Recent CCS cases

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Let us compile a list of recent CCS cases in this wiki!

One list of 9 cases solved. Read it critically and come up with alternative plans, changes, or modifications. The only way to master CCS is to be critical and use your own judgement. Wikify the page by adding wiki links and external links for more info on relevent topics. To add a wiki link, click on edit this page and enclose a key word in double square parenthesis [[like this]].

1. 60 yr old african american pt with h/o arthritis and s/p chronic aspirin therapy presented to office with c/o fatigue(firsth thing came in mind was peptic ulcer dz vs gastritits)..........ordered cbcd, lyte plus, tsh,ua.......normocytic normocho anemia with slightly low h/h........did upper barium study came negative......pt was feeling still same.........started on famotidine and advised to stop aspirin.......ordered couple days f/up and ordered gasstroenterology consult......still no improvement......then finally did endoscopy......and result was positive for erosive gastritis.......i continued famotidine(she was taking antacid with marginal relief), advised to quiet aspirin, quiet smoking, quiet alcohol, started her on acetaminophen for pain and case ended...........( also advise this pt about routine self breast exam, exercise pgm, mamography, advanced directive etc......Keep these age appropriate counselling in mind for every case ... cash extra few positive points.......always give pt opportunity to discuss about advanced directive....i this is new medicare and medicaid requirement and it is a law that hospital/clinic discuss advanced directive issue with all pt irrespecitve of their age)

2. 55 yr old black woman with fatigue, weight gain, loss of lat third of eyebrow, obese and other nonspecific signs/sy presented to office (got a sense of hypothyroidism )--------did cbc, tsh(don't jump right away to whole thyroid function test as tsh is cost effective compared to whole thyroid pannel....if tsh comes abnormal then do whole thyroid pannekl), comprehensive met pannel,ua and ana...tsh was high so ordered whole thyroid pannel which comfirmed hypothyroidism......so started on levothyroxine and scheduled wk f/u appt....now i also ordered ekg (h/o obesity and slight elevated bp) then i struggleed about ordering about cxr but didn't instead preferred to order lipid profile(i was very ambivalent about ordering lipid profile in this guy from cost effectiveness/expense/unncessary vs necessary test etc) but surprisingly this guy had bad lipid profile so advised him low cholesterol,low fat, and low na(highbp) diet, exercise pgm, etc.....i also did stool guiac as part of yearly exam in this old pt but it was negative.......case ended on time and when 5min left screening warning came, i ordered repeat tsh (to make sure,it is going down)

3. 18 months infant presented with wheezing/coughing for six hours (knew right away foreign body apiration).....started o2, iv access, cbcd, bl culture, lyptes, pulse ox, abg.....ordered cxr portable.....ordered pulmonology consult(u can ordered either pulmonology or cardiothoracic surgery consult for bronchoscopy)......message reads continue managing pt...no additional comments.........ordered endoscopy.......pt felt better.......transferred to ward.......ordered clindamycin first iv and then oral therapy(for postob pneumonia)........pt got better..message read peanut was revealed in bronchoscopy........case ended on time.....(i forgot to order postbronchoscopy material for c/s as per std textbook instead started clindamycin empirically)

465 yr old man with unilateral headache/tenderness.......classic case of temporal arteritis......ordered cbc, tsh, esr, lyte plus......esr was 100.....started on prednisone......ordered f/u appt and gave age appropriate counselling.....case ended

5.yound woman brought in unconscious with bradycardia, hypotensive and pinpoint pupils classic case of narcotic od.......ordered oxygen, iv access and gave triple combo (thiamine, dextrose 50% and naloxone-all are iv bolus one time dose)......pt got awake.(Don't go first for physical exam in this case. Unconsciousness/unstable pt warrants urgent treatment).....i then did brief physical of 3min......meanwhile i started her on normal saline, did cbcd, lyte plus, ekg 12 lead, cxr portable, pulseox, ekg monitoring, ua, urine drug scrren, blood alcohol, blood aspirin and bl acetaminophen level, ordered gastric lavage(which revealed pills fragments).......started naloxone drip.....transferred to icu..at one time i have to start here ng tube and intubation...........she eventually got better......transferred her then to ward...........ordered psy consult, advice for relaxation techquine to ease with stress ........(now can u belive what big mistake i did.....i had overdose protocol in my mind and i was writing all orders as it popped out of my mind......there i ordered charcol along with gastric lavage...this was big blunder........but surprisingly pt got better......i imagine i have her already on intubation.....even with this big mistake CASE ended peacefully)

6 young girl with fever, headache and generalized maculopapular rash of one day onset..........classical case of toxic shock syndrome......ordered symptomatic rx...admitted and ordered cbcd, urine pregnancy, gono/chly vag culture, bl culture, cbcd, comp met pannel, ua ....started her on iv oxacillin and then oral dicloxacillin.....pt got better (now in physical, it read "tempon removed")..........still i go ahead and wrote remove tempon(computer has this order in storage)......did contraception, drug, alcohol, smoking, safety counselling being teenager. In the case i was confused about one thing i.e. culture and sensitivity.....i was not sure where to take specimen from? so i ordered bl culture, vaginal stapyloccoal culture, and then tempon c/s (someone can help with this issue).......case ended appropriately

7. 55 yr old immigrant psychiatrist came in with classical sy of pul tb------hemoptysis, wt loss, night sweats............so did cbcd, ppd, cmp, ua, sputum afb smear, tb culture and pcr test.......(afb was negative.....pcr came positive after couple days)......pt was in office.......i wanted to order resp isolation but computer won't accept it and same token case was not appropriate for admission as she was young and independent and relatively healty......now i wanted to do sputumx3 (practical and theoritical approach) but computer won't accept it 2nd time).....ppd was 12mm, cxr revealed upper apical infilt/cavity........started her on inh, pyridoxin, rifampin, etham....ordered f/u appt with f/u sputum study.......orderd inf/pneum vaccine, multivitamin/notify health dept........i also did hiv counselling in this pt.........other things to check......hep b surface antigen........( lady was not drug addcit so i didn't do rpr)

8 one case was 50 yr old guy with symptoms of dka, abdominal pain......treated as dka but case kept dragging on and on........

9. s/p mva, s/p internal fix of tibia # in 50 yr old guy in inpt setting.......nurse runs with c/o decreased urine outpt.........case of acute renal failure..........treated this case as mva.....don's assume that this pt has everything on place......start with abc....o2, iv ring lac, foley cath, spine, cxr, pelvi xray...........orderd abg, ua, lyte plus.......significantly low calcium, and k was 7.5.........ordered calcium chloride, ekg 12 lead and cont monitor......case ended exactly at 14min.....diagnosis.........arf/hperkalemia/hypocalcemia......

impt points: 1. first always decide pt is stable or unstable.....if unstable/unconscious start treatment first and then do physical.......... 2. it takes 2-3 min to load pt.........i was scared becasue in all my pts, it was either 3rd or 4th min when i was able to wirte first order.......i think one has to be patience as computer takes little while to load info 3. always do age app counselling.... 4. think twice before u write any order......think about cost/necessity/futility/whether it will change your mx (like always go first with tsh and then order whole pannel......first do nonfasting cholesterol before going to fasting sample)

Do practice,practice and practice...... i have reviewed all ccs cases within last 4months and practiced those couple times.........it really helped me lot in the exam......Best thing would be discuss with friend. In my case, me and my friend used to discuss everyday 5 case on the phone. while talking to eachother through cell phone, we kept our computer open and practiced on those 5 std cases. we pretended case of asthma instead of pneumothorax and wrote all ordereds/treatment of astham and watched the capability of computer and how it comes up with words........say for example while doing osteoporosis case before the test, when I ordered DEXA scan, computer doesn't recognize it but after several attempts, i was able to come up with right word"bone absorbtiometry" and computer picked up it right away so if u know this thing it will save time in real test....

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