Posted by Doctor Don from IP 70.131.218.59 on May 16, 2008 at 14:46:04:
CASE16: Vaginal Discharge and Itching
Case Summary
• 26-year-old woman with vaginal discharge and itching for 2 days.
• Vital signs are unremarkable.
• History reveals the discharge is malodorous and yellow in color. She has pain on urination and mild lower abdominal tenderness. She is sexually active with two male partners and uses the oral contraceptive pill and occasionally condoms.
• Examination reveals frothy, yellow vaginal discharge and vulvar excoriations.
• Laboratory studies show vaginal pH 5.9 and motile organisms on wet mount.
Exam Genitalia, abdomen +/- complete
Orders HCG, vaginal pH, vaginal wet mount, vaginal KOH prep, vaginal GC culture, vaginal chlamydia culture, Pap smear
Clock Advance clock to results of vaginal tests
Orders Metronidazole, HIV test ELISA, advise safe sex, advise treat partners, advise side effects of medication, advise no alcohol, advise no intercourse, reassure
Clock Advance clock to additional results and case end
End Orders None
DX: TRICHOMONAS VAGINITIS
CASE17: Abdominal pain
Case Summary
• 21-year-old woman with right upper quadrant abdominal pain for 5 hours.
• Vital signs show elevated temperature (38.5°C, 101.3°F).
• Abdominal pain is worse when taking a deep breath, accompanied by nausea and vomiting, History of sickle cell anemia.
• Examination reveals mild jaundice, abdominal tenderness to deep palpation in right upper quadrant.
• Imaging reveals gallstones.
• Laboratory findings reveal microcytic anemia with sickle cells on CBC, elevated bilirubin on LFT.
Orders Oxygen, pulse oximetry, intravenous access, normal saline 0.9% NaCl
Exam General, skin, lungs, heart, abdomen, rectal
Orders Abdominal ultrasound, abdominal x-ray acute series, ECG, CBC, BMP, cardiac enzymes, amylase, lipase, LFT, bood culture, urinalysis, HCG urine, urine culture, meperidine, metoclopramide
Clock Advance to imaging/lab results
Orders Cholecystectomy, consult general surgery, type and crossmatch blood, PT/PTT, transfusion RBC, nasogastric tube, reassure, NPO
Clock Advance to cholecystectomy and case end
End Orders CBC
DX: ACUTE CHOLECYSTITIS
CASE18 :Back pain and fatigue
Case Summary
• 68-year-old man with fatigue and tea-colored urine for three months.
• Vital signs are unremarkable.
• History reveals flank pain, family history of breast and colon cancer, smoker of 1 pack per day for 30 years.
• Examination reveals pale conjunctiva, right flank mass, and tenderness.
• Imaging shows solid mass in right kidney on ultrasound, renal cell adenocarcinoma on CAT scan.
• Laboratory results show microcytic anemia on CBC, blood in urinalysis, low ferritin and serum iron.
Exam Abdomen, rectal + skin, HEENT, heart, lungs, lymph nodes
Orders Abdominal ultrasound, CBC, BMP, LFT, TSH, fasting glucose, urinalysis, urine cytology, advise no smoking
Clock Advance clock to reschedule patient when all results are reported
Orders Abdominal CAT scan, ferritin, iron studies, chest x-ray pa/lateral, ESR, fibrinogen, PT/PTT
Clock Advance clock to reschedule patient when all results are reported
Orders Nephrectomy, consult general surgery, consult oncology, iron sulfate, diet high iron, advise cancer diagnosis, reassure
Clock Advance to case end
End Orders CBC
DX: RENAL CANCER
CASE19: Wrist pain
Case Summary
• 33-year-old woman with wrist pain after a fall.
• Vital signs are unremarkable.
• History reveals she tried to break her fall with her right hand, she has multiple previous visits for falls and injuries, she is a divorced mother of 2 children, her boyfriend is argumentative with staff, she has smoked 1 pack of cigarettes per day for 10 years, she is a recovered heroine user.
• Examination reveals multiple bruises of varying ages, chipped tooth, right wrist swelling.
• Wrist x-ray reveals Colles fracture; counseling reveals domestic violence.
Exam Skin, HEENT, abdomen, genitalia, extremities +/- others
Orders CBC, PT/PTT, wrist x-ray, acetaminophen
Clock Advance to results
Orders Cast extremity, counsel patient, advise safety plan, consult social services, advise restraining order, reassure patient, advise no smoking
Location Change to ward
Clock Advance to case end
End Orders None
DX: DOMESTIC VIOLENCE
CASE20: Back Pain
Case Summary
• 63-year-old man with severe back pain.
• Vital signs show tachycardia (104 beats/min), tachypnea (22 breaths/min), and hypotension (90/60 mmHg).
• History reveals acute onset of sharp, severe back pain with nausea, vomiting, weakness, and lightheadedness. He has a history of diabetes, hypertension, and hypercholesterolemia. He has smoked cigarettes for 35 years.
• Examination reveals pulsatile abdominal mass.
• Abdominal CAT scan shows ruptured abdominal aortic aneurysm.
Orders Pulse oximetry, BP monitor, cardiac monitor, oxygen, IV access, normal saline, elevate foot of bed
Exam General, heart, lungs, abdomen, spine
Orders Laparotomy, consult surgery vascular, abdominal CAT scan, type and crossmatch blood, CBC, BMP, PT/PTT, ECG, cardiac enzymes, morphine
Exam Skin, HEENT, lymph nodes, neurologic, rectal
Clock Advance to laparotomy
End Orders Advise patient no smoking, CBC
DX: ABDOMINAL AORTIC ANEURYSM