Posted by Doctor Don from IP 70.131.218.59 on May 16, 2008 at 14:48:08:
CASE21: Headache
Case Summary
• 11-year-old boy with intermittent cough and headache for 3 weeks.
• Vital signs show tachycardia (120 beats/min) and tachypnea (28 breaths/min).
• History reveals cough and headache usualy occur in the moring or when he plays outside. Symptoms usually last several minutes to an hour then resolve on their own. He has a history of eczema and childhood asthma.
• Peak flow is reduced and spirometry shows reduced FEV1.
Orders Pulse oximetry, oxygen, elevate head of bed
Exam General, heart, lungs, HEENT + additional
Orders Peak flow, spirometry flow, chest x-ray PA/lateral, ECG
Clock Advance to peak flow results
Orders Albuterol
Clock Advance to additional results
Orders Vital signs, peak flow, advise asthma care
Clock Advance to case end
End Orders None
DX: ASTHMA
CASE22: Shortness of Breath
Case Summary
• 20-month-old boy with wheezing and cough for 5 hours.
• Vital signs show tachycardia (150 beats/min) and tachypnea (33 breaths/min).
• History reveals symptoms began abruptly while he was unattended. Syptoms resolve briefly but then return intermittently.
• Exam shows a loud expiratory wheeze predominately in the right lower lobe of the lung.
• Bronchoscopy results in removal of foreign body.
Orders Cardiac monitor, oxygen, pulse oximetry, elevate head of bed
Exam General, heart, lungs, HEENT, abdomen, skin, extremities
Orders Chest x-ray PA/lateral, ABG
Clock Advance to results
Orders Bronchoscopy
Clock Advance to results
Orders Albuterol, chest physiotherapy, chest x-ray, vital signs, reassure, counsel
Location Change to ward
Clock Advance to case end
End Orders None
DX: FORIEGN BODY ASPIRATION
CASE 23: Fatigue
Case Summary
• 58-year-old man with fatigue and weakness for 3 months.
• Vital signs are unremarkable.
• History reveals tongue pain, mild confusion, memory loss, poor diet, smoker of 1 pack per day for 35 years, heavy alcohol use.
• Examination shows pale conjunctiva, tongue enlarged and reddened, mild hepatosplenomegaly, mildly diminshed deep tendon reflexes.
• Laboratory studies show abnormal LFT (elevated AST/ALT with AST 3 times greater than ALT, low albumin), CBC with macrocytic anemia and hypersegmented neutrophils, low vitamin B12, low folic acid.
• Abdominal ultrasound reveals fatty liver.
Exam Complete
Orders CBC, BMP, LFT, TSH, glucose fasting, advise no smoking, advise no alcohol, Alcoholics Anonymous
Clock Advance clock to reschedule patient when all results are reported
Orders Reticulocyte count, vitamin B12 serum, folic acid serum, folic acid eryhtrocyte, ferritin, iron & TIBC, PT/PTT, hep B surface antigen, hep C antibody, abdominal ultrasound
Clock Advance clock to reschedule patient when all results are reported
Orders Vitamin B12 therapy, folic acid therpy, thiamine, consult dietary, reassure, counsel
Clock Advance to case end
End Orders CBC
DX: MACROCYTIC ANEMIA
CASE 24: Abdominal pain and constipation
Case Summary
• 76-year-old woman with constipation and abdominal pain for 2 days.
• Vital signs are unremarkable.
• History reveals she is aphasic and bedridden. She has not had a bowel movement in 2 days and vomited two times.
• Examination shows abdominal distension, reduced bowel sounds, tenderness to palpation, and dullness to percussion.
• Abdominal x-ray reveals sigmoid volvulus.
Exam General, skin, heart, lungs, abdomen, rectal
Orders Abdominal x-ray acute series, CBC, BMP, LFT, amylase, lipase, ECG, cardiac enzymes, meperidine, metoclopramide
Clock Advance to abdominal x-ray
Orders Sigmoidoscopy flexible
Clock Advance to sigmoidoscopy results
Orders Consult surgery, nasogastric tube, intravenous access, normal saline, type and crossmatch blood, Foley catheter, urinalysis, urine output, nothing by mouth, vital signs, reassure
Location Change to ward
Clock Advance to surgery consult and case end
End Orders None
DX: SIGMOID VOLVULUS
CASE25 :Asymptomatic
Case Summary
• 17-year-old adolescent male for routine physical examination.
• Vital signs show elevated blood pressure (170/90 mm Hg) and increased weight (102.7 kg, 226.4 lbs; BMI 32.2 kg/m2).
• History shows patient is asymptomatic, smokes a few cigarettes a day, and drinks alcohol several times a week.
• Examination is unremarkable.
• Laboratory studies do not reveal any abnormalities.
Exam Complete
Orders Blood pressure
Clock Advance to repeat blood pressure result
Orders CBC, BMP, ECG, urinalysis, lipid profile, glucose fasting, urine protein 24 hour, TSH, uric acid, diet calorie restricted, diet low sodium, diet high potassium, diet low fat, advise exercise, advise no smoking, advise no alcohol
Clock Reschedule for follow-up in about 1 month.
Orders Blood pressure, weight
Clock Advance to blood pressure and weight result
Orders Reassure
Clock Reschedule for follow-up in about 1-2 months and case end
End Order None
DX: HYPERTENSION