CCS Acute Gout Attack
Step 1:keep foot elevated
Labs:cbc, sma7,Uric acid,Stool guaic, UA with microsynovial fluid :for light polarising micrograph.C&S,Gramstain,glucose,protein,cell count.
X-RAY JOINT.24 hour urine for UA
Diet:low purineMedication:Motrin PO or IndomethacinPo for 2 days,then hypouricemic therapy:Probenicid increase until UA level falls below 6.5..Allopuinol ,after attack.
symptomatic:Ranitidine bid. Meperidine or Vicodine
CCS Splenic Rupture
diagnosis : splenic hematoma
HPI 23 y/o male after MVA.
step 1 ABC, PE focusLabs:serum glucose and rapid bedside glucose determination, CBC, serum chemistries, amylase, LFT's, UA, coagulation studies, blood type and match, abg, blood ethanol, urine drug screens.
Bedside u/s, DPL(for unstable), CT(for stable) and emergent surgeon consult.Chest x-ray, supine & erect abdomen x-ray.
Vital Signs, Cardiac, and BP monitoring on bed side.
Foley catheter and Urine output check.
NPO, Ringer's lactate solution I.V before results from Lab.
Transfer to ICU if patient is not stable.
posted by raavii02good work up I would add surgical consult for repair also prefer NS as IVF rather than LR because in case he develops rhabdo. (MVA) NS is fluid of choice.
HPI: 45 yom brought to the ER with excruciating stabbing pain on chest/inner arm for 20 min. No history of previous attack, but hypertensive c BP 190/ 96 when last taken. He is conscious but looks anxious.
VS: temp-97, pulse-86/min,resp. rate-33/min,
Step I : Emergent management: A, B, C, D- O2, IV access
Step II : Focused PE: Heent/Neck, Chest/Lungs, Heart/Cv, Abdomen, Extremities
Step III : Diagnostics: EKG, CXR, CK-mb, Troponin-I, CBC, Chem ?7, Continuous cardiac monitoring, may be Tc99 scan also
1. NTG 0.4mg sl 2. Aspirin
3. Morphine if patient is in pain
4. ACE Inhibitor (onopril)
5. Depending on time since onset (if 3 h or less), consider t-PA if not contraindicated or cardiac cath.
6. Consider NTG drip. Other antihypertensive you may consider is labatelol or nipride( more severe cases).
Step IV: Changing pt?s location
1. Admit Pt. to CCU, if patient is symptomatic send to ward.
2. Repeat cardiac markers
3. D/C cardiac monitor after 24 hours if patient is stable
4. When stable, consider sub-maximal exercise test
5. All Pts. with MI should go home on B-blockers, ACE inh if the patient also has CCF and also low dose aspirin
6. Check lipid profile
7. Consult on healthy life style prior to discharge
8. Make appointment to see him in about a week
STEP V: Educate Pt?s family, Console patient, stop smoking, diet, excercise.
STEP VI: Final Diagnosis.AMI
HPI 25 yoWF c/o lower abd pain.
PE:Pregnancy testCBCChem7Endocervical gram stain-for gram-negative intracellular diplococciEndocervical culture-for gonorrheaEndocervical culture or antigen test-for chlamydiaTREATMENT:Outpatient, normallyHospitalization recommended in the following situations:Uncertain diagnosisSurgical emergencies cannot be excluded, e.g., appendicitisSuspected pelvic abscessPregnancyAdolescent patient with uncertain compliance with therapySevere illnessCannot tolerate outpatient regimenFailed to respond to outpatient therapyClinical follow-up within 72 hours of starting antibiotics cannot be arrangedHIV-infectedGENERAL MEASURES Avoidance of sex until treatment is completedInsure that sex partners are referred for appropriate evaluation and treatment. Partners should be treated, irrespective of evaluation, with regimens effective against chlamydia and gonorrhea.SURGICAL MEASURES Reserved for failures of medical treatment and for suspected ruptured adnexal abscess with resulting acute surgical abdomenInpatient treatment; Cefoxitin IV cefotetan IV (or other cephalosporins such as ceftizoxime, cefotaxime, and ceftriaxone) plus doxycycline orally or IV Therapy for 24 hours after clinical improvement and doxycycline continued after discharge for a total of 10-14 daysClindamycin plus gentamicin loading dose IV or IM Therapy for 24 hours after clinical improvement with doxycycline after discharge as aboveOutpatient treatmentceftriaxone plus doxycycline orally for 10-14 daysOfloxacin orally for 14 days plus either clindamycin orally or metronidazole PATIENT MONITORING Close observation of clinical status, in particular for fever, symptoms, level of peritonitis, white cell countsafe sex practices education-particularly for those who have had an episode of PID
HPI: 40 yo executive man comes to the office with chief complaint of headache.Later he gives history of financial problem and starts crying.First pay attention to history for alcohol or recent drug use.you should check HPI to see when these headaches started ,is it reoccurent?, is patient's energy level has change recently, etc..R/O medical cause.PE:completeLabs:CBC- posssibly WNLChem-7UA- WNLAlcohol and Urine Drug screening- need to rule out drug use.TSH- probably WNL- rule out thyroid problem.if all above normal. depression index- response to 20 question indicates depression.start antidepressant- if patient is obese use celexa otherwise any ssri would be fine.schd. psychotherapy (with psychiatrist) to augment medication.schd. patient for follow-up in 3 weeks.
CCS Spleen rupture
HPI 23 yom after MVA.ABCPE;focusLabs:serum glucose and rapid bedside glucose determination CBCserum chemistriesamylaselftsuacoagulation studiesblood type and matchabg, blood ethanolurine drug screens.Bedside u/s, DPL(for unstable), CT(for stable) and emergent surgeon consult.Chest x-ray, supine & erect abdomen x-rayAbdominal sono(er) or abdominal CTVital, Cardiac, and BP monitoring on bed side.Foley cather and Urine output check.Ringer's lactate sol I.V before results from Lab.Transfer to ICU if patient is not stable.
CCS chron's disease
HPI 28 yof comes to office c/o diarrhea for several days.PE:Complete- Labs:CBC- check for leukocytosisChem7Guiac - positive for bloodstool culture- WNLstool for ova and paraside- WNLColonoscopy- biopsy- inflammatory process consistence with chron's diseasTreatment:mesalamineantidiarrhealreevaluate patient in couple days- patient diarrhea has improved. Patient is feeling better.see patient in 2 weeksdiagnosis:chron's disease
CCS Squamous cell Lung cancer
HPI 67 yof with 30 years history of smoking come to office c/o cough.PE:completeLabs:Pluse oxo2CBCChem 7CXR- mass on left upper lobebiopsy- sq. cell carcinomasurgical and onconlogy consultdiagnosis:sq. cell carcinomayou may ask how I am going to treat this patient. You probably won't have time to do any kind of treatment because when you make the diagnose case will end.
HPI 5yo child with acute asthmatic attack Note vital signs: BP, Pulse, Resp. Rate, Temp. Step I : Emergent management: A, B, C, D- O2 , broncodilaters MDI or nebulizer, depending on severity consider systemic corticosteroids. Step II : Physical Examination General appearance, HEET/Neck, Chest/Lung, Heart/CV Step III : Diagnostic Investigations: 1. O2 sat.2. PEF3. CBC4. Chem 75. CXR6. ABG- should be considered in severe distress of when FEV1 <30% of predicted values after initial treatment. Treatment: 1. O2 2. Beta 2 agonist with MDI or Nebulizer every 20 mins 3. methyprednisolone IV q6h for first 24-48 hours then inhaled steroids Step IV: Decision about changing patients location Discharge home if symptoms resolve quickly or FEV1 is greater than 70% of predicted or personal best.Recommendation for hospitalization1. response to treatment is poor2. recent hospitalization for asthma3. failure of aggressive outpatient management4. previous life- threatening attack.5. If PEF or FEV1 is less than 50%6. arterial carbon dioxide tension is greater than 427. If patient is confused of drowsy8. If no easy access to ERIf patient is discharge need to return to office within 5-7 days for follow up. Step V: Educate patient and family:Instruct patient/family to avoid factors that aggravate patients disease.Instruct on proper use of MDI Step VI: Final Diagnosis - Acute Asthma Attack
CCS Nortryptiline Toxicity
HPI 27 yof was found unconcious with a bottle of pill. ensure ABC PE:Heent/Neck, skin, CV, Lung, ABD labs:CBC, Chem13Puls ox, EKG, ABG, drug level Treatment:Gastric lavageActivated charcoal with intermittent gastric suctioning. Induce alkalinisation with NaHCo3 to maintain pH of 7.45 to7.55. If he is intubated hyperventilate to a PCo2 <35 and >25mmHgFoley. If ECG normal and patient is asymptomatic, observe for 6 hrs in ER. otherwise admit to icu. After Admission ECG should be normal for 24hrs to discharge for psychiatric disposition
CCS Sickle cell crisis
6 AAM was broght to your office because of pain he has a history of sickle cell disease.
BUN & Cr
type and cross
exchange blood transfusion
Penicillin V 125 mg bid up to age 3; then 250 mg bid up to age 5
immunization: H.influenzae B and pneumoccal vaccines
Aminocaproic acid for hematuria
If recurrent CVA, chronic transfusion program
Bone marrow transplation
More: Over 70 cases at Wikimd.org below Source: http://wikimd.org/wikimd/index.php?title=Step3CCS, also look at the part 2 link on wikimd for more CCS cases