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09-23-2009
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USMLE Forums Newbie 50 star ccs cases
Steps History: 1+CK+CS Posts: 3 Threads: 1 Thanked 10 Times in 1 Post Reputation: 20
found this on another forum so thought of sharing here
. femur neck#--ER 2. Advanced maternal age 3. Snake bite 4. HEPATIC ENCEPHALOPATHY 5. Post-op atelectasis. 6. Septic Abortion7. Incomplete abortion with heavy bleeding and acute PID. 8. Infected peripheral IV access 9. atrophic vaginitis 10. polycystic ovarian syndrome 11. gono 12. AGN 13. BPH 14. acute psychotic disorder 15. spontaneous abortion
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16. malrotation 17. child with rash 18. obesity in adolescent 19. CTS 20. teenager comes for a pre-employment 21. JRA 22. kawasaki disease 23. Osteomyelitis 24. Hypoglycemia 25. Dilated cardiomyopathy 26. Down's Syndrome neonate 27. Preeclampsia 28. MM 29. Hypercalcemia-office 30. Hypercalcemia-ER 31. MS 32. HELLP 33. Endometrial Hyperplasia without Atypia 34. Gastric cancer 35. TURP-HYPONATREMIA 36. testicular pain-acute unilateral, childER 37. hypertensive crisis with SAH 38. Hypertension-secondary 39. fever unknown origin adult 40. septic shock 41. Alcohol withdrawal 42. retained placenta 43. Chronic renal failure 44. Acute renal failure 45. RAPE 46. HUS 47. New onset DM-42 yr old c polydipsia & polyuria 48. Fever Unknown origin-child 49. Cx ca
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50. Failure to Thrive
1-femur neck#--ER Hx- 55 female post meno Exter. Rot. & shorten Right LL VS- stable P/E general skin heent look for hematoma heart lung abd cns extr Orders IVA oxy sat Pulse oxy cardiac monitor bp monitor EKG nss cbc bmp ua pt ptt inr fobt blood type,crossmatch Ca,phoph,pth,mg x ray chest,hip(ap/lat) ,knee morphin-pain consent form orthopedic consult ; reason hip fracture admit to wd interval+rest ex cefazolin IV on time npo bed rest ,bathroom urine output foley ranitidine cbc/d bmp/d h&H ptt-4h heparin sq pneumatic surgery donepost-sx morphi ambulate early calcium vit d if shows patient improves, discharged and f.u after 2wks Counseling mobilization
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exercise alendronate medicine comp stop smoking limit alcohol seat belt calcium rich diet Dexa scan colonoscopy lipid mammography --------------------------------2-Advanced maternal age office: PE--complete. urine HCG (+ve) CBC BMP UA urine culture LFTs lipid profile blood type & cross type and Rh pt/ptt EKG pap smare USG trans vaginal mammography gonorrhea chlymydia RPR Hep B antibody HIV ELISA toxo rubella titer Educate patient pregnancy pregnant mother counseling no smoking, safe sex, seat belt, safety plan diet (high calory,High protein) iron oral folic acid oral multi vitamins-prenatal follow up after 1 month in 1st trimester 2nd visit full physical vital(BP check) Weight UA Fetal heart monitoring fundal height
do triple screen --serum HCG, AFP, estradiol [MS AFP], if high amniocentesis Triple marker screen-TRIPLE TEST Valproic acid level send her home.. counsel about the vit and folic and RATED SEX further diagnostic plan continue Valproic acid Genetic counseling
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Genetic Sonogram Amniocentesis Karotyping of the fetal amniocytes....cells found in the amniotic fluid --------------------------------3-Snake bite ER Location 25 y young guy 30min after hx of snake bite. Havent brought snake, ordervitals/hr IV Access NS Pulse oxi O2 Abg Cont BP moniter Cardiac moniter cbc bmp ua pt ptt Bleeding time ECG CXR Blood type and cross match. Foley Urine output NPO PE-(complete) shows local cellulitis, noticed 2 fang sites on his ankle Neuro xam shows drowsiness orderPolyvalent snake antivenom -SNAKE Shift to ICU interval hx+rest Ex Bedrest Vitalsq2h Pulse Oximetry q2h Neuro exam q2h Monitor Bleeding time, PT, PTT, Platelet counts (Can develop DIC) H&H-6h Ranitidine Inj TT Ampicillin/Cloxacillin IV ABG q8h cbc/24 Bmp/24 If Neuroparalyis symptoms---- (Atropine + Neostigmine IV) If devloping resp failure---- intubate and mech ventilation D/C ASV when Bleeding time/PT/PTT parameters normal and neuro symptoms subside, D/c IV antibiotics; make oral When pt okto wd Later send home counselling ----------------4-HEPATIC ENCEPHALOPATHY pt presented with altered state of mind... had h/o of cirrhosis of liver already. was given oxycodone my dentist following which he devleloped symptoms..HEP C cirrhosis LOOK FOR-alkalosisi,low k,SBP,HIGH PROT diet,.. ER routine (IV access, pulse oximetry, cont bp, cont cardiac moniter)
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fingers stick glu Thiamine inj 50% dxt NGT suction (to look for variceal bleeding) EKG CXR CBC, BMP, S.NH3 NPO NSS GPE( signs of cirrhosis, confused patient, asterixis) LFT, PT, PTT, urine r/e, toxicology, blood alcohol level ,Mg URINE culture BLOOD culture (pt marginally raised, lft deranged as for cirrhosis serum NH3 sky high) admit ICU urine output, bed rest, continue thiamine and dextrose normal saline drip, propranolol to control portal HTN./ spironolactone PARACENTESIS-SEND FLUID LEVOFLOXACIN----IF PARACENT+VE{>250CELL) CHANGE TO CEFTRIAXONE .Lactulose oral [ampicillin po or neosporin po/ neomycin] enemas to evacuate stool Moniter PT/PTT/ cbc/bmp/ammo daily . Pt improves ADD diet salt restriction .shift to wards in 24 hrs or when better Case usually ends after 6 hrs of pt getting better. rehab 5-Post-op atelectasis. [after 36 hr of Surgery]... DD's were: Pneumothorax PE Pneumonia CXR--it showed Atelactasis It is one of the first cause of Fever, High WBC and shortness of breath... So.. I did..blood culture Removed the Foley Catheter and put a new one UA culture And Started.. IV Antibiotics Acetaminophen Per Rectal And Incentive Spirometry... Patient become stable...I transferred him to Inpatient Unit.. ---------------6-Septic Abortion-
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Do cultures IV Antibiotics Call OBGYN When patient is accepeted by OBGYN for D&E Just do medical Management in ICU 7-Incomplete abortion with heavy bleeding and acute PID. Do cultures IV Antibiotics Call OBGYN When patient is accepeted by OBGYN for D&E Just do medical Management in ICU -------------8-Infected peripheral IV access iva (if central line, dc cental line and new central line) oxy vitals q1h (qday when stable temp) cardiac monitor (risk of septic shock) fingerstick stat b-hcg cbc stat bmp stat focused pe pt/ptt stat ua/uc+s blood cx cxr esr crp xray site doppler arm remove iv line cath tip for c+s, gm stain, fungal cx clinda + zosyn (if admitted >48 hrs) tylenol ekg 2 d echo full pe elevate arm bed rest iv nss iv heparin if signs of cord-like thickening/bluish discoloration (new iv access already done in beginning to give empiric abx) when cx back: iv naf for 2-3 days (until improvement) dc zosyn and clinda in this case do not worry abt dc'ing patient or po meds and patient has iv line for a reason. 5 min: repeat cbc, chem in 3-4 days counsel screen ---------------9-atrophic vaginitis 62 yo vaginal itching clear discharge painful intercourse
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vulvar erythema mucus bleed during exam dd atrophic vag bacterial vagi candidial vagi vulvar ca cervicitis tricho office work up cbc cmp lipid profile as a health maintainance exam-safer to do bu no credit wet prep trich gono chly pap may need emb colpo etc if finding in cervix or pap if pap positive story goes further otherwise cou vaginal gelly for lubrication local hrt estrogen cream follow up as needed ----------------10-polycystic ovarian syndrome 21 yo f beard excessive hair weight gain menstrual irregularity darkening axillry thickened skin normal vitals dd polycystic ovarian syndrome congenital late onset adrenal hyperplasia adrenal tumour drug effects like minoxidil phenytoin ovarian neoplasm cushing syndrome idiopathic hirsutism cbc lft bmp endocrine--dhea lh fsh ratio prolactin tsh dhea
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testerone blood glucose insulin level serum 17 hydroxyprogesterone us pelvis result - testerone increse lh fsh ratio increase insulin fasting glucose ratio increse urine pregnancy test -do it anyway -rx ocp exercise metformin spirolactone smoking cesation fu 6 month ---------------11-gono-male 21 m unprotected sex urethral discharge fever sickness burning sensation during urination o/e urethral discharge red urethra suprapubic tender d/d -acute cystitis epidymitis forign body nephrolithiasis orchitis prostitis pyelonephritis reiter's syndrome urethritis --gono chlymydia office w/u ua culture urethral gram stain urethral discharge for gono chlymydia vdrl cbc finding -- gram stain gram neg culture awited rx azithromycin 1 gram stat
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ceftrixone 250 mg stat coun safe sex practice smoking alcohol safe driving drug culture -fu 4 week pt coun treat patner ------------12-AGN 10 m tea urine priorbit edema had fever with hx of sore thrat 3 wk bak bp 140/85 ankle edema dx -cryoglobunemia iga nephropathy membranoprliferative gn post streo gn er work cbc chem 8 ua no need of cs he does not have fever 24 hour urine protein aso titer complement -low ua--proteinuria wbc cast rbc cast rx lasix captropril penicillin office work up us renal throat culture office rx furosemide captropril nephrology consult fu 3 week family couns dietary consult low sodium diet fluid restriction seat belt ---------13-BPH 70m sono need of pregnancy test?
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night urin frequency urgency hesitency terminal dribbling double micturation weak stream sensation of incomplete evacuation vita wnl prostate normal but enlarged office cbc bmp-urea creatinine normakl ua cs us prostate psa esr residual urinary volume rx finesteride prazocin which is a selecting short acting alpha blocker
second visit urology consult urodynamic study
fu six month for dre and psa dietary consult seat belt smoking alcohol patient counseling ----------14-acute psychotic disorder dd mania bipolar 1 stress malingering panic scizophrenia drug delirium vital s -wnl so pe medsolazapine valproic acid we should give a antipsychotic and mood sabliser- lithium or valproic acid order-cbc bmp no need of lft pt ptt order tsh uds no need of ua no need of ekg xray cardiac enzymes do psychotherpy psychiatry consult coun med compliance
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suicide contract regular exercise patient education send home appointment - one week agin exam if not allright -vdrl hiv sle ect can be given monitor cbc with antipsychotic ------------15-spontaneous abortion 27 yo f lmp 6 week ago lower abdominal crmp vag bleed cervix - open blood in vault vitals tachy bp wnl dd ectopic abortion polyp cancer inflammation or cervicitis normal menstration with dysmenorrhoea er work up cbc pregnancy test qualitative then quantiatative us blood group rh iv saline no cervix tenderness - no pap gono cz now hb -9 no bllod transfusion now pt is stable us -- fetus dead - fetal pole uterine pregnancy gyn consult for d and c d and c admit to ward iv saline pneumatic compression methylprednisolone doxy cbc folow up grief counselling counsel pt rebirth control follow up 3 week ------16-malrotation VOLVULUS 1 dy old m bilious vomi
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poor feed lethargy rectal bleed oedistension 170 pulse 89 sat dd duodenal atresia intestinal atresia malrotation with volvulus meconium plug necrotising enterocolitis will do gi series to r/o duodenal will do plain xray will r/0 infections transfer to er iv aceess iv normal saline o2 abg cbc bmp lft abdominal xray cxr BLOOD C/S if fever abg-metabolic acidosis- means something in the intestine cbc leucocytosisaxr-airless rectum large gastric bubble- means some obstruction
rx as intestinal obst rx--NPO ng tube suction iv bicarb if ph less than 7 pediatric surgery consult ward upper gi sries barium enema ng tube suction
upper gi -- bird beak corkscrew proximal jejunum barium enema cecum in RUQ
rx ng tube suction iv normal saline bmp
fu 48 hours
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family counselling ---------------------17-child with rash ruleout drug reactin?? rule out lyme if suspected Office W/U Complete PE CBC, stat BMP, stat Pulse oximetry ESR, routine blood culture UA, urine culture CXR, stat EKG, 12 lead, stat Neck x ray, stat culture of scraping from rash No aspirin send the patient home and F/U in 4 days ------------18-obesity in adolescent Complete PE Measure Height Measure Weight Calculate BMI -- you have to do this manually...not in the CCS software cbc BMP LFT Fasting Plasma Glucose Fasting Lipid Profile Serum TSH UA 24 hour urinary cortisol If the age of the PT is 2-7 years old and BMI with 95 percentile......or more without complication, the goal should generally be maintenance of baseline weight, For children 27 years old with BMI at the 95th percentile or above and secondary complications, weight loss is indicated For children older than 7 years with BMI between the 85th and 95th percentile, without complications, weight maintenance is an appropriate goal. I guess this patient's BMI >95th percentile so, Weight Loss diet Counsel Patient for Exercise Program Counsel Patient Counsel Family
Follow-up visit in 4 months If no change... Sibutramine or Orlistat, po Follow up in 6 weeks If morbid obesity, BMI more than 45
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Consider Bariatric surgery ------------19-CTS pe xray cbc esr crp tsh ra ana ca magnesium bmp lipid hcg
fu 3 days night splint-SPLINT EXTREMITY nerve conduction study nsaid usual counselling another visit carpal tunnel confirmed another cou 3 month not better ortho consult for surg
20-teenager comes for a pre-employment she is 5ft 2 inches and weighs 180 lbs. Bp 155/90 pt eats fast food.. it is all about weight loss....
bmp show no Potasium drop abdominal exam ...no striae.... PE does not point towards high cortisol for her BP do urinanalysis chest x ray ekg bmp for her bmi lipid profile fasting FBS TSH cbc follow up one week bp in both arm counselling life style low sodium low fat low cholesterol
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weight mange oreder calorie count and exercise folow up three month better not better add hctz it is not secondary hypertension bmp normal no cushing no coarctation ---------------21-JRA 7 yr old girl with fever, rash and polyarthritis PE: Complete Order: cbc ( stat ) bmp or may be just BUN and Creatinine (stat) ESR ANA RF UA LFTs Xrays of the joints involved PT/PTT ( if planning to do arthrocenthesis ) athrocenthesis can be done as well.... CULTURE-URINE/BLOOD/THROAT Tylenol CXR 12 Lead EKG Echo d-dimers and fibrinogen ( i do not know the indication ..maybe coz it's a vasculitis) will pretend the child does not have a high fever...so send him home. see in next 4-5 days with the lab results.. Results: Cxr of joint without erosive changes...( so no methorexate) ANA positive such pts get eye involvement, thus eye exam q 3mths RF positive BUN nad CR wnl ASPIRIN MTX-SECOND LINE Interval hx: improved Order Rheumatology consult Eye consult Physical therapy consult EXERCISE Med compliance Multi-Vits Calcium supplements/ diet rich in calcium Educate family MRI and Dexa--? then do RATED SEX...mneumonic counsellin...whatever is applicable
22-kawasaki disease..... < 5yrs of age fever, rash, conjunctival injection, cervical lympphadenitis, inflammation of lips and the oral cavity, redness and swelling of the hands and feet. coronary arteries aneurysm unknown etiology.
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PE ; complete Orders: pulse ox oxygen cbc bmp lfts esr ua 12 lead ekg bld cxs LP Urine cx CXR IVA results: thrombocytosis elevated ESR sterile pyuria EKG=ST seg depression and T-wave flattening mild hypoalbuminemia ORDER: 2-D echo Coronary angiogram....maybe??? Aspirin ( untill pt is afebrile for several days) IVIG Consult Peads Cardiologist (like Dr. Fisher says on CCS always Consult; it wont harm U) should continue 3-5mg/kg/day, d/c after 6-8 weeks if no signs of coronary involvement and practically indefinitely if there is a coronary problem. Influenza vaccine before starting aspirin to prevent REYE'S Syndrome MMR and Varicella to be delayed till 11 months INTERVAL HX: PT HAS DEFERVESCED I do not know what to do now....maybe... ORDER: d/c home on aspirin f/u in 7 days cbc on follow up may be in 30 days to look for platelets esr follow up repeat ECHO. 6-8 weeks out counselling...
23-Osteomyelitis PE; complete..except breast, genitalia and rectal * Orders: admit iv acess iv saline blood cs urine ua and cs cbc bmp pt ptt ESR C-reactive protiens
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X-ray of the involved leg ~Results...x-ray wnl... ESR 90..... *Order MRI or Bone scan( if MRI is... C/I)..........MRI more specific! Bone Biopsy
~Results ..... MRI= Mild destruction fo tibia... Bone Bx=GM shows neutrophils & Stph aureu grows on cxs! * Admit to ward diets bedrest with bathrm privilages cbc for day #2 Empiric coverage with Oxacillin & Cipro ...OR.... Ofloxacin & ceftriaxone....treatment for 6 -12 wks....IV... Gram negative osteomyelitis treated with Cipro orallay. * 5 minute screen RATED SEX age appropriate tests... ----------------24-Hypoglycemia 27 yrs old female nurse found unresponcsive, daiphoretic and tachycardic. Prior to this she wa sc/o headache and tremors. Pupils are wnl. PmHx is insignificant. diffrential includes Insulinoma Exogenous Insulin SU overdose Prolonged fasting O2 pulse ox IVA Vitals Q 1 HR BP Cards ekg CXR Accuecheck Beta Hcg urine thiamine dextrose 50 naltrexone- if pupil constricted then iv infusion-5%dex ~PE : HEENT, LUNGS, HEART AND ABDOMEN *Result BS 50 and pupils are wnl ~ORDERS: cbc bmp cal mag phos lfts UA abg C-peptide Insulin serum Insulin antibodies Bld alcohol level Urine tox
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SU urine screen TSH Cortisol level Lipid panel ~PE: come back and finish the exam now. * Interval histoyr...pt is a little awake ~Results: C-peptide rasied and SU urine tscreen +ve for glyburide! ~Order: Octreotide SC x 1 bolus do ct/ABD to see insulinoma gastroenterology surgeon consult for surgey * Interval Hx and VItals: improving ~Orders: Transfere to ICU Octreotide sc q 8hrs Accue check q 1hrs NPO Urine output teds bedrest cbc in AM bmp in AM Psychiatyr consult * Interval History/vitals check... * improved.. d/c npo, bedrest and octreotide and dextrose.when BS in the range of 85-90 * Move to the ward.... ~ "5 MINUTE SCREEN" PAP Rated SEX ..whatever is applicable screening (mamo if age >40) colono if age>50 counsel (I select as many counsellings for all patients as poss) diet consult suicide contract if OD resched visit in another 4 wks f/u in 2 weeks after the discharge...
================================================== ===== If insulinoma is suspected..then CT abdomen or USG abdomen.. DEBULKING i.e surgery is the treatment then..... anyone still feels the need to add something...lol...be my guest.. this is an exhausting one, for sure!
25-Dilated cardiomyopathy 55 yr old pt presents w bilateral LE edema, sob on exerction, no cough. h/o drinking 5 quarts of wine every day. PE bibasilar wet crackles and evidence of moderate ascites!!! Casuses of dialted CM alcohol adriaamycin radiation viral myocarditis amyloidosis
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sarcoidosis hemachromatosis Thiamine deficiency ~ Order: put thme in as STAT O2 Pulse OX EKG CXR Cards Vitals q 2 CBC BMP IVA Fingerstick PE ; COMPLETE Cal Mag Phos Lfts Amylase Lipase UA PT PTT lipid tsh e cho B12 FOLIC BLOOD ALCOH HEAD ELEV * Results : CXR=Enlarged heart w Kerley B llines + EKG= ST-T waves non-specific abnl ~ Admit to floor ~ ~Order IVA Low Na diet Bedrest w bath rm privilages TEDS Hepari SC Lasix IV KCL MORPHI Foley Strict Input and Output Daily weights Cardiac Echo ...now! CXR Q day BMP q day * interval hx...pt hope meds will help ~Result: echo shows dilated heart w EF 25% ~Order iv carvedilol iv spirono iv lisino iv digi Anticoagulation...consider in longterm .... if evidence of thrombosis strict daily wt, i/o (foley for strict uo) daily mvi, thiamine and folate (commonly deficient) bed rest low salt diet
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fluid restriction statin if abn lipids cards consult D/C ALCOHOL ACE receptor blockers for those who cannot tolerate ACEI when stable: dc all iv meds-->poday3 f/u in 1 wk with another bmp and ekg echo in 2-3 wks screen counsel dietician consult ~ 5 Minute Screen alcohol anonymous alcohol abstienance lipid colonospcopy Rated SEX RPT ECHO-3MONTHS CARD REHAB Maybe you will have to manage the pt for 2-3 days in the simulated time...on the software... but d/c home on ace, beta bxs, spironolactone, dig and lasix...with follow up in next 7-14 days... Of course change IV meds to PO befor discharge
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26-Down's Syndrome neonate new born downs most probably presents with vomitting ( duoenal atresia) telemetry Pulse oxy IVA iv one fourth normal saline oxygen BP monitoring Cardiac MONITOR NPO NGT IV metoclopramide stat Brief physical ABG CBC BMP CXR EKG AXR acute series USG abd UA urin culture LFTs amylase lipase USG confirms the Diagnosis Consult Pediatrics GI surgery Transfer to ICU
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vitals Q 1 hr NPO Urin out put karyotyping BP check electrolytes Karyotype confirms Down's ECHO audiometry TSH Genetics consult ------------------------------------27-Preeclampsia 21 yr 0ld at 33wks gestation, c/o facial and upperextremity edema.... how will you proceed pulse oxy IVA BP monitor Cardiac Monitor brief physical
CBC BMP LFTs blood typr n cross match ( if not done already) pt/ptt UA Obtretical USG DEXAMETH MGSO4-IM[deli/labo] IF SEVERE PRE-ecl- Im-MgSO4 stat-cont IV hydralazine stat-cont ECL IV MgSO4 stat-cont IV hydralazine stat-con Urin creatinine ( it will be included in UA I guess) Transfer to ward interval hx-check-neuro pulse oxy Q 2hrs Vitals Q 2 hrs urin output bp check complete bed rest serum Mg Q 4 hrs-if give Urin 24 hr uric acid FHR monitoring fetal doppler OB consult observe for 24 hrs pt gets better
deliver the baby after term-nvd with oxy
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28-MM Multiple Myeloma** patient presenting with Hypercalcemia CCS: hypecalcemia in a pt who is presenting acutely...... lets say a 45 year old male presents with abdominal pain, wife reports he has been acting a bit strange over the last few days.... how would you proceed.... Presented in emergency.! Differential will be following: 90% Primary Hyperparathyroidism Malignancy--1-* Osteolytic Hypercalcemia due to Myeloma, Lymphoma, Breast carcinoma 2-*Humoral Hypercalcemia-PtHrP Sq Cell Cacinoma of lungs, head & neck, renal or bladder. 3-*Tumoral Calcitriol production is Hodgkins & Non Hodgkin Lymphomas. ~ORDERS: Iv Access Pulse oximetry Oxygen inhalation continuous Vitals x 1hr Focused PE : General, HEENT , Heart , Lung, Abdomen, Extremities ~ORDERS: cbc- ----- Stat bmp ------Stat calcium--- Stat Mag ---Stat Phos ---Stat Lfts ---Stat UA ---Stat EKG ---Stat CXR ---Stat Move the clock get the result ~*Results show Ca 13.5mg/dl ~*Results show Hb 8.7g/dl . Also BUN and Creatinine slightly Increased ~* EKG shows shortened QT Interval ~ORDER; Iv 0.9% Saline Continuous Salmon Calcitonin - SC q 6-12 hours Or IV Pamidronate Continuos (over 2-6 hours0 PTH assay 24 hr urinary calcium Sulfosalicylic Acid Test (to detect ~*Bence Jones Protein coz Normal urine dipsticks will not detect light chain) Seum Protein Electrophoresis Urine Protein electrophoresis Seum alkaline phosphatase (to rule our Hyperparathyroidism & Paget disease) Serum Ferritin TIBC Serum Iron Ultrasound of Abdomen (to rule out Renal carcinoma) ~*Do Interval and Check for volume overload by focused Heart & lungs ~ORDER; If Volume overload then give Iv Furosemide One time only *******Patients feels better so move the patient to Ward ~ORDER; Vitals q 2 hours Iron Enriched Diet Ambulate at will Urine output BMP daily Sodium Docusate (stool softner)
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Calcium Daily Bone Xrays Move the clock get results ~* Results show Bone X ray *Lytic Lesions. ~* Results show SPEP and UPEP *Positive ~* Results show PTH .*Normal Order *Bone Marrow Biopsy Consent for Procedure Move the clock Get the biopsy result ~* which shows Plasma cells in Bone Marrow ~*Call Oncology consult... Patient with Multiple Myeloma needs chemotherapy ~ORDER; Chemotherapy ---Vincristine, Adriamycin, Dexamaethasone. Hopefully case ends here 5 minute screen do all the counselling and age appropriate test. Epogen** SC to fix his anemia----- erythropoietin
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29-Hypercalcemia-off ice 30 yr old with hyper calcemia on routine tests with h/o renal stones some 2-3 yrs bcak. Serum calcium is 11.5 mg/dl. PE complete except breast, recal and genitalia ~ORDERS: cbc bmp calcium Mag Phos Lfts PT PTT UA EKG CXR send the pt home..call him when all the lab result return! Pt returns...do a small PE Results show ca 11.5mmg/dl ORDER; PTH assay 24 hr urinary calcium Dexa Scan pt home, call with results of the tests Results show..PTH 23 mEq/ml Call general surgery consult...parathyroidectomy..... as pt fulfills 2 criteria for undergo parathyroidectomy + age less than 50 and h/o Renal stones.. Hopefully case ends here 5 minute screen do all the counselling
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and age appropriate test. ------------------------30-Hypercalcemia-ER a 45 year old male presents with abdominal pain, wife reports he has been ating a bit strange over the last few days.... iva pulse oxi stat vitals q1h cardiac monitor cxr abdo usg cbc stat bmp stat ca, mg, phos stat ua stat amylase stat lipase lfts tsh pt/ptt morphine iv full physical npo sr. pth 24 hr ur. ca spep/upep vit d level abdo ct normal saline iv furosemide iv calcitonin if better: tt ward vitals q4h bmp, ca, mg, phos q4h consult surg if pth for parathoidectomy (blood type and cross match, npo, foley) dc all iv's alendronate send home after 48 hr f/u in 1 wk with cbc, bmp, ca, mg, phos, sr. pth 5 min screen: colono counsel f/u in 4 wks with same labs ----------------------
31-MS 24 yr F pt comes to your office with blurring of vision in L eye and weakness of right leg. Past history of such weakness episode on R arm prior to 6 months.--ER PE(complete) fundoscopy shows blurring of disc margin, disc atrophy; admit to ward
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Pregnancy test cbc bmp ua tsh vit b12 pt/ptt mri brain and spine( shows demylinating lesions) iv methyl prednisolone consult neurology consult opthal LP( shows oligoclonal bands) neuro check-2h baclofen for spasticity if pain gabapentin bladder hyperactivity oxybutinin fatigue amantadine or flouxetine urinary retention bethanecol Contracpetive normal diet/urine output/ambulation at will r/w after 12 hrs interval history and PE symptom free-- on day3 d/c IV methyl pred Fasting blood sugar cbc bmp calcium vitaminD Interferon or Glatimer acetate start counsel patient contraception oral predni vacc-influ eye consult follow up appointment; after 3 months MRI repeat -----------------------32-HELLP 35 wks getation...bp 170/115, headache, scotoma, epigastic pain-ER
pulse ox Oxygen cardiac monitors Bp continous IV access NS NPO MgSO4..IV Latetalol..IV DEXAmethasone.. IM P/E Admit to ICU...
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BED U OUT PNEU RANITIDINE-IV CBC BMP Ca, Mg. Phos LFTs----------------CONSULT OB PT/PTT Retic FSPs D-Dimers UA USS-PELV Labor monitor FETAL MONITOR CULTURE-VAG,GONO,CHLAM MONITORBP,PLT,UA-PROTEIN,PT.PTT,BMP type and cross 2 units of PRBCs FFP Platelet PENICILLIN G-IV OXYTOCIN NVD 5MIN H&H ORAL DIET PT PTT OMEPRA BF PAP LFT
---------------------------------33-Endometrial Hyperplasia without Atypia hx if imp for age, if she wants childbirth or contraception. usually presents with abnormal heavy uterine bleed. (if very heavy: send to ER), lets assume here its moderate, no distress, pt now in office. full PE CBC BMP UA LFTS B-HCG TSH PT/PTT BLEEDING TIME PAP ENDO BX USG-PELVIS-ENDO THICKNESS Call her again in 2 days: if anemic, order FOBT, RETIC, PERI SMEAR, TIBC, SR. IRON, FERR RESULTS ALL WNL. BX SHOWS HYPERPLASIA WITHOUT ATYPIA
CYCLICMONOPHASIC OCP'S IF SHE DESIRES CONTRACEPTION
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OR MEDROXYPROGESTERONE ORAL FOR 14 DAYS IF NOT FESO4 MVI Call back in 14 days IMPROVED BLEEDING: NO SYMPTOMS: CAN DC MEDROXY IF PERSISTENT: CONTINUE MEDROXY FOR 6 MONTHS Call in 1 month to check 5 min screen: pap x1 yr mammo endo bx x6months Colono counsel IF OLD PATIENT: SEVERE BLEEDING: HYSTERECTOMY
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34-Gastric cancer Weight loss , Abdominal pain , Nausea, presntation was Gastric obstruction Dysphagia, Melena, Early satiety ,Ulcer-type pain NPO NG Tube IV Fluid Vitals Iva Pulse oxy ABG CARDIAC MONITOR CBC BMP UA CXR EKG XRAY-ABD-series P/E FOBT LFT LIP ID FBS PT PTT ALBUMIN CA,MG,PHOS AMYLASE LIPASE PHENERGAN MORPHINE WD OUTPUT Barium upper GI studies CONSENT CONSULT-GASTRO ENDOSCOPY BIOPSY-NO OPTIONIN SOFTWARE
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COLONOSCOPY ENDOSCOPY,BX ADENO CA ANEMIA-IRON STUDIES,VITB12 FESO4, VITA C CT-CHEST CT-ABD PT PTT TYPE NEXT ORDER CONSENT CONSULT GASTRO-SX CONSULT-RADIO CONSULT-ONCO CONSULT-DIETICIAN ADVANCE DIRECT --------------------------------------------
35-TURP-HYPONATRE MIA Manifestations of the TURP Syndrome: - acute hypo-osmolality - acute hyponatremia - congestive heart failure - pulmonary edema - hypertension - hypotension - solutee toxicity: hyperglycinaemia (glycine) hyperammonaemia (glycine if detected intra-operatively bleeding points should be coagulated, surgery terminated as soon as possible and iv.fluid should be stopped
OXY VITALS CARDIO BP MONIT OXY FOLEY CULTURE-BLOOD/URINE CBC BMP UA EKG CXR DC-NSS DC-SX FUROSEMIDE-IV-AFTER LOW Na
ICU BED NPO OUT PT PTT
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CBC HandH TYPE ABG PULSE OXY IF SEIZURE/confusionDIAZEPAM 3% NACL -----------------------------
36-testicular pain-acute unilateral, child--ER testicular torsion, - the most dramatic and potentially serious of the acute processes torsion of the appendix testis,-MC epididymitis.
abrupt onset of severe testicular or scrotal pain.N,V awaken with scrotal pain in the middle of the night or in the morning VITALS-FEVER NO IVA OXY CARDIO BP MONITOR CBC BMP UA/culture PHENERGAN MORPHIN P/EGENTAL,ABD!! !HORIZONT LEVEL CREMESTERIC REFLEX-NEG NPO TRANSILLUMINATION USS-SCROTUM--------TEST:TORSION CX R amylase lipase LFTs PT PTT TYPE CONSULT-PED SX Cefazolin B/L ORCHEOPEXY Orchiectomy is performed if the testicle is nonviable
IF FEVER+POSITIVE CREMESTER WITH NEG USS---ACUTE EPIDIDYMITIS frequency, dysuria, urethral discharge UTI CULTURE CHILD WTH UTI-CEPHALEXIN,BACTRIM GONO- CEFTR+DOXY scrotal support, rest ----------------------------------------------
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37-hype rtensive crisis with SAH Ischemic stroke or subarachnoid or intracerebral hemorrhage -- Intravenous labetalol Other first-line agents include transdermal nitroglycerin paste and intravenous nicardipine nitroprusside should be considered second-line therapy Sublingual nifedipine should be avoided o Antihypertensive agents previously were advocated for an SBP greater than 160 mm Hg or diastolic BP (DBP) greater than 90 mm Hg. o Keep systolic blood pressure 90-140 mm Hg before aneurysm treatment, then allow hypertension to keep systolic blood pressure less than 200 mm Hg
Acute pulmonary edema -- Nitroprusside or nitroglycerin with a loop diuretic Drugs that increase cardiac work (hydralazine) or decrease cardiac contractility (labetalol or other beta blocker) should be avoided Angina pectoris or acute myocardial infarction - nitroprusside and nitroglycerin Aortic dissection - beta blocker such as propranolol or labetalol. +/- Nitroprusside Noncontrast brain CT or brain MRI Electrocardiogram Complete blood count including platelets Cardiac enzymes and troponin Electrolytes, urea nitrogen, creatinine Serum glucose Prothrombin time and international normalized ratio (INR) Partial thromboplastin time Oxygen saturation Lipid profile Lumbar puncture if subarachnoid hemorrhage is suspected and head CT scan is negative for blood Electroencephalogram if seizures are suspected -----------------------------------38-Hypertension-secondary youn g man no risk factor cbc bmp lft pt ptt inr lipid tsh ua uds cxr ekg FBS home if sodium high potassium lo normal anion gap give KCL office go for aldesterone/rennin activity ratio if high-24 aldosterone level spiranolactone abd/ct
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monitor BMp home ct-adrenal mass ward consent consult pt ptt type npo laparoscopic adrenalectomy -------------------------------if cxr show cardimeg rib notching-MRA go for coarctation if ua proteinuria do ultrasound kidney mara kidney do nephro consult do surgey consult
measure bp in both arm start meds beata-2 hctz-1 acei ccb smoking obesity alcohol drug hx coumsel call back --------------------------
39-fever unknown origin - adult
h pe cbc bmp lft pt ptt inr cxr ekg ua uds if prtinent blood culture
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urine cs sputum lp if meningitis suspected or alter mental
ct if necessary gyn consult -- if gyn cause surgery if abscess if lft increse hepatitis panel
if central lines line culture if janeway osler roth spot or bacterial endo--echo if throat pain lad mono atypical lypho in blood rapid strep test if viral syndrome vdrl hiv if leg pain or sob or pe suspected vq scan later -doppler or low -d dimer if no improve -
joint lymph node ry eye dry mouth connective tissue panel treatwith abx iv saline npo if sepsis suspected surgical consult and ct if abscess see the bllod cs report change the abx no response you may have to add amphotericin if herpes thing - add acyclovir ----------------------------------------40-septic shock
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fever shock tachy low bp left lowe quadrant pain iv normal saline iv access oxygen pulse oxy later abg focus pe cbc lft pt ptt ua uds urine culture blood culture times two ct abdomen and pelvis with contreast lactic acid cxr echo if bacterial endocarditis suspected--later in floor if he does not improve can do cardiac enzyme to rule out cardio shock amylase lipase xray abdomen - do or dont do because yo do ct anyway start abx cefotaxime genta intake out put foley urine out put 1 hourly pt get bette -continue ct reort comes surgical consult for drainage of abscess better dc with cipro ------------------------------41-Alcohol withdrawal tachy,sweating,tremor,agitated iva o2 pULSE OX cARDS MONITORS bP Accue check PE... real quick HEENT RESP CARDS Labs... STAT.. npo nss cbc bmp lfts
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Blood alcohol level Urine toxicology ABG amylase lipase PT PTT Thiamine IV Folic acid Iv Calcium serum Mag srum Phos serum
now come back and Complete the PE...what ever is lfet librium transfere to ICU seizure precaution aspiration precaution
5 minute screen counselling RATED SEX... alcohol anonymous.. ----------------------------------42-retained placenta (ER,3post op D, w fever and abd tenderness)
Pulse Oxymetry IV Access IV NSS Complete PE CBC with Diff PT/PTT Blood Grouping and Cross Match LFTs UA and CS Blood Cultures Cervical Cultures and gram staining IV Ceftriaxzone IV Clindamycin Consult OBG, for retained placental removal send the pt to medical ward: Bed rest NPO Vitals Q4H ---------------------------------43-Chronic renal failure
in office
take complete physical exam
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order vitals cbc bmp ua cxt abd ultra sound abg ekg serum lipids serum albumin serum calcium phosphate vitamin D pth lft if pt in emergency then we do iva and also see the urnie output check phosphate lever and also pt ptt and do blood typing as tehre might be anaemia so we mite need transfusion or even dialysis if acidosis calcium tratment is diet ---------------------------------44-Acute renal failure 80 yr old man comes to ER with n/v and maliase. PMhx is significant for Htn, DM and osteoarthritis. Pt is on NSAIDS, lisinopril. Also reports making very little urine over the last 24 hrs.
PE : General, heent, LUNGS, ABDOMEN ~ Orders: iva nss pulse ox vitals Q 2 hrs cards ABG Accue check ekg and cxr CBC BMP Cal Mag Phos UA Urine cxs LFTs tylenol ~PE: come back and complete the rest of the exam now... *!* Results..(.pH 7.29, PCO2 20, PO2 80). (BMP NA 138 & HCO3 12)
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~Transfere to ward ~Order low potassium diet/diabetic diet bed rest with bathroom privilages d/c NSAIDS d/c Lisinopril FOLEY Strict input/putput Teds Urine NA ( NL IS LESS THAN & EQUAL TO 10) and Creatnine 24 hr Urine protien eosinnophils in urine...(seen in allergic nephritis) Renal USG ( if BPH...call urology consult) Hgb A1c DAILY WEIGHTS Accue check q 4 hrs Insulin sliding scale ( if need be ) BMP q 2-4 hrs hopefully pt starts to improve after d/c nsaids and NSS infusion... pre-renal RF treated with fluids...if no rsponse...IV lasix.... Dobutamine and dopamine (if heart failure) ~famous 5 minute screen RATED SEX...what ever is applicable. --------------------------------------------45-rape complete physical orders: maybe one ste of vitals.. RAPE KIT... cbc..for baseline UA pregnancy test..beta HCG urine cervical smear KOH prep Hanging drop cervical gram stain and culturegonorrhoe DNA probe testing Chlamydia DNA probe testing morning after pill..i think it is LEVONORGESTREL-oral(high dose estrogen) for 2days Now STD prophylaxis: Ceftriiaxone 125 mg IM Azithromax 1gm PO Probenecid Metonidazole 2gm po for trichomonas add vdrl rape crisis consult cervical sample for chlamy and gonorr elisa for HIV Hep B surface antigen Social services consult Psych Consult? ---------------46- HUS
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ER Focused PE IVA NSS Oxygen pulse oxymetry Monitor Blood Pressure NPO CBC BMP UA, Culture AXR acute series Stool leuco, cultu, ova & para peripheral smear ldh haptoglonin in/output pt/inr pt/ptt blood type cross match D-DIMER FIBRIN DEGRADATION PRODUCTS-fdp results come as low platelet fragmented RBC no FDP no D dimers PT/PTT are normal K+ is elevated treatment with keyexalate Once stable transfer to ICU monitor BP cbc check BMP again every 1 hr till K+ normalizes followed by every 4hrs pt/ptt supporitve for now. consult hema pediac counsel pat/fam If case doesn't improve plasmapheresis ***check for ldh inc. schisto in peripheral, retic increa BUN & crea are in BMP ---------------47-New onset DM-42 yr old c polydipsia & polyuria DD- DM, DI, Factitious Disorder since it is a clinic setting...no emergency.. Pe: complete ORDERS: cbc bmp ca, mg, phos UA 12ekg ABG lipid profile cxr HgbAIC lft
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Finger stick BS 325mg/dL.DIAGNOSTIC DM Admit to inpx service monofilament skin test, serum/urine ketones, serum/urine osmolarity, urine microalbumin. UA-CULTURE -ivf nss, -sliding scale:bld glucose 100-200-do nothing bld glucose 200-300-5u insulin bld glucose 300-400-10u insulin blood glucose (accucheck or finger stick) q2h, BMP-2h -vitals q4h, Activity prn, foley's catheter for intake output,1800 ADA (55-60% cho,less tham 30% fat,15-20% protein,vitamins,minerals,H20), lisinopril and other anti HTN (if HTN) -podiatry or chiropody consult -endocrinilogy consult -ophthalmology consult -If insulin 100-200,dc insulin and institute glipizide, dc ivf -counsel:weight loss,diet,exercise, annual ophthalmologic exam, foot care and protection,medication compliance, depression couseling, family counseling,medication side effect counseling,annual health maintenance and flu vaccine couseling. -follow-ups.
--------------------
48-Fever Unknown origin-child INFANT-bac,HSV Child-infect,connective Cbc Ua Bmp Cu lture-blood,urine,throat Lft Ana Rf Esr Cxr Lp-irritable Ppd Hiv Syph Ct-abd Wbc scan-gallium/indium NO-emp..ABx --------------------------------------- ----------49-Cervical cancer
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physical exam cbc bmp ua urine beta hcg gonorhea probe chlamydia probe wet mount vaginal ph HIV ELISA VDRL pap move the clock forward if has come with chlamydial infection/ginorrhea treat that call in 3 days (pap result comes in 3 days) Colposcopy Endocervical curretage(its there in the software but asks for Gynecolgy consult) Gynecology consult(No Endocervical biopsy on the software so can ask for that also on the Gynec consult) Move the clock forward Call her in a week colpo-cx ca Interval history Admit to ward Bed rest with bathroom previleges cxr lft pelvic ex IVP CSYTOSCOPY SIGMOIDOSCOPY abdominal ct pelvic ct bone scan RADIO-CONS oncology consult ekg 12 leads blood type cross match pt ptt Serum Iron with TIBC reticulocyte count
interval history TAH+BSO(If family done) Gynecology consult RADIATION/CHEMO-CISPLATIN patient education no smoking no alcohol supportive psychotherapy Iron enriched diet 50-Failure to Thrive 2yr - below 5th percent
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If severe malnutrition/abuse---Hospitalization ddlow intake abuse chd infection endo genetical Hx+EX Head,neck,weight Cbc Bmp Ua Cxr Fobt Lft Culture-stool/urine Folic Vit b12 Stool-ova/fat/ -HIV PPD TSH Sweat test Galactose------Caloric count Nutrient supp Cons-dietician Social service
F/u-q week
The Following 10 Users Say Thank You to navz For This Useful Post: angelina vivien (04-04-2011), chatti (09-02-2011), dr.dhruvdesai (06-16-2011), drrsahuja (11-12-2011), jahn77 (2 Weeks Ago), jatnpatl (05-18-2010), missmbbs (11-27-2010), mle_asap (05-05-2010), shaan (07-14-2010), tommylee (02-24-2012)
Foods To Lower Cholesterol Healthy diets and tips. Find foods to lower cholesterol. BestHealthDiets.com Ask a Urologist Online A Urologist Will Assist You Now! Questions Answered Every 9 Seconds. Health.JustAnswer.com/Urology Test Your PT/INR at Home Check your own warfarin levels with Philips PT/INR Self Testing at home inrselftest.com
09-23-2009
#2 Steps History: Step 1 Only Posts: 5 Threads: 0 Thanked 1 Time in 1 Post Reputation: 11
carroline
USMLE Forums Newbie
woow I kept scrolling and scrolling down and this post never finish how reliable is this info!
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4/16/12 11:27 AM
09-23-2009
#3 Steps History: 1+CK+CS Posts: 3 Threads: 1 Thanked 10 Times in 1 Post Reputation: 20
navz
USMLE Forums Newbie :)
hahaha i think it is pretty short for 50 cases..bt i think it covers some vital stuff u that cud help u for sure while working wid uw stuff!!!
11-27-2010
#4 Steps History: 1+CK+CS Posts: 31 Threads: 1 Thanked 9 Times in 8 Posts Reputation: 19
missmbbs
USMLE Forums Scout
Thanks!
thanks so much for the post! much appreciated.
09-02-2011
#5 Steps History: 1+CK+CS Posts: 1 Threads: 0 Thanked 0 Times in 0 Posts Reputation: 10
chatti
USMLE Forums Newbie 100 important USMLE STEP 3 CCS cases
that's helpful this is a list of dr.red 100 important CCS cases , i think it will help http://www.slideshare.net/usmlegalaxy , in this see the dr.red pdf CCS cases
11-11-2011
#6 Steps History: 1+CK+CS+3 Posts: 64 Threads: 1 Thanked 3 Times in 3 Posts Reputation: 13
slime66
USMLE Forums Scout Thanks
WOW!!! I am speechless. And Thanks.
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50 Star Ccs Cases - USMLE Forums

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Steps History: 1+CK+CS Posts: 3 Threads: 1 Thanked 10 Times in 1 Post Reputation: 20

found this on another forum so thought of sharing here