Posted by Doctor Don from IP 70.131.218.59 on May 16, 2008 at 14:39:24:
CASE 1: Motor vehicle accident
Case Summary
• 33-year-old man with chest pain and respiratory distress following a motor vehicle accident.
• Vital signs show tachycardia (118 beats/min), tachypnea (32 breaths/min), and hypotension
•(100/60 mm Hg).
• History reveals he was the unrestrained driver and his chest hit the steering wheel.
• He did not hit his head and there was no loss of consciousness.
• He was initially alert and responsive and then became dyspneic, agitated, and restless in the ambulance prior to arrival in the emergency department.
• Examination reveals soft heart sounds, weak central and peripheral pulse,
• jugular venous distension and pulsus paradoxus.
• ECG reveals electrical alternans; chest x-ray shows enlarged cardiac silhouette;
• echocardiography reveals cardiac tamponade
Orders Blood pressure monitor, cardiac monitor, oxygen, pulse oximetry, elevate foot of bed,
intravenous access, normal saline 0.9% NaCl
Exam General, heart, lungs
Orders Pericardiocentesis, consult thoracic surgery, chest x-ray, ECG, echocardiography,
morphine
Exam Additional: skin, HEENT, abdomen, extremities + others
Orders CBC, BMP, PT/PTT, cardiac enzymes, amylase, type & crossmatch blood, alcohol blood,
cervical spine x-rays, pelvis x-ray, toxicology urine
Clock Advance to pericardiocentesis
Orders Chest x-ray, echocardiography, vital signs
Clock Advance to vital signs
Location Transfer to ICU
Clock Advance to additional results and case end
End Orders Advise patient drive with seat belt
DX: CARDIAC TAMPONADE
CASE2. Fatigue
Case Summary
• 66-year-old man with fatigue and constipation for 4 months.
• Vital signs are unremarkable.
• History reveals occasional left lower quadrant abdominal pain, 9-kg (20-lb) weight loss, smoking 1 pack cigarettes a day for 30 years.
• Examination shows occult blood positive.
• CBC reveals microcytic anemia; colonoscopy reveals colon adenocarcinoma
Exam Rectal, HEENT, heart, abdomen, lymph nodes +/- complete
Orders CBC, BMP, TSH, glucose fasting, LFT, urinalysis, colonoscopy, advise no smoking
Clock Advance clock to reschedule patient when all results are reported
Orders Ferritin, iron & TIBC, CEA, abdominal CAT scan, chest CT scan, bone scan,
advise cancer diagnosis, reassure
Clock Advance clock to reschedule patient when all results are reported
Orders Colectomy, consult general surgery, iron sulfate, ECG, PT/PTT,
type and crossmatch blood
Clock Advance to case end
End Orders CBC, CEA, ferritin
DX: COLORECTAL CANCER
CASE3. Abdominal pain
Case Summary
• 19-year-old woman with abdominal pain for 6 hours.
• Vital signs show tachycardia (106 beats/min), hypotension (100/60 mm Hg), low-grade fever (38.2°C, 100.8°F).
• History shows pain is sharp, constant, and focused predominately in the right lower quadrant. History is also significant for 6 weeks amenorrhea, vaginal spotting, sexual activity with three men, occasional use of condoms, previous treatment for Chlamydia.
• Examination reveals lower abdominal tenderness, closed cervical os, cervical excitation present, right adnexal mass with tenderness.
• Laboratory studies reveal positive urine HCG test.
• Imaging with transvaginal ultrasound shows a complex right adnexal cyst.
Orders Blood pressure monitor, cardiac monitor, pulse oximetry, oxygen, intravenous access,
normal saline, elevate foot of bed
Exam Abdomen, genitalia + general, heart, lungs
Orders HCG urine, morphine
Clock Advance to HCG results
Orders Laparotomy, consult OB/GYN, transvaginal ultrasound, type & crossmatch blood,
HCG serum quantitative, CBC, BMP, PT/PTT
Clock Advance to laparotomy and case end
End Orders CBC, RhoGAM; advise patient safe sex techniques
DX: ECTOPIC PREGNANCY
CASE 4 Back pain
Case Summary
• 28-year-old man with painful urination and low back pain.
• Vital signs show elevated temperature (38.0°C, 100.4°F).
• History reveals sharp and severe pain during urination, increased urinary frequency, nocturia,chills, and perineal pain.
• Examination shows tender swollen prostate.
• Laboratory studies show urinalysis positive for blood, nitrite, leukocyte esterase, leukocytes, and bacteria. Urine Gram stain positive for gram-negative rods. Urine culture positive for Escherichia coli. CBC with elevated WBC count.
Exam General, abdomen, genitalia, rectal +/- complete
Orders Urinalysis, urine Gram stain, urine culture
Clock Advance clock to results of urinalysis and Gram stain
Orders CBC, Blood culture, ciprofloxacin, acetaminophen, colace, reassure, counsel
Clock Advance clock to additional results and patient update
End Orders None
DX: ACUTE BACTERIAL PROSTATITIS
CASE 5: Shortness of Breath
Case Summary
• 61-year-old hospitalized woman with shortness of breath.
• Vital signs show tachycardia (112 beats/min) and tachypnea (30/min).
• History reveals she was admitted 2 days ago for pneumonia.
• The shortness of breath began acutely and is associated with right sided chest pain, worsened when taking a deep breath. She is on hormone replacement therapy.
• Examination shows loud S2 and right calf tenderness.
• Laboratory studies show elevated d-dimer, and spiral CT chest confirms pulmonary embolism
Orders : Intravenous access, cardiac monitor, oxygen, pulse oximetry, elevate head of bed
Exam : General, heart, lungs, extremities
Orders : ECG 12 lead, ABG, chest x-ray portable, d-dimer, cardiac enzymes, BNP, CBC, BMP, nitroglycerin.
Exam: Skin, lymph nodes, HEENT, abdomen, rectal
Clock : Advance to d-dimer result
Orders: Spiral CT chest
Clock : Advance to spiral CT result
Orders : Heparin, PT/PTT, vital signs, reassure patient
Location :Change to ICU
Clock :Advance to case end
End Orders:PT/PTT, coumadin
DX: PULMONARY EMBOLISM