100 VIP CCS Step-3 Exam

100 VIP CCS STEP-3 Note HEMATOLOGY 1-30 Yo Greek man with fever in ER co of acute back pain, headache, lightheadedness, jaundice, dark urine, lastly he eat in Middle eastern restaurant ( fava beans) , PH, mild anemia and recurrent GB stone, cholecystectomy. Order • Pulse oxy and Oxygen therapy if hypoxia • Acetaminophen,oral Continous • EKG, stat • Iva, stat • NSS, stat Order • PT, PTT,, stat • LFT , stat>>>>hi indirect Bilirubin >>>hemolysis • Cbc, stat>>>>Hb 6 • Retics count, >>>>3% • Peripheral blood smear>>>bite cells, Heinz bodies • Bmp,stat • Coombs test>>>>> -ve not Autoimmune hemolysis • Blood culture • U/a, stat • Urine hemosiderin, stat • Urine Hb, stat, • Haptoglobin, stat • Abd USG, stat to check for the GB stone 2ry to chronic hemolysis • Counsel to avoid offending drugs and avoid fava beans ttt only supportive care, hydration, and care to avoid RF. avoid offending drug and food. reschadule patient after 3 wks to check Serum G6PD enzyme level 2- 25 yo women in ER with epistaxis stopped by pressure, OE, multiple spots on her both ankles, and gingival bleeding, CBC platelet 10.000.vitally stable. Order • CBC, Peripheral smear • Bmp, • PT, PTT ,BT • Antiplatelet antibodies, serotonin release assay if there was any heparin intake history, • Fibrinogen, D-dimer >>>N • LFT>>>> N IF life-threatening bleeding, give IV Ig + Dexamethazone. • HIV Eliza, negative➖ cbc,bun, creatinine daily, • ANA negative Rituximab, or Romiplostim and • BM biopsy, stat>>>>megakaryocytes>>>>ITP eltrombopag.

• Consult hematologist Order • Prednisone for 6 wks oral ( only if the platelet < 50). • Immunoglobulin if acute or life threatening hage • Danazole or vincristine if refractory, 3- 70 yo women hospitalized 1 wk ago for pneumonia, treated with broad spec. antibiotics. PH: PUD, on pantorpazole.. she had one pisode of coffegroud emesis this morning but selflemitted. vitally stabel. Order complete PE, rectal. Order • CBC, stat>>>>N • PT, PTT, BT, stat,>>>> ⬆ PTT, ⬆ PT. • • • • • • • • •

Fobt, >>>>➕ Bmp, stat Abdominal x ray, stat >>> no free air under the diaphragm Abd. USG, stat Blood typing and cross match, stat Bilirubin, stat>>> N Fibrinogen, stat>>>N D-dimer,stat LFT, stat>>>N

Rituximab works by removing the lymphocytes that make the antibodies that attack platelets. You know that rituximab removes CD20-positive lymphocytes. This is the same mechanism for how it works in cold agglutinin disease and how it works in rheumatoid arthritis. Romiplostim and eltrombopag are stimulants of megakaryocytes. They are thrombopoietin. These medications are used when splenectomy does not control the disease. It seems that ITP is not entirely a “destruction problem” and that stimulating production seems to help.

Order>>>>>> SCI VIT- K for three days. • Schedule colonoscopy after one month for screening • Vaccine influenza, pneumococcal, herpez softer. 3- Vitally stable 65 yo 👨 in ER to undergo transurethral resection of prostate for BPH. With elevated PTT blood test. Consulting you before doing surgery if he need any FFP transfusion before surgery. Order: complet PE Order: • CBC, stat>>>N • PT, PTT, BT, stat>>> high PTT • Fibrinogen, stat, >>>N • Mixing study, stat>>>> abnormality doesn't correct • VWF Assay is normal➖ • VDRL, Stat➕

DD of High PTT: 1- APS 2- FACTOR XII def 3- VWF def 4- Hemophilias.

VDRL is always false + in Antiphospholipid syndrome

• FTA, stat, >>>>➖ Order • No need for FFP transufsion or any clotting factor replacement becuase this is Antiphospholipid syndrome, • Prophylactic anticoagulantion (aspirin + LMWH as Dabigatran) after surgery against thrombosis is mandatory. 4- 28 yo woman was hospitalized 3 days ago with I wk fever after chemotherapy for Hodjken lymphoma, fever resolve by antibiotics but she co fatigued and her Hb was 7

and 2 U blood transfused to her. During the first unit, she developed rigor, fever, back pain, agitated confused, feverish 39", BP 80/60, pulse 140. Oozing from IV sites and epistaxis Stop the transfusion first >>> EPI IM immeidately in case this is anaphylasi Order focused PE. Order • Oxygen, stat • Pulse oxy, stat • Iva, stat • NSS, stat • Cardiac monitor stat, • BP monitor stat, Order • CBC, stat>>>>platlet 90.000 • ABG, Stat • Bmp,stat>>> creat 1.7 • Fibenogen, stat,⬇ • FDP, stat ⬆ • PT, PTT, stat⬆ • U/a, stat>>> ➕ Hb. • LFT, stat>>>> ⬆ indirect B. • Haptoglobin,stat>>>⬇ • LDH, stat>>>⬆ • Blood typing and cross match, stat DIC IS SUSPECTED Order: • FFP, STAT • Monitor renal function improvement if not improved give mannitol and frusemide (to prevent ATN) if still no improvement consider dialysis. • Platlet transufsion if sever bleeding • Factor XII Transfusion if life threatening bleeding. 5- 75 yo man comes in for routine check up in your office,PH, HTN controlled on Nifidipine, routine blood test, showed elevated total proteins 9.5g, albumin 3.5g, vitally stable, ROS is unremarkable. Order complete PE Order • CBC, stat • Bmp, stat>>>>N • in bmp BUN, create stat normal • TSH, stat • Urine electrophoresis >>> ➖ for Benz Jhons Prtns • Serum electrophoresis >>>monoclonal spike in gammaglobulin < 2.5. • Skeletal survay, N • BM biopsy stat>>> 5 % plasma cells • Diagnosis is MGUS • Schedule colonoscopy after one month

• Vaccine influenza, pneumococcal vac, herpes zoster vaccine, 5- 25 yo woman come to office co of progressive fatigued for last 6 mons, FH freq cold & sinus infections.,noticed multiple bruises on arm and legs without truma. Paint worker. Order complet PE Order • CBC, stat >>>> pancytopenia • RF>>Negative.... • BMP, stat>>> • TSH, stat • HIV ELIZA, STAT • PPT, stat

DD of Pancytopenia 1- SLE 2- APLASTIC ANEMIA 3-PNH 4- BM MALGNANCY 5- MDS 6- Famconi syn.

• To exclude PNH one of cause of pancytopenia, urinary hemosiderin>> if positive order coombs>>> it should be ➖in PNH >> flow cytometry to confirm diagnosis of PNH. Abscent CD 59-55.

• ANA, Stat to exclude SLE • Vit-12 level, stat • Folic acid level, stat • BM biopsy >>> hypocellular >>> aplastic anemia • Hematology consult Order • Avoid exposure to offending agent eculizomap is DOC for PNH. • Antithymocyte globin + cyclosporine. BM transplant in resistant •

6- 75 yo man in your office with lethargy,, with erratic and volatile mode, genralzied weakness and fatigued depression and worsening ataxia. OE decreased sensation of lower limb and vibratory sense. Hyperreflexia of LL. Order complete PE. Order • Pulse oxy, stat, • oxygen ,stat • CBC, stat • TSH, stat • Brain CT, stat>>>mild diffuse atrophy • Bmp, stat • U/a stat • VDRL, stat>>> • Vit-B 12 level, stat, >>>>> low • Antipriatal cell antibodies, stat➕ • Anti-internist antibodies. Stat ➕ • If antibodies were ➖ do schilling test. • Methylmalonic acid level, stat ⬆ Order • Vit B 12 IM injections ( not oral) daily for a week. Then oral therapy afterward.

• Schedule colonoscopy after one month • Vaccine influenza, pneumococcal, varicella, herpes zoster vaccine. 7- 28 yo African American comes in office for routine checkup. CBC shows MCV 59 Hb 11. A symptomatic Patient. Complet PE Order • CBC, stat n • Bmp, stat, • Iron, stat>>> N • ferritin, stat>>>> N • Peripheral smear, stat>>> target cells • Hb electrophoresis>>> ⬆ Hb A2 >>> thalassemia • Counsel • Educate your patient • Reassure , no ttt is requires. 8- 25 yo women comes to office for examination for new job. Co of fatigued, palpitation,regular mensis. She appears pale. Complete PE Order • CBC,stat>>> Hb 9, N • MCV, stat >>> ⬇ • Peripheral smear, stat >>> hypo chromic microcytic RB cells • Iron, stat • Ferritin, stat • TIBC, stat>>>>⬆ This is iron deficiency anemia, Order oral ferrous sulfate three times a day Follow up by cbc & retics. 9- 22 yo man in office co of abn bleed after shaving intermittent for years. Become sever after he took a sprin this week. Order complete PE Order • CBC, stat>>> N • PT,stat >>>>N • PTT, stat>>>⬆ • BT, stat, >>>⬆ • VWF level >>>low • Ristocetin cofactor assay>>> abn low>>> due to defective platelet function. This is VWF Defieiceny disease Order • Desmopressin, • Factor VIII replacement if still bleed. • Avoid aspirin in future.

10-55 yo 👨 comes to office co of fatigued and left UQ pain + vitally stable. Order complet PE>>>fullness in RUQ Order • CBC, stat >>> leucocytosis, thrombocytosis • Abdominal USG, stat >>> splenomagly • Peripheral smear, >>>N no blast cells • Leukocyte alkaline phosphatase level,stat>>> low • Philadelphia chromosome, stat >>> ➕

These are all crieteria of CML

• BCR/ABL>>>➕ • BM biopsy>>> neurtophil infiltrations❓ 👹 Order • Imatinib. • BMT if refractory to Gleevec. • If acute leucocytosis >400,000 >>>leukopheresis • Schedule colonoscopy after one month • Vaccine influenza and pneumococcal vaccine, 11- 57 yo 👨 is admitted with SOB after Pulmonary embolism. Has been on IV UH. On third hospital day platlet dropped from 180.000 to 60.000. Coumadin was started two days ago. Order complet PE>>>> N Order • Cbc, stat>>> low platlet 54000 • PT, stat>>> N • PTT, stat>>> therapeutically high • Bmp, stat>>>>N • Platlet factor 4 antibodies level, stat>>>> ➕ • Serotonin release assay from platlet, stat>>>➕ Order • Stop Heparin • Start lepirudin, IV, Continous • CBC, stat every day after platlet reach 100.000 • Use warfarin (coumadine) for the plum emploism • Schedule colonoscopy after one month • Vaccine influenza, and penumococcal vaccine. 12- 50 yr old woman has admitted for Up GI bleed due to PUD. She received 2 u of blood, her blood type B Rh negative. She has mild icterus. Order complete PE Order • CBC, stat>>>Hb 7 • Bmp>>> renal function is normal • PT,PTT, stat are N

• • • •

LFT, stat, AST/alt are N , indirect Bili, ⬆ Urine hemosider, stat >>> N Haptogblobin, stat >>> N Coombs stat,>>> ➕

• Rh of transfused blood, >>>>➕ Order: • reassure, admit the medical erro to your patient. Monitor the Renal function. • Schedule colonoscopy after one month • Vaccine influenza,penumococcal vaccine. • Mammography 13- 40 yo 👨 in office, co of fatigue, wt loss 15 pounds over few months. He also have infertility co, recently lost interst in sex. Also intermittent non specific abdominal pain. Joint pain, palpitation, lightheadedness. Order complet PE>>> mild icterus, frequent ectopic heart beat, reg rhythm & rate. Atrophic testicles. Light bronz appearance. Order • CBC,stat>>>N • BMP, stat,>>> ⬆ glucose, • LFT, stat, >>>⬆ AST/ALT, • ECG, stat>>> PVCs • Iron, stat>>>⬆ • TIBC, stat, >>>l⬇ Hemochromatosis case

• Ferritin, stat>>>⬆

• Transferring, stat>>>>⬆ • Liver biopsy >>>> hi iron • Genetic screen of the family>>>> HFA gene Order • Phylepotomy every 2 u weekly until Hb 15 g/dl, ferreting < 45% then I u /3 month. • Deferoxamine, SC infusion

Nephrology 14- 72 yo woman come to ED co of nausea, malaise. PH, sever osteoarthritis on ibuprofen.vitally stable. Order focused PE. >>> mild JVD, tachycardia, left basilar tracks in lung, bilateral LL edema. Order • Pulse oxy, stat • Oxygen, stat >>> discontinue oxy therapy if O2 sat > 92 • EKG 12 leads, stat • BP monitoring Order • CBC, stat • U/a, stat>>> trace protinuria

• Urine stain for eosinophilia >>> ➖ • Urine Sodium >>>⬆ than 20 >>> renal failure secondary to NSAIDs • ABG, stat,>>>> Po2 80, bicarbonate 12, PH 7.29>>> meta acidosis • Bmp, stat>>> K high • CXR, stat • Lipid profile, stat • Uric acid, stat Order • Admit to the ward • Renal diet • Ambulateat well • Urine outpu • Discontinue NSAID • Ca gluconate • telemetry monitoring • IV GLUCOSE 50 % • IV regular insulin to treat hi K • ABG, Q 4 hrs • Bmp, Q 4 hrs • If still bmp and ABG do not normalize go for dialysis • Schedule colonoscopy after one month • Vaccine influenza, penumococcal vaccine • Mmography, after month

Dont forget to order ABG for any renal disease.

15- 27 yo woman, co to ED with sever pain left flank, dark urine, no fever, only has been co of burning and frequency in urination, treated with TMBSMZ. Pain sever enough to prevent her talk to you, with nausea, vomiting, Order, focus pE... Normal acute distressed patient Order • Pulse oxy • IV Ketorolac, stat, Continous, • EKG, monitor, • U/a, stat • 24 hr Urine calcium stat, • Urine culture, stat • Bmp, stat, • Uric acid, • Abd, X ray KBU • Abd helical CT, Order • IV • IVF NSS, bolus • IVF NSS, Continous • Interval History and exam • Shock wave lithripsy if stone < 1cm in upper tract • Nephrostomy or uretroscopy if stone > 1 cm or in distal tract. • Stones < 0.5 mm pass spontaneous by IVf and analgesics only.

16-52 yo woman with breast cancer treated with lumpectomy and axiliary LN dissection, no chemotherapy needed. She come to your office co of puffiness of her face, and body swells. Order complet PE >>> periorbital edema, • Order • CBC, stat • Bmp, stat,,>>>RFt all N • Ur/a , stat>> + 4 protinura, fat bodies, no cast. • Urine Sodium >>> ⬆ 20 • Total protein, stat>> N • Serum alabumin, ⬇ • Lipid profile, >>> ⬆ Causes of nephrotic synd: • LFT, stat >>> N 1- Membranous, MPGN or Order. Look for cause of nephrotic synd --- all will show N minimal changes GN, or • some will order only nephrotic consultation to check for the cause . FSGN GN. • but i would prefer to give some highlights on managment here. 2- SLE, DM, Amyloidosis, • ANA, complement for SLE. Cryoglobulin. • HBsAg, • HCV, Ig Order • renal biopsy >>> thick GBM with spikes, electrons microscope, subepithelia deposition. >>> membranous GN ( idiopathic or due to tumor) • oral steroids, • Oral vit D oral Ca. omebrazol coz steroid predisbose to gastric ulcers • Dexa scan baseline • Lisinopril for protinura ip even if BP is N. • Renal diet, restricting Protien. Order • Follow up after 6 wks, If the patient does not improved, order cyclosporine. • Monitor Bmp, u/a. • Mammography after months • Schedule colonoscopy after one month • Vaccine influenza, 17- 52 yo woman with type1 DM, comes to your office becuase of genralized weakness, has difficult in clear thinking, she lost while she walk in the clinic to see you. Order Complet PE>>> chest mild basilar rales, no murmurs, +2 edema, somewhat confused. Order • CBC, stat>>>N • Bmp, stat>>>⬆ BUN, ⬆ Cr,⬆ k (6), ⬇ bicarbonate (15) • ABG, stat>>> Met acidosis • Acuecheck >>>140 Oliguric + • U/a, stat, >>>>3+ protinuria, 1+ glucose. hyperkalemic+ • Urine Sondium, stat acidotic= D5W + • LFT, stat bicarbonate to avoid • Renal ultrasound>>> bilateral large kidneys overhydration and • 24 hr urinary proteine collection, Phosphorous,Mg, if bmp shows hypercalcemia order PTH stat • correct

hyperkalemic and acidosis

Order • Admit to ward • Bed rest • Diabetic diet • Acuecheck Q 8 hrs • Regular insulin, basale blous regimine • Serum uric acid, stat • Lipid profile, stat • Nephrologist consult cause Chronic renal failure. • EKG, STAT for K level. • IV regular insulin, and 50% glucose • Ca gluconate, stat • IV bicarbonate, if acidosis did not correct consider hemodialysis. • Pt, PTT, bleeding time, stat>>> cause uremia cause platelet disfunction After improvement of chimestry lab,,..discharge home Order • Oral Sodium polystyrene sulfonate or Kexylate, to get k out of body in stool, • Vit D • Oral Ca acetate, if Hi Ca in bmp, follow up ca level>> still hi >> sevelamir/calcitriol(vit-D). • PTH level, every month if high >> order cinacalcet in follow up visits.>> if not>>> thyroidectomy. • Patient education, medical compliance, no alcohol, renal diet, resitric Na, proteins. • Mammography, after 4 wks, • Colonoscopy, after 4 wks, • Dexa scan after 4 wks, • Schedule colonoscopy after one month • Vaccine influenza, 18- 57 yo 👨 with lung cancer history, comes to your office co of confusion. On chemotherapy for lung cancer. Still has hemoptesis and perihilar LN. He is depressed on SSRI. Diabetic on Glyburide. Order complete PE>> weak, disoriented. Order • Pulse oxy >>> 96% • CBC,>>>>N • Bmp, hyponatremia. N renal function, N Glucose. • U/a>>> N • EKG,>>> N • CXR, >>> peihilar Lymphadenopathy • Brain CT>>> N Order • Plasma osmolarity >>>>200 • Urine osmolarity >>> 600 • Urine Sodium,>>> ⬆ 40 Order>>>> this is hyponatremia secondary to SIADH • Water restriction • Oral frusemide • Stop SSRI, cause hyponatremia • Demeclocycline oral • Schedule colonoscopy after one month

• Vaccine influenza, 19- 27 yo woman in office with Continuos headache, she known Hypertensive and take CCB. (headache is seems to be due to uncontroled blood pressure). Order complete PE >>> high pitched sound on epigastric area Order • CBC, >>> N • Bmp, >>>cr 1.2, BUN 36 • U/a>>N • TSH >>>N • Abdominal ultrasound>>> bilateral small kidneys • MR Angiopgraphy>>> decrease up take of left kidney • MR Duplex Ultrasound of renal artery>>> left renal artery stenosis • MR arteriography ( gold standard) >>> stenosis of renal artery Order • Balloon angiography of stenosis lesion>>> if fail repeat second time. • Operative repair • Control HTN by ACE inhibitors. 20- 32 yo man come in office co of painless gross hematuria after URTI. He has similar episode from 3 years ago resolved by course of antibiotics. pH: HTN, Hyperlipidemia. Order>> complete PE >>> BP155/92 ..otherwise N. Order • CBC, • Bmp, >>> Cr 1.2, • U/a +3 protinuria, > 10 RBCS, • Serum albumin , N

• • • • • • •

24 hr urine protein try to determine the cuase of nephrotic COMPLEMENT C3. C4 HbSAg HCV antibodies ANA Lipid profile

All are negative

Order • IVP to diagnose cause of hematuria >>> if negative in young so no further tests required if negative in elderly next oder Cystoscope. Order • Renal biopsy >>> mesangial hypercellularity, hyalinosis of arterioles, sclerosis, and intimal fibrosis. • Electrons microscope: subendothelial immune type deposition. IgA deposition. Order • ACE Inhibitor • Nephrologist consult • Prednisone oral

• • • •

Vit D, Calciam Dexa scan Patietn Education: avoid Blood product transfusion

Rhuematology 21- 35 yo woman in your office, she had joint pain and swelling for one year, pain began in her right knee, left elbow, right wrist, bilateral MCP joint. Morning stiff for one hour. Fatigue, weakness. Complete physical exam>>> warm swelling, tender knee, wrists, elbow, MCP, PIP, & ankle. No murmur but if there were murmurs you should order blood culture and echo to exclude valve vegetation of endocarditis. Order • CBC, Routine • Bmp, routine • LFT, routine, • BHCG, routine, • TSH, routine, • ESR, routine • ANA, routine All are negative • Rheu factor, • Anticitrulinated peptide, routine • EBV titre • IgM parvovirus abs • Hepatitis panel... • Fobt, routine • X ray of hand, routine...erosion of MCP. Order • Endomethacine, • Mxt, oral • Folenic acid, oral, • Pantoprazole, • Multivitamins, • Counsel, no smoke no, alcohol, safe sex, medication compliance • Avoid sick contacts. • Schedule after 4 wks.>>if does not improved order etanercept oral, with PPD test before use etanercept. • Order CBC, LFT, fobt. 22- 48 yo woman in your office with history of brseat cancer co of proximal ms weakness for 5 wks, general fatigue, rash on her eyelids, face, up chest from sun exposure. Order complete PE. >>> upper weakness of shoulder and thighs bilateral. Order • CBC,routine • Bmp, routine All are negative except TSH, •

• ESR, CRP, • CPK,>>> high • Serum ferritin>>>⬆ >>> mostly dermatomyocytis • EMG, to exclude Mythenia graves,>>>>repeatitive discharge positive sharp wave...N • Anti-Ro/ anti- La>>> ➕ ⬆ • Anti-Jo, Order >>> muscle biopsy >>> lymphocytic infiltration Order • Oral prednisone, • Vit D • Calcium • Schedule after 6 wks • CBC, CPK level • Council, • Pap smear • Mammography .

23- 35 yo woman in office co of back pain after weekend vigorous athletic activity.

Order complete PE>>>sym, decrease ROM on lumbar spine planes as flextime, extension, lateral bending, rotation, straight leg test is N,

DD, Muscke sprain, herniated disc, cuada equina, spinal stenosis, ankylosing spondiolitis.

Order • ESR All are negative X ray on limbo sacral spin,

• • Oral Endomethacine (NSAIDs) • Pantobrazole, • Baclofen, muscle relaxant 24- 50 yo woman comes in office co of numbness of fingers after work as typist for many hours, also she noticed weakness in hand.

Order complete PE exam >>> thenar eminence muscle atrophy. Order • EMG, median nerve compression at wrist • TSH, • Lipid profile. • Fasting blood glucose • Mammography • Colonoscopy Order • Splint at night • Decrease repetitive motion • physical therapy at wrist • If methods fails surgical release. • Consult surgeon.

25- 42 yo man come to the office co of joint pain for 5 month duration, associated with lower back stiffness. Recent onset of left ankle join pain with several small joint that also become stiff in morning for more than 2 hrs. PH psoriasis for 3 yrs.

Complete PE >>> well demarcated scaly skin rash on elbow knew, small punctuate lesion on nail bed. Left ankle swollen painful. Tender sacroiliac spines. Order • CBC, • LFT, • Bmp, • U/a • Ibuprofen, • MXT • Folenic acid • X ray of ankle and limbo sacral spine • ESR, • Pantobrazole,

26- 50 yo woman in office co of sand in her eyes, dry mouth, chronic bronchitis with Ms pain.

Complete PE>>>> dry oral mucosa, enlarged parotid.

Order • CBC, • Bmp, • Schimer test>>> decrease lacrimal tears, ( wet area 5 min) • Ophthalmic consult>> rose Bengal dye slit lamb exam • Anti-Ro/anti/La>>> ➕ Order • Artificial tears • Hydroxy urea • oral bilocarpin

26- 60 yo man in you office co of increase LFT knee pain that was chronic from 6 month ago, and he recently notice pain in DIP of second and third finger of right hand too.

Order complete PE>>> no swelling, redness of knew or DIP, there is crepitation but no tenderness.

Order • CBC, • Bmp, • Lipid profile • Fobt, • ESR, • Rheu factor • ANA • Plain X-ray of hand>>> loss of joint space, osteophytes

Order

All are negative except

• • • • • • •

Acetaminophen oral if not improve give Oral NSAIDs if not improve pain order Oral tramadol, if not improve order Oral Ketorolac Schedule colonoscopy after 4 wks Vaccinate influenza Vaccinate pneomcocal

27- 30 yo African American woman comes to office co of swollen hands for two mons, with bluish red discoloration finger tips on exposed to cold.

Order complete PE>>> Raynaud phenomenon, thickened skin on hand and face with shiny forehead.

Order • CBC, • Bmp • TSH • X-ray of hands • ESR • Anti topoisomerase test,,,➕

All are negative except

• Anti centromere antibodies,,,➕ • U/a Order • Nifedipine,... • Enalapril,.....

28- 30 yo woman comes to office with intermittent joint pain, discrete swelling of the joint recently of wrist, MCP, PIP. Mourning stiffness last more than 1 hr., intermittent fever, wt loss.

Order complete PE>>> N Order • CBC>>> pancytopenia • Bmp • U/a>> proteinuria • ESR>>➕ • IgM antibodies of parvovirus ➖ • HBsAg➖ • HCV➖ • Lyme titer➖ • ANA➕ • • • • •

Rheu Factor ➖ X ray of hand PPD➖ CXR >>>N Lipid profile>>> SLE increase CV risk

Order • 24 hrs Urine Protein measurement • Anti-dsDNA antibodies

• Rheumatology consult reason ( 30 yo male with SLE for renal biopsy) Order • Prednisone oral • Consider azathioprine and cyclophosphamide if refractory • Vit D • Calcium oral • Pap smear • Council, avoid sun, use Sun screen. Respiratory 29- 39 YO man comes to your office for routine screening for new job. He is a symptomatic. PH is HIV positive, PPD skin test ( CD4 < 550). He come for reading of PPD test that was placed by nurse to him from 2 days ago. Order complete PE>>> all N but PPD < 5 mm.>>> Latent TB. Order • CBC, stat • Bmp, stat • CXR, • Sputum culture and gram stain, AFS • LFT, stat Order • IZH + pyridoxine B6 oral.

All are negative except

30- 39 yo homeless man in your office co of productive cough for several months, fever 39.5, chilles, wt loss. Non smoker. PH was admitted with pneumonia for the past 4 month. Order complete PE>>> Vitally stable, fever 39, bitemporal wasting, poor dentation, 2cm cervical LN. Order • Oxygen • Pulse oxy Order • CBC, • CXR, >>>cavitation lesion in right upper lobe.>>> 1ry TB • U/a • Sputum gram stain, culture, AFS, >>>>TB • LFT, Order • INH+ pyrazinamide+ ethambutol+ rifampin for 2 month • Reschedule after 2 wks order uric acid, LFT, examin your patient for neuropathy, do ophthalmology exam on eye. • After 2 month stop Pyrazinamid & ethambutol. And continue INH + rifampin for 7 mons

31- 43 yo woman with persistent productive cough for the past 2 year with greenish yellow sputum. Ph of bronchitis, on multiple antibiotic. Twice pneumonias in childhood. Order complete PE>>> scattered rhonichi, bibasilar coarse crackles. Order • CBC, • Bmp, • Sputum culture, gram stain, AFS.>>> non specific • CXR.>>> crowding bronchi ( tram trach)>>>> broncheictasis • Chest CT scan>>>> dilated medium and small bronchi though out the lung. Order • Sweat Cl test>>N • Ciliary motion test>>N All are negative • Serum Ig>>> specific IgG4 deficiency • Skin test for aspergillosis Order • Monthly Ig therapy • Postural drainage exercise • Ampicillin or TMB/SMZ • B2 agonist albuterol MdI 32- 65 yo white man comes to office for SOB on exertion for several months. He co of dry cough, he never smoke, no pets, no travel history, Order complete PE >>> overweight augmented P2 Velcro rales at lung base bilateral, clubbing. Order • CBC, • Bmp, • CXR>> bibasilar interstitial infiltration with peripheral honey combing. • EKG, • Echo • Lipid profile, as screen • FBS, screen • Pulmonary function test>>> increase FEV1/FVC ratio, decrease DLco.>> restrictive Order • Tracheobroncheal biopsy >>> fibrosis >>> diagnosis is Idiopatic Pulm fibrosis Order To confirm Diagnosis of IPF it is recommended to do • Corticosteroids, oral open lung biopsy, bronchoscopic biopsy help to exclude • Vit D other cause but not to confirm the diagnosis of IPF. • Calcium • Pantobrazole • Consider cyclophosphamide and azathioprine if refractory cases. • Vaccine influenza and pneumococcal, • Couple avoid smoke, alcohol. Exercise regularly. 33- 66 yo retired constructor worker comes to yr office co of SOB for the past 5 mons. Associated with dry cough started from one month ago. He is walking 2 mile daily for many years, recelty unable to walk for three blocks. He is smoker, 2 packs from 20 yrs. he quite 3 months ago.

Order complete PE >>> bibasilar coarse crackles, clubbing. Order • CBC, • Bmp, • ABG, • CXR>> honey combing, pleural Plaques.. >>asbestosis • EKG, • Echo • Pulmonary function test>>> ⬇ TLC, RV, DLco • Trans bronchial biopsy >>> fibrosis, asbestosis fiber. Order Annual chest radiography

All are negative except

32- 25 yo woman comes to office with productive cough on and off for one year. Dyspnea on exertion, has lost 5 pounds, has occasional low grade fever. She has intermittent pain in the shoulder and knees, worsen vision in last 2 weeks. Order complete PE>>> mobile enlarged cervical LN, bilateral dry crackles, knee pain on motion, painful red nodule on LL. Order • CBC • Bmp, • EKG • Sputum culture and gram stain, AFS, • PPD • U/a • Blood culture • Urine culture • CXR>>> bilateral hilar LN === mostly will be sarcoidosis Order • Cervical LN biopsy >>> non case aspiring granualoma. Order>>> Oral steroid, vit D, calcium oral, pantoprazol, DEXA baseline, 34- 65 yo white man come to office with worsening Dypnea on exertion, recently was treated for acute bronchitis with fever and productive cough, lost weight over last year. Smoke one pack a day for 50 yrs. Order complete PE>>thin, use accessory ms, tripod position. Scattered rhonchi, hyper resonance chest, barrel shaped chest. Order • CBC • Bmp • CXR>>>hyperinflation • Sputum culture and gram stain, AFS. • EKG • Echo • ABG>>>. pH < 7.42/40/74/94% in room air. Respiratory alkalosis • Pulmonary function test>>> ⬇ FEV1, FEV1/FVC, FEF25-75%, DLco. Order

• Oxygenation • Tiotropium • Antibiotic ( azithromycin) • Oral steroids, • Vit D, oral calcium • Mechanical ventilation if the PH < 7.2. Order • Smoke cessation • Home oxygenation 24 hrs if the PaO2 < 55, or O2 sat 88%. Or PaO2 55-59, sat < 89 with Pulm HTN, CHF, or Hct > 56 secondary erythrocytosis. • Tiotropium MDI is first line ttt of emphysema or COPD. 35- 28 yo woman comes to your office co of intermittent cough. She start running several times a week, cough worsen after return from running. Order complete PE>> N Order • Pulm function test>>> Normal completely • Methacholine challenging test>> FEV1 drop to 48 of the predicted Order • Inhaled Albuterol before exercise • Cromlyn is alternative 35- 72 yo immigrant comes to ER with persistent dry cough for I month, right sided chest pain, Dypnea with exertion.lost wt, smoke 2 packs of cigarette per day for past 50 yrs. vitally stable. Order complete PE >> tachycardia, decease breath sound on the right side from the base, dull on percussion, no wheezes. Order • Pulse oxy • Oxygen therapy • EKG • ABG>>> 7.48/30/65. Order • CBC • Bmp • CXR>>> right large pleural effusion, right hilar mass Order • Thoracoscentesis • Pleural fluid (LDH, Prtn, Glucose, AFS, cells count, culture, cytology). • Serum Protien • Serum LDH, • Serum Glucose • Lipid profile Order • Admit to the hospital

• Chest tube with pleurodesis.>>> malignant cells in pleural effusion >> end stage unrest table lung cancer • Chemo radiotherapy is ttt of choice • Oncology consult

Oncology 36- 40 yo man comes to your office co of persistent sore throat for the past 2 wks. He completed 1 wk course of ampicillin without a change in symptoms, progressive malaise over the past 2 wks, fever, to 38.9. Night sweat and easily bruising. DD, AML, ALL,Leukemiod leukemia. Order complete physical exam>> temp 38.9, palatal petechia, , tachycardia, petechia on ankle Order • CBC>>> HB 7, platelet 20.000 • PT, PTT, • Fibrinogen • DFP, • D-dimer • Bmp, • CXR, • Blood culture • U/a • Urine culture 37- 45 yo woman broguht to ED with altered mental status and hemiparesis of right side. She was well until 2 wks earlier when she developed intermittent fever and sore throat. She has suffered from several nosebleeds and gum bleed over the last week. Order focused PE >> lethargic, confused, not moving right side, temp 38.3, BP 160/100, withdraws her limbs to painful stimuli. Order • Pulse oxy • Oxyg • Elevation of head • Suction airways • Iv access • NSS • Thiamine • Naloxone • Glucose IV Order • CBC>>> 1500, Platlet 22000, Hb 7.>> .pancytopenia • Peripheral smear>> auer rod, immature myeloid cells. • PT/PTT >> high • BMP >>> N • TSH>> N • Vit B12>> N • LFT>> N • Head CT >> left intraparenchymal hemorrhage in parietal cells.>> hemorrhagic stroke • Fibrinogen >> N to exclude DIC that associated with M3.

• FDP >> N Order • Platlet transfusion • Cytosine arabinosine ( ARA-C) and daunorobicin or idarubicin. • Allttrans-Retinoic acid (ATRA) only for M3 ( if there was associated DIC). • BMT for refracotry cases. 38- 22 yo man to clinic coz persistent sore for the past 2 wks. He recently completed course of ampicillin without a change in symptomes, he note progressive malaise over 2 wks, fever 38.9, night sweats, easy brushing. Order complete PE >> platal petechia, no LN, tachycardia.temp 38.3 Order • CBC>> WBCs 105.000, Hb 7.5, Platlet 20.000. • Peripheral smear >> blast cells. • BMP >> • Blood culture • U-a >> n • Urine culture >> N • Bone marrow aspirate: megakaryocyte, blast cells. Order • Cell markers>>> CD 10, myeloperoxidase negative, terminal deoxynucleotidyle transferase positive. • Cytogenetics>> N 46 xy • LP>> No for malignancy Order>>>> acute lymphocytic leukemia • Vincristine/prednisone • Allopurinol + hydration. • Monitoring electrolyte for Tumor lysis syndrome • Intrathecal MXT prophylaxis CNS.

Gastroenterology

42- 48 yo woman in ER co of fever abd pain and distention. Last several mons, she developed ascities, anorexia, progressive wasting, sever itching. PH drug abuser, alcohol intoxication. Focused PE>>> temp 38, poor dentation, enlarged parotid, scleral icterus. Abd, distended, tympanic, tender, with shifting dullness. Palpable spleen, palmar erythema, spider angioma. So diagnosis is alcoholic hepatitis>> fever + HS megaly + hi transaminases Order • Pulse oxy • IV access

• IV ibuprofen Order • CBC, • Bmp, Any celiac dis or PBC • LFT>>> elevated transaminases don't forget to add • Total protein>>>N Vitamins A,D,K,E to • Albumin>>>2.8 treatment retiming. • PT, PTT>>> prolonged Consult dietary. Celiac • GGT >>> high in alchoholic clever disease use soya bean,rice, • Hepatitis C antibodies potato. Add iron to celiac • HBsAg test Disease. • HBsC antibodies Order • paracentesis >>> WBC 50 >>> you exclude spontaneous bacterial peritonitis • Abd USG>>>nodular fatty liver • Ceruloplasmin • Ferritin>>> N • Alpha-1 antitrypsin >>> • Antimitochondrial antibodies>> N to exclude PRIMARY BILIARY CIRRHOSIS • Schedule UGD to check esophygeal varices. Order • Salt restriction • Diet enriched branched aa chain to avoid hepatic encephalopathy • Frusemide and spironolactone • Counsel against alcoholic ingestion • If UGD shows eosoph varices so give Proparnolol to decrease portal hypertension. 43- 72 yo man in ER vomiting blood. History of ethanol abuse, previous two UGI bleeding in the past. He was drinking bing earlier today. Focused PE>> BP 80 palpation, HR 125, stupor, reeks of alcohol, scleral icterus, Gynecomastia, spider angioma,splenomegaly, non tender abdomen. Order • Pulse oxy • Oxygen therapy • IV access • IV NSs • NG tube for gastric lavage>>> blood clots and coffee ground emesis • IV thiamine • Acue check..>> if hypoglycemia give glucose 50 % IV Order • CBC>>> platelet 80,000 alcohol causes thrombocytopenia , HB 10 • Bmp, • PT, PTT>>>⬆ • Fibrinogen >> N • LFT • Total protein • Total albumin

• Blood type and cross match • Repeat Hb and Hct every 4 hrs • Transfusion of packed RBCs becuase NG tube showed GI bleeding • FFP....coz coagulopathy Order • Upper EGD >>> band ligation of eosoph. Varices • Admit to ICU • Bed rest • Pneumatic compression devise • NPO • IV Octeotides is mainstay ttt • Proparnolol, once BP stabilize • Omiprazole • Norfloxacin as prophylaxis against SBP • Order interval history and PE to check bleeding and vital signs • If the bleeding is not controlled next step is TIPs and blakemore tube is rarely used as pride to prepare to TIPs. 44- 52- man cone to ER with 2 mons history of epigastric pain. Wake him up from sleep. Antacid relieves him. Occasional smoke takes aspirin for back pain. Complete PE. >>>> mild epigastric pain Order • Pulse oxy • IV access • IV Morphine • IV omiprazole Order • CBC • Bmp • Lipid profile • Abdominal x ray erect • Abdominal USG • LFT • Amylase/ lipase Order • Upper EGD>>> ulcer on duodenum • Biopsy for H.pylori and exclude cancer • CLO- urease test >>> ➕ • H. Pylori serum titre>>>➕ Order • Oral amoxicillin + omiprazole tiwce daily + Clarithromycin for 14 day • Reschedule after 10 wks to do fecal ag test ... • Fecal antigen test after stop ttt by 8 wks • Avoid NSAID, alcohol, smoke, • Vaccine infeluenza. 45- 65 yo man come to ER with upper Abd pain, coffee ground vomitus, Pain started 2 mons ago, worsening by food ( direct us to Gastric ulcer) no wt loss, occasional use of NSAIDs for back pain, smoker for 29 yrs. vitally stable

Complete PE >>> mild epigastric tenderness, rectal exam brown guaiac positive stool, no hemorrhoids.

All are negative except

Order • CBC • Bmp • Abdominal x ray • Abdominal USG • LFT • PT PTT • Amylase/lipase Order • Upper EGD >>> gastric ulcer • Biopsy >> no cancer • CLO- urease test➕ Order • As previous case 46- 45 yo man was admitted 2 days ago for an acute upper GI bleed, he is alcoholic, on admission found to have duodenal ulcer that responded to PPI, and has been on thiamin. Nurse noticed he became confused this morning. Order neurological exam, Abd, chest, heart, general. Order • Pulse oxy • Oxy therapy Order • Cbc, • Bmp, • LFT • PT, PTT • Acuecheck • Ammonia ⬆ ⬆ ⬆ ⬆ ( N < 65) • U/a • Urine culture • Blood culture • CXR Order • Correct infections or GI bleed or electrolyte disturbance ( m.c.c of Ppt hepatic encephalopathy) ( do not give benzodiazepines to ttt alcohol withdrawal in HE) Airway protection>> incubate if necessary • • Lactulose oral ( acidified colonic content, trap ammonia to the lumen, and prevent its absorption) • Neomycine oral or rifaximin & ampicillin>> kill urease producing colonic bacteria • Restrict prtn diet. 47-27 yo woman come to office co of 8 mons diarrhea, wt loss, purritic skin rash.

Order complete PE >>> abdominal mild distended hyperactive sounds, diffuse papulovesicular rash over elbow, knees, buttocks, back. Order • CBC, iron studies if CBC shows Iron Def anemia • Bmp • Stool ( microscopic exam, G. stain, Culture, ova, parasite and fecal WBCs) • Stool fat collection, trypsinogen • HIV Eliza>>➖ • Anti endomycial, anti transglutaminases, antiglydine antibodies >>➕ • D xylose absorption test.>>> abn low < 5 g in 5 hrs. Order Lower endoscopy to take small Bowel biopsy ( to confirm diagnosis) >>>total villus atrophy Order • Gluten free diet • Eat rice, soya beans, potato, corn. • Ferrous Iron, oral, replace fat soluble vitamins by supplements of multivitamines • Folate, oral 48- 55 yo man in your office, co of progressive dysphasia over 3 months. Start by solid food then became difficult to swallow fluids also. Smoke pack of cigarette per day. Social drinker. Complete PE >>> cachectic, rectal positive for blood in stool. Order • CBC • Bmp, FOBT • Barium swallow>>

Circumferential mass in mideosophygus.

Send patient to Emergency room

Order • PT PTT • Consent • Upper endoscope and biopsy >> SCC • Endoscopic Ultrasound >> to check the stage of invasion the esophageal wall >> invade the wall. • Chest CT>>>➖ PET Scan for DM

• Abdominal CT>> ➖ Order • Surgical resection • RT + neoadjuvant chemo.

Consult Oncology & General surgery

counsel cancer diagnosis

49- 78 yo African American woman in office co of progressive left lower abd pain for past 24 hrs with low grade fever. She had the similar episode from 3 months ago. Resolved spontaneous. Order complete PE >>> temp 38.5, mild rebound tenderness on left lower quadrant. Order

• CBC Before any surgery: • Bmp, Blood culture • 1-Cephazoline • CXR 2-Blood type & • U/a 3- Cross match • Urine culure 4- PT/PTT. • Abdominal X-ray >> N 5- Foly's catheter & • Abdominal CT>>> inflamed sigmoid colon, no masses. Order UOP. • Admit to hospital ( mild cases can be treated outpatient) 6- NPO. • NPO 7- DM: D/c Oral HG • IV access & Start Insulin • IV NSS infusion. Acue • Ciprofloxacin + metronidazole or pipracilline/Tazobactam IV Omiprazole • check /1hr • IV Morphine • IV acetaminofin • advance timer or do interval Hx & PE >> If improvment>>> send home>> Reschedule after 4 wks for colonoscopy to diagnose diverticulosis & exclude cancer • If no improvement >> G. surgery consult for surgical exploration for abscess drainage. If CT scan showed mass or abcess from the begining >> call of surgery first 50- 17 yo woman in office co of bright red blood per rectum and loose stool in past 2 wks. Associated with rectal bleeding 6 soft stool per day and lower Abd discomfort. Order complete PE>> tender left lower quadrant, bright red blood in rectal ampulla. Order • CBC>>> leucocytosis • Bmp All are negative except • PT, PTT • Abdominal x ray • Abdominal USG • Stool culture, G stain, cytology, ova, parasite, WBCs>> ➕ leucocye in stool Order • Unprepared flexible sigmoidoscopy >> petechia Enders hypermedia >> invasive infectious enterocolitis on Biopsy>> Campylobacter jejuni Infection. Order Azithromycine or ciprofloxacine. 51- 58 yo man is brought to ER co of painless blood per rectum. He noticed maroon blood in stool yesterday. BP 120/80 on HR 80 but on standing BP 104/70 HR 105. Complete PE. >>> tachycardia, rectal shows clotted blood but no masses or hemorrhoid Order • IV access • Pulse oxy • NSS • BP monitoring • Cardiac monitoring • Foly's catheter, • NG tube >> for nasogastric lavage and to localize 90% of upper source if GI bleeding> no blood, only bile.

Order • CBC, • Bmp, blood typing & cross matching • Transfused packed RBCS • PT, PTT • LFT • Flexible sigmoidoscopy >> if did not determined the source of the bleeding So next step do colonoscopy, if the bleeding continue >>sulfur colloid bleeding scan if slow rate bleeding ( 0.1ml/min) or angiography if fast rate bleeding ( 1ml/min) angiography can be used in treatment by infusing Intra-arterial embolization or vasospastic agents ( vasopressin ). If the patient continue to bleed consult surgeon and do bowel resection >>> colonoscopy was done and showed diverticulosis • Anoyscopy • H & H Q 2 hrs Order • Transfer to ICU>> IVF , Omiprazole • Monitor further any sign of bleeding by ordering Vital /1 hr & UOP+ H & H/ 2hrs • In older pts or patients with CAD keep Hct > 30 • High fiber diet • Multivitamins • Ferrous iron oral on discharger. 52-52 yo man co of diarrhea for a year. Several bowel movement. Recurrent PUD. Despite the treatment of H.pylori. Order complete PE >> thin, mild epigastric tenderness, no masses. Stool is yellowish brown and guaic negative. Order • CBC>> No megaloplastic anemia (X pernicious an) • Bmp> Normal calcium >X malabsorption causes • Stool(WBCs,ova,parasite,G. stain, 72hr fat culture). • Upper EGD, >> large mucosal folds. Order • 24 hr gastric pH >>>⬆ . • Serum Gastrin level⬆

Chronic diahrreah 1. IBS 2. IBD 3. Malabsorption: sprue, bact. Overgrowth & Celiec dis. 4. Chronic pancreatitis (72 hr Fecal Fat). 5. Lactose intolerance 6. Pernicious anemia 7. Laxative abuse 8. Hypothyroid hyperparathyroid 9. Zollinger Ellison Syn ( gastrinoma) 10. Carcinoid

• Secretin test >>>⬆, Not suppressing gastrin • PTH >>>N • TSH>>⬆ Order • Omiprazole • Abdominal CT to localize tumor • Somatostatin receptor scintigraphy • Endoscopic ultrasounds • Surgery consult reason: Pt with zollinger Ellison Syn for resection of the tumor.

53- 40 yo woman come to the office with history of progressive dysphasia to solid, liquid, wt loss of 15 pounds. Food Regurgitation after meal. Order complete PE>>> chronic ill, thin. Order • CBC • Bmp • FOBT • ESR • Esophageal barium swallow>>> bird beak sign Order • Esophageal manometry >>>confirm Achalesia pattern • Esophageal endoscopy and biopsy >>> no malignancy Order >>> pneumatic dilatation of LES or Heller myotomy

Cardiology 54- 68 yo man come to ER co of one hour history of sever dull substernal chest pain while moving furniture in his home, no radiation, there is SOB, but not diaphoretic. FH father died from Heart trouble. Order focused PE>>> vital stable, tachycardia, otherwise is normal. Order • Pulse oxy >>>99% + Oxygen therapy • EKG>>> 2mm ST seg elevation in V2 V4 • IV morphing • Aspirin • Metoprolol IV • NG SL • Lisinopril for all AMI

start ACE inhibitors then stop after 6 wks for normal EF...Continue for dysfunctional lV with low EF.

Order • CK-MB level every 2 hours >>> elevated >>> so diagnosis is ACUTE MI • admit to ICU • NPO • Bed rest • Pneumatic compression devise • clopidogril • IV Bivalorudin for 48 hrs better than Unfracnated Heparin • IV ebtifibatide IIb/IIIa Inhibitors • Consult cardiology>>> cardiac angiography after move the pateint to ICU>> RCA Stenosis • Cardiac angioplasty if 90 and 60% >> then order CABG. • Post PCI>>> Clopidogril for 4 wks and aspirin for year • For unstable MI you can use IntraAortic ballon until patient arrive to Cath lab if you refer him to another hospital with available cath.lab. or give 1 dose of thrombolysis then transfere him to closest facility with Cardiac Cath Lab.

55- 68 yo man admitted though ER to ICU for chest pain and EKG consistent with acute inferior wall MI, resolved chest pain, and stable patient, nurse called you coz sudden drop of HR and BP without any chest pain and the patient started to be confused. Order focused PE>>> BP 70/50, pulse 40/min, cannon a wave, in confused patient. Order • EKG >>> complete Heart Block • IV Atropine I mg • IV fluid • IV dopamine • transcutaneous Pacemaker • NB! All above labs should be ordered once in unstable patient 56- 72 yo man comes to ER co of chest pain < 1 hr with diaphoresis no radiation. history of arrhythmia but not taking any meds. Similar episode in the past. Order focused PE>> BP 80/60, pulse 180, RR 24, JV distention, breath sounds decrease on the base, distant heart sounds. Order • Pulse oxy • Oxygen • EKG>>> ventricular tachycardia • Cardiac monitoring • BP monitoring • NSS, • IV access Order • DC cardioversion ( synchronized cardioversion, 100J, 200J, 360 J, 360 J).if persist Amiodarone followed by lidocaine. • ABG • Bmp • CBC • Cardiology consult • Echocardiogram • For stable patients >> Amiodarone, 2nd is Lidocaine, 3rd is iptifibatide or Amiodarone • Treatment of underlying cause. 57- 65 yo man recently discharged from hospital after ttt for acute MI, he is brought to ER coz of palpitation, while you examine him, he became unresponsive, and lose his pulse. Order • EKG>>> vent fibrillation • PULSE OXY • IV access • OXY Therapy • Cardiac monitoring • BP montoring

• ABG Order. ( asyncronized cardioversion) • CPR (30/2 x 5 cycles) until defibrillator arrive • Defibrillation at 360 J continue CPR >>>360J + vasopressin 1mg >> 360 J + Epi 1mg>>360 J. • Intubation • Amiodarone or lidocaine ( in MCQ if both are given in choices choose Amiodarone) • Bicarbonate 58- 62 yo man with HTN, come to ER, with pressure like retrosternal chest pain, radiate to neck, and left arm after claiming stair only two floors. He is on atenolol, carries SL NG for occasional episodes he took NG with pain attack with subsequent relieving, Order complete PE >> vitally stable, S4 HRT sound. Order • EKG, >>> Normal >>> so no need for STESS EKG and no need for serial CK-MB. Order • Admission to ward • Telemetry • Serial cardiac enzymes Q 8 hrs • Ambulate at well • Oral Propranolo, • Oral NG • Oral aspirin • CBC • Bmp • ECho • Lipid profile • Atorvastatin oral irrespective to lipid profile result • If there is a history of worsening Physical Function or more frequency of pain, >> proceed for cardiac angiography >>> to determine if he needs CABG or not • If patient improved send patient home. Order • Atenolol, NG, aspirin, • Statin oral. • Schedule for cardiac catheterization after 2 wks 59- 58 yo man with DM, HTN, is refered to you by vascular surgeon for clearance before his femrolpopliteal bypass graft. He denies chest pain, non smoker, No FH of CAD. Initial EkG was okay. You decided to do stress EKG which shows reversible inferior wall Ischemia, surgeon was conserved because his LDL is 202. Order complete PE>>> arcus senilis, lower legs are smooth and shiny Order • Fasting Lipid profile>>> total cholesterol 212, LDL 138, TG 125, HDL 52. • Bmp • CBC

• TSH • LFT Order • Statin forward the clock 6 month then reschadule your patient to check the lipid profile, Serum CK, LFT. • Life style modification Stop the smoking if he smoke, priscribe nicotin patches for few months if not swich to • Exercise Low fat diet Buprobion or varinicline (CI in cardiovascular disease or depression) • 60 - 68 yo woman is brought to ER by ambulance coz of SOB, PH of several MI, on diuretics, digoxin, captopril, over the last days she became more dyspneic. Order focused PE> vitally stable, edematous, JV distention, bilateral rales, tachypnia, tachycardia, 3/6 systolic murmur, S3. Bilateral LL edema. Order • Pulse oxy • Oxygen therapy Continous • Cardiac montoring • BP monitoring • NG SL, Continous • IV Morphine • EKG=== sinus tachy, Q wave in V2-V4 • ABG===7.42/34/72.>> respiratory alkalosis • CXR===bilateral pleural effusion, kerley B lines, cardiomegaly >> pulmonary edema Order • CK-MB Q 8 hrs >>>N • Echo >>> 30% EF • Brain natriuretic peptide >> high >>> acute HF lead to pulmonary edema Order • Admit to ICU • Semi setting position ( upright position) • Bed rest • Pneumatic compression devise • NPO • swan-Ganz cath, to proper reading of intravascular volumes and pressure • IV frusemide Q 20 min • IV NG • IV Morphine • IV dobutamine >>> positive intotropic drug • IV Enalaprilat, after load reduction to allow increase SV or nitroprusside. • With EF < 30 %>>> IV spironolactone inhibit RA system and ⬇ aldosterone water retention effect. • Nesiritide>> synthetic atrial naturities peptide if not respond to above ttt. • After stabilization add digoxin oral, propranolol, Oral. 61- 47 yo man come to ER co of several hours of Dypnea, blurring of vision, difficulty thinking, headache dizziness, mild palpitation. PH, HTN on thiazides, Order focused PE >>> BP 230/150, eye exam arterial narrowing and AV nicking, S4. So this is HTN emergency you should search for End organ damage to exclude HTN Urgency.

Order • Pulse oxy • Oxygen therapy • EKG>> LVH ( S in V1 + R in V5 = 35 mm) and ST seg depression Hypertrophic cardiomyopathy. • Cardiac monitoring • BP Monitoring • Bmp • U/a • Lipid profile • TSH Order • Transfer patient to ICU • NPO • Bed rest • Pneumatic compression devise • Arterial line • IV Nitroprusside (Target to decrease diastole > advance the clock to get BP • You can not give nitroprusside in ER, it has to be in ICU under Arterial line monitoring • Afte controlled >> ward & Dc arterial line and IV drugs to oral. • Oral thiazides, or atenolol, or ACE inhibitor according to your case. 62- 58 yo man comes to ER co of swelling of his LL, Exertional SOB, acutely distressed. Drinks 2 bottles of pears every day. Order focused PE >> BP 95/60, HR 110, lateral displaced maximum impulse, 2/6 systolic radiate to axilla, bilateral bitting edema. H Order • Pulse oxy • Oxygen therapy • EKG=== tachy, vent ectopy, decrease voltage and non specific T waves, and st seg changes. • Cardiac montoring • BP monitoring • CXR >>> cardiomegaly full chambers, Kelly's lines on lung • Echo>> dilated all chamber insufficiency of MV, PV, TV. EF < 25% Order • Ace inhibitor ( Enalapril) • Carvedolol • Frusemide • Digoxin • Spironolactone • LMWH (Dabigatran)for 24 hrs then start warfarin oral • Counsel stop alcohol • Diagnosis is alcoholic dilated cardiomyopathy 63- 36 yo come to office co of progressive Dypnea, coughing to blood daily, palpitations.

Order complete PE >> vitally stable, JV distention, a wave, bibasilar rales, loud S1 and snap after S2. Order • CXR>> straight Left heart border, • EKG>>> biphasic P wave in V 1 ( large atrium) • Order >> Echo >> dilated left atrium and MS • Order cardiac catheterization >> valve size 1.3 cm outlet ( if < 1cm >>sever MS need commissurotomy or replacement ) Order • Salt restriction • Frusemide • Schedule follow up after 2 wks • If no improvement do balloon valvuloplasty.

Lower limb claudication is very easy case, do Ankle brachial index if < 1 so it is diagnostic >> consult vascular surgeon, order cilostazol, physiotherapist consult, aspirin also will help.

66- 59 yo Patient with h/o DM, HTN, CHF comes with complain of shortness of breath and leg swelling. Order focused PE>>> tachycardia, BP is low, JVP elevated, Diffuse or Basal crackles in the lung field, lower extremity edema. Order • O2 inhalation, • Pulse ox; • cardiac monitor; • IV access, Order • CBC, • CHEM 8, • PT, PTT, • Cardiac enzymes every 8 hour, • Liver function test, • EKG 12 leads • Ttt (Nitroglycerine, sublingual and Aspirin can also be given here) • Chest x-ray portable; • Lasix IV, one time; • Morphine IV, one time bolus (Decreases anxiety and work of breathing, so will decrease central sympathetic outflow and thus causes vasodilatation also); Nitroglycerine, topical (Decreases preload). Note: If patient is hypertensive BP >150/90 can use IV Nitroglycerine, continuous; If hypotensive systolic BP 5.0 • Beta blocker should be added prior to hospital discharge, or when patient comes back to clinic for follow up. 67- 4 year old child with fever and rash for >5 days Vitals: febrile, rest are normal. HPI: child is very irritable Examine the child: Bilateral conjunctival injection, strawberry tongue, cervical lymphadenopathy, maculopapular rash, erythema and swelling of hands and feet. Order: IV line, CBC, BMP, LFT, Urine analysis, CRP, ESR, Blood culture, Urine culture, CXR Note: Kawasaki is a clinical diagnosis, we don’t have to wait for lab result Order: stat of IV Immunoglobulins, Aspirin-oral-continuous, order: Echocardiogram then Move the clock: Get all the report Change location to Ward, if coronary artery aneurysm, call Pediatrics cardiology consult.

ENDOCRINOLOGY 67-28 yo man with IDDM, type 1, since age of 12 same dose of insulin ( 22NPH. 18 regular in AM) ( 18 NPH , 8 regular PM) for the last 8 months. He started new exercise program wk ago. He noticed hypoglycemia s&s ( headache, diaphoresis, palpitation) Glucose Diary: am ( 104,98,103) noon (85,92,91) Pm (62,40,35,37). Bedtime (88,82,89,93). Order complete PE >> hypoglycemia is < 60 Order • CBC • Bmp>>>k 6 ( +++) , Na 130 ( low), BUN 60 ( +++), glucose 580...and no Renal failure • Hb A1c • ESR • Serum acito acitic acid and B-hydroxybutirate (ketone bodies) • LFT Order >> decrease insulin ( NPH am), continue exercise. Counsel diabetic diet.

68- 49 yo obsess female is brought to ER co of drawsiness, not eating much for last 4 days. Urinate every hr, thirst, no fever, chills, nausea or vomiting. HTN for 10 yrs. impaired diabetic ttt only by diet. Order focused PE>> confused, vitally stable with orthostasis. Order • Pulse oxy • EKG • IV access • IV NS bolus • ACUECHECK>> 990 ORDER • CBC • Bmp>> Na(130), K(5.2), BUN 58, glucose 990! • U/a>>> ketosis no WBCs • • • •

Uncontrolled type 2 DM on glipizide, add metformin +glitazone+ insulin and ask for home glucose monitoring ==> then order Hb A1c next visit to check and home FBG ( should be < 126). Do ophthalmology consult, check u-a for albumin give ACE inhibitor for microalbuminuria.

Toxicology screen >> ➖ ABG>>> metabolic acidosis pattern IV NS continous IV regular insulin >>>> acue check / hr>> Diagnosis is Hyperosmolar hyperglycemia

69- 30 yo man comes to office for evaluation of hypercalcemia. PH significant for several episode or renal stone for 3 yrs. PE unremarkable Order • Total serum ca >>> 11.3 >>> keep in your mind Indications for parathyroidectomy. And also history of kidney stones is indicate this patient for resection. • Ionized ca • Total protein • Serum albumin.>>> normal coz it will affect level of total and isonised ca false reading • Immunoassay of PTH >> high • Mg Serum level of 1,25 (OH)D, 25(OH)D • Phosphorus • CXR >> exclude sarcoidosis • Bmp Order • Endocrinology consult • MRI of the neck to localize the PT adenoma or sestamimi scan • Surgery consult>> for parathyroidectomy after surgery check Ionized Ca/2hrs> IV Ca gluconate if low. 70 -33 yo woman come to your office for evaluation of several hours of sever headache, flushing, palpitation. She recall several similar episodes in the past. PH migraine. Order complete PE: she is diaphoretic, anxious, BP 195/110. ( might be normal BP). Tachycardia. Order • Phenoxybenzamine for here HTN first • 24 hr urine collection for catecholamine >> high

• • • • •

Plasma free metanephrines>>> high Meta iodobenzaylguanidine scan (MIGA Scan)>>> no distal metastasis Abd CT scan >>> left adrenal mass Send patient home then schedule her visit after result come back RET Oncogene >>> ➖ to exclude the association with MEN 2.

Order • Phentolamine or phenoxybenzamine for 2 wks before surgery ( avoid BB initially) after stabilizing her BP you can add BB. Phentolamine IV >> if Pt present in Emergency room • Admit patient to ward • Ambulated at well • IV access, NPO, BMP, CBC, u/a, • Echo to assess for catecholamine cardiomyopathy. • PT, PTT, blood type and cross match, IV NS, IV cephazolin. • Consult surgery • Consult endocrinology • Advance the clock to get the procedure done. 71- 56 yo man in office co of one yr history of generalized headache, joint and muscle aches, Skull enlargement, weight gain and coarsening and enlargement of facial feature. He recently develope diabetes,no visual impairment. Order complete PE>> normotensive, prognathism and macroglosia of face. S3. Order • Measure serum insulting like Growth factor>> high • Give oral glucose 75 g and measure GH-2 hrs later. >>> high GH • MRI of brain>>> pituitary adenoma • Admit patient to ward • Consult surgery>> order tras-sphenoidal pitutary resection • Somatostatin analogue ( octreotide) oral >>> decrease size of the Tumors Preoperative or if the surgery failed, or unfit patient for surgery. • Cabergolin for high prolactin. 72- 32 yo man comes to your office for routine physical exam. No significant medical history or complaint. He excercise regularly. FH is significant for NIDDM type -2. Order according to his age and FH • Fast lipid profile>>> LDL172, HDL52, TG 126. • Fast glucose test>>> 102. Order - LFT, CPK, TSH before prescribing statins - Simivastatin - Counsel life style modification> exercise program, no smokeing, limit alcohol. - Low fat diet, balanced diet. - Reschadule after 3 wks >> check CPK, LFT.

NEUROLOGY

70- 57 yo man come to ED coz increasing confusion, blurring vision, nausea, and unsteady gait. Ex-Alcoholic, was on phenobarbital program. PH of seizures, repeated head truma from intoxication. Only on phenytoin. Order complete PE: obese, slurred speach. Both horizontal and vertical nystagmus are present. Wide base unsteady wide based gait, daysmetric finger to Jose test. Dysarthria on speach. Order Causes of horizontal • CBC nystagmus: • Bmp labyrinthitis, Menière • U/a disease,cerebellar stroke, • Alcohol level vasculitis of vestibular nerve. • Phenytoin level>>> high toxicity Drug toxicology screen • • Brain CT • TSH Causes of vertical • SYPHYLIS nystagmus: • Erythrocytes thiamine transketolase (ETKA) if >25% if Meningitis, diagnostic for thiamine deficiency. Order • Hold phenytoin

barbiturate, alcohol, phenytoin.

71- 55 yo woman with chronic back pain and History of breast cancer comes to office becuase of worsening back pain. The pain recently begun to radiate around her body like a tight belt. She take ibuprofen and acetaminophen. Order PE>> spinal tenderness over the lower thoracic spine and poor effort on motor examination due to pain. Tone in lower extremities is increased, there is sensory and plantar response are extensor bilaterally. Order • CBC • Bmp • Spinal MRI • CXR >> mass in right lung • Spinal x ray >> destruction of vertebral body at T10 • Pelvic CT • Chest CT • Pet scan Order • Steroid • Radiation therapy to spine • Morphine for pain. • ttt each cancer based on his type, add chemotherapy on lymphoma for example. 73- 54 yo man has noticed a drooping of his eyelids, double version later in day, difficult finishing dinner coz of fatigue.

Order complete PE>> immobile mouth is turned down at the conrners. When smiling his mouth resembles more of a snarl. There is marked weakness of elevator palpebrae and eye closure. Order • CBC • Bmp • Antiacetyle choline antibodies • Tension test >> ➕ • EMG>>> rapid reduction of amplitude of ms action after repeatitive movement, reverse after edrophonium injection. • CXR • TSH • CPK Order • Pyridostigmine, neostigmine • Steroids • Thymectomy • Azathioprine, cyclosporine • Plasmapheresis in refractory cases. 74- 65 yo man developes leg pain after walking 4 blocks. The pain started on left leg then spread to right leg, numbness and tingling increase as he walks. PH mild lower back pain, intact bowel and bladder function. Order complete PE >> reflexes are absent on recumbent position, but reflexed regain on stoop forward position. Mild decrease in vibration sens below the knee. Peripheral uses are normal. Order • API >>>. More than 1 • MRI of spin >> hypertrophic of ligamenum flavum, osteaophytic overgrowth, spire formation and narrowed lumber canal. • CT Mylography if patient cannot have MRI due to pacemaker. Order • Rest • NSAIDs • Surgical decompression with laminectomy if symptomes did not resolve. 75- 54 yo African American with history of BP non insulting DM, hypercholesterolemia is brought to ER because of hand weakness and grabled speach, onset sudden from 24 hrs. Tow wks earlier has lost vision in left eye with resolve after few hours. Order focused PE >> frequent errors while speaking fluently, right visual defect, wide palpebral fissure, flat nasolabial fold on right, brisk reflexes on right, babiniski sign in right. Order • Pulse oxy • Oxygen • EKG >> normal

• Cardiac montoring • Elevation of head • Mouth suction Order • Brain CT without contrast >> negative >>> repeat it after 3 hrs if ➖ do LP • Aspirin ( do not order aspirin after excluding SAH) • Carotid Doppler >>> ➖ • Echo • If EKG and echo Normal >> order 24 hr holster monitoring. Order • If present < 3 hrs, persistent, disabling, deficit, no bleeding >> tissue plasminogen activator. • If arrhythmia >> digoxinm, bb, diltiazem, if there is AF > 48 hrs give warfarin. • Control HTN, DM, • Counsel smoke cessation. • Clopidogril used if stroke occurs while on aspirin. 76- 30 yo woman come to OFFICE with history of dipecrease vision on right eye from 5 yrs ago. Also had elisodes of blurring of vision in her right eye, that usually fade quickly. Last wk she had ascending numbness and tingling in her legs, followed by difficulty of walking. Order complete PE>> pale optic disc, with color desaturation in right eye. Left inter nuclear ophthalmoplegia, spastic LL. sensory level T4. Brisk reflexes in LL, positive babiniski bilaterally. Order • CBC • Bmp • U/a • TSH • Lipid profile • MRI of the brain >> hyper intense lesions on T2 weighted images in peri ventricular white matter. • MRI of spin with gadolinium >> hyper intense lesions at T4 level on T2 weighted image that enhance gadolinium. • LP if MRI was inconvenient >>> ➕ for oligoclonal band. Order • INFb 1-a or INF-1b. • Azathioprine for eye symotomes, • copolymer ( galtiramer acetate). • Back often for spasticity • Vit D and calcium • Vaccinate infeunza and pneumococcal ( avoid live vac) 77- 25 yo man who has developed ascending weakness in LL and parasthesias after event episode of Gstroenteritis comes to the office.

ORDRR complete PE >> Flaccid paralysis of Ll, loss of ankle reflex, symetic weakness of LL.

Order • LP >> hi Protien • ABG • BMP • Mean inspiration pressure • EMG/ nerve conduction velocity >>> delay F wave response. • Vital capacity Order • Admission • Bed rest • Respiratory support up to intubation if CASE need • Plasmapheresis • IV Ig daily for 2 weeks.

78- 28 yo man working on construction site had shaking arms then lost conscious, he had no memory to this, but his friends told him.

Order complete PE >>> right visual field defect, right facial droop, right pronation drift, increasingly tone, hyper reflexes on right.

Order • BMP • CBC • Toxicology screen • CXR >> • U/a • brain CT >> ring enhanced lesion

Order HIV ELIZA >>> ➖

Order • Lorazepam • Phenytoin • Prime thiamine + sulfasalazine + frolic acid

79- unconscious young man is brought by ambulance to emergency department. He has no wallet and was found by peopel who were walking by. He is well dressed. Temp 35.8, BP 90/60, RR 10/min.

Order focused PE >> pupils small equall, reactive to light, withdrawon his limb from painful stimuli. Absent DTR. Several bullae are present on thighs. ( bullae are indicative of barbiturate). Order • Pulse oxy • Oxy • EKG • Cardiac montoring • HEAD ELEVATION • Airways suction • Intubation • Iva • NSS

• • • •

If toxicology screen come back negative >> order brain death work up: Clinical diagnosis of BD 1-No response to painful stimulation 2- Positive apnea test. Absent reflexes 3- core temp > 32, Negative toxicology screen, no medical illnesses. Confirm by 1- EEG 2- trans cranial Doppler USG 3- tech-99 brain scan 4- cerebral angiography 5- No somatosensory evoked potential ion stimulation of median nerve. 6- consult neurology to declare BD.

Thiamine Naloxone Acuecheck>>> Hypoglycemia Orde IV glucose

Order • CBC • Bmp • U/a • Head CT • ABG • LFT • Gastric lavage >> tablets present ( intubation is mandatory for Gastric lavage). • Charcoal in any intoxication • Urine toxicology screen Order • Bicarbonate IV to alkalanize urine • Hemodialysis hemodialysis. Infectious disease 80- 6 yo body is bought to office with rsh started as superficial accumulation of several small vesicle on his legs below the knee. No fever or chills, ox honey down crusted lesions on erythema tours base Nothing to be done >> this is classical distribution of empetygo cursative organism strep pyogenes Topical Mopirocin if not oral dicloxacillin & nafcillin. Pen allergy erythromycin s or azithromycin. 81- 32 yo man comes to ED room with 5 days of fever, productive cough, pleuritic chest pain. He is active IV drug user and last used on the day before his presentation.

Order complete PE>>> Temp 39, thin, lying on stretcher, peteciae on his mouth and conjunctiva. Bilateral clear.thin red lines on his fingernails. Order • Pulse oxy • Oxygen • IV access >>> Norma saline • Cardiac monitoring Order • CBC • BMP • Ua • Blood culture >>> MSSA >>> • Urine culture • IV Vancomycin + gentamycine • CXR >>> multiple modular lesion bilateral • Echo >>> vegetation Order • Admition • Nafcillin+Genta for 6 wks coz vegetations.

82- 37 yo woman has 3 days of progressive joint pain in her ankle, knees, wrists. There is also pain in the back of her hand and forearms as she flexes or extends her fingers. Order complete PE >> temp 38.7, pharyngeal injection, skin peyechial rash. Swollen red tender knee and ankles with decrease range or motion. Order • CBC • Blood culture • PT, PTT • Ua • Urine culture • Swab rectal, oral, urethral. • Arthrocentesis • Joint fluid C&s, cells, • Thyer- Martin media culture • Vaginal C&S, DNA probe for chylamedia and Gonorrah, • Rpr, VDRL • HbsAg, anti Hbc Ab. • HIV Order • IV Cephtriaxone 1 g Q day for 7 - 10 days is TOC for disseminated Gonorrhea. 83- 54 yo man with DM comes to your office, he began have RUQ pain, chills, fever. PH known biliary tract disease.

Order complete PE>> 38.9 temp, vitally tachycardia , N. BP, mild icterus, RUQ Tenderness, no masses. No peritoneal signs, Order • CBC>> leucocytosis, • BMP • Abd ultrasound >> dilated common bile duct with stone and mass lesion in right lobe of liver, consistent with hepatic abscess. • Abd xray acute series. • Alkaline phosphatase • LFT>>> total bilirubin 3. • PT,PTT • Ua • Blood culture • U culture • CXR>>> fluid in Right costophrenic angle, • Amylase • Lipase Order • Send PT to ER • NPO • Iva • NSS • CT scan of the abdomen >> dilated CBD, 5X3 cm mass in right lobe of liver>> abscess. • Stool for (ova, parasite, culture, G stain) • IV ampicillin/ sulbactam + doxycycline or Cephtriaxone + metronidazole. • Surgical consult, reason : cholangitis for possible hepatic abscess. • Percutaneous drainage of liver. 83- 24 yo man had an painful ulcerative genital lesion for 33 days. The lesion began as a papule with an erythematous base. Order complete PE >> soft, tender ulcer on prepuse with inguinal LN. Order • VDRL & RPR • HIV • Wight stain of scraping>> N to test for granuloma inguinale caused by Donnovanosis. • Gram stain>> peomorphic gram negative rod in "school of fish" pattern. • Dark field examination. • Chylamedial antibody testing of scraping. Order • Culture of scrap>>> ➕ H. Duryi Order Azithromycin 1 g single oral dose or Cephtriaxone 250 IM single dose. 84- 24 yo man come to your office co of maculopapular rash all over his body, had mild fever, headache, sore thoat. 2 wks ago he had painless genital ulcers that resolve on it own.

Order>> complete PE >> alopecia, diffuse MP rash dark reddish, few pastules. Generalized moderate adenopathy. Order • CBC • BMP • Ua • VDRL & R&R>> high titre HZV shingle cases order • HIV Wright or giemsa stain of • HbsAg, anti HBc antibodies. unroofed lesion (Tzanck prep) Order &Viral culture or PCR. • FTAA>>> ➕ • Culture of pustules. No growth Order • LP normal • CSF VDRL, RPR, FTAA.>> all non reactive Order Penicillin G 2.4 million single IM dose. 85- 55 yo man comes to your office with almost 2 wks of progressive worsening headache, fever, and 2 days of left hand and leg weakness. There has been nausea and some vomiting. Order complete PE >> temp 39, bulging red right tympanic members. Left Upper and lower extremely weakness. Intact sensory exam. Order • CBC • BMP • U-a • Urine culture • Blood culture • CXR • Brain CT with and without contrast >> hypodense area on right tempropariatal lobe. Marked enhancement with contrast. >> consistent with brain abscess Order • Send to ED • NPO • PT, PTT • Fibrinogen • FDP • Stereotactic CT guided needle biopsy of the lesion. >> G positive cocci in chain and G negative rod >> culture >> strep viridans and bacteriodes melaninognicus. Order • IV Penicillin + metronidazole for 8 wks, or phetriaxone + metro • Repeat CT after 3 wks. • Surgical drainage if resistant to antibiotic. 86- 25 yo man return from nicking trip with sever excruciate headache, fever, chills, myalgia.

Order complete PE >> nuchal rigidity, right facial palsy. Temp 39. Order • CBC • BMP • Fibrinogen • Blood culture • Brain CT • Lumbar puncture>> as usual add antibodies agaist Burrelia burgedorferi ( ELIZA and western blot), bacterial and viral culture. Order • Burrelia burgedorferi Serum IgM level ( ELIZA )>> high titer • Serum Western blot Order Cephtriaxone for 3 wks. 87- 24 yo woman comes to your office co of several days of fever, mayalgia, sore throat, malaise, headache, mild nasal stuffiness. She had dry cough. She comes becuase the cough worsening and become dyspneic. She do not have pets.

All are negative

If fungal infection order KOH preparation + culture= hair/ nail give itraconazole or ketoconazole, griseofulvin. Otherwise topical clotrimazole.

Order >> complete PE >> fever 38, mild enlarged cervical LN, erythematous pharynx, scattered rahles bilaterally.

Otitis media culture Order or ear drainage & ttt • CBC>> by topical polymyxin • BMP B + neomycin. • Blood culture Hydrocortisone • Urine analysis drops in sever cases. • Urine culture CXR>> bilateral interstitial markings. • • ABG >>> 7.48/30/70. O2 sat 93%. • Sputum G stain >> few leucocytes • Sputum culture for bacteria, viral, mycobacterium fungi >> viral ag detected. Order • Admit to hospital • Respiratory support ( oxygen, humidified air) if her ABG deteriorating do intubation • Ozeltamivir/ zanamivir • Antibiotic if there is bacteria, infection detected in culture 88- 17 yo man comes to your office with 1 wk of increasing sever sore throat, fever, fatigue, malaise, headache and myalgia. He was in ED from 2 days ago and received ampicillin for his pharyngitis. Order >> Complete PE >> temp 39, cervical LN, petechia over the trunk and oral mucosa, liver enlarged 3 cm, splenogpmegaly. Order • CBC>> leucocytosis, atypical lymphocytes, thrombocytopenia. • BMP • CXR

• LFT>> high bilirubin and ALT • Blood culture Order • Heterophile antibodies/ monospot test.➕ • Viral capsid antigen IgM➕ Order • Acetaminophen • Avoid contact sport • Prednisone if thrombocytopenia and hemolytic anemia is sever

Dry scaly red indurated lesions in interdigital area with pruritis >>> is Tenia pedis and not scapies. Do KOH exam, fungal culture. Treat with topical clotrimazole. Capitis & onychomycosis give oral griseofulvine,itraconazole ( not in children).

89- 27 yo man comes to your office a weekafyer initial visit for ear pain and decrease hearing. He was compliant with amoxicillin that you had prescribed it to him from week ago. He comes now because the worsening pain and deterioration of hearing. Order >> complete PE >> temp 38, bulging red tympanic membrane, intact membrane, tender Pinna, which displaced inferiorly and laterally. Area abive the pinna is tender and Small fluctuate mass. Order • CBC • BMP • Plain x ray of mastoid process>>> obliteration of mastoid air cells and destruction of trabecular mesh work. • CT of mastoid process >> massive destruction and subperiosteal collections. • Tympanocentesis and culture >> Strep. pneumonia. • Mastoid biopsy is the most sensitive test. Order • IV penicillin only for pen sensitive pneumococcal infection • Pen resistant >> cefotaxime or Ceftriaxone • Vancomycine for one resistant. 90- 78 yo woman is brought to ED with fever, chills, RUQ pain, light stool color and darker color of urine, HTN on beta blocker. Order complete PE>> 38.6 temp, BP 90/60, HR100, scleral Icteric,RUQ tenderness, mild rebound tenderness. Well healed scar in the RUQ. Order • Oxy, Pulse oxy • IV access, NSS • NPO Internal bleeding hemorrhoids IV ambicillin/ sulbactam if allergic to pen use azteronam + • in vitally stable do office Metronidazole cover G negative org. sigmoidoscopy + colonoscopy • EKG and barium enema. Add also • Cardiac monitoring lft PT PTT. Schedule Order colonoscopy after month. • CBC • BMP>> BUN high, • Fibrinogen • Blood culture • Urine analysis

• Urine culture • LFT>> bilirubin 4 (hi) , alk 300 (hi), rest are N. • Abdominal USG >> dilated common bile duct >> no masses. Order • admit to ward • Consult surgery • Order ERCP to review the stone from Bile duct if failed >> exploratory laparotomy. Pharyngitis picture in pediatric order rapid antibody test, throat culture, ttt Pediatric tips for CCS by penicillin V BID for 10 days. If HS megaly there order Monospot test, ttt supportive. Constipation in pediatrics Functional constipation stool in rectal vault but hirschsprung empty rectal vault. Diarrhea in pediatrics: order stool Hirschsprung do, anorectal manometery ( no sphincter stuffs + enzyme immunoassay for relaxation), first abd x ray, barium enema ( transitional Rotavirus❗ most it will be ➕ ⏩ ttt zone), rectal biopsy ( no ganglion cells). Surgical resection by IV NS! Allow breast feed, Never to and anastomosis. use antidiahreal or antibiotic in viral Functional constipation, asso with encorporesis (>4 YO) diahrreah. ( overflow spill), rectal exam stool in vault, do Abd x ray Bact diahrreah: salmonella < 1 year ( stool through out the colon), anorectal manometery treat with TMB/SMZ or ( relaxed sph), barium rectal enema to evacuate the stool, ciprofloxacin.cambylobacter & shows no transition zone. Usually no need to do barium ( erythromycin). Yersina ( no enema or USG or rectal biopsy to traditional cases of antibiotic except if Yer. septicemia by functiona constipation only do Abd x ray the start blood culture metronidazole treatment. Oder clean out enema if large collection, high +cephazoline ), C. Difficile fiber diet, postprandial toilet, drink a lot of water, don't use ( Metronidazole). long term laxative.

Evaluation of limb cases: X-ray standing AP & Frog leg on hip. Legg-Calves-Perthes ( > Cerebral palsy. Order spinal MRI, Brain MRI, s. Creatine kinase. Pancreatictherapy, cancer physical

TTT: occupational CBC, BMP, Abd USG and Ct scan, ERCP, therapy,speech therapy, social therapy, CA-19. Pancreaticoduodenectomy ( whipple surgery if need, pediatric neurology orthopedic consult. palliative Procedure). If non-resectable ERCP with Stenting or surgical bypass.

CYSTIC FIBROSIS: CXR , CBC, sweat Cl test, if -ve nasal membrane potential (⬆ ) Serum trypisongen (⬆ ),DNA tests CFTR gene. Ttt albuterol, piperacillin+ gentamycine + steroids+ recombinant Dnsase ( mucolytic), chest physio therapy. .

Congenital Rubella Order Rubella IgM titer Echo and hearing screen

Any recurrent infection pediatric case order serum immunoglobulins and respiratory burst test, flow cytometry.

Esophageal cancer CBC, BMP, CXR, Upper gastrointestinal swallow, UGD + biopsy, endoscopic USG to measure the depth of tumor in esoph. Wall, Chest CT scan, echo, PET scan for bone metastasis.

Colonic volvulus CBC, BMP, Abd X-ray, rigid sigmoidoscopy, rectal tube to release the tention and untwist bowel. Admit, NPO, IV NS.









Arterial embolization (of lower limb) CBC, BMP, ABG, CXR, EKG look for AF, IV LMWH, If abusless + motor function preserved= IA thrombolytics (tpA) if the motor weakness do emergent embolictomy, if in addition there is total anaethesia so this is irreversible ischemia need amputation.

Obstetrics and gynecology



Vaginitis Painless vaginal bleed in 32 hydroxide wks pregnant Potassium Iva, blood type & cross match, NSS, do not do prep genital exam in placental case. Do not Vaginal prévia secretion KOH order pelvic USG onlyCervical do obstetric USG, NST smear after you stabilizeG&C yourDNA patient, obstetrics probe test consult, for Cesarean section if unstable or >37 Vulval itching in PMW wks, don not forget to give RoGam for Rh -ve Vulval biopsy women with Rh + husband. ( no kleinhaur Gynecology consult test).





PG in 32 wks co of headache, BP 160/90. Repeat BP after 15 min. UA ( +3) CBC, bmp, Uric acid, LFT, PT, PTT, urine toxicology ( all Normal) Obstetric USG ,NST ( no BPP,AFI in CCS). If result showed HELLP creiteria, NPO, 1st give MgSo4, IV Labetaol/ hydralazine, oxygen,pulse oxy, start oxytocin to dleiver her if no CI for VD. If NST shows late non reactive or late deceleration after induction of labor run to cesarean.

External fetal monitoring shows late deceleration in active labour Turn off the oxytocin Give oxygen 10 L face mask Give IVF, turn mom to her side, do genital exam to exclude cord prolapse,do digital scalp stimulation & observe acceleration it should be reassuring >> hyperstimulation is reason

Metreorragia in 32 Yo

1st Bhcg even if PH hasTubal ligation.



2nd Pelvic USG MPA (10 mgX7 days) oral Continous. No change

Hysterogram ( saline us)

Hysteroscopy

Obstetrics consultation

High maternal serum AFP Next do amniotic fluid chromosomal analysis ( amniocentesis) Genetic USG Genetic counsel Routine ANC

Uncontrolled GDM with macrosomic EFW Admit to ward to control sugar Provide insulin therapy Diabetic diet Twice weekly NST, no AFI or BPP in CCS soft ware .

2ry amenorrhea after labor from 15 mons BHCG Progesterone therapy once IMI ( NO PCT in CCS Software). If -ve order P +E oral Continous ( P&E CT) >> if -ve order HSG ( obliteration of uterine cavity)

Post date Assure the dates by USG& fundal height NST Fetal monitor ( external)

Nonvavrable cervix give vaginal PGE2 Valve rabble cervix admit, start induction by oxytocin, consult obstetrics.

Atonic PPH Bimanual uterine massage IV oxytocin IM methylergonovine IV Prostaglandine E1 one time bolus.

Functional cyst (5 cm right simple cyst in 25 yo mom) BHCG USG Conservative follow up after 6-8 wks

Pregnant with any medical illness Order weekly NST Growth chart by fetal USG

Septic abortion CBC, BMP, urine, blood, cervical culture Transvaginal USG ( do not wirte only USG) Ampicillin + gentamycine+ clindamycine Suction D&C