Posted by Doctor Don from IP 70.131.218.59 on May 16, 2008 at 14:44:21:
CASE11: Fatigue
Case Summary
• 48-year-old woman with fatigue and constipation for 5 months.
• Initial vital signs show bradycardia (55 beats/min) and increased weight with BMI 28.8 kg/m2.
• History reveals increasing weight despite no change in appetite.
• Examination reveals thick, yellow skin and loss of lateral eyebrows.
• Laboratory studies show elevated TSH, reduced free T4 and free T3.
Exam Skin, HEENT, heart, lungs, abdomen, rectal +/- complete
Orders CBC, BMP, TSH, glucose fasting, urinalysis, LFT, ECG, depression index
Clock Advance clock to reschedule patient when all results are reported
Orders Lipid profile, free T4, free T3
Clock Advance clock to reschedule patient when all results are reported
Orders Levothyroxine, diet high fiber, diet low fat, advise medication compliance,
advise side effects of medication, advise exercise program, reassure
Clock Advance to case end
End Orders TSH in 6 weeks
DX: HYPOTHYROIDISM
CASE12: Chest Pain
Case Summary
• 48-year-old man with chest pain for 12 hours.
• Vital signs show mild fever (37.9°C, 100.2°F).
• History reveals sharp, severe chest pain that radiates to the neck. Pain worsens with deep inspiration and when lying down. Leaning forward improves the pain. Upper respiratory tract infection 1 week ago.
• Examination reveals pericardial friction rub.
• ECG shows diffuse ST elevation; echocardiogram shows no significant pericardial effusion.
Orders Pulse oximetry, oxygen, IV access, nitroglycerin
Exam General, skin, heart, lungs, abdomen, rectal, extremities
Orders ECG, CXR, CBC, BMP, ESR, cardiac enzymes, D-dimer
Clock Advance to ECG result
Orders Naproxen, echocardiography
Clock Advance to additional results
Orders Reassure, counsel, advise rest at home
Location Change to home
Clock Advance to case end
End Orders None
DX: ACUTE PERICARDITIS
CASE13 :Back pain
Case Summary
• 63-year-old man with back pain for 2 months.
• Vital signs are unremarkable.
• History reveals back pain occurs predominately when he rotates or twists his back while playing golf. He also has increased fatigue and a reduced energy level. He has had a 10 pound weight loss over the last 3 months.
• Examination reveals tenderness in the lower back on palpation and a firm, irregular prostate.
• Laboratory studies show elevated PSA, prostate cancer on biopsy, and positive bone scan for metastases
Exam Complete
Orders Spine x-ray lumbosacral
Clock Advance clock to x-ray result
Orders CBC, BMP, phosphorus, glucose fasting, TSH, LFT, urinalysis, PSA total, DEXA scan,
prostate fine-needle aspirate, advise rest at home, acetaminophen with oxycodone,
colace
Clock Advance clock to reschedule patient after all results are reported
Orders Abdominal CAT scan, chest CT scan, bone scan, advise cancer diagnosis, reassure
Clock Advance clock to reschedule patient after all results are reported
Orders Leuprolide, advise side effects of medication, consult general surgery, consult oncology,
consult radiation therapy, advise advance directive
Clock Advance to case end
End Orders None
DX: PROSTATE CANCER
CASE14: Abdominal pain
Case Summary
• 37-year-old man with abdominal pain for 2 hours.
• Vital signs show mild tachypnea (21 breaths/min).
• History reveals abdominal pain is generalized, crampy, occurs at several-minute intervals, and is accompanied by nausea and vomiting. Past history of abdominal surgery.
• Examination shows abdominal scar, mild distension, high-pitched hyperactive bowel sounds, and moderate abdominal tenderness.
• Abdominal x-ray reveals small bowel obstruction
Exam General, skin, heart, lungs, abdomen, rectal
Orders Abdominal x-ray acute series, ECG, CBC, BMP, amylase, lipase, LFT, cardiac enzymes, urinalysis, creatine phosphokinase, lactate, meperidine, metoclopramide
Clock Advance to abdominal x-ray
Orders Consult general surgery, nasogastric tube, nothing by mouth, intravenous access, normal saline, cefoxitin, type and crossmatch blood, PT/PTT, reassure patient
Clock Advance to surgery consult and case end
End Orders None
DX: ADHESIONS
CASE15: Fatigue and tea colored urine
Case Summary
• 43-year-old man with fatigue for 2 months.
• Vital signs show hypertension (170/90 mm Hg).
• History reveals he also has intermittent tea-colored urine and a dull ache in his lower abdomen. Family history shows his mom died of kidney failure.
• Examination reveals enlarged bilateral kidneys.
• Abdominal ultrasound shows polycystic kidney disease.
Exam Complete
Orders CBC, BMP, ECG, lipid profile, urinalysis, urine culture, urine cytology, abdominal ultrasound
Clock Advance clock to reschedule patient when all results are reported
Orders Lisinopril, diet low sodium, diet low protein, advise exercise, advise no sports, counsel, reassure
Clock Advance to case end
End Orders None
DX: ADULT POLYCYSTIC KIDNEY DISEASE