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41 Cards in this Set

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30yo F with knee, wrist pain, morning stiffness

DDx? Dx? Optimal approach including tx?

DDx: OA, infectious arthritis, RA, SLE, gout and psoriatic arthritis

Dx: RA

Optimal management: PE (extremities, CV, lungs, abd, skin, HEENT and lymph nodes), RF or anti-CCF, CBC, arthrocentesis, ANA, ESR, CRP and joint XRs

Rx: NSAID or steroid + DMARD (methotrexate or etanercept)

65yo F with L sided CP, HTN, tachycardia w/ bounding central and peripheral pulses, diastolic decrescendo murmur

Dx? Optimal approach?

Dx: aortic dissection

Optimal approach: ECG 12 lead, portable CXR, stabilize with IV BB + another antihypertensive, IV morphine, continuous cardiac monitor, pulse ox. Once stable - CT chest w/contrast, echo or MRI. W/U: BMP, CBC, CPK, cardiac enzymes, d-dimer and type & crossmatch. Thoracotomy or dissection repair

4yo M w/ SOB for 3 days, coughing & wheezing esp after playing outside, h/o pollen allergy and atopic dermatitis

Dx? Optimal approach?

Dx: asthma

Optimal approach: targeted PE (HEENT, lung, CV and abd), pulse ox, O2 therapy, bronchodilators (albuterol) and steroids (betamethasone) are essential. Include - counseling family on asthma care, med side effects, chest exam after treatment

65yo M w/ sharp R-side CP and respiratory distress. No breath sounds on R lung exam.

Dx? Optimal approach?
Dx: pneumothorax

Optimal approach: focused PE, then needle thoracostomy followed by chest tube. CXR to confirm tube placement. Important to minimize W/U before needle decompression
31yo F w/ lethargy, N/V, h/o DM1. On exam, fever, tachypnea, tachycardia and hypotension. No insulin for 24hrs.

Dx? Optimal approach?
Dx: DKA

Optimal approach: focused PE (lung, CV, abd & neuro/psych), serum random glucose, UA, CBC, IVF (NS or Ringer's), broad spectrum abx (cephalosporin or fluoroquinolone). Once serum glucose is obtained, IV insulin and cardiac monitor. Include ABG, blood cx and BMP. Continue monitoring glucose, electrolytes, pH after treatment
25 yo F at 38wks gestation to ED after seizure w/ LOC. Exam shows tachycardia, low-grade fever, and HTN.

Dx? Optimal approach?

Dx: eclampsia

Optimal approach: focused PE (skin, HEENT, lung, CV, abd, genital, extremities, neuro), CBC, IV mag sulfate, IV antihypertensive (hydralazine or BB). Immediate delivery - vaginally (use oxytocin or misoprostol PRN) or C-section. Measure pt urine output. Include - BMP and PT/PTT.

Don't forget about pt comfort. How do you manage pt in pain, nauseous, constipated, with diarrhea or insomnia?
Pain: IV morphine
Nausea: IV phenergan or ondansetron
Constipation: PO docusate
Diarrhea: PO loperamide
Insomnia: PO temazepam
25F with urinary frequency and burning. LMP 24 days ago. No fever, N/V/D, or flank pain.

Optimal approach?
Focused PE. bhCG (positive), UA (positive nitrite and leukocyte esterase), urine cx

Uncomplicated cystitis - TMP-SMX 3 days
Complicated - TMP-SMX 7 days
If pregnant, nitrofurantoin PO, prenatal vitamins
List prenatal labs
Blood type, antibody screen, Rh type, CBC with diff, BMP, Pap smear, rubella status, syphilis screen (VDRL or RPR), UA and urine culture, hep B surface ag, HIV counseling and testing, chlamydia testing

Don't forget about counseling, prenatal vitamins, iron sulfate and folic acid
28M with bright red blood per rectum; also has colicky abd pain. Older brother has UC. Smoker.

Optimal approach?

Dx: UC

Focused PE (gen, skin, HEENT, CV, lungs, abd, rectal, extremities). CBC, BMP, stool for O&P/WBC/culture, LFTs, PT/PTT, ESR, sigmoidoscopy and rectal biopsy,

Rx: mesalamine, loperamide, dicyclomine (anti-cholinergic), dietary consult, counseling, smoking cessation

26F with amenorrhea and abd pain. LMP 7 wks. Currently sexually active with husband and practices safe period for contraception. H/o 2 episodes of PID.

Optimal approach?
Dx: Ectopic pregnancy/PID

Focused PE. b-hCG (positive) stat. NPO, VS Q1hr, IV access, IV NS, complete bedrest, quantitative b-hCG, transvaginal US, type and crossmatch, blood group and Rh, CBC, PT/PTT, BMP, LFTs, cervical GC cx (abx if positive) - all stat orders.

Tx: ob/gyn consult, PO MTX, IV morphine

F/u orders: cancel NPO, VS, IV access, IV NS and complete bedrest. Order rest at home. Counseling.
Management of ectopic pregnancy
If hemodynamically unstable - IV access/NS, type and cross - transfuse as needed, continuous BP monitoring, PT/PTT, b-hCG and pelvic US, consult sx or ob/gyn for laparotomy

If hemodynamically stable - r/o rupture, b-hCG quantitative. Perform transvaginal US
- If b-hCG > 1500 and US shows intrauterine preg, ectopic is unlikely
- If US is equivocal and b-hCG +, then repeat test in 2 days
- If b-hCG > 1500 and US shows adnexal mass < 3.5cm, give MTX (contra in renal/liver failure and breast feeding). Mass > 3.5cm or MTX contra then perform laparoscopy. Give Rhogam to Rh neg pts
27F with 3mo h/o abd pain and altered bowel habits (diarrhea and constipation). No ill contacts. Sexually active with husband only. LMP 1wk.
Dx: IBS

Complete PE. CBC, BMP, TSH, FOBT, EST, stool O&P/WBC/Cx, 72hr stool fat, Pap - routine. Send home.

Return in 1 wk - order lactose free diet, high fiber, loperamide, biofeedback, reassurance, relaxation exercise, counseling. F/u in 2 wks.
40F c/o insomnia, easy fatigability, and feelings of worthlessness. She also reports feelings of guilt and hopelessness, and is unable to concentrate. Lack of appetite, no pleasure in her normal activities. Recent loss of loved one 2 mos ago.

Optimal approach?
Dx: major depression

Complete PE. CBC, BMP, TSH, B12 - routine. Fluoxetine PO. Counseling. Appt in 10 days.

Next appt: interval f/u, PE. Schedule an appt in 14 days.
Vaginal discharge, pruritus management?
Trichomonas - presents with a frothy, yellow-green discharge and strawberry cervix. Motile flagellated organism.
- Tx: metronidazole (avoid alcohol). Treat partner

BV - presents with a white/gray discharge and fishy odor
- Tx: metronidazole (avoid alcohol)

Vag candidiasis - itching, white curd-like discharge
- Tx: miconazle/clotrimazole suppositories or vaginal cream

Orders: vag pH, wet mount, vag gram stain, Pap, GC cx, UA
75M with gradual worsening of forgetfulness. Poorly groomed, difficulty with activities of daily living (ADLs). Paranoid features (accused son of mixing poison in his food). No med problems.

Optimal approach?
Dx: Alzheimer's

Orders: complete PE. CBC, BMP, LFT, TSH, B12/folate, CT head or MRI brain - routine. Send home. Appt in 7 days

Rx: donepezil (cholinesterase inhibitors), olanzapine for delusions. F/u in 6wks.
65M with severe SOB and wheezing; h/o COPD, yellow malodorous sputum. Smoker.

Optimal approach?
Dx: COPD exacerbation

Orders: emergency orders (elevate head, cardiac monitor, pulse ox, O2, IV access), focused PE (gen, HEENT, lungs, CV, abd, extremities), PEFR (peak expiratory flow rate) Q1hr, CXR, ABG, ECG, CBC, and BMP - all stat

Rx: albuterol continuous; if PEFR and O2 sat are low add ipratropium nebs, IV methyl-prednisone, PO or IV antibiotics

Final orders: counseling, flu/Pneumovax vaccines, smoking cessation
43F to ED c/o severe RUQ. Pain started after breakfast. She is nauseated and vomited 1X. Similar episode last year.

Optimal approach?
Dx: acute cholecystitis

Orders: focused PE. Order: CBC, BMP, LFTs, serum amylase/lipase, blood cx, abd XR, abd US - stat

Rx: IV access + NS, NGT, NPO, IV piperacillin-tazobactam, ketorolac IM and phenergan IV - stat

Order: bedrest with bathroom privileges, consult sx, PT/PTT, type and crossmatch

Clock: advance 8-12hrs until patient improves and becomes afebrile.

Order: laparoscopic cholecystectomy, counseling
Management of any diabetic patient
HbA1C, Accucheck, mention drug compliance, diabetic foot care, regular Accuchecks at home, diabetic diet, if chronic pt, ophthalmology consult for fundoscopy
5 minutes left... what to do?
RATED SEX
Reassurance, Alcohol, Tobacco, Exercise, Diet
Seat belt, Educate pt/family, X (Safe sex)

Convert or cancel all IV meds
Order LFT/lipid profile to assess drug side effects
Child with high lead level. Now what?

Must check "serum venous lead level" to confirm.
If > 70, must admit immediately and give dimercaprol and EDTA.

Must check house for lead - order "lead abatement agency" and "lead pain assay" upon discharge

Acute abdomen patient with suspected perforation. What abx to give?
Triple therapy - gentamycin, ampicillin, and metronidazole
Any bleeding patient, what should you order?
PT/PTT, blood type and crossmatch
Patient with GI distress or is at risk for aspiration (elderly with AMS). What should you order?
Head elevation, aspiration precautions

NPO - in case of surgery
All children given gentamycin... what should you order?
Hearing test, and check BUN/Cr before and after treatment
All ICU patients get what for stress ulcer prophylaxis?
IV omeprazole
Patient > 50 yo, no h/o colonoscopy or FOBT. What should you order?

DRE, FOBT, and sigmoidoscopy or colonoscopy. Remember to bowel prep - NPO, IVF, and order "polyethylene glycol"


In males, add prostate exam and a PSA

Patients with terminal disease. Don't forget what?
Advanced directives
Patients with diarrhea. What should you order?
Stool ova and parasites, white cells, culture, c. diff antigen
What is the standard pre-op set of orders?
NPO, IV access, NSS, blood type and crossmatch, analgesia, PT/PTT, pneumatic compression stockings, Foley catheter, urine output, CBC and appropriate antibiotics (Keflex, metronidazole/ciprofloxacin, imipenem)
Patient in anaphylaxis and on a beta-blocker for HTN. What should you give first?
Beta-blocker will decrease efficacy of epinephrine so glucagon is given to neutralize BB.
Orders for suspected dementia patients
Head CT, B12, folate, TSH, fasting glucose, depression index, CBC, BMP, UA, LFT

If history indicates, VDRL/RPR and HIV ELISA
After thoracocentesis, what should you order?
Send effusion and peripheral blood sample for LDH, protein and pH of effusion
Vaginal discharge. Orders?
KOH prep, saline (wet) prep, vaginal pH, chlamydia/GC culture
Colon, pancreatic, liver, ovarian cancer markers?
CEA, CA19-9, AFP, CA125
Infant < 3 mo with fever. Orders?
Assume sepsis and culture blood, urine, sputum, and CSF
Patient with Mobitz II or complete heart block. What to do?
Order immediate "transcutaneous pacemaker" then a cardiology consult to place a "transvenous pacemaker."
OD patient. Don't forget to order the following...
If suicidal, then add:

Urine tox, gastric lavage, activated charcoal
Suicidal patients: admit, sign "suicide contract," order "suicide precautions"

Alcoholic ketoacidosis patient. Orders?
IV dextrose, NSS, and thiamine
If CXR shows effusion, what is the next step
Next step is decubitus CXR
Respiratory trouble? Orders:
Suction of secretions, nebulized albuterol, ipratropium, IV methylprednisolone, PEFR/RFT/FEV1, chest PT, percussion therapy, and ABG