CCS Cases Notes-Raj

CCS CASES 1. Office-25 yr old female with burning micturition Abdomen and genital/pelvic exam U/A and urine B-hcg. Amox for 7 days if pregnant, TMP-SXZ for 3days if not pregnant, uncomplicated and 7days if not pregnant and complicated. If penicillin allergic gives nitrofurantoin. Prenatal vitamins, regular follow ups, standard counsel. Pyelonephritis- OP oral Cipro-14days, IP- IV Ceftriaxone-14days. Diagnosis: Acute Cystitis uncomplicated. 2. Office-75yr old male with forgetfulness Complete exam except breast CBC (R), bmp (R), LFTs (R), TSH (R), vit b-12 (R), folic acid (R), CT scan head without contrast (R). Donepezil oral, olanzapine oral for psychosis. Advance directives, no driving, medical alert bracelet, Regular counsel. Diagnosis: Alzheimer’s dementia. 3. ER- 60yr old male with severe chest pain Pulse Oxy, oxygen inhalation cont., EKG stat, cardiac monitor cont., bp monitor cont., IV access stat, NS IV cont., aspirin oral cont., nitroglycerin SL stat one time. Focused PE FOBT stat, heparin IV cont., metoprolol IV cont., CXR PA stat, CK-MB stat q8h, troponin-I stat q8h, CBC stat q1d, bmp stat q1d, PT stat, PTT stat. Interim h/o Shift to ICU, nitroglycerin IV cont., EKG stat, npo, complete bed rest, urine output, metoprolol oral cont., simvastatin oral cont., and interim h/o. D/c iv nitroglycerine, shift to ward, continue all oral medications, LFTs(R), echo stat, lipid panel(R), consult cardiology (cardiac cath). On discharge low salt and low fat diet, regular counsel, oral aspirin, metoprolol, simvastatin, s/l nitroglycerine, clopidogrel. 4. Office-24 year old female with nausea and vomiting Complete physical examination, Urine B-hcg. Stat. CBC (R), bmp (R), blood grouping and typing (R), Rubella screen (R), antibody screen (R), U/A &C/S (R), chlamydia culture (R), Hbsag (R), Consent and HIV Elisa (R), Pap smear (R), USG trans vaginal (R). Prenatal vitamins oral cont., iron sulfate oral cont., folic acid oral cont., high fiber diet, high calorie diet, regular counsel, follow up every 4wks till 28wks then every 2wks till 36wks and every wk till delivery from 36wks. Follow up visit: complete PE, BP, Weight, FHR, U/A, and Fundal measurement. 2nd trimester: breast feeding, danger signs of pregnancy, childbirth classes, and preterm labor education.

Diagnosis: Pregnancy & Antenatal Care. 5. Office-28yr old male with BPR Complete physical exam. Cbc(R), bmp(R), Esr(R), stool for ova and parasites(R), stool for wbcs(R), stool C/S(R), LFTs(R), PT & PTT(R). Consent for the procedure, flexible sigmoidoscopy stat, and rectal biopsy stat. Loperamide oral cont., dicyclomine oral cont., mesalamine rectal cont., dietitian. Regular counsel. Diagnosis: Ulcerative Colitis. 6. Office-28yr old male with 2mth abd.pain and altered bowel habits. Complete physical exam. CBC (R), bmp (R), stool for fat, wbcs, C/S and ova& parasites, FOBT, TSH, and ESR. Loperamide oral cont., lactose free diet, high fiber diet, biofeedback (R) and regular counsel. Diagnosis: IBS. 7. ER-65yr old male with severe breathlessness Focused PE-1st? Head elevation, pulse Oxy stat, oxygen, cardiac monitor cont., IV access stat, PEFR stat&q1h, FEV1 stat&q1h, EKG stat, CXR PA& lateral stat, ABG stat. Albuterol nebulizer cont., ipratropium nebulizer cont., prednisone IV cont., levofloxacin oral cont., CBC stat, bmp stat. Interim h/o Shift to ward, reg.diet, ambulate at will, urine output, vitals q4h, D/C cardiac monitor. Discharge home with follow up 2wks, regular counsel, MDI Albuterol, MDI Ipratropium, Oral Levofloxacin, Home Oxygen therapy, Influenza & Pneumococcal Vaccine. Diagnosis: Acute exacerbation of COPD. 8. Office- 40yr old female with insomnia, worthless and easy fatigability. Complete physical exam. Cbc®, bmp®, TSH®, EKG®, Vit b-12 and folate®. Fluoxetine oral cont., suicide contract, regular counsel. Diagnosis: Major Depression. 9. ER- 55yr old male with acute confusion, blurry vision and headache. Focused PE Pulse Oxy stat, oxygen cont., IV access, cardiac monitor, bp monitor, and EKG stat. CT head without contrast. Sod.Nitroprusside IV cont., check bp regularly. CBC stat, bmp stat, U/A stat, CXR stat Shift to ICU, NPO, bed rest complete, and urine output. Shift to ward D/C IV access, nitroprusside, npo, cardiac monitor, and oxygen. Metoprolol oral cont., low salt diet, vitals q6h.

Discharge home lipid profile, regular counsel. Diagnosis: Hypertensive Encephalopathy. 10. ER- 7mth old child with severe onset of sudden breathlessness. General, lungs, chest examn-1st? Pulse oxy stat, oxygen cont., IV access stat, cardiac monitor, CXR PA&lateral stat, Neck xray lateral stat, and CBC stat. Methylprednisone IV onetime bolus, cefazolin IV onetime bolus, Bronchoscopy stat, Pulmonolgy consult. Diagnosis: Foreign body aspiration. 11. Office- 40yr old female with lump in left breast. Complete physical examn Mammography®, FNAC®, general surgery consult, PAP smear, regular counsel, reassure and follow up in 3mths. Diagnosis: fibro adenoma of breast. 12. 20yr old female with vomiting and abdominal pain. 90/60,128bpm, RR-30. Focused PE-1st? Pulse oxy stat, oxygen cont., IV access stat, cardiac monitor cont., NS IV cont., and finger stick glucose stat. Urine b-hcg. Stat, Cbc stat, bmp stat, ekg stat, serum Ca stat, amylase stat, lipase stat, U/A stat, ABG stat, osmolality serum stat, ketones serum stat, insulin regular IV, phenergan IV, D/C oxygen. Shift to ICU, NPO, bed rest complete, vitals, urine output, HbA1c, KCL IV cont., ABG q2h, BMP q4h then q12h then q1d, after 4hrs shift NS to ½ NS. Shift to ward then discharge, D/C IV insulin, fluids, cardiac monitor, Reg.insulin SC cont., NPH insulin SC cont., diabetic diet, diabetic foot care, home glucose monitoring, regular counsel, diabetic teaching, follow up in 10days. Diagnosis: DKA. 13. ER-28yr old female with unconsciousness. Breathing pattern, Suction airway stat, pulse oxy stat, oxygen cont., iv access stat, NS IV cont., cardiac monitor stat, ABG stat, finger stick glucose stat, naloxone IV onetime bolus, thiamine IV onetime bolus, 50%Dextrose IV onetime bolus. Focused PE. Cbc stat, bmp stat, ekg stat, cxr pa stat, U/A stat, urine toxicology screen stat, blood alcohol stat, LFTs stat, b-hcg serum stat, NG tube & gastric lavage stat, activated charcoal oral onetime, naloxone IV cont. Shift to ICU, NPO, bed rest, urine output, and bmp next day. D/C cardiac monitor, IV fluids, naloxone, ng tube, oxygen, regular diet. Discharge with regular counsel, Psychiatry consult routine, suicide contract, and suicide

precautions. Diagnosis: Narcotic Overdose. 14. ER-65yr old male with weakness of right side and dysphasia. Focused PE. CBC stat, bmp stat, IV access stat, EKG stat, ct head without contrast stat. Admit to ward, diabetic diet, ambulate at will, vitals q6h, continue home meds, ECHO stat, aspirin oral cont., accuchecks glucose q6h, cardiac monitor cont., carotid Doppler stat. Vascular surgery consult stat. If accepted pt, ptt, consent, blood grouping and typing. Diagnosis: TIA. 15. ER-22yr old female with fever and pelvic pain. Focused PE. CBC stat, bmp stat, urine b-hcg stat, U/A & C/S stat, gram stain cervix stat, gonococcal culture cervix®, chlamydial culture cervix®, VDRL test®, HIV ELISA®, PAP ®. Admit to floor, npo, vitals q4h, bed rest with bp, iv access stat, NS IV cont., phenergan IV cont., morphine IV onetime, cefoxitin IV cont., doxycycline IV cont., examine next day. Discharge with doxycycline oral for 14days, D/C all IV meds, reg. Diet and reg. Counsel. Diagnosis: Acute PID. 16. Office- 25yr old male with jaundice Complete PE Cbc ®, bmp®, LFTs®, pt®. Admit to floor, iv access stat, NS IV cont., reg.diet, ambulate at will, reticulocyte count stat, LDH serum stat, serum haptoglobulin, U/A stat, type and cross match stat, PRBC transfusion stat. G6pd levels stat, reg.counsel, follow up in 2wks. Diagnosis: G6PD deficiency Anemia. 17. Office- 2yr old boy with failure to gain weight & loose stools. Complete PE. Admit to floor, Pulse oxy stat, IV access stat, CBC stat, BMP stat, Sputum for gram stain stat, sputum C/S stat, blood Cultures stat, CXR PA & lateral stat, sweat chloride test®, sinus Xray®, fecal 72hr fat. Oxygen cont., amoxicillin and clavulonic acid oral cont., nebulized Albuterol cont., multi vitamin tablets oral cont., chest physiotherapy, vitals q6h, D5 ¼ NS IV cont., ambulate at will, reg. Diet. D/C IV fluids, augmentin. Oral cephalexin cont., influenza & Pneumococcal vaccine, dietitian consult, pancreatic enzymes oral cont., genetic counsel. Diagnosis: Cystic Fibrosis.

18. Office- 26yr old female with amenorrhea and abdominal pain. Focused PE. Urine B-hcg stat. Admit to floor, NPO, bed rest complete, IV access stat, IV NS cont., vitals q1h, serum B-hcg quantitative stat, USG transvaginal stat, CBC & BMP®, PT & PTT®, blood grouping & typing stat, culture cervix for gonorrhea & chlamydia, PAP smear. OBGYN consult stat, IV methotrexate one time stat, IV morphine one time stat. Regular counsel & follow up in 4days with B-hcg quantitative serum. Diagnosis: Ectopic Pregnancy. 19. Office- 5yr old boy with blood oozing after dental extraction Complete physical examn. CBC stat, bmp stat, bleeding time stat, pt and ptt stat, LFTs stat. Factor 8 and 9 plasma stat. Factor 8 therapy, genetic counsel, and no aspirin. Diagnosis: Hemophilia. 20. ER- 36yr old asthmatic with severe breathlessness Pulse oxy stat, oxygen cont., IV access stat, head elevation. Focused PE. Abg stat, PEFR stat, EKG stat, CXR PA stat, Cbc stat, bmp stat, Albuterol nebulizer stat and every 20min, Methyl Prednisolone IV cont., interim h/o in 20min. Admit to floor, vitals q2h, PEFR q2h; ambulate at will, reg.diet, frequent examn. Next day: D/C IV and nebulizer, MDI Albuterol, MDI beclamethasone, Oral prednisone, reg.counsel. Discharge and follow-up in 1week. Diagnosis: Acute exacerbation of Asthma. 21. Office- 62yr old male with constipation Complete PE Cbc®, bmp®, TSH®, serum magnesium®, serum phosphate®, LFTs®, FOBT®, HbA1c®, high fiber diet, regular exercise, plenty of fluids, accuchecks q4d, Metamucil, follow-up in 1week. NPO past midnight, colon preparation, GI consult- colonoscopy. Diagnosis: Constipation. 22. ER- 64yr old male with SOB Head elevation, Pulse oxy stat, oxygen cont., IV access stat, EKG stat, cardiac monitor cont. Focused PE. Lasix IV stat&cont., CBC stat, bmp stat, cxr pa&lateral stat, ck-mb stat q8h, troponin-I stat& q8h. Admit to ward, telemetry, ambulate at will, low salt diet, low cholesterol diet, diabetic diet,

fluid restriction, weights, urine output, pneumatic compression stockings, continue home meds., ekg repeat, bmp q1d, HbA1c, lipid panel, accucheck q6h, KCL oral cont., Digoxin oral cont., ECHO®. IV to oral, reg.counsel, follow-up in 2wks. Diagnosis: CHF. 23. ER- 75yr old male with altered mental status and decreased urine output. Complete PE-1st? Pulse oxy stat, IV access stat, IV NS cont., Foley catheter stat, ekg stat, abg stat, cbc & bmp stat, Mg & phosphate stat, U/A stat, Urine C/S stat, Urine sodium and creatinine. Admit to floor, D/C lisinopril & Ibuprofen, continue his home meds, vitals q2h, diabetic & renal diet, complete bed rest, urine output, compression stockings, weights, accuchecks q6h, HbA1c®, sliding scale insulin, USG renal®. IV to oral, regular counsel. Diagnosis: Pre-renal Azotemia. 24. Office- 16yr old female with heavy menstrual bleeding. Focused PE. Urine B-hcg®, CBC®, PT & PTT®, serum TSH®, serum prolactin®, Pap smear®. OCPs low estrogen, low progesterone, cont., oral iron sulfate cont., iron rich diet, reg. Counsel. Diagnosis: Dysfunctional Uterine Bleeding. 25. ER- 16nth old infant with runny nose, mild cough Pulse oxy stat- 1st? Focused PE Cool humidified air, if not relieved oral or IV decamethasone. Diagnosis: Viral Croup. 26. OP- 6mth old infant with vomiting and diarrhea. Focused PE IV access stat, IV NS stat & cont., CBC & BMP stat, stool for heme, cells, C/S, U/A, breastfeeding. Admit to floor, vitals q4h, IV potassium, physical examn q6h, BMP next day, discharge if hydrated & normal BMP. Diagnosis: Acute Gastroenteritis. 27. ER- 9yr old female with fever, poor eating and abdominal pain. Focused PE. Pulse oxy stat, IV access stat, IV NS cont., CBC & BMP stat, LFTs stat, PT & PTT stat, FOBT, NPO, X-ray abdomen stat, USG abdomen stat, General surgery consult stat, IV

analgesia onetime stat, IV cefazolin & metronidazole stat. Diagnosis: Acute Appendicitis. 28. OP- 3mth old infant with runny nose, poor eating & low grade fever. Pulse oxy stat. Focused PE Admit to floor, pulse oxy q1h, cardiorespiratory monitor, ABG stat, CXR stat, Humidified oxygen, IV NS cont., Suction q1h, chest PT q2h, epinephrine nebulizer as needed, Albuterol nebulizer q2-4h. Diagnosis: Bronchiolitis. 29. Office- 40yr old white male with knee pain & swelling, fever. Focused PE Admit to floor, NPO, vitals q4h, CBC & BMP stat, blood cultures stat, PT & PTT stat, IV morphine onetime stat, consent for procedure, arthrocentesis stat, Synovial fluid for cells, C/S, crystals, gram stain, GC culture; X-ray knee stat, oral acetaminophen cont., IV ceftriaxone cont. D/C ceftriaxone, IV nafcillin stat, Orthopedic surgery consult stat. Diagnosis: Septic Arthritis. 30. ER- 47yr old male with chest pain Focused PE Pulse oxy stat, oxygen cont., IV access stat, cardiac monitor cont. Oral aspirin cont, EKG stat, CBC & BMP stat, CXR PA & lateral stat, ESR stat, CK-MB & Troponin-I stat, blood cultures stat. Admit to floor, reg. Diet, ambulate at will, vitals q4h, ECHO stat, telemetry, D/C oxygen, oral Indomethacin cont. Discharge home with reg. Counsel. Diagnosis: Acute pericarditis. 31. ER- 62yr old male with pain and swelling of right lower extremity. Focused PE. Pulse oxy stat, IV access stat, IV NS cont., admit to floor, vitals q4h, NPO, bed rest with leg elevation, CBC & BMP stat, X-ray leg stat, blood cultures stat, HbA1c stat, accuchecks q6h, D/C metformin, sliding Reg. Insulin scale, analgesia stat & as needed, acetaminophen stat & cont. IV clindamycin cont., IV Ciprofloxacin cont., CBC & BMP q1d, interim h/o & physical q4h, diabetic diet. IV to oral, restart metformin, reg. counsel, foot care, follow up in 2wks. 32. ER- 34yr old female with MVA.

Cervical spine immobilization, Pulse oxy stat, oxygen cont., IV access stat, IV NS cont., cardiac monitor cont., BP monitor cont. Focused PE Morphine IV bolus, blood type & cross match stat, CBC & BMP stat, LFTs stat, PT & PTT stat, serum amylase stat, U/A stat, pregnancy test, blood alcohol level, urine toxicology screen, X-ray cervical spine, X-ray chest PA & lateral, X-ray abdomen, X-ray pelvis. CT abdomen with contrast stat, H&H q6h, Surgery consult stat. D/C cervical immobility, shift to floor, Foley catheter, pulse oxy q4h, NPO, IV morphine cont., interim h/o q4h, repeat CT next day, discharge if stable oral percocet cont., reg. counsel, follow up in 1wk. Diagnosis: Splenic Rupture. 33. Office- 29yr old female with 1wk dry cough & breathlessness. Complete PE Pulse oxy stat, CBC(R), BMP(R), Gram stain & culture Sputum, Methenamine silver stain sputum, AFB for sputum, CXR PA & lateral(R), HIV ELISA(R). ABG stat, TMP-SXZ oral, HIV western blot, serum LDH(R). CD4 count, PCR for HIV RNA, PPD testing, HBsAg, Anti-HCV, Toxoplasma screen, VDRL, LFTs, Pap smear, Influenza & Pneumococcal Vaccine, Zidovudine oral, Didanosine oral, Indinavir oral, Support groups, reg. counsel. Diagnosis: PCP. 34. Office- 50yr old male with 10day constipation & extreme weakness. Complete PE. CBC stat, BMP stat, U/A stat, LFTs stat. Admit to floor, IV access stat, IV NS bolus & cont., CXR PA (R), USG abdomen(R), PTH(R), serum iron, ferritin & TIBC(R), SPEP, serum alkaline phosphatase. CT abdomen & chest, Bone scan, Oncology consult stat, serum Ca q1d. Diagnosis: RCC. 35. Office- 39yr old female with vaginal discharge. Focused PE Vaginal Ph, Wet mount (Saline prep + KOH), Pap smear, gram stain of discharge, GC culture, Chlamydia culture, CBC, U/A. Topical clotrimazole for 2wks. Diagnosis: Candida Vaginitis. 36. Office- 55yr old male for routine check up with high BP. Complete PE CBC(R), BMP(R), U/A(R), EKG(R), Lipid panel(R), follow up in 1wk. Regular counsel, oral atenolol cont. Diagnosis: Essential hypertension.

37. Office- 13yr old female with short stature & primary amenorrhea. Complete PE U/A(R), BUN & Creatinine(R), fasting blood sugar(R), serum FSH & LH(R), Karyotype(R), follow up in 1wk. USG pelvis(R), serum TSH(R), Skeletal survey, Audiometry, ECHO(R). Growth hormone SC cont., oral conjugated estrogen cont., estrogen replacement counsel, vit-D oral cont., psychiatry consult, OBGYN consult, reg. counsel. Diagnosis: Turners Syndrome. 38. ER- 65yr old male with fever and severe LLQ pain. Focused PE Pulse oxy, IV access, IV NS cont., EKG stat, CBC & BMP stat, LFTs, serum amylase & lipase, U/A, Ciprofloxacin IV cont., Metronidazole IV cont., Phenergan IV stat bolus, Morphine IV stat bolus, FOBT, X-ray acute series, CT abdomen. Shift to ward, bed rest with BP, vitals q4h, pulse oxy q4h, urine output, NPO, pneumatic stockings, continue morphine, CBC & BMP q1d. IV to Oral, reg. counsel, high fiber diet, oral docusate cont., follow up in 4wks for sigmoidoscopy/ colonoscopy. Diagnosis: Acute Diverticulitis. 39. ER- 15mth old boy with burns on his buttocks. Complete PE Silver sulfadiazine cream, wound dressing, admit to floor, reg.diet, skeletal survey stat, bone scan stat, PT & PTT stat, bleeding time stat, CBC & BMP stat, U/A stat. Consult CPS, Consult Ophthalmology, Consult Psychiatry, counsel parent. Diagnosis: Child Abuse. 40. ER- 45yr old male with sudden onset of abdominal pain. IV access stat, IV NS bolus, Pulse oxy stat, oxygen cont., BP monitor cont., cardiac monitor cont, EKG stat. Focused PE NPO, NG suction, CBC & BMP stat, LFTs stat, serum amylase & lipase stat, X-ray abdomen acute series, NS IV cont. IV Phenergan bolus stat, IV morphine bolus stat, IV ranitidine cont., IV Ampicillin cont., IV gentamicin cont., IV metronidazole cont., surgery consult. Surgery- PT & PTT, consent, blood grouping & typing. No surgery- Shift to ICU, bed rest complete, urine output, pulse oxy q4h, pneumatic stockings, continue NPO, IV fluids, antibiotics, antiemetics, analgesics. Diagnosis: Perforated Duodenal Ulcer.

41. office- 20yr old female with hirsutism Complete PE Urine B-hcg, serum testosterone free & total, serum DHEA-S, 24hr urine 17-keto steroids, 24hr urine cortisol, FSH & LH, prolactin, TSH, USG Pelvis, follow up after results. Fasting lipid profile, GTT, Pap smear, OCPs, reg. counsel. Diagnosis: PCOD. 42. Office- 52yr old female with sleeplessness. Complete PE Pap smear, Fasting lipid profile, Mammogram, flexible sigmoidoscopy, DEXA-Scan, FOBT. HRT oral cont., oral Vit-D cont., Oral Calcium carbonate cont., reg. counsel. Diagnosis: Menopause. 43.

44. Office- 55yr old male with fatigue. Complete PE CBC®, BMP®, TSH®, FOBT®, LFTs®. GI consult stat, Colonoscopy®. CT abdomen & chest with contrast, oral iron sulfate, CEA level, refer for colorectal surgery. Diagnosis: Adenocarcinoma of Colon.

45. Nursery- 39week old infant with jaundice. Complete PE, vital signs, input-output. Blood type of mother and child, CBC stat, direct coombs test stat, indirect and total bilirubin, CRP stat. H&H q8h, bilirubin q8h, breast-feeding. Shift to NICU, phototherapy, erythromycin ointment for eyes, and IV fluids for maintenance D5 1/4NS. D/C IV fluids, phototherapy, follow bilirubin levels. Diagnosis: Jaundice.

46. Office- 3yr old male with facial and scrotal swelling. Complete PE U/A stat, CBC & BMP stat, LFTs stat, PT & PTT stat, C3 and C4 levels stat, lipid panel. Admit to floor, I/O, vitals q4h, cardio respiratory monitor, Nephrology consult, Albumin 25% IV 8h, IV Furosemide 4h, CMP am, no salt high protein diet. Oral Prednisolone, vitals q12h, repeat albumin & Lasix therapy. Discharge home, prednisone for 4 to 6 wks; follow up in 3 to 5 days. Diagnosis: Nephrotic Syndrome. 47. ER- poor responsiveness and feeding Pulse oxy and complete PE. Oxygen, IV access stat, CBC stat, bmp stat, blood cultures stat, urine culture stat, CSF for pressure, protein, glucose, cells, gram stain and culture, CXR, CRP. Admit to ward, vitals, npo, cardiorespi monitor, IV D5 1/4NS, ampicillin IV cont, cefotaxime IV cont., urine output, cbc and bmp q1d. Continue monitor, frequent exams, iv to oral. Discharge home, oral amoxicillin. Diagnosis: Group B streptococcal pneumonia. 48. ER- 7yr old boy with altered mental status and stumbling. Pulse oxy stat, oxygen cont., IV lock, Cardiorespiratory monitor cont., Finger stick glucose, IV naloxone bolus, Urine toxicology screen. Focused PE D 50% IV bolus, IV NS cont., Blood alcohol level, CBC & BMP stat, serum toxicology panel, accuchecks q1h until stable. Admit to floor, NPO, IV D5 1/2 NS with KCL, BMP am, BAL q12h. Discharge home with counsel, screen for abuse and domestic violence. Diagnosis: Child Intoxication. 49. ER- 65yr old female with SOB and chest pain. Pulse oxy, iv access stat, oxygen cont., cardiac monitor cont., head elevation, aspirin SL. Focused PE. Ekg stat, cxr pa stat, abg stat, troponin-I stat, ck-mb stat, pt and ptt stat, cbc stat, bmp stat, iv ns cont. Fobt stat, heparin iv cont., V/Q scan, d-dimer stat. Admit to icu, npo, bedrest, urine output, vitals, pulse oxy q2h, telemetry cont., cbc q1d, PTT q6h, interim h/o q4h. Iv to oral, d/c monitors and oxygen, warfarin oral cont., pt(2 to 3) and platelet count. Discharge with oral warfarin for 12mths, follow up in 2days, check PT levels, D/C heparin on 5th day, anticoagulation teaching, Reg. counsel. Diagnosis: Pulmonary embolism.

50. office- 43yr old male with pain and swelling of 1st metatarsophalyngeal joint. Focused PE Cbc stat, BUN and creatinine stat, pt and ptt stat, serum uric acid(R), X-ray joint, Indomethacin oral cont., Arthrocentesis stat, synovial fluid for cells, crystals, culture, gram stain. Low protein diet, reg. counsel. Diagnosis: Acute Gout. 51. ER- 50yr old male with sudden onset of severe headache. Focused PE IV access stat, IV ketorolac stat onetime, ESR stat, CT head without contrast stat. Shift to ICU, NPO, bedrest complete, urine output, pneumatic compression stockings, pulse oxy q2h, Neuro check q1h, neuro surgery consult stat, cbc stat, bmp stat and q1d, pt and ptt stat, IV NS cont., oral percocet cont., oral nimodipine for 21days, oral omeprazole cont., oral docusate cont. Diagnosis: Subarachnoid hemorrhage. 52. office- 48yr old female with rapid heart beat and palpitations Complete PE Cbc stat, bmp stat, ekg stat, serum tsh stat, serum free T3 and T4. Radio-iodine uptake-24hrs. Propanolol oral cont., methimazole oral cont., followup in 4wks, stop methimazole 4days before appointment. Radio-active iodine onetime, followup in 1mth, stop methimazole, cbc stat. Diagnosis: Primary hyperthyroidism. 53. OP- 2&1/2 yr old girl with abdominal pain and constipation. Complete PE Cbc(R), bmp(R), blood lead level, docusate oral cont., milk of magnesia oral cont., calcium level(R), U/A(R). Venous blood lead level. Lead paint assay, multivitamin with iron oral cont., succimer oral cont., serum iron, ferritin & TIBC, LFTs and erythrocyte protoporphyrin, followup in 1mth. Blood lead level, erythrocyte porphyrin, cbc (R). Diagnosis: Lead poisoning. 54. OP- 65yr old male with cough Pulse oxy-1st? Focussed PE Admit to ward, oxygen cont., IV access stat, IV NS cont., vitals q4h, urine output q4h, pulse oxy q4h, bedrest with BP, CBC and BMP stat, CXR PA and lateral Stat, EKG stat, blood cultures stat, sputum for gram stain and C/S, oral levofloxacin cont., nebulizer for albuterol

and ipratropium cont. Spiral CT chest, bronchoscopy, consult pulmonary medicine, cbc&bmp q1d, continue Oxygen. CT abdomen and pelvis, bonescan, LFTs, PFTs, MRI of brain with and without contrast, serum Ca, Consult Oncology and radiation oncology, MDI of albuterol and ipratropium, high protein diet. Diagnosis: Bronchogenic Ca with Obstructive Pneumonia. 55. ER- 54yr old male with fever and chills. Focused PE. Pulse oxy stat&q2h, IV access stat, iv ns cont., npo except meds., hold atenolol, urine output q2h, vitals q2h, complete bedrest, pneumatic compression stockings, head elevation, cbc stat q1d, bmp stat q1d, u/a & c/s stat, blood cultures stat, pt and ptt stat, phenergan iv PRN, acetaminophen oral PRN. Once blood cultures are taken ceftriaxone iv cont., vancomycin iv cont., LP stat, CSF for cells, protein, glucose, gramstain, fungal stain, C/S. interim h/o q2h, triage the patient. Diagnosis: Meningitis. 56. office- 38yr old female with pain and swelling of right leg Focused PE. Shift to ER, pulse oxy stat, venous Doppler stat, cbc stat, d-dimer stat. Rectal examn., fobt stat, pt and ptt stat, D/C OCPs. Enoxaparin q12h SC, acetaminophen and oxycodene as needed, no smoking, anticoagulation teaching, followup next day in office. Warfarin oral cont. for 3mths, PT every day till 2 to 3, platelet count on 5th day of heparin, brief physical. Diagnosis: DVT. 57. office- 53yr old female with abdominal distension. Focused PE. Admit to ward, pulse oxy stat q12h, vitals q12h, reg.diet, cbc stat, cmp stat, cxr pa&lateral stat, u/a stat, usg abdomen stat, fobt stat, pt and ptt®. Paracentesis abdomen diagnostic, fluid for cells, protein, glucose, cytology, ct abdomen & chest ®, mammogram®, pap smear®, CA-125 ®. Obgyn and oncology consult. Diagnosis: Ovarian Ca. 58. ER- 63yr old nursing home resident with colicky abdominal pain. Focused PE Iv access stat, NS iv cont., NPO, cbc stat, bmp stat, x-ray abdomen stat. NG suction, GI consult, sigmoidoscopy, rectal tube. Admit to ward, monitor 2 to 3 days for signs of bowel ischemia, continue IV fluids, consult

gen.surgery, discharge home with follow up in 1wk. Low fat diet, high fiber diet, patient counsel. Diagnosis: Sigmoid Volvulus. 59. ER- 50yr old female post chemotherapy with fever Complete PE. IV access, continue lansaprazole, CBC stat, CMP stat, CXR PA&lateral stat, blood cultures stat, U/A stat & C/S, sputum for gram stain and C/S, Ceftazidime IV cont. Admit to ward, reg.diet, vitals q4h, activity as tolerated, regular interim h/o, cbc q1d, acetaminophen oral PRN, discharge with oral meds till 14days. Diagnosis: Febrile neutropenia post chemotherapy. 60. ER- 35yr old female with sudden RUQ pain. Focused PE. Pulse oxy stat, IV access stat, NS IV cont, NPO, NG suction, cbc stat, cmp stat, abdominal x-ray acute series stat, urine b-hcg stat, u/a stat, pt and ptt stat, serum amylase and lipase stat, phenergan iv onetime, morphine iv onetime. USG abdomen stat, ampicillin and gentamicin iv cont?? General surgery consult stat. Admit to floor, vitals q4h, activity as tolerated, urine output, pneumatic compression stockings, cbc and bmp q1d. Diagnosis: Acute cholecystitis. 61. ER- 39yr old male with fever and chills Focused PE. Pulse oxy stat, IV access stat, IV NS cont., CBC stat, BMP stat, PT & PTT stat, blood cultures stat × 3, Chest X-ray PA & lateral stat, EKG stat, Urine tox. Screen stat. IV Vancomycin cont., IV gentamicin cont., oral acetaminophen onetime, admit to floor, NPO, bedrest with bp, pulse oxy q4h, vitals q4h, urine output, pneumatic stockings, advance clock for 8h, TEE stat, CBC next day. Consider HIV elisa, HbsAg, antibodies for HBC if not done before. D/C vancomycin, IV nafcillin cont. for 4 to 6 wks, IV central line placement(R), blood cultures q1d till sterile, examn next day. Regular counsel, gentamicin D/C after 5days, followup in 1wk, SBE prophylaxis. Diagnosis: MSSA Rt.sided IE. 62. office- 60yr old female with irregularly irregular pulse. Focused PE. Pulse oxy stat, IV access stat, EKG stat. IV diltiazem bolus, cbc stat, bmp stat, CXR PA & lateral stat, CK-MB & troponin-I stat q8h, U/A stat, TSH stat, free T4 (R), LFTs stat, PT & PTT stat. Admit to floor, pulse oxy q4h, vitals q4h, telemetry cont., OLD records, carbohydrate diet,

bedrest with bp, HbA1c stat, accuchecks QID, 2D-ECHO (R), continue all home meds, IV diltiazem cont., IV heparin cont., PTT q6h, cbc q1d. Urine C/S stat, TMP-SXZ oral for 3days. Interim h/o in 2h, telemetry monitor, ekg repeat, interim h/o in 6h telemetry. Once HR