lower extremity. 
 Basic labs, which include CBC with peripheral smear, U/A, BUN, Cr, EKG, and 
 CXR, should be ordered.

Treatment:

 In hypertensive emergency blood pressure should be lowered within one hour to 
 limit the end organ damage. In hypertensive urgency the aim is to reduce the 
 diastolic blood pressure to about 100-105 mm hg with in a period of 2-6 hours. 
 The maximum initial fall should not be more than 25 mm Hg. More aggressive 
 reduction of BP decreases the blood pressure below the auoregulatory range and 
 may cause ischemic events like stroke. Once the goal is reached, the patient 
 should be switched to oral medications. The diastolic pressure should be 
 lowered to 85-90 over a period of 2-3 months.  
 IV nitroprusside is the drug of choice for hypertensive crisis. It acts within 
 seconds and it has a very short half-life. The patient BP should be monitored 
 with intra-arterial line. Prolonged infusion i.e. >48 hrs may cause cyanide 
 toxicity, especially in patients with renal insufficiency. It is not a first 
 line medication in pregnant women. The other good alternatives to 
 nitroprusside are IV labetalol and hydralazine. Hydralazine is the drug of 
 choice in pregnant patients. 
 IV phentolamine is the drug of choice in pheochromocytoma. 
 Esmolol is an IV beta-blocker and is effective in acutely lowering BP when 
 used in conjunction with a vasodilator. Myocardial ischemia is an important 
 indication for its usage.

Management of hypertension varies in certain situations:

 Rapid reduction for blood pressure is detrimental in patents with 
 cerebrovascular accident. These patients can be differentiated form 
 hypertensive emergency by the abrupt onset of focal neurological findings.  
 Patients with acute pulmonary edema are best treated with combination of 
 nitroprusside or nitroglycerine and loop diuretic. Drugs like hydralazine or 
 beta-blockers or labetalol should be avoided. 
 Patients with acute coronary syndromes are best treated with IV nitroglycerine 
 or IV labetalol or IV nitroprusside. 
 Aortic dissection: The primary goal is to decrease both the systemic BP and 
 cardiac contractility. The best regimen is a combination of IV nitroprusside 
 and an IV beta-blocker either a labetalol or metoprolol. Nitroprusside alone 
 should not be used without a beta-blocker. 
 Rebound hypertension secondary to abrupt withdrawal of short acting 
 sympathetic blockers such as clonidine is best treated by re-administration of 
 the discontinued rug and if necessary with IV phentolamine. 
 The rare causes include 1. Pheochromocytoma 2.Cocaine intoxication 3. 
 Interaction of MAOI and tyramine containing foods can also cause hypertensive 
 crisis. This is best treated with IV phentolamine.

10)

LocationLocation: Emergency room Presenting complaint: A 7-month-old boy presents with severe breathlessness of sudden onset Vitals: Pulse: 100/min, B.P: 80/55 mm Hg, Temp: 98.70F, R.R: 40/min, Weight: 6.8 kg (15lbs), Height: 53 cm HPI: A 7-month-old boy is brought to the ER with severe cough, stridor, and breathlessness. His 6-year-old brother went to school leaving peanuts near him.

Mom found the child in respiratory distress and rushed him to the hospital.

There is no family history of asthma. The infant was healthy prior to this incident. Developmental milestones are being achieved at the appropriate ages. He has no allergies. Vaccinations are up-to-date. FH: Father is 32 and healthy; mother is 28 and has DM. He has one elder brother who is healthy. ROS are unremarkable. How to approach this case: This child presents with acute dyspnea due to upper airway obstruction. Stridor is one of the important clinical signs of upper airway obstruction. There are a number of causes of upper airway obstruction in the pediatric population. Etiologies vary according to the age of the patient. Careful history, and examination as well as lateral and PA chest X-rays should be done in all such patients. First General examination HEENT/Neck Chest/lungs CVS Results of PE General examination: The baby is crying, and in obvious respiratory distress.

                                     Chest/lungs: The child is tachypneic with

nasal flaring, suprasternal, and intercostal retraction. Inspiratory stridor is noted. Air entry is reduced, and percussion note is resonant bilaterally.

                                     CVS: Normal S1 and S2.  No murmurs, rubs,

or gallops. Pulses are normal. No jugular venous distension. Blood pressure is equal in both arms. Review orders: Start the patient on supplemental inhaled oxygen Gain IV access, stat Pulse oxymetry, stat and continuous Cardiac monitoring, stat CXR-PA/lateral views, portable, stat X-ray neck lateral views, portable, stat CBC with differential, stat Results of Labs: CBC: normal. CXR PA and lateral views: No abnormality found. Pulse oxymetry: oxygen saturation is 91 percent on room air, and 97% on 2-lit oxygen. Cardiac monitoring: no abnormality of rate or rhythm. Discussion: This child has sudden and dramatic onset of symptoms. He had peanuts in the vicinity before he developed symptoms. Based on these findings, symptoms are most likely due to aspiration of a foreign body. The next step in this case would be bronchoscopy, which will confirm the diagnosis and aid in the removal of aspirated foreign body. Before bronchoscopy, IV steroids and IV antibiotics may be used to help reduce the chances of edema and infection. Other important causes of upper airway obstruction include croup, laryngitis, epiglottitis, retropharyngeal abscess, angioedema, peritonsillar abscess, and laryngeal papilloma. Croup is common in children aged 6 months to three years and it develops insidiously as an upper respiratory tract infection. Patients with croup have a characteristic barking cough. Laryngitis occurs in children aged greater than five, the voice is hoarse, and there is no stridor. Epiglottitis is more frequent in children aged 2-6 years. There is a short prodrome, drooling is noted, and the patient feels better when leaning forward. Patients with retropharyngeal abscess are usually younger than 6 years, and they do not have stridor. The voice is muffled and they are found to be drooling. Angioedema can occur at any age, onset is sudden, and clinical features of stridor, retractions of intercostal muscles, and facial edema are found. Peritonsillar abscess occurs in children greater than 10 years of age, onset is gradual but with sudden worsening, and there is no stridor. Laryngeal papilloma is encountered in patients of ages 3 months to 3 years, onset is chronic and voice is hoarse. The majority of foreign bodies are not visible by plain films. So, a normal radiograph can never rule out aspirated foreign body in a highly suspicious patient like this. STAT orders: IV methylprednisolone, one dose IV cefazolin, one dose Stat consult otorhinolaryngology (ENT) subspecialty for confirmation and removal of aspirated foreign body by bronchoscopy Primary Diagnosis: Foreign body aspiration @2002-2003 All Rights Reserved

11) LocationLocation: Office Presenting complaint: A 40-year old female patient presents with lump in her left breast. Vitals: BP:130/80 mm Hg, Pulse:86/min, Temp: 98.70F, R.R:16/min, Height:162.5cm, Weight:55 kg (12lbs). HPI: A 40-year-old white female presents with mass in the upper outer quadrant of her left breast. She first noted this mass two months ago, the mass is painless and its size does not change pre or post-menstrually. There is no nipple discharge.

She does not give a history of breast lumps.  There is no family history of

breast cancer. She is a 10-pack year smoker and drinks alcohol socially. She is married and uses oral contraceptives. The patient denies recreational drug use. Her age at menarche was 13 and her menses have always been regular. LMP was 10 days ago. She is gravida 2, para 2, one at the age of 23 and the other at 27. Both deliveries were spontaneous vaginal. Her mother is 65 and is diabetic; her father is 70 and has angina. The rest of her ROS are unremarkable. How to approach this case: This 40-year old female has presented with a lump in her breast. Careful examination of breasts and lymph nodes especially supra clavicular and axillary should be performed when any woman presents with a breast lump.

First order the physical examination: General examination HEENT/Neck Heart examination Lung examination Abdomen examination Breast examination Lymphnode examination Here are the results of examination: General, HEENT/Neck, heart, lung, and abdomen examination is WNL. Breast examination: There is a 2 cm size solid, mobile, firm, non-tender mass with distinct margins, located in the left upper and outer quadrant. There is no nipple discharge. There are no skin changes. Lymphnode examination: There is no palpable lymphadenopathy. Discussion: Based on the history and examination, this patient most likely has benign breast disease. There are multiple causes of benign breast disease. Fibroadenoma: Typically a 15-30 yr old female presents with firm, painless, mobile, (breast mouse) and well-circumscribed lumps. Fibrocystic changes: Multiple and bilateral cystic breast swellings, which are noted to be particularly painful and tender premenstrually. Papillomas: C/O bloody nipple discharge (Non-bloody nipple discharge is usually benign). Duct ectasia: Presents with fever, greenish cheesy discharge, pain, and tenderness. Mastitis: Patients complain of the sudden onset of pain, fever, chills, and local erythema, tenderness, and induration. Breast cancer: Consider risk factors first - elderly age, family history of breast cancer, early menarche, late pregnancy, nulliparity, and late menopause. On examination you have to look for the characteristics of cancerous lesion (Single, hard, immobile lumps with irregular borders and a size of more than 2cm).

Diagnosis: The best way of making the diagnosis is by using a combination of physical examination, mammography, and fine needle aspiration cytology/biopsy (triple diagnosis). Interpretation should be followed as.

 If all three, suggest a benign lesion - Follow the patient with 3 to 6 monthly 
 physical exam for 1 year to make sure the mass is not enlarging. 
 If all three, suggests malignancy - Refer to definitive therapy. 
 If any one of the three suggests malignancy - Perform excisional biopsy.

Women younger than age 35:

 Mammogram is not useful in this age group, as the breast tissue is very dense. 
 However, it can be done in very high-risk patients. 
 If you find a lump and appears to be cystic, perform FNAB/FNAC. If the 
 aspirated fluid is non-bloody, the patient can be reassured and followed in 
 four weeks to check for recurrence. If it recurs then the patient should be 
 referred to surgical specialty.  If the fluid is bloody, send it for cytology. 
   
 If the mass is not cystic, obtain an ultrasound.  If ultrasound shows a solid 
 mass, the patient should undergo biopsy (Core biopsy or excisional biopsy).

Women age 35 and older:

 The only difference from the above age group is all these patients should 
 undergo bilateral mammogram along with clinical exam.  
 Management is similar to the above group.

Upto 15% of palpable breast cancers will not be visualized by mammogram. So, a negative mammogram doesn't eliminate the need for biopsy in a patient with palpable mass. We will follow triple diagnostic approach here, and will perform mammography and FNAB.

Order Review: Mammography, Bilateral FNAB Ask her to come with the results Results: Mammography and FNAB are consistent with the diagnosis of fibroadenoma. In this patient, the fibroadenoma is small; therefore it does not need to be excised. The patient can be followed every three to six months for one year to assess the size of the mass. Order review: Reassure the patient Follow up visit at 3 months Screening of cervical cancer by Pap smear Counsel the patient

 Patient education 
 Contraception 
 Safe sex 
 Smoking cessation 
 Limit alcohol intake 
 Safety plan 
 Seat belt use

12)

LocationLocation: Emergency room Vital signs: BP:90/60 mmHg, HR:128/min regular, Temp:100.0° F, R.R:30/min rapid and shallow C.C: Vomitings and abdominal pain. HPI: A 20-yr-old woman presents to E.R with 5 episodes of vomiting, abdominal pain, weakness and increasing drowsiness of one-day duration. During the last 2 months she has noticed increased thirst and increased urination. The abdominal pain is diffuse, 4-5/10 in severity, constant, non-radiating and there are no aggravating or relieving factors. Vomiting is non-bloody. She has no other medical problems. She has no known drug allergies. She is not on any prescription or over the counter medications. She is not a smoker or alcoholic, and denies IV drug abuse. She has a family history positive for Type 1 Diabetes Mellitus. Her father, and paternal uncle and grandfather are all diabetics. Review of systems: She denies weight changes, fever, chills, night sweats, diarrhea, constipation, skin, hair, or nail changes, blurry vision, acute bleeding, easy bruising, indigestion, dysphagia, changes in bowel movements, bloody stools, burning on urination, recent travel, ill contacts, vaginal discharge or itch, pregnancy, heat or cold intolerance, drug or alcohol use. Last menstrual period ended four weeks ago, was normal in flow and duration. How do you approach this case? First quickly examine the patient General HEENT Neck Heart Lungs Abdomen Extremities Here are the results of the exam: General: Patient is in mild to moderate abdominal pain and appears very distressed. HEENT: Very dry mucus membranes, no JVD, EOM are intact. Rest is unremarkable. Lungs: Clear to auscultation B/L. Heart: Completely normal except tachycardia. Abdomen: Soft, non tender, normal bowel sounds and no guarding or rigidity. Extremities: No edema, calf tenderness, but week peripheral pulses. Discussion: Now, make a mental checklist of differential diagnosis, i.e. 1. Abdominal pathology like appendicitis, gastroenteritis, pancreatitis, acute intestinal obstruction etc. 2. Menstrual symptoms or pregnancy related complications 3. DKA (Based on the family history and presenting clinical features) 4. Nonketotic Hyperosmolar state 5. Alcoholic ketoacidosis 6. Drug intoxication Order the following stat: Pulse oxy, stat and continuous Oxygen, nasal canula 2 lit, continuous NS 0.9%, bolus, stat (This patient is severely dehydrated. She is hypotensive and tachycardic. So, she needs IV fluids.) NS 0.9%, continuous, stat Finger stick glucose test, stat Urine pregnancy test, stat CBC with differential, stat BMP, stat EKG, stat Serum amylase, stat Serum lipase, stat Blood alcohol, stat Blood acetaminophen, stat Urine toxicology screen, stat Abdomen KUB, stat U/A, stat Ok here are the results: Pulse oxymetry showed 96% on room air Finger stick glucose shows 600mg/dL Urine pregnancy test is negative WBC 10,000/µL and normal differential Sodium is 129, Potassium is 5.0, Chloride is 90, Co2 is 14, calcium is 8.0, and a blood sugar of 600mg/dL EKG sinus tachycardia, nothing concerning Serum Amylase - mildly elevated Serum Lipase WNL Serum alcohol not present Serum acetaminophen - Negative Urine tox screen is – Negative for substance abuse Abdomen KUB is negative for obstruction, and no intraabdominal pathology is seen

U/A showed 4+sugar, but no evidence of infection How do you approach this case? So this patient most likely has either DKA or Non-ketotic hyperglycemia. The diagnosis is based on clinical features, elevated blood sugars, and increased anion gap. To confirm the diagnosis we need to order serum ketones and serum osmolality. She has pseudohyponatremia i.e. secondary to elevated blood sugars. Treatment of hyperglycemia resolves her hyponatremia. Now order: Stat serum osmolality, stat Serum ketones, qualitative, stat Give regular insulin 15 units (bolus), stat Followed by regular insulin, IV, continuous Put the patient on cardiac monitor ABG, stat Serum Phosphate levels Serum Mg levels Here are the results: Serum Osmolality 305 Serum Ketones - high Serum Phosphate 3.2 (WNL) ABG showed metabolic acidosis, compensated by respiratory alkalosis (pH of 7.3)

Review orders: Admit the patient to the intensive care unit Nothing by mouth Bed rest Vitals as per ICU protocol Strict input and urine out chart Add potassium 20 - 30 meq to each liter of IV fluids HbA1C level Follow the patient with

 BMP Q 2-4 hours, then Q 8-12hours, then Q day 
 ABG Q 2 hoursx2

After 4 hrs

 Stop 0.9% NS and give ½ Normal saline, IV, continuous

Monitor potassium deficiency and add IV potassium chloride as needed Consider antibiotics if the precipitating cause is an infection, get a chest X-ray, sputum gram stain, and culture/sensitivity; obtain blood cultures, U/A and urine cultures. Once nausea is decreased, start oral fluids. Once the patient is stabilized transfer to ward/floor.

During discharge: D/C IV insulin Start Insulin, SQ Diabetic diet (Diet, American diabetic association) Diabetic teaching Consult ophthalmology Diabetic foot care consult Home glucose monitoring, instruct patient Lipid profile Age appropriate vaccination Cessation of alcohol Smoking cessation Exercise program Seat belts Follow up appointment in 10 days Discussion: Diagnosis of DKA is based on an elevated blood glucose (usually above 250mg/dl), a low serum bicarbonate level (usually below 15 mEq/L), and elevated anion gap, and demonstrable ketonemia. Both amylase and lipase are often elevated in patients with DKA by an unknown mechanism (do not to confuse with pancreatitis). Diagnosis of Hyperosmolar hyperglycemic is based on: serum glucose levels in excess of 600 mg/dl, serum osmolality greater than 330 mOsm/kg, absent or minimal ketonemia, arterial pH above 7.3, and a serum bicarbonate above 20 mEq/L. Hyperosmolar hyperglycemic state is characterized by severe fluid and electrolyte depletion due to the osmotic diuresis produced by the extreme levels of glucose in the serum (often >1000 mg /dL). Hydration: Patients with DKA are profoundly dehydrated and foremost in the treatment of DKA is restoration of the intravascular volume. Estimates of fluid deficits in the decompensated diabetic is 4 to 10 liters (usually 5-6 liters). Initially, one to two liters of normal saline is given as bolus, followed by 500 mL/h for the first four hours followed by 250 mL/h for the next several hours. This initial management should be guided by the patient's general condition and response, with more or less fluid as indicated. After the first 3-4 hours, as the clinical condition of the patient improves, with stable blood pressure and good urine output, fluids should be changed to 1/2 normal saline at 250-500cc an hour for 3-4 hours. Ongoing reassessment is critical. Insulin: The standard insulin dose is an initial bolus of 10 to 15 units of regular insulin followed by a continuous infusion at a rate of 8 to 15 units per hour. When the glucose levels begin to approach 250 mg/dl, insulin infusions are continued, but the fluid composition is changed to include 5-10% dextrose in water to avoid hypoglycemia. Potassium: Potassium: Regardless of the serum potassium level at the initiation of therapy, during treatment of DKA there is usually a rapid decline in the potassium concentration in the patient with normal kidney function. Potassium replacement is indicated in all patients with the following features: K of <6, no EKG changes, and normal renal function. Bicarbonate Therapy: The use of bicarbonate in the treatment of DKA is highly controversial. Current recommendations for bicarbonate therapy are as follows. Use of bicarbonate is considered unnecessary when the blood pH is greater than 7.1. Phosphate is normally an intracellular substance that is dragged out of the cell during DKA. Similarly to potassium, at presentation the serum level may be normal, high, or low while the total body supply is depleted. Despite this depletion, replacement of phosphate has not been shown to affect patient outcome and routine replacement is not recommended. Primary diagnosis: DKA @2002-2003 All Rights Reserved

13) History of present illnessLocation: Emergency room

Vitals: BP 100/60 mm Hg; HR is 50/min, regular; RR is 10/min; Temp. 37C(98.6).

HPI: 28-yr old white female is brought to ER in unconscious state. Family reports that she is a very healthy female, has no medical problems, not on any medications, and did not find any empty bottles. She has no allergies. She doesn't smoke or drink alcohol. She has a boyfriend. She has never been pregnant. Her father is very healthy except borderline hypertension. Mother has diabetes. No other history is available. How do you approach this patient? Discussion: Step I: Emergent management: This patient is hemodynamically unstable, so A, B, C, D is the most important component of the management of this patient. A: Airway suction, pulse oxy, stat, and continuous monitoring, O2 B: Endotracheal intubation is indicated in patients who cannot protect their airway or if O2 saturation does not improve with O2 nasal/face mask, or PaO2<55, or PCO2>50 on ABG. C: IV access; continuous cardiac monitor; place a Foley; obtain a finger stick glucose. D: Drugs: Administer thiamine, dextrose 50%, and naloxone - all are IV bolus one time dose

Exam: Respiratory (assess the breathing pattern)

Order review: Suction airway Pulse oxy, stat and continuous Oxygen via mask, stat or Intubation IV access, stat Connect to cardiac monitor Finger stick glucose, stat Thiamine, IV stat Dextrose 50%, stat Naloxone, IV stat ABG, stat

Step II: Physical Examination: General HEENT/Neck Heart/CVS Skin Chest/Lung Abdomen Extremities Neurological exam Results: On examinations she found to have pinpoint pupils. She is very drowsy. So, she has bradycardia, hypotension, and pinpoint pupils, which are classic symptoms for narcotic overdose. Step III: Diagnostic Investigations: EKG 12 lead, stat CBC with differential, stat BMP, stat CXR, portable LFT's, stat PTT/PT, stat U/A, stat Urine toxicology screen Serum acetaminophen level Serum CK B-HCG, stat Initial Treatment: Order gastric lavage gets the result (which revealed pill fragments) Order activated charcoal Started naloxone drip Interval history and brief physical Step IV: Decision about changing patient location Move patient to ICU Check electrolytes again DC Intubation if patient has improved DC NG Tube Cont cardiac/ox pulse 24 hrs DC Naloxone Step V: Educate patient and family: Psych consult (result will tell, the history consistent with suicidal attempt) Order suicide precautions Move patient to psychiatry ward DC IV line Start regular diet Start patient on antidepressant if needed

Step VI: Final Diagnosis: Narcotic overdose Discussion:

 Orthostatic hypotension resulting from mild peripheral vasodilation is common. 
 However, persistent or severe hypotension should raise the suspicion of 
 co-ingestants. 
 In all patients with moderate-to-severe toxicity, it is important to obtain 
 baseline studies, including a CBC with diff, basic metabolic panel, LFT's, 
 ABG, and CK (Creatine kinase level). 
 Positive urine drug screens are observed up to 36-48 hours postexposure. 
 A 12 lead EKG should be obtained on all patients with intentional overdose, as 
 there is always a possibility of cardiotoxic co-ingestants. 
 Chest x-ray is important to rule out any pulmonary edema or aspiration 
 especially in a patient with an unprotected airway. 
 Naloxone should be given to patients with significant CNS and/or respiratory 
 depression.  
 Continuous IV infusion of naloxone is very safe in patients who were not 
 opioid dependent. However, in patients who are opioid dependent this practice 
 is dangerous and may precipitate withdrawal symptoms. 
 Activated charcoal should be administered to all patients with opiate 
 intoxication following ingestion. Because of the delayed gastric emptying 
 produced by opiate intoxication, it is effective even in patients who present 
 late following ingestion. Orogastric lavage is indicated if the patient 
 presents within one hour of ingestion. 
 All patients with significant respiratory depression, recurrent sedation 
 should be observed in the hospital for at least a period of 12-24 hours. Most 
 physicians admit the patients if they require a second dose of naloxone. 
 Patients should have continuous cardio respiratory monitoring. 
 @2002-2003 All Rights Reserved

14) TIALocation: Emergency room Vitals: BP 150/90 mm Hg, HR 70/min, RR 16/min, and Temperature 37C. HPI: A 65 yr old white male is brought to the ER by his wife after he dropped a glass on the floor. His speech became slurred and he was unable to understand what she was saying. She asked him to write something. He wrote a couple of sentences that didn't make any sense. The episode lasted a few hours. She brought her husband to ER. He denies any residual weakness or sensory changes. He also denies any visual changes, headache, nausea, vomiting, bowel, or bladder dysfunction. His other medical problems include hypertension, hypercholesterolemia, and DM. He takes enalapril 10 mg po QD, Simvastatin 10 mg po QD, and metformin 500 mg BID. He has no allergies. He has been smoking one PPD for the past 30 years. He occasionally drinks alcohol. His father died with MI at the age of 68. His mother died from a stroke. He has no known allergies. How do you approach this patient? Consider the D.D: Thrombotic or embolic TIA Subdural hematoma Seizure Hypoglycemia Brain tumors Labyrinthine disorders

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

Step II: Physical Examination General appearance, HEENT/Neck, Heart/CV, Lymph Nodes, Skin, Chest/Lung, Abdomen, Extremities, Neuro. A loud bruit was auscultated over the left carotid, no murmurs, rubs, or bruits were heard over pericardium. Neuro was nonfocal. Rest of the exam is within normal limits.

Step III: Diagnostic Investigations: CBC with differential, stat BMP, stat ECG 12 lead, stat CT head/brain without contrast, stat

CT: NEGATIVE for acute cerebrovascular event. (Most of the time CT scan will not show any deficits in the first 24 hours.)

Diagnosis: Considering history, physical, & the test you have done: this patient most likely had a TIA. TIA by definition, deficit lasting <24hrs. There is a bruit on left carotid. It might represent a plaque that sent a small embolus to the brain. Step IV: Decision about changing the patient’s location Admit to ward Vitals Q 12 hours Diabetic diet Allow ambulation Continue his home medications Accu-checks BID Carotid doppler Tele monitoring 2D-Echocardiogram Aspirin, oral, once daily Results: >70% stenosis in left carotid artery No arrhythmia No valvular disease, no evidence of thrombus, normal left ventricular function, normal atrial size

Treatment Plan: Vascular surgeon consult for elective CEA

Step V: Educate patient and family: Stop smoking Better BP control (exercise, diet, and pharmacological) DM control (exercise, diet, and pharmacological) Continue aspirin

Step VI: Final Diagnosis: Transit Ischemic Attack. Discussion: Basically TIA has three pathophysiologic subtypes:

   Large artery low flow TIA (true TIA) 
   Embolic TIA, 
   Lacunar TIA 
 The best way of differentiating these entities is by good history. Low flow 
 TIAs are brief (lasts minutes to few hours), recurrent, and stereotyped. The 
 underlying pathology is some kind of atherosclerotic stenosis in cerebral 
 vascular system, most likely the internal carotid artery. On the other hand, 
 embolic TIAs are characterized by discrete, usually single, and more prolonged 
 (several hours) episodes of focal neurologic symptoms. 
 All patients with suspected TIA require urgent evaluation. Routine inpatient 
 evaluation following TIA is controversial. American Heart Association does not 
 recommend inpatient evaluation following TIA, unless the time to obtain the 
 basic tests takes longer as an outpatient. Initial evaluation should include 
 good history, physical examination, and some basic tests. CBC with 
 differential and BMP should be obtained to exclude the hematologic 
 (thrombocytosis) and metabolic causes (hypoglycemia, hyponatremia) of 
 neurologic symptoms. ECG is useful to diagnose an unsuspected atrial 
 fibrillation and a recent MI. CT of the head without contrast and carotid 
 doppler should be performed on all patients. MR angiography is used primarily 
 to diagnose abnormalities in the posterior cerebral circulation.  
 Patients with embolic TIA should have a cardiac evaluation, preferably with 
 transesophageal echocardiogram. Most of the emboli are <3mm and transthoracic 
 echocardiogram cannot visualize these. TEE is also useful for suspected atrial 
 thrombi. However, TTE can be considered in elderly patients with H/O CHF or 
 previous MI since the left ventricular apex is not well seen with TEE (This is 
 a common site for left ventricular thrombi.). In general, we proceed with TTE 
 because it is noninvasive. TEE is indicated if the TTE is negative and the 
 decision of the management depends on TEE findings.

Treatment:

 Aspirin is the mainstay of therapy regardless of the pathophysiology of the 
 TIA. Patients who cannot tolerate aspirin should be treated with either 
 clopidogrel or ticlopidine.  There is no evidence that the combination use has 
 superior results than aspirin alone. However, the combination therapy can be 
 considered in patients who have a TIA while on aspirin alone. 
 Further therapy depends on weather the TIA is: 1. Atherothrombotic 2. Embolic.

Atherothrombotic:

 If a large vessel, like internal carotid artery, is involved carotid 
 endarterectomy should be performed. A Multidisciplinary Consensus Statement 
 from the American Heart Association concluded that carotid endarterectomy is 
 of proven benefit for symptomatic patients with 70% to 99% stenosis, provided 
 the surgical risk is less than 6%. The presence of 100% carotid stenosis, 
 previous stroke with persistent neurologic symptoms, and presence of multiple 
 co morbid medical conditions are contraindications for CEA. 
 There are no indications to give either warfarin or heparin to this patient 
 population, unless they have an associated H/O atrial fibrillation. 
 Risk factor management includes treatment of hypertension, diabetes mellitus, 
 smoking, dyslipidemia, and hyperhomocysteinemia.

Embolic:

 There is definitive evidence that patients with obvious cardiac source of 
 embolism will benefit from antithrombotic therapy. The use of heparin is 
 controversial in patients with acute TIA and has an evidence of atrial 
 fibrillation. However, all patients should be treated with warfarin unless 
 there are contraindications. 
 If the patient is on warfarin because of atrial fibrillation and develops a 
 stroke/TIA, low dose aspirin can be added while maintaining the patient on 
 warfarin with a target INR.

15) LocationLocation: Emergency room Presenting complaint: A 22-year-old woman presents with fever and pelvic pain Vitals: Pulse:102/min, Temp:102.5F, R.R:19/min, B.P:125/80mm Hg, Height:162.5cm, Weight:60 kg (132lbs). HPI: A 22-year-old female presents to the ED with a one-day history of severe lower abdominal and pelvic pain with high-grade fever and chills. The pain is dull and aching and does not radiate. Movement and coitus make the pain worse. This type of pain is completely new for the patient. Her last menstrual period was 4 weeks ago but there is an ongoing slight vaginal bleed. The patient is also nauseated and has vomited on three occasions. She is sexually active with her boyfriend and uses hormonal contraception. She has never been pregnant. She has no known allergies. She has no other medical problems. She is not on any medications other than OC pills. Her vaccinations are up to date. FH: Father is 50 and has diabetes; mother is 47 and has asthma. She has one older sister who is healthy. SH: She does not smoke; however she drinks alcohol daily. She denies recreational drug use. She is un-married and has no children. ROS are unremarkable. How to approach this case: This young woman presents with pelvic and abdominal pain and high-grade fever. Based on the history, she is most likely has PID. Another possible cause is appendicitis, which needs to be ruled out in all cases of acute abdomen. Pregnancy related problems are likely when the duration of the LMP is greater than 6 weeks. In patients of age greater than 35, MI, cholecystitis and pancreatitis must be considered. Therefore, do the following:

Order physical examination: General examination HEENT/Neck Heart and lungs examination Abdominal examination Genital/pelvic examination Rectal examination Extremities Here are the results of examination: General examination: Patient appears ill and in moderate pain. Heart and lung examination is within normal limits. Abdominal examination: There is bilateral lower abdominal tenderness, normal bowel sounds, no hepatosplenomegaly. No rebound or rigidity. No evidence of abdominal distention. Genital examination: There is bilateral adnexal tenderness as well as cervical motion tenderness. Mild bloody discharge is present on the cervical os. Rectal examination: Sphincter tone is normal; heme negative brown colored stools; no palpable masses. Extremities: no edema, calf tenderness, rashes, or joint swellings. Discussion: The following minimal clinical criteria has been suggested for the diagnosis of PID: adnexal tenderness, abdominal tenderness and cervical motion tenderness plus fever of 38C or greater or Leukocytosis or evidence of pus in the peritoneal cavity or evidence of pelvic abscess or sexual contact with someone who is infected with chlamydia or gonococcus. This patient meets the clinical diagnostic criteria for PID. Obtain a CBC, gonococcal and chlamydial cultures as well as gram stains to increase the specificity of the diagnosis. Other non-specific tests, which can be ordered, are ESR and C-reactive protein. Urinalysis is appropriate to rule out a co-existent UTI. Pregnancy testing should be done in every sexually active female of childbearing age. An abdominal ultrasound is appropriate when pregnancy related problems are considered (LMP is greater than 6 weeks). STAT Order review: IV access, stat CBC with differential, stat Basic metabolic panel, stat Urinalysis, stat Urine culture and sensitivity, stat Gram stain, cervix, stat Gonococcal culture, cervix Chlamydial culture, cervix PAP smear ESR, stat (Optional; usually we don’t do in real time practice)

Meanwhile, start the management of this patient of acute PID. This patient needs inpatient treatment, as she is nulliparous, has GI complaints, and fever greater than 102.2F. Other criteria for inpatient treatment include elevated WBC, adolescence, peritoneal symptoms, uncertain diagnosis, failure to respond to 48 hours of outpatient management, inability to tolerate outpatient treatment, pregnancy and immunodeficiency.

Antibiotic treatment is empirical. The inpatient regimen is IV cefoxitin or IV cefotetan plus oral or IV doxycycline administered until at least for 48 hours after clinical recovery. Then continue oral doxycycline for 14 days. (Or) IV clindamycin and a loading dose of IV gentamycin. Continue IV clindamycin for 24 hours after the clinical recovery. Give oral doxycycline treatment for 14 days.

Outpatient treatment is a single oral dose of cefoxitin or a single IM injection of ceftriaxone plus a single oral dose of Probenecid and oral doxycycline for 14 days. Order review: Shift the patient to ward NPO status as she is vomiting Bed rest with bathroom privileges Vitals: Every 4 hours IV normal saline, continuous IV Metaclopropamide, continuous Pain control Cefoxitin, IV continuous Doxycycline, IV continuous Acetaminophen 1gm po Q 6 hrs prn (as needed) Result of Labs: CBC with differential: WBC counts: 12000/mm3 RBC counts: 5.1 million/mm3 Hemoglobin: 15.9 g/dl Platelet counts: 200,000/mm3 MCV 86cu micron MCH: 27 pg/RBC MCHC: 33 g Hb/dL Red cell distribution width: 12

WBC differential: Segmented neutrophils: 85 Juvenile neutrophils: 3 Lymphocytes: 6 Monocytes: 3 Eosinophils: 2 Basophils: 1

Peripheral blood smear: Normochromic normocytic erythrocytes Leukocytes and platelets normal in number and morphology

ESR: 25 mm/hr Urinalysis: normal Gram-staining: no bacteria found Gonococcal cultures: pending Chlamydial culture: pending

The patient is pain free, afebrile and her condition remains improved for 48 hours. Order review: Stop Metaclopropamide Stop IV fluids Start regular diet as soon as she is able to take D/C IV Cefoxitin D/C IV Doxycycline Oral doxycycline, continuous VDRL, routine HIV serology, routine Safe sex counseling Smoking, cessation Advise patient to limit alcohol use Send her home Primary Diagnosis: Acute PID @2002-2003 All Rights Reserved

16) LocationLocation: office Presenting complaint: A 25-year-old African-American male presents with jaundice. Vitals: Pulse:95/min, B.P:110/75 mm Hg, Temp:98.8 F, R.R:16/min, Height:72 inches (180 cm), Weight:72 Kg (158.4 lbs) HPI: A 25-year-old African-American male presents to the outpatient clinic with the sudden onset of jaundice and dark colored urine. He complains of back pain and fatigue. The patient is afebrile and denies recent travel. He does not smoke, drink alcohol or use recreational drugs and uses condoms whenever he engages in sexual activity. On further questioning, it is revealed that he took TMP-SMZ for diarrhea a few days ago. An uncle has a history of some type of blood disorder.

     Hospitalization/ProceduresNone 
     Other Medical ProblemsNone 
     AllergiesNKDA 
     Current MedicationsNone                      
     VaccinationsUp to date 
     Family HistoryMother died at the age of 60 yrs due to MI.  Father is alive 
     and healthy at the age of 65 yrs. No sibling. 
     Social HistoryHe is single but has a girl friend.  Denies tobacco, alcohol 
     and drug use. 
     Sexual HistoryHe is sexually active with his girl friend. 
     Occupational HistoryRestaurant owner. 
     RecreationalHe plays basketball and enjoys traveling.

Review of Systems:

     Generalsee HPI 
     Skinpallor, itch, no rashes 
     HEENTIcterus 
     MusculoskeletalNo muscle aches or joint stiffness                          
      
     Cardio respiratoryWithout complaint                                 
     GenitourinaryDark colored urine, denies dysuria 
     Abdominalsee HPI

How to approach this case: This is a presentation of jaundice. Jaundice can be due to hemolytic causes and disorders involving the liver or biliary tracts. First perform a physical examination: General examination Skin Lymph nodes HEENT/Neck Heart exam Lung exam Abdominal examination Extremities Neuro

Results of PE: General: Icterus is noted on sclera; He also appears pallor.. Abdominal examination: no masses, tenderness, or organomegaly. Normal bowel sounds. Rest of the exam is WNL Routine Orders: CBC with differential, routine Basic metabolic panel, routine Peripheral smear, routine LFTs, routine Prothrombin time, routine Results of Labs: WBC counts: 8200/mm3 RBC counts: 1.8 million/mm3 Hemoglobin: 9 g/dl Hematocrit: 33 % Platelet counts: 200,000/mm3 MCV: 98 cu microns MCH: 28pg/RBC MCHC: 35 g Hb/dL WBC differential: Segmented neutrophils: 72% Juvenile neutrophils: 2% Lymphocytes: 18% Monocytes: 5% Eosinophils: 2% Basophils: 1% Peripheral blood smear: Normochromic normocytic erythrocytes, bite cells are also present. Leukocytes and platelets are normal in number and morphology.

LFTs Bilirubin, serum, total 5 mg/dL Bilirubin, serum, direct 0.5 mg/dL Aspartate transaminase, serum 25U/L Alanine transaminase, serum 20U/L Alkaline phosphatase, serum 182U/L Protein, serum, total 7.2 g/dL Prothrombin time 11 sec Discussion: This patient has no history of fever or abdominal pain and also no risk factors for hepatitis. Thus, acute cholangitis or hepatitis is unlikely as a cause of his jaundice. Normal abdominal examination with absence of tenderness further excludes liver or biliary tract pathology. The presence of pallor, and dark colored urine suggests an intravascular hemolytic cause of the jaundice. Other points to elicit are positive family history and exposure to sulpha drugs.

Normal LFTs rule out liver or biliary tract disease. Elevated levels of indirect bilirubin are a clue towards hemolysis. CBC shows anemia and presence of bite cells on peripheral smear. This suggests that the jaundice is due to hemolysis. Next do the following tests to confirm the presence of hemolysis and to determine if it is intravascular or extravascular. Routine Order review: Admit the patient in floor/ward IV access Start IV NS, continuous Diet: Regular diet (avoid fava beans) Activity - allow ambulation Type and cross 2 units of blood Reticulocyte count (to confirm that jaundice is hemolytic as reticulocyte count is elevated in cases of hemolysis) Calculate reticulocyte production index (to correct reticulocyte count for the degree of anemia) Serum haptoglobin Serum LDH (it is elevated in intravascular hemolysis) Urinalysis (to detect hemoglobin or hemosiderinuria) Repeat Hb and hematocrit in 12 hours Results: BUN 12 mg/dL Serum creatinine 0.6 mg/dL Rest of the BMP WNL Serum LDH 400 IU/L Serum haptoglobin 20 mg/dL Urinalysis normal

Elevated reticulocyte count confirms the presence of hemolytic anemia and elevated LDH with low haptoglobin indicate that the hemolysis is intravascular. A positive family history, history of exposure to sulpha drugs and presence of bite cells on peripheral smear are all suggestive of G6PD deficiency anemia. G6PD deficiency is confirmed by G6PD assay. Other hereditary causes of hemolytic anemia are sickle cell anemia, thalassemias and hereditary spherocytosis.

In sickle cell anemia, peripheral smear shows sickle shaped RBCs and in hereditary spherocytosis RBCs exhibit a loss of central pallor. Thalassemias produce a microcytic picture with target cells. For thalassemias and sickle cell anemia, hemoglobin electrophoresis provides useful diagnostic information. Autoimmune hemolytic anemia is an important non-hereditary cause and in such cases coomb’s test is an important diagnostic tool. Intravascular hemolysis can also be a part of thrombotic thrombocytopenic purpura, but in such cases fragmented RBCs are found on peripheral smear and platelet counts are also low along with renal impairment. Regarding treatment of G6PD deficiency anemia, all affected individuals should avoid exposure to drugs with oxidant potential. Heterozygous females should also avoid exposure to such drugs during pregnancy and lactation as they may trigger hemolysis in the fetus or neonate. Transfusions are needed when anemia is very severe due to impaired compensatory erythropoiesis. Routine Order: RBC G6PD assay Result: G6PD levels are low (levels can be normal during or immediately after the acute hemolytic episode, therefore you can repeat the test to confirm the diagnosis) Order review: Schedule an appointment after 2 months and at that time re-evaluate G6PD assay Reassurance Patient education Limit alcohol use Regular exercise Safe sex counseling Primary Diagnosis: G6PD deficiency anemia @2002-2003 All Rights Reserved

17) LocationLocation: Office Presenting complaint: A 2-year-old boy is brought with complaints of failure to gain weight and loose stools. Vitals: Pulse: 100/min, B.P: 80/56 mm Hg, Temp: 101.2 F, R.R: 18/min, Height: 27.2 inches (68cm), Weight: 7.2 Kg (16 lbs) HPI: A 2-year-old Caucasian child is brought to the doctor’s office by his parents for an evaluation of loose greasy stools and failure to gain weight despite adequate nutrition. His other problems are intermittent productive cough and rhinorrhea. The parents state that he has been wheezing and coughing up a purulent expectoration for 4 days. They deny fever or chills. He has had pneumonia 4 times since birth. Delivery of the child and neonatal course were uncomplicated. He was breast-fed until the age of 4 months. There is a history of CF in the family of both of his parents. Review of Systems: General: Skin: No rashes or lesions HEENT: Nasal discharge Musculoskeletal: No joint swelling Cardio respiratory: see HPI Genitourinary: No complaints Abdominal: see HPI Development: Delayed Vaccinations: Up-to-date How to approach this case: This child presents with failure to thrive. Failure to thrive has both organic and non-organic causes. The etiology of failure to thrive in this child is most likely cystic fibrosis. Clues to cystic fibrosis in this patient are positive family history, repeated chest infections and malabsorptive diarrhea. Order: Complete physical examination RESULTS: The child seems to be emaciated; his height and weight are lower than expected for his age. Chest examination shows generalized hyper-resonance and scattered crepitations bilaterally. He also has wheezing especially during expiration. ORDER REVIEW: Admit to the ward, stat Pulse ox, stat Intravenous access, capped, stat Sputum gram stain and culture, stat Blood cultures, stat CBC with differential, stat BMP, stat CXR-PA/Lateral, stat X-ray PNS, routine Sweat chloride, routine 24 hr fecal fat estimation, routine Treatment: Nasal oxygen, continuous (If saturation are <92% on room air) Amoxycillin and Clavulonic acid, oral, continuous Nebulized Albuterol, QID (4 times a day) Multivitamin tablets, oral, once daily Consult respiratory therapist, reason: Chest physiotherapy, every 2 hours Vitals Q 6 hours IV fluids D5NS, continuous High calorie diet Ambulation at will RESULTS: CBC shows neutrophilic leukocytosis Sweat chloride is 85 meq/L BMP showed low sodium and potassium CXR shows hyperinflation of both lung fields. X-ray PNS shows opacification of paranasal sinuses. Gram staining of sputum does not show any predominant organism. Sputum culture is pending. 24 hr fecal fat estimation is pending DISCUSSION: Cystic fibrosis is an autosomal recessive disorder commonly affecting Caucasians. Its clinical manifestations include acute or persistent respiratory symptoms, failure to thrive, meconium ileus, diarrhea, rectal prolapse, nasal polyps, electrolyte or acid-base disorders and hepatobiliary disease. Diagnosis of cystic fibrosis is made when evidence of CFTR dysfunction is present along with typical clinical features or positive family history. Elevated sweat chloride on two separate occasions is an evidence of CFTR dysfunction. Other important tests are gram stain, culture and sensitivity of the sputum, chest X-ray, X-ray of the para nasal sinuses. 24 hour fecal fat estimation should be used to diagnose the malabsorption. All children who are suspected to be suffering from CF should be admitted to the hospital. Evaluation should include baseline testing, accurate diagnosis, initiation of treatment and education of the patient and parents. Follow-up should be done every 2-3 months for monitoring. History, physical examination and staining and culture of sputum or pharyngeal swab are required on each follow-up visit. Prophylactic immunization against influenza, measles, and pertussis should be given.

Treatment:

 Antibiotics are given when a patient of CF develops acute or sub-acute 
 increase in sputum production, cough, dyspnea and/or fever. Antibiotics are 
 selected according to the results of sputum culture. Sputum cultures are 
 performed at least on yearly basis to help identify the bacteria, which are 
 chronically inhabiting the respiratory tract. Oral antibiotics are used when 
 exacerbation is mild, while IV antibiotics are used when exacerbation is 
 severe and when bacteria are resistant to oral antibiotics. For S. aureus, 
 oral antibiotics used are cephalexin, dicloxacillin or 
 amoxicillin-clavulanate.  For P. aeruginosa, ciprofloxacin is used as an oral 
 antibiotic. IV regimen for P. aeruginosa is a combination of tobramycin and 
 anti-pseudomonal penicillin like piperacillin.   
 Bronchodilators like albuterol or salmeterol are used in patients with airflow 
 obstruction. 
 DNase is usually prescribed for those with daily productive cough plus airflow 
 obstruction. 
 Combination of physiotherapy and exercise should be considered in patients 
 with more retained purulent secretions. 
 Inhaled glucocorticoids can be used in patients of CF who have clinical 
 evidence of airway hyperactivity. 
 Oxygen therapy should be considered in all patients who have evidence of 
 hypoxemia at night or rest or pulmonary HTN. 
 Lung transplantation is the only definitive treatment in patients with severe 
 infections and grossly damaged lungs with a FEV1 of 30% or less of the 
 predicted value. 
 Nutrition: Recommended diet is one with high protein and high calories. 
 Vitamin supplementation of fat-soluble vitamins and pancreatic enzyme 
 replacement are also very important.

Results review: 24 hr fecal fat is elevated. Sputum culture grew staphylococcus aureus, sensitive to cephalexin. ORDER REVIEW: D/C Amoxycillin and Clavulonic acid Stat cephalexin, oral, continuous Influenza vaccine Pneumococcal vaccine Consult dietitian Pancreatic enzymes, oral, continuous Genetic counseling Follow up at 2-3 months PRIMARY DIAGNOSIS: Cystic fibrosis @2002-2003 All Rights Reserved

18) LocationLocation: Office Presenting complaint: A 26-year old female presents with amenorrhea and abdominal pain. Vitals: PR: 84/min; Temp: 98.90F; R.R: 17/min; B.P: 125/80mm Hg; Height: 162.5cm; Weight: 60 kg (132lbs). HPI: A 26-year-old white female presents to your office with a one-day history of lower abdominal pain. The pain is dull and aching, 4/10 in severity, and does not radiate. She feels nauseated but has not vomited. Her last menstrual period was 7 weeks ago. Previously, her menstrual cycles have always been regular, 29-30 days in duration. Now, she complains of slight vaginal bleeding. The patient is sexually active with her husband and uses safe period for contraception. Her history includes two episodes of PID. She has never been pregnant and does not smoke or drink alcohol. She has no known allergies. She is not on any medications. FH: Father is 50 and has COPD; mother is 46 and healthy. She has two older sisters who are healthy. ROS are unremarkable. How do you approach this case? This young woman presents with amenorrhea, abdominal pain, and vaginal bleeding.

Differential diagnosis includes: ectopic pregnancy, abortion, molar pregnancy,

degenerating leiomyoma, adnexal torsion, ruptured corpus luteum, PID, acute diverticulitis, pyelonephritis, or IBD.

The triad of amenorrhea, abdominal pain, and vaginal pain suggests ectopic pregnancy. The condition of this patient is stable; therefore we can safely proceed towards a complete examination. Stable patients require continuous monitoring for signs of rupture like increasing abdominal pain, or tenderness, shock, and bleeding. In addition to doing a focused examination, also perform a pregnancy test, which will help us include or exclude conditions related to pregnancy. If the patient is unstable, as indicated by hypotension and tachycardia, obtain immediate IV access, administer normal saline, type and cross match blood and start the blood transfusion along with continuous BP monitoring followed by consultation with Surgery/Obstetrics & Gynecology for possible laparotomy.

Start with the following orders General examination HEENT/Neck Heart examination Lungs examination Abdominal examination Genital examination Rectal examination Extremities Result of examination: General examination: Well nourished, well developed woman in pain and appears sick. Abdominal examination: abdominal tenderness in left lower quadrant; normal bowel sounds; no bruits; spleen and liver are not palpable; no hernias. Genital examination: Uterus is slightly enlarged and feels boggy. A small amount of dark brownish-red blood is coming from cervical os. There is mild left adnexal tenderness. Rectal examination: Sphincter tone is normal; stool is brown colored without occult blood; no palpable masses. Rest of her exam is unremarkable. Order: HCG, beta, urine quantitative, stat Result of Labs: Positive urinary beta-HCG Discussion: Positive urinary beta-HCG testing coupled with the classic triad of abdominal pain, amenorrhea, and vaginal bleeding is highly suggestive of ectopic pregnancy. But other pregnancy related problems like spontaneous abortion, molar pregnancy, and ruptured corpus luteum are included in the differential. They can all be excluded by ultrasonography. With molar pregnancy, there may be a history or evidence of passage of vesicles, hyperemesis gravidarum, large for date pregnancy, very high serum beta-HCG levels, or a snowstorm pattern on pelvic ultrasonography. With incomplete or compete abortion there is a history of vaginal passage of products of conception. To confirm the presence of ectopic pregnancy, perform a quantitative serum HCG plus transvaginal ultrasonography.

Progesterone measurement add nothing to the information already obtained by quantitative serum HCG and transvaginal U/S. Therefore, they need not be performed routinely.

Perform coagulation studies, blood typing, and cross matching, as well as cervical culture for Gonococcus and Chlamydia.

LFTs and renal function tests are important studies to perform, as impaired functioning of these organs is an important contraindication to the use of methotrexate. Methotrexate can be used as a medical treatment for ectopic pregnancy. Culdocentesis will show any blood in the cul-de-sac but this information can be obtained by transvaginal ultrasonography.

Laparoscopy is used mostly for treatment purposes as diagnosis is often established by ultrasound and hCG measurements.

Admit the patient to the ward NPO Intravenous line IV NS, continuous Bed rest, complete Vitals every 1-hour Transvaginal ultrasonography, stat Quantitative serum beta-HCG levels, stat Blood typing and cross matching, stat CBC with differential, routine PT, routine PTT, routine BMP, routine Gonococcal culture, cervix Chlamydia culture, cervix PAP smear (if not documented before) Discussion: If beta-hCG level is greater than 1500 IU/L and TVS shows an intrauterine pregnancy, ectopic pregnancy is ruled out. If beta-hCG level is greater than 1500 IU/L and TVS does not show any intrauterine pregnancy, EP is very likely and these studies should be repeated after two days. If there is an adnexal mass along with beta-hCG level greater than 1500 IU/L, EP is almost certain. When beta-hCG level is less than 1500 IU/L and there is no intrauterine or extrauterine pregnancy on TVS, repeat these tests within two to three days. Results of labs: Transvaginal ultrasonography: A non-specific left adnexal mass is observed, 2.2 cm in size. Quantitative serum beta-HCG levels: 2000 IU/L Blood typing and cross matching: A-positive CBC with differential, stat: WBC count: 8200/mm3 RBC count: 5.1 million/mm3 Hemoglobin: 15.9 g/dl Platelet count: 200,000/mm3 PT, stat: 9.5 sec PTT, stat: 24 sec LFTs: Within normal limits BMP: Within normal limits Cervical culture: Pending Discussion:

 Presence of an adnexal mass along with elevated serum beta-HCG levels confirms 
 the presence of ectopic pregnancy. Treatment can now be started.  The 
 available treatment options are medical therapy with methotrexate, 
 laparoscopic surgery, laparotomy, and expectant management. 
 Laparotomy is indicated when the patient is in shock and when the size of 
 ectopic pregnancy is greater than 3.5 cm. When the patient is hemodynamically 
 stable and the size of gestation is less than 3-3.5 cm, she can be treated 
 with either methotrexate or laparoscopy. 
 MTX treatment can be employed successfully in those who are asymptomatic, 
 whose serum beta hCG level is less than 5000 IU/L, US shows that tubal size is 
 less than 3 cm, and there is no fetal cardiac activity. Post treatment 
 compliance is also an important consideration in these patients. There are 
 some contraindications to the use of MTX like renal failure, liver failure, 
 hypersensitivity to MTX, and breast-feeding. 
 Some patients who are asymptomatic, stable, and have un ruptured EP can be 
 managed expectantly. 
 Patients of ectopic pregnancy who are Rh negative should receive Rh 
 immunoglobulin. 
 The patient here is stable hemodynamically, the size of her gestation is 
 smaller than 3 cm, and there is no contraindication to the use of methotrexate 
 therapy; therefore treat with either MTX or laparoscopic surgery.

Order Review: OBGYN consult Methotrexate IV, stat, one time Send her home with follow up visit at 4 days for quantitative serum beta-HCG. Safe sex counseling Contraceptive counseling Patient education Primary Diagnosis: Ectopic pregnancy @2002-2003 All Rights Reserved

19) LocationLocation: office Presenting complaint: A 5-year-old boy presents with continuous oozing of blood after dental extraction two days ago. Vitals: Pulse:80/min B.P:110/70 mm Hg Temp:98.70F R.R:16/min Height:103cm Weight:18.0 kg HPI: A 5-year-old boy is brought to the physician’s office by his mother complaining that there is continuous oozing of blood from the site of his extracted tooth. He underwent tooth extraction two days ago. The bleeding stopped initially but restarted spontaneously a few hours later and continue