Dr. Red Sample C C S Casesfor U S M L E Step3.Doc

CCS for USMLE Step 3The following is a general outline of several concepts that are discussed in CCS workshops. This is just forquick review. Comprehensive explanation and demonstrations are available in CCS Workshops.EMERGENCY ROOM GENERAL PROTOCOL:Check follow-up Hx often in ER to monitor subjective improvement in the complaints.Use control button on an ORDER screen to pick up several options. Always check report time of the orderafter placing the order - this allow seeing how long the procedure or order will takeAlgorithm for ER: ( Refer Powerpoint Slides)Initial orders + pain managementFocused PEAdditional ordersFull exam once stableOrders:Oxy – oxygen – several optionsIVA – IV accessVitals – q1hrCard – cardiac monitor,Bmp – basic metabolic panelCounsel: seat belt, safe sex, weight loss, exercise, contraception, breast exam, smoking cessation, low Na (forHTN), diet, calorie – restricted (for HTN, obesity) – In ER Cases, reserve this routine counseling to 5 minscreen.Algorithm for office:Full Physical ExamTreat the SymptomOrder labs and Send patient home (unless there are criteria for admission or unstable vitals or severe pain)Schedules follow up appointment when diagnosis is likely to be availableTreat the diagnosis during follow up visit, check follow up history and focused physical during follow upvisit.The following are several sample CCS cases subject-wise which were practiced in several previousCCS Workshops at the request of the attendees. A selection of the sample CCS cases will be practicedin the CCS Workshop. In addition, most of the Cases that are requested by the attendees will bepracticed during CCS Workshops. Discussion of NBME copyrighted cases is strictly prohibited.Students are advised to kindly not discuss exam cases or kindly not disclose NBME or USMLE Step 3exam questions during the CCS Workshops.Pediatrics1. Newborn Downs baby. Get chromosomal analysis2. Duodenal Atresia: 1 day old Down syndrome baby presents with vomiting – ultrasound with duodenal atresia. Get abdominal US, then General surgery consult.3. Ventricular Septal Defect. The child presents with CHF. Hx of Down syndrome. PE: pansystolic murmur. Initial mngt: furosemide, CXR, echoKG, Cardiology consult to get cardiac catheterization to rule out pulmonary hypertension even it is not read on echo report (because if you will close VSD there will be no blood coming to the LV). If pulmonary hypertension is present you cannot close VSD, than the only

option is lung transplant.4. Constitutional growth delay in african american kid. Check bone age, genitalia to rule out cryptorchidism, chromosome analysis to rule out Klinefelter syndrome and Turner syndrome.5. CHILD ABUSE: 3 y/o African American boy presents with lethargy, CXR reveals multiple posterior rib fractures and CT head subdural hematoma. Call child protection services and social work6. Intussusception in child. Order abdominal x-ray and then barium enema7. Bacterial meningitis in an infant. Get blood culture and start ceftriaxone and IVF immediately, then get head CT and lumbar puncture8. JRA. Check rheumatoid factor (should be negative), give NSAIDs, get ophthalmology consult to rule out uveitis.9. 9mos old baby with fever unknown cause all tests including CBC are negative, wait three days by advancing the clock for rash to appear (Roseolum infantum)10. 8 month old child with fever11. Turner’s syndrome. Get chromosome analysis, check GH, CXR to look for aorta (rule out coarctation), start GH replacement.12. Foreign body aspiration. Look for unilateral (right side) wheezing.13. Childhood sleep apnea14. Sickle cell crisis with splenic calcification. Get CBC, reticulocyte count, Hgb electrophoresis, give oxygen, IVF, analgesics (narcotics), consider blood transfusion if symptoms are severe. Vaccine (pneumo), PCN V15. Sinusitis. For a child <10 get CT scan (not x-rays). Start amoxicillin or TMP-SMZ.16. HUS. ER: 8 yom with rash all over the body for 1 day. PMH: recent bloody diarrhea for 3 days which improved on its own. DDx: TTP, ITP, HSP, HUS (elevated creatinine, hemolytic anemia), thrombocytopenia. PE: brown-reddish, macular, diffuse rash (purpura). CBC: Hgb 8 (rule out ITP), plt 20.000 (rule out HSP); BMP: elevated creatinine; coags normal (rule out DIC); bleeding time, INR, UA normal, vitals. Peripheral smear shows fragmented RBCs (schistocytes; hemolytic anemia). D- dimer, fibrinogen, FDP, reticulocyte count, LDH elevated with hemolysis, LFT, direct Coombs negative, haptoglobin decreased with hemolysis. Tx: supportive care, if creatinine is not improving consider dialysis. Order Nephrology consult, dialysis, dialysis IV consent. Check CBC for possible ongoing hemolysis, consider plasmapheresis. Check BMP. Admit to ICU.17. 5 yom with recurrent nosebleeds in the last 24 hrs. Hx of recent URI. DDx: ITP, TTP, HUS, HSP. PE: a red rash. Initial mgnt: nasal direct pressure, CBC shows low platelets, normal Hgb. Observation and platelet count monitoring. IVIG.Psychiatry1. Bipolar disorder. Depression index, start lithium or valproic acid, check TSH, follow TSH and lithium level. If the pt in psychosis give haloperidol. Counsel alcohol cessation.2. Panic Attack. Breathing in a paper bag, start fluoxetine, psychotherapy.3. Alzheimers disease (had to rule out other causes of dementia before making the diagnosis). Do cognitive testing (this is a term for MMT), head CT, start donepezil4. Acute manic disorder. If the pt in psychosis give haloperidol, consider ECT5. Anxiety6. Depression. Get depression index, start fluoxetine.OBGYN1. Pregnancy2. Pregnancy in a 44 yof. Check at first visit Pap smear, UA, CBC, blood type, Rh type and antibody screen, RPR or VDRL (if positive confirm with FTA-ABS or MHA-TP), rubella titer (if unclear vaccination Hx), HIV, glucose (if the pt has risk factors). Repeat at every visit UA. “Triple” screen (AFP + estriol + HCG) at 15-20 wks. If it is positive, get US to confirm accurate dates and do amniocentesis for chromosome analysis and AFP. Check fasting glucose and glucose load test at 24-26 wks. Group B streptococcal vaginal and rectal Cx at 35-37 wks.3. Pregnancy with asymptomatic bactiriuria, UTI with 12 week pregnancy. Start ampicillin

4. Incomplete abortion. US, observation, emergent D&C, check HCG5. X2 Eclampsia... presented with seizures, AMS, and peripheral edema at 38 weeks pregnancy. Tx with magnesia sulfate IV drip, monitor vitals q2hrs. follow magnesium level. Stop magnesium if you notice decreased respiration or hyporeflexia (first sign) or CNS depression. Check for HELLP with LFT and CBC. Deliver the baby with labor or C-section. If status epilepticus => intubate. OB consult.6. Vaginal Bleeding secondary to Fibroids requiring hysterectomy.7. Dysfunctional uterine bleeding. ER: 25 yof, c/o vaginal bleeding, dizziness, diaphoria. Vitals: low BP. PMH: negative, regular cycles which recently became longer and heavier (menorrhagia). FHx: pt’s uncle had severe bleeding in major surgery and was diagnosed with the same disease. DDx: ectopic pregnancy, blood dyscrasia, fibroid, dysfunctional bleeding. Initial mngt: oxygen, IVA, NS, NPO, type and cross blood, BPM, vitals, cardiac monitor – continuous, UA, HCG (if positive then get quantative HCG; for this pt negative). Focused PE (chest, abdomen, genitalia): a lot of blood, no tenderness. CBC 7.4, platelets 300.000. BMP normal, coags: PT/INR normal, bleeding time prolonged. TSH. Advance the clock. Interval Hx: vitals are more stable, but the pt is still dizzy. Transfuse blood (acute anemia <8 or symptomatic pt, e.g. SOB). Conjugated estrogen IV (work as a hemostatic agent). BT 9, PTT 44 (vWD: woman, prolonged BT and PTT, positive FHx). Give DDAVP, if the first dose did not work, then give cryoprecipitate (it has more factor 8 than FFP). Check CBC q4hrs (should improve after blood transfusion). Interval Hx: the pt continue to bleed, transfer to ICU. Pelvic US normal (no fibroid, if positive needs Tx with uterine artery embolization or if the pt >45 yo - hysterectomy). Eventually bleeding decreases, the pt feels better. Postmenopausal woman with vaginal bleeding. If she is on HRT, she can have bleeding in first 6 months. Get US, if hyperplasia >5 mm get endometrial biopsy. If it comes back negative, then progestin. If it shown atypical hyperplasia do D&C or hysterectomy. If endometrial CA proceed with hysterectomy.8. Acute PID. Check ESR, CBC, vaginal Cx. Start cefoxitin + doxycycline for 2 wks outpatient or clindamycin + gentamycin IV inpatient (pregnant, severe N/V, ileus, fever>39C, WBC>20.000). Follow with pelvic exam and US if fever persists >48 hrs to rule out tubo-ovarian abscess. Continue ABx.9. Bacterial vaginosisSurgery 1. Intussuception2. AAA dissection. ER: 75 yom, c/o sudden onset of severe back pain when he tried to lift a heavy object. Pain 10/10. Vitals are stable. PMH: HTN, PAD. PSH: smoking. DDx: prostate CA, HLD, abdominal aneurysm dissection. Pain mngt: morphine IV without PE, then oxygen, vitals, IVA, EKG, CBC, BMP, pulse oxymeter. PE: absent peripheral pulses, spine – benign (rule out real spine problem; x-ray may help for possible metastases). Abdominal US can help with abdominal aneurysm but not show dissection; get abdominal CT with contrast (check creatinine before): shows AAA dissection. Start metoprolol. Get lumbar spine x-ray. Complete PE: now back pain is better, but the pt has abdominal pain and dropped BP (shock). Surgical consult for aneurysm repair, BPM, cardiac monitor, IVF. After OR transfer to ICU, monitor urine output, CBC q8hrs, check lipid panel. Counsel: smoking cessation, vaccines.3. PTX. 65 yom with excruciating right chest pain for 1 hr and severe respiratory distress. PMH: asthma, emphysema. DDx: tension PTX, MI, aortic dissection, PNA. PE: absent breath sounds on the right side. Initial mngt: needle thoracocentesis, followed by chest tube placement. Confirm the lung reinflation with CXR. .Trauma1. Motor vehicle accident with splenic rupture. Postsplenectomy prophylaxis with pneumococcal, meningococcal, and H.influenza vaccines, continuous PCN G.2. Splenic hematoma3. Osteoporosis with compression fracture. DDx: medications (esp. steroids), hyperthyroidism, multiple myeloma. Get serum Ca, TSH, PTH, urine for Bence-Jones protein, DEXA scan, start Ca carbonate, vitamin D, alendronate, for women raloxifene or conjugated estrogens + progesterone.4. back pain due to osteoporotic fracture

5. Heat stroke. DDx: neuroleptic malignant syndrome, serotonine syndrome, sepsis. Risks of arrhythmia and rhabdomyolysis. Initial mngt: electrolytes, CPK q6hrs and BMP q6hrs to monitor effects of Tx, cardiac monitor, NS, don’t give Na bicarbonate right away, cooling, intubate if the pt don’t respond quickly.6. Trauma patient with cardiac tamponade. Pericardiocentesis.7. 75 y/o female fell and sustained right hip fracture – orthopedic consult, orif, cbc, transfuseHTN1. 50 + y.o. F with high BP in office. Diet (low sodium and low cholesterol), counsel for exercises. Check CBC, BMP, lipid profile, EKG, UA.2. annual health check up, essential hypertension3. hypertensive encephalopathy. ER. Initial mngt: place arterial line catheter to follow arterial pressure; neurological signs, nitroprusside IV, start labetalol PO, BPM, head CT to rule out hemorrhagic stroke, check other organ involvement (BMP, EKG, cardiac enzymes)DM1. DKA. Check BMP and UA. Cardiac monitor. Start IVF and insulin even before intubation, follow glucose level. Give KCl and phosphorus when UOP>30 ml/hr is established. Blood Cx. Follow anion gap.2. New Onset DM type II. Check lipid profile, Ophthalmology consult.3. Hyperglycemia/ new onset DM4. Uncontrolled DM type 2 - came with increased thirst and urinationCholesterolSmokingAlcoholObesety1. Obese man with essential HTN – evaluate for Sleep apnea, if positive nocturnal CPAP2. Obesity in a teenager. Check lipid profile. Low calorie diet.DVT, PE1. Pulmonary embolism2. Septic pulmonary emboli in IVD abuser.Acid base / electrolyte disorder1. Dehydration/ Hypernatremia - 70 y/o man with altered mental status, no urine output sent from NH to ER. No fever. (BMP comes back shows NA + 160, BUN high, Crea normal) --> two things here , this patient has confusion which could be secondary to dehydration or hypernatremia. If euvolemic hypernatremia with CNS symptoms --> you would use D5W IV. However, in this case there is a clue that the urine output is low --> indicating hypovolemic hypernatremia --> so, would hydrate first with NS , NG tube, free water orally, R/o sepsis ( if CBC showed leucocytosis or if there is fever - please be sure to r/o sepsis , get CXR, blood cx, urinalysis and urine cx, if any source of infection seen start empirical antibiotics pending cultures), get head CT, Foley catheter ( r/o obstructive uropathy since there is no urine output), and next put orders to monitor pts response to your therapy ( I/O monitoring, neurochecks q4hrs and BMP q4hrs - check if Na and BUN are improving, don’t drop Na too fast due to risk of cerebral edema)2. Hypercalcemia/ renal mass (likely RCC) - Elderly man presenting with fatigue, do physical, make sure he is not dehydrated (if he is dehydrated, needs admission and IV fluids) - office visit - routine tests - BMP reveals hypercalcemia - stop clock and start w/u on order sheet, i.e., PTH, Serum phos, ionized calcium, LFTs (check alkaline phosphatase - increased level may indicate bone lesions), vitamin D level, SPEP, U/A, UPEP, 24 Hr urinary calcium excretion ( to r/o familial hypocalciuric hypercalcemia. 24 hr urine calcium is increased in primary hyperparathyroidism where as decreased in hypocalciuria), CXR (R/o sarcoidosis - hilar adenopathy, R/O LUNG MASS, Cancer) . R/O metastatic cancer ( back pain, breast

mass etc) from the history itself - All come normal, so remember to r/o ectopic PTH secretion that is seen as PTH related peptides (PTHrP is not picked up by the software) --> so, next do w/u for r/o occult malignancies that can lead to hypercalcemia by ectopic PTH secretion (SQUAMOUS CELL LUNG CANCER, SQUAMOUS CELL HEAD AND NECK CANCERS, BREAST CANCER, MULTIPLE MYELOMA [UPEP/SPEP], T-CELL LYMPHOMAS, RENAL CELL CANCER, AND OVARIAN CANCER ) -- > do a CT chest and abdomen (will help to r/o lung ca, lymphoma and renal cell ca) - CT abdomen reveals a 10 cm renal mass ( make sure they say complex renal mass) - call nephrologist, oncologist and surgeon - rx is nephrectomy which will resolve hypercalcemia ( but remember, if the presentation revealed dehydration or coma or calcium > 13 gm% - suspect hypercalcemic crisis, admit patient and hydrate first and then work up everything as inpatient! Give bisphosphonates for all cancer related hypercalcemia)ShockCardiology1. Acute pericarditis - rx (make sure to do echo, don’t do unnecessary pericardiocentesis if there is mild to moderate pericarditis without clinical or echocardiographic evidence of tamponade)2. Acute MI. ER: 65 yom, c/o severe left chest pain 10/10 which started at rest and radiates to the left shoulder. Vitals are stable. PMH; HTN, PAD, AAA. Start with pain mngt: MONA = morphine IV x1, oxygen, nitroglycerine sublingual x1, aspirin and tests: vitals, pulse oxymeter, IVA, cardiac monitor, BMP, CXR, EKG 12 lead (the most important test), cardiac enzymes x3. Then get focused PE => normal => get full PE including rectal (the pt will probably need heparin). Advance the clock for EKG result, shows STEMI (if it is negative, then you need to rule out non-STEMI with cardiac enzymes). Start BBL (metaprolol; decrease mortality), clopidogrel, heparin x24 hrs, abciximab (Reopro; continue for 1 yr if there is a stent, if not then just for 1 wk), statin, cardiology consult for cardiac catheterization (do thrombolysis with tPA only if cannot get cardiac catheterization promptly). It will give you EF (if EF is low start ACEI) and show a blood clot. Check PT/PTT. Follow CBC for possible HIT, BMP for possible contrast nephropathy, check lipid panel, check diet. Counsel for sex activitiy, exercise, education, smoking. Get cardiac rehab. Get submaximal stress test in 1 wk after STEMI for exercise recommendations (not used that often now). For non-STEMI (without cardiac catheterization) proceed with full stress test in 1 wk if there is ongoing ischemia. If the pt cannot walk on the treadmill get pharmacological persantine or depyridamole test.3. DM w/ MI4. Stable Angina5. atrial fib6. Congestive heart failure in a post-op patient (make sure they are not giving too much IV fluids in post op setting, I/O monitoring, daily weights, lasix, 2d echo, r/o MI, EKG, CXR, BNP - Lasix, if flash pulm edema, give morphine)7. complete heart block (MVA) – actually, MVA secondary to syncope from 3rd degree heart block. Bradycardia / heart block mngt. Stabilizing orders before Dx: monitor cardiac, oxygen, pulse oxymetry, check monitor cardiac, EKG 12 lead, ABG, blood pressure monitor (BPM), IV access. Check TSH, cardiac enzymes, give midozalam to sedate the pt for transcutaneous pacer; consult cardiology, place pacemaker transthoracic (transcutaneous). Then transfer the pt to the ICU, change the pacemaker to transvenous (more stable); d/c any meds that decrease cardiac conduction (BBLs, ACEIs), then change transvenous pacemaker to permanent (get cardiothoracic consult). Diet: normal. Counsel family/pt, seat belt, medic alert button. Vaccine: influenza, pneumo. TEE to look for possible clots.Endocrinology1. Secondary Hypertension, Hypokalemia – adrenal mass2. Constipation, hypercalcemia, primary hyperparathyroidism3. Hypothyroidism in a man. Office: 33 yom, c/o extreme tiredness and constipation for several wks. The pt lost 10 lbs in the last month. Smoker. FH: DM. PE (complete without genital/rectal [do if >50 yo]): delayed reflexes, obese, mild brady (may be normal in young person). DDx: hypothyroidism, anemia, colon CA, hypercalcemia. Tests: TSH, CBC, LFT, EKG, UA, BMP, FOBT. Respond to sxs for

constipation: docusate, bisacodily, diet with high fiber. Send the pt home, schedule appt when results are back. TSH 35 (you start with screening test, if it is positive, then do confirmatory tests; stop the clock, order T3/T4). Order levothyroxin, thyroid peroxidase antibodies (antimicrosomal antibodies), lipid profile (if LDL is elevated it might be caused by hypothyroidism, so don’t need to treat it right away, it may improve on levothyroxine). Counsel: smoking cessation, side effects of medications, seat belt, safe sex practice. Later check TSH and lipid profile in 1 month. Follow thyroglobin for effectiveness of Tx.Gastroenterology1. Alcoholic hepatitis2. Acute Hepatitis A3. 50 yom with epigastric pain (erosive gastritis, had h/o long term NSAID use)4. Hepatic encephalopathy. ER: 65 yom brought in by his wife for AMS since am; he has constipation for 7 days, on spironolactone. PMH: hepatitis C, ascitis, portal hypertension. Initial mngt: secure airway, oxygen and pulse oxymeter, suction airway q1hr, vitals, IVA, cardiac monitor, BMP, thiamine IV, accucheck, Tylenol level, CBC, UA, CXR, LFT, ammonia = 82, coags. Do paracentesis for cell count, culture, cytology, Gram stain, protein (if WBC>250 the pt has SBP). Lactulose per rectum (the pt can start responding after 1-2 bowel movements, so try not to intubate but secure airway. Levofloxacin for SBP prophylaxis (ceftriaxone for SBP treatment). Neurochecks q1hr. BMP and CBC negative. PTT prolonged, INR 1.5. After lactulose the pt is more awake, opens eyes. Very low AST, ALT, albumin (means advanced cirrhosis). Don’t give albumin, it will not stay in the vessels and make edema worse. Get EGD to look for varices, check AFP q6 months and US q6 months for future hepatocellular carcinoma screening. SCDs for DVT prophylaxis.5. Acute cholecystitis6. Inflammatory bowel syndrome (ulcerative colitis and Crohn disease). Office: 25 yom, c/o abdominal cramps, bloody diarrhea for 5 wks, tenesmas, lost 10 lbs. SH: smoker (quit 2 months ago). DDx: infectious diarrhea vs. IBS. Vitals stable => proceed with full exam (without breast, genitalia): normal, without dehydration, rectal – guaiac positive. Orders: stool for culture, fat, ova / parasites (Giardia antigen is more sensitive but takes more time), WBCs, Gram stain; CBC, ESR, BMP. Tx: loperamide (but not for infectious diarrhea caused by Shigella or Clostridium difficele), check orthostatic, oral electrolyte mixture, dicyclomine for abdominal cramps. Send the pt home, follow in 3 days. Gram stain shows GNRs – normal bacteria in bowels (don’t be fooled; follow culture which will show normal flora). WBCs elevated – an important sign of inflammation. ESR elevated, CBC normal. Follow-up: check interval Hx, get focused PE: the pt still has diarrhea. Get colonoscopy, GI consult, low residue diet (less fiber). Colonoscopy shows pseudopolyps. Tx: meselamine (later add steroids) or sulfasalazine.7. Erosive esophagitis/ GERD8. Acute pancreatitis9. 53 y.o. F with Lower GI bleed and anemia10. acute diarrhea11. Diverticulitis12. ischemic colitis13. Gastric ulcer. 55 yom c/o epigastric pain 5/10 for 2 wks, wakes at night, pain is worse with eating, without melena, N/V, heartburn. SH: ETOH positive, tobacco positive. PMH normal. DDx: ulcer disease, GERD, cancer, pancreatitis, MI, dyspepsia. Full PE: mild epigastric tenderness, FOBT negative. Initial mngt: CBC, ESR, BMP, EKG, LFT, lipase, omeprazole, H.pylori breath test (urea breath). GI consult and consent for EGD. EGD shows gastric ulcer, get biopsy for H.pylori (but you don’t have to order biopsy for CA, it will be done by itself). Counsel for alcohol and smoking cessation. Follow-up in 3 days when biopsy stain is back, H.pylori is negative. Focused PE. New follow-up in 1 month. New counsel for colonoscopy and check lipid profile.Hematology1. G6PD in AA (?aplastic anemia) kid presented with jaundice.2. Anemia secondary to colon cancer3. 20 month old african american boy brought for fatigue and lethargy to office (initial orders - CBC

reveals anemia, MICROCYTIC TYPE - do iron studies (serum iron, ferritin and TIBC), blood lead levels, reticulocyte count, LFTs, haptoglobin, sickle screen and LDH - ferritin low. No evidence of hemolysis (r/o sickle cell at this time), do stool guaic (rectal exam in the beginning itself r/o blood loss as a cause of Fe def) --> Fe defeciency diagnosed which is most common in children during growth spurts if nutrition is not adequate ( remember you already ruled out other causes of Fe deficiency i.e; lead poisoning, GI blood loss, ongoing hemolysis) . Order iron rich diet (very important to order this diet since lack of balanced diet is the reason for Fe def in children during growth spurts) , iron oral pills ( FERROUS SULFATE)- check cbc in 1 month/ schedule follow up visit - usually blood counts return to normal in 2 months --> so, schedule follow up CBC and Ferritin level for "LATER" date i.e; 2 months later on 5 minute screen ( continue ferrous sulfate for at least 6 months even when blood count normalized)Infectious1. Urosepsis. ER: 72 yof brought in for AMS. Hx of hospitalization for PNA, then diarrhea 2 months age. SH: lives in assisted living facility. Temperature 101, vitals stable. DDx: urosepsis. Initial mngt: oxygen and pulse oxymeter q 1hr, airway suction q1hr, IVA, vitals, cardiac monitor, EKG 12 lead normal, BMP normal, CBC with WBC 18.000, blood culture x1, LFT, portable CXR normal, UA: cloudy, positive LE, positive nitrites, get urine culture. Aspiration precautions: elevate HOB.2. Toxic Shock syndrome3. 40 y.o. M with IVDA and SOB with fever (Infective Endocarditis)4. Chlamydia urethritis in 23 y/o male5. Acute bacterial prostatitis6. OsteomyelitisNephrology1. Minimal change disease: Child had scrotal swelling. Office: 10 yom, c/o swelling for 10 days including low extremities and scrotum. PMH: strep sore throat 10 days ago. DDx: glomerulonephritis, nephrotic syndrome with protein >3.5 (minimal change disease), allergy, liver disease, malnutrition. Full PE: swelling, no rash, without rales/crackles. Initial mngt: UA stat in the office (dipstick takes 30 min) shows no blood (rules out glomerulonephritis), positive for protein, ?lipid casts, CBC, LFT, BMP, order diuretics only if pulmonary edema, CXR AP/lat, urine protein for 24 hrs, diet with low Na. follow-up in 3 days: focused PE still shows edema. BMP normal, 24 hr Na 50 confirms minimal change disease, maybe lipiduria, start prednisone, does not need renal biopsy. Next follow-up in 4 wks. Counsel parents, order lipid panel, check 24 hr protein in 4 wks, continue low Na diet.2. 50 + y.o. F with Renal failure and family h/o ADAPKD, HIGH K+3. CystitisOncologyFor any pt with CA seen in the office do metastatic work-up for staging and call Oncology.1. Breast CA2. benign endometrial hyperplasia3. Endometrial carcinoma4. X2 cervical cancer5. ovarian tumor, ovarian teratoma6. Vulvar Squamous cell cancer7. X2 pancreatic ca, old man with fatigue, weightloss - exam shows icterus - go ahead with CT8. gastric carcinoma9. Adenocarcinoma colon10. ALL : 4 yo boy presents with weakness, disinterest in activity and lesion on leg. On examination, the lesion was ecchymosis and there was generalized lymphadenopathy with liver enlargement. CBC, BMP, LFTs, LDH -- > revealed CBC: anemia, thrombocytopenia, neutropenia, lymphocytosis with 95% lymphocytes on DC, peripheral smear shows blasts (schistocytes if there is concomitant DIC), LDH elevated in leukemias/ lymphomas, hepatosplenomegaly on ultrasound, CXR: many enlarged lymph

nodes, then now need to do bone marrow biopsy (diagnostic step) and this reveals many lymphoblasts. Admit and call ped/onc, CT chest and abdomen (shows wide spread lymphadenopathy), bone scan, karyotype- counsel: cancer diagnosis. Check PT/PTT, FDPs and fibrinogen to r/o DIC as 10% ALL patients may have DIC. If there is fever at presentation, make sure to get pan cultures. Make sure to order "neutropenia precautions" if there is absolute neutropenia (ANC < 500)Pulmonology1. Acute Asthma Attack2. 14 y.o. F with Asthma exacerbation in office, shift her to ER after doing the pulse oxy and PEFR3. Exacerbation of Asthma – diffuse wheezes. Nebs, iv steroids, o2, PEFR4. Right upper quadrant pain, cxr - PNA - right lower lobe - community acqd pneumonia. ER: 66 yom, c/o severe, sharp, continious RUQ pain x8 hrs a/w deep breath. DDx: cholecystitis, right-side PNA, pleuritis, pancreatitis, renal stones, hepatitis. Initial mngt: morphine x1 (pain is a priority, even for abdominal pain), vitals q1hr, oxygen and pulse oxymeter, IVA, cardiac monitor, EKG (normal), CBC, BMP, LFT (normal). PE: tenderness, guarging RUQ but without Murphy sign or rigidity. Portable CXR (the pt is in pain) shows RLL PNA. Admit for IV ABx (the pt is old, high fever). UA, amylase / lipase (more specific for pancreatitis) – normal. Check interval Hx and finish PE – normal. Tylenol PRN and advance the clock. NPO, NS, ceftriaxone (Gram-positive and Gram-negative coverage + azythromycin (only to cover atypical organisms) or levofloxacin (covers everything including Mycoplasma and Legionella). Get sputum and blood cultures. Now can change location after first dose of ABx. Criteria for discharge – 24 hrs afebrile. Check CBC on day 2. Vaccine: influenza on day 5 IM, pneumo IM. Counsel: colonoscopy. Change diet to regular.5. bacterial pneumoniaRheumatology1. Osteoarthritis of the knee (if there is large joint effusion, always do arthrocentesis)2. SLE3. 4 yo. F with ANA +ve Arthritis4. Polymyalgia rheumatica. Office: 75 yof, c/o stiffness in both shoulders and fatigue for 6 wks. PMH: osteoarthritis, without weight loss. SH: normal. ROS: HA on the left side. DDx: polymyocytis, temporal arthritis, dermatomyocytis, rheumatoid arthritis, polymyalgia rheumatica, hypothyroidism (fatigue), osteoarthritis. Complete PE: normal, stiffening limitation in shoulders and hips, without tenderness. Initial labs: CBC, BMP, UA, ESR (very high; confirms polymyalgia rheumatica), x-ray of bilateral shoulders and hips (use control button) shows only mild osteoarthritis (not explaining pain); CRP normal, rheumatoid factor negative, TSH normal. Give Tylenol and physical therapy (symptomatic Tx even not sure about Dx), send home, follow in 1 wk. follow-up appt: focused PE, start prednisone, check DEXA (as prednisone will be for a long time) for baseline, esp. she is at risk for osteoporosis as postmenopausal. Start Ca carbonate, vitamin D3 (calciferol), alendronate, temporal artery biopsy, colonoscopy (does not need mammogram as she is already 75 yo).5. Giant cell arteritis6. septic arthritis7. rh. arthritisDermatologyImmunology1. HIV with PCP and lymphoma2. HIV in a 25 y/o f with multiple partners – presents with with weightloss, fatigue and cough. Do HIV test, viral load, genotyping. Then cd4 count.3. Anaphylactic reaction. ER: 25 yof, c/o SOB, itching and wheezing after bee sting. Vitals: low BP, tachycardia. Start Tx without PE: IVA, oxygen and pulse oxymeter, vitals q1hr, cardiac monitor, epinephrine x1, NS, BPM, diphenhydramine, famotidine, prednisolone for 5 days, albuterol continious. Finish PE. When BP is stabilized transfer to ICU for possible delayed reaction. Check HCG, CBC, BMP, vitals. Later: skin test (when the pt is off steroids), allergy in 2 wks (check for more broad allergies);

immunology consult, Pap smear, counsel: use epinephrine.Neurology1. TIA2. Woman with multiple sclerosis (comes with weakness and has nystagmus on neuron exam)3. CIN IIIToxicology1. Tylenol overdose2. TCA Overdose : 30 year old man with no history know brought in the ER by a neighbor with unconsciousness and unresponsive state....he had some depression as per neighbor (TCA overdose). How will you manage? DDx: overdose medication, schizophrenia, infection, drugs, hypoglycemia. Initial management: secure airway, continuous suction (start with it, don’t intubate right away; but if irreversible, than intubate); oxygen, IVA, blood sugar with Accucheck (takes 2 min; if low give dextrose), ethanol level, give thiamine IV, naloxone IV x1, salycilate level, Tylenol level, UA, CBC, BMP, EKG 12 lead shows prolonged QT interval (?TCA), portable CXR, toxicology screen in urine takes 2 hrs shows TCA. Do neurochecks q2hrs to follow Tx. As reversible causes of unconsciousness are ruled out you can intubate the pt before starting treating something. Consult pulmonary medicine for ventilator settings. Give Na bicarbonate IV (lidocaine for V-tach), NG tube, do gastric lavage. Transfer to ICU, consult psychiatry, make suicide precautions, check depression index.3. Lead poisoning4. Opoid poisoning5. Alcohol intoxication- 40 year old man presents to ER in comatose state and is unresponsive. Alcohol breath. ETOH level very high . How will you manage? .GeriatricsElder abuse

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