CCS Cases 6-10

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Posted by Doctor Don from IP on May 16, 2008 at 14:41:50:

CASE 6 :Back pain
Case Summary

67-year-old woman with back pain for two days.
Vital signs are unremarkable.
History reveals sharp, constant, localized lower back pain.
Acetaminophen only partly relieves the pain. Menopause at age 54.
Examination shows mild kyphosis, tenderness at L4.
Imaging reveals L4 - L5 vertebral compression fractures;
DEXA scan shows osteoporosis with a T score of -2.8.

Exam HEENT, lymph nodes, spine/extremities, neuro +/- complete
Orders Spine x-ray lumbosacral
Clock Advance clock to spine x-ray
Orders CBC, BMP, phosphorous, LFT, TSH, DEXA scan, back brace, advise patient rest at home, acetaminophen plus oxycodone, colace
Clock Advance clock to reschedule patient when all results are reported
Orders Calcium carbonate, vitamin D, alendronate, raloxifene, diet of high calcium,
physical therapy, advise exercise, advise estrogen replacement, advise side effects,
Clock Advance to case end
End Orders None

CASE 7 :Fatigue
Case Summary
42-year-old woman with fatigue for four months.
Vital signs show BMI of 39.6 kg/m2.
History reveals two previous urinary tract infections.
Laboratory examination reveals an elevated fasting blood glucose and hemoglobin A1c.

Exam HEENT, heart, abdomen, rectal, lymph nodes +/- complete
Orders CBC, BMP, TSH, glucose fasting, urinalysis, LFT, lipid profile, depression index,
diet low fat, diet calorie restricted, advise exercise program
Clock Advance clock to reschedule patient when all results are reported
Orders Hemoglobin A1c, magnesium, urine microalbumin, ECG, consult opthalmology,
consult dietary, consult podiatry, diet diabetic, vaccine influenza,
vaccine pneumococcal, diabetic teaching
Clock Advance clock to reschedule patient when all results are reported
Orders Metformin, aspirin, lisinopril, advise side effects, advise medication compliance,
Clock Advance to case end
End Orders Hemoglobin A1c
CASE 8: Shortness of Breath
Case Summary
25-year-old woman with shortness of breath and facial swelling.
Vital signs show tachycardia (108 beats/min), hypotension (105/70 mm Hg), tachypnea (28 breaths/min)
and mild fever (38.0C, 100.4F).
History shows generalized itching, feeling warm, facial swelling, wheeze, and shortness of breath began
while eating a meal composed of crab, shellfish, and shrimp. She has a history of allergies
and childhood asthma.
Examination reveals expiratory wheeze, facial flushing, reduced pulses.

Orders Blood pressure monitor, cardiac monitor, pulse oximetry, intravenous access, oxygen,
normal saline, epinephrine, diphenhydramine
Exam General, lungs, skin, HEENT, heart
Order ECG, chest x-ray, BMP, albuterol, prednisone, cimetidine
Clock Advance to results
Order Vital signs, reassure, counsel, advise medic alert bracelet
Location Ward
Clock Advance to case end
End Orders None
CASE 9: Breast lump
Case Summary
36 year old woman with right breast lump
Vital signs are unremarkable
History reveals she does not normally perform self breast exam, mass is mobile & non-tender,
no nipple discharge, maternal aunt with breast cancer
Examination reveals 3cm firm, mobile, non-tender mass. No axillary lymphadenopathy
Ultrasound shows the mass is solid, Mammography does not show any calcifications,
fine needle aspirate is interpreted as a fibroadenoma
Exam General, skin, breast, lymph nodes + Additional
Orders Mammography, Breast ultrasound, Breast fine needle aspirate
Clock Advance clock to reschedule patient when all results are reported
Orders Reassure patient, Advise patient breast self-examination
Clock Advance to case end
End Orders None
CASE 10: Shortness of Breath
Case Summary
68-year-old woman with shortness of breath and nausea.
Vital signs show tachycardia (110 beats/min), tachypnea (22 breaths/min) and hypertension (170/90 mm Hg).
History shows sudden onset of shortness of breath, weakness and nausea.
She has had previous less severe episodes before. She has diabetes (glipizide), hypertension (hydrochlorothiazide) and hyperlipidemia (atorvastatin).
She has smoked 1 pack of cigarettes per day for 30 years.
Examination reveals S3 heart sound, pulmonary rales, jugular venous distension, and lower extremity edema.
ECG reveals acute inferior myocardial infarction; chest x-ray reveals pulmonary edema;
cardiac enzymes and BNP are elevated.

Orders BP monitor, cardiac monitor, pulse ox, IV access, oxygen
Exam General, heart, lungs
Orders ECG, CXR, ABG, CBC, BMP, D-dimer, glucose random (fingerstick), cardiac enzymes,
Exam Skin, HEENT, abdomen, rectal, extremities
Clock Advance to ECG (results show inferior wall MI)
Orders PT/PTT, magnesium, phosphorus, consult cardiology, coronary artery stent placement,
type and crossmatch blood, NPO, bedrest, aspirin, nitroglycerin, metoprolol, heparin,
abciximab, lisinopril, colace.
Clock Advance to chest x-ray (results show pulmonary edema)
Orders Echocardiography, Foley, urine output, furosemide, cancel hydrochlorothiazide
Clock Advance to additional results and case end
End Orders Advise patient no smoking

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