100 VIP CCS STEP-3 Note

HEMATOLOGY
1-30 Yo Greek man with fever in ER co of acute back pain, headache, lightheadedness,
jaundice, dark urine, lastly he eat in Middle eastern restaurant ( fava beans) , PH, mild
anemia and recurrent GB stone, cholecystectomy.
Order
Pulse oxy and Oxygen therapy if hypoxia
Acetaminophen,oral Continous
EKG, stat
Iva, stat
NSS, stat
Order
PT, PTT,, stat
LFT , stat>>>>hi indirect Bilirubin >>>hemolysis
Cbc, stat>>>>Hb 6
Retics count, >>>>3%
Peripheral blood smear>>>bite cells, Heinz bodies
Bmp,stat
Coombs test>>>>> -ve not Autoimmune hemolysis
Blood culture
U/a, stat
Urine hemosiderin, stat
Urine Hb, stat,
Haptoglobin, stat
Abd USG, stat to check for the GB stone 2ry to chronic hemolysis
Counsel to avoid offending drugs and avoid fava beans
ttt only supportive care, hydration, and care to avoid RF. avoid offending drug and food.
reschadule patient after 3 wks to check Serum G6PD enzyme level
2- 25 yo women in ER with epistaxis stopped by pressure, OE, multiple spots on her
both ankles, and gingival bleeding, CBC platelet 10.000.vitally stable.
Order
CBC, Peripheral smear
Bmp,
PT, PTT ,BT
Antiplatelet antibodies, serotonin release assay if there was any heparin intake history,
Fibrinogen, D-dimer >>>N
LFT>>>> N
IF life-threatening bleeding, give
IV Ig + Dexamethazone.
HIV Eliza, negative
cbc,bun, creatinine daily,
ANA negative
Rituximab, or Romiplostim and
BM biopsy, stat>>>>megakaryocytes>>>>ITP
eltrombopag.

 Consult hematologist
Order
Prednisone for 6 wks oral ( only if the platelet < 50).
Immunoglobulin if acute or life threatening hage
Danazole or vincristine if refractory,
3- 70 yo women hospitalized 1 wk ago for pneumonia,
treated with broad spec. antibiotics. PH: PUD, on
pantorpazole.. she had one pisode of coffegroud emesis
this morning but selflemitted. vitally stabel.
Order complete PE, rectal.
Order
CBC, stat>>>>N
PT, PTT, BT, stat,>>>> PTT, PT.

Fobt, >>>>
Bmp, stat
Abdominal x ray, stat >>> no free air under the diaphragm
Abd. USG, stat
Blood typing and cross match, stat
Bilirubin, stat>>> N
Fibrinogen, stat>>>N
D-dimer,stat
LFT, stat>>>N

Rituximab works by removing the

lymphocytes that make the
antibodies that attack platelets.
You know that rituximab removes
CD20-positive lymphocytes. This
is the same mechanism for how it
works in cold agglutinin disease
and how it works in rheumatoid
arthritis. Romiplostim and
eltrombopag are stimulants of
megakaryocytes. They are
thrombopoietin. These
medications are used when
splenectomy does not control the
disease. It seems that ITP is not
entirely a destruction problem
and that stimulating production
seems to help.

Order>>>>>> SCI VIT- K for three days.

Schedule colonoscopy after one month for screening
Vaccine influenza, pneumococcal, herpez softer.
3- Vitally stable 65 yo in ER to undergo transurethral resection of prostate for BPH.
With elevated PTT blood test. Consulting you before doing surgery if he need any FFP
transfusion before surgery.
Order: complet PE
Order:
CBC, stat>>>N
PT, PTT, BT, stat>>> high PTT
Fibrinogen, stat, >>>N
Mixing study, stat>>>> abnormality doesn't correct
VWF Assay is normal
VDRL, Stat

DD of High PTT:
1- APS
2- FACTOR XII def
3- VWF def
4- Hemophilias.

VDRL is always false + in Antiphospholipid syndrome

FTA, stat, >>>>

Order
No need for FFP transufsion or any clotting factor replacement becuase this is
Antiphospholipid syndrome,
Prophylactic anticoagulantion (aspirin + LMWH as Dabigatran) after surgery against thrombosis is
mandatory.
4- 28 yo woman was hospitalized 3 days ago with I wk fever after chemotherapy for
Hodjken lymphoma, fever resolve by antibiotics but she co fatigued and her Hb was 7

and 2 U blood transfused to her. During the first unit, she developed rigor, fever, back
pain, agitated confused, feverish 39", BP 80/60, pulse 140. Oozing from IV sites and
epistaxis
Stop the transfusion first >>> EPI IM immeidately in case this is anaphylasi
Order focused PE. Order
Oxygen, stat
Pulse oxy, stat
Iva, stat
NSS, stat
Cardiac monitor stat,
BP monitor stat,
Order
CBC, stat>>>>platlet 90.000
ABG, Stat
Bmp,stat>>> creat 1.7
Fibenogen, stat,
FDP, stat
PT, PTT, stat
U/a, stat>>> Hb.
LFT, stat>>>> indirect B.
Haptoglobin,stat>>>
LDH, stat>>>
Blood typing and cross match, stat
DIC IS SUSPECTED
Order:
FFP, STAT
Monitor renal function improvement if not improved give mannitol and frusemide (to
prevent ATN) if still no improvement consider dialysis.
Platlet transufsion if sever bleeding
Factor XII Transfusion if life threatening bleeding.
5- 75 yo man comes in for routine check up in your office,PH, HTN controlled on
Nifidipine, routine blood test, showed elevated total proteins 9.5g, albumin 3.5g, vitally
stable, ROS is unremarkable.
Order complete PE
Order
CBC, stat
Bmp, stat>>>>N
in bmp BUN, create stat normal
TSH, stat
Urine electrophoresis >>> for Benz Jhons Prtns
Serum electrophoresis >>>monoclonal spike in gammaglobulin < 2.5.
Skeletal survay, N
BM biopsy stat>>> 5 % plasma cells
Diagnosis is MGUS
Schedule colonoscopy after one month

 Vaccine influenza, pneumococcal vac, herpes zoster vaccine,

5- 25 yo woman come to office co of progressive fatigued for last 6 mons, FH freq cold
& sinus infections.,noticed multiple bruises on arm and legs without truma. Paint
worker.
Order complet PE
Order
CBC, stat >>>> pancytopenia
RF>>Negative....
BMP, stat>>>
TSH, stat
HIV ELIZA, STAT
PPT, stat

DD of Pancytopenia
1- SLE
2- APLASTIC ANEMIA
3-PNH
4- BM MALGNANCY
5- MDS
6- Famconi syn.

To exclude PNH one of cause of pancytopenia, urinary hemosiderin>> if positive order

coombs>>> it should be in PNH >> flow cytometry to confirm diagnosis of PNH. Abscent CD
59-55.

ANA, Stat to exclude SLE

Vit-12 level, stat
Folic acid level, stat
BM biopsy >>> hypocellular >>> aplastic anemia
Hematology consult
Order
Avoid exposure to offending agent
eculizomap is DOC for PNH.
Antithymocyte globin + cyclosporine.
BM
transplant
in
resistant

6- 75 yo man in your office with lethargy,, with erratic and volatile mode, genralzied
weakness and fatigued depression and worsening ataxia. OE decreased sensation of
lower limb and vibratory sense. Hyperreflexia of LL.
Order complete PE.
Order
Pulse oxy, stat,
oxygen ,stat
CBC, stat
TSH, stat
Brain CT, stat>>>mild diffuse atrophy
Bmp, stat
U/a stat
VDRL, stat>>>
Vit-B 12 level, stat, >>>>> low
Antipriatal cell antibodies, stat
Anti-internist antibodies. Stat
If antibodies were do schilling test.
Methylmalonic acid level, stat
Order
Vit B 12 IM injections ( not oral) daily for a week. Then oral therapy afterward.

 Schedule colonoscopy after one month

Vaccine influenza, pneumococcal, varicella, herpes zoster vaccine.
7- 28 yo African American comes in office for routine checkup. CBC shows MCV 59 Hb
11. A symptomatic Patient.
Complet PE
Order
CBC, stat
n
Bmp, stat,
Iron, stat>>> N
ferritin, stat>>>> N
Peripheral smear, stat>>> target cells
Hb electrophoresis>>> Hb A2 >>> thalassemia
Counsel
Educate your patient
Reassure , no ttt is requires.
8- 25 yo women comes to office for examination for new job. Co of fatigued,
palpitation,regular mensis. She appears pale.
Complete PE
Order
CBC,stat>>> Hb 9,
N
MCV, stat >>>
Peripheral smear, stat >>> hypo chromic microcytic RB cells
Iron, stat
Ferritin, stat
TIBC, stat>>>>
This is iron deficiency anemia, Order oral ferrous sulfate three times a day
Follow up by cbc & retics.
9- 22 yo man in office co of abn bleed after shaving intermittent for years. Become sever
after he took a sprin this week.
Order complete PE
Order
CBC, stat>>> N
PT,stat >>>>N
PTT, stat>>>
BT, stat, >>>
VWF level >>>low
Ristocetin cofactor assay>>> abn low>>> due to defective platelet function.
This is VWF Defieiceny disease
Order
Desmopressin,
Factor VIII replacement if still bleed.
Avoid aspirin in future.

10-55 yo comes to office co of fatigued and left UQ pain + vitally stable.

Order complet PE>>>fullness in RUQ
Order
CBC, stat >>> leucocytosis, thrombocytosis
Abdominal USG, stat >>> splenomagly
Peripheral smear, >>>N no blast cells
Leukocyte alkaline phosphatase level,stat>>> low
Philadelphia chromosome, stat >>>

These are all crieteria of CML

BCR/ABL>>>
BM biopsy>>> neurtophil infiltrations
Order
Imatinib.
BMT if refractory to Gleevec.
If acute leucocytosis >400,000 >>>leukopheresis
Schedule colonoscopy after one month
Vaccine influenza and pneumococcal vaccine,
11- 57 yo is admitted with SOB after Pulmonary embolism. Has been on IV UH. On
third hospital day platlet dropped from 180.000 to 60.000. Coumadin was started two
days ago.
Order complet PE>>>> N
Order
Cbc, stat>>> low platlet 54000
PT, stat>>> N
PTT, stat>>> therapeutically high
Bmp, stat>>>>N
Platlet factor 4 antibodies level, stat>>>>
Serotonin release assay from platlet, stat>>>
Order
Stop Heparin
Start lepirudin, IV, Continous
CBC, stat every day after platlet reach 100.000
Use warfarin (coumadine) for the plum emploism
Schedule colonoscopy after one month
Vaccine influenza, and penumococcal vaccine.
12- 50 yr old woman has admitted for Up GI bleed due to PUD. She received 2 u of
blood, her blood type B Rh negative. She has mild icterus.
Order complete PE
Order
CBC, stat>>>Hb 7
Bmp>>> renal function is normal
PT,PTT, stat are N

LFT, stat, AST/alt are N , indirect Bili,

Urine hemosider, stat >>> N
Haptogblobin, stat >>> N
Coombs stat,>>>

Rh of transfused blood, >>>>

Order:
reassure, admit the medical erro to your patient. Monitor the Renal function.
Schedule colonoscopy after one month
Vaccine influenza,penumococcal vaccine.
Mammography
13- 40 yo in office, co of fatigue, wt loss 15 pounds over few months. He also have
infertility co, recently lost interst in sex. Also intermittent non specific abdominal pain.
Joint pain, palpitation, lightheadedness.
Order complet PE>>> mild icterus, frequent ectopic heart beat, reg rhythm & rate. Atrophic
testicles. Light bronz appearance.
Order
CBC,stat>>>N
BMP, stat,>>> glucose,
LFT, stat, >>> AST/ALT,
ECG, stat>>> PVCs
Iron, stat>>>
TIBC, stat, >>>l
Hemochromatosis case

Ferritin, stat>>>

Transferring, stat>>>>
Liver biopsy >>>> hi iron
Genetic screen of the family>>>> HFA gene
Order
Phylepotomy every 2 u weekly until Hb 15 g/dl, ferreting < 45% then I u /3 month.
Deferoxamine, SC infusion

Nephrology
14- 72 yo woman come to ED co of nausea, malaise. PH, sever osteoarthritis on
ibuprofen.vitally stable.
Order focused PE. >>> mild JVD, tachycardia, left basilar tracks in lung, bilateral LL edema.
Order
Pulse oxy, stat
Oxygen, stat >>> discontinue oxy therapy if O2 sat > 92
EKG 12 leads, stat
BP monitoring
Order
CBC, stat
U/a, stat>>> trace protinuria

 Urine stain for eosinophilia >>>

Urine Sodium >>> than 20 >>> renal failure secondary to NSAIDs
ABG, stat,>>>> Po2 80, bicarbonate 12, PH 7.29>>> meta acidosis
Bmp, stat>>> K high
CXR, stat
Lipid profile, stat
Uric acid, stat
Order
Admit to the ward
Renal diet
Ambulateat well
Urine outpu
Discontinue NSAID
Ca gluconate
telemetry monitoring
IV GLUCOSE 50 %
IV regular insulin to treat hi K
ABG, Q 4 hrs
Bmp, Q 4 hrs
If still bmp and ABG do not normalize go for dialysis
Schedule colonoscopy after one month
Vaccine influenza, penumococcal vaccine
Mmography, after month

Dont forget to order

ABG for any renal
disease.

15- 27 yo woman, co to ED with sever pain left flank, dark urine, no fever, only has been
co of burning and frequency in urination, treated with TMBSMZ. Pain sever enough to
prevent her talk to you, with nausea, vomiting,
Order, focus pE... Normal acute distressed patient
Order
Pulse oxy
IV Ketorolac, stat, Continous,
EKG, monitor,
U/a, stat
24 hr Urine calcium stat,
Urine culture, stat
Bmp, stat,
Uric acid,
Abd, X ray KBU
Abd helical CT,
Order
IV
IVF NSS, bolus
IVF NSS, Continous
Interval History and exam
Shock wave lithripsy if stone < 1cm in upper tract
Nephrostomy or uretroscopy if stone > 1 cm or in distal tract.
Stones < 0.5 mm pass spontaneous by IVf and analgesics only.

16-52 yo woman with breast cancer treated with lumpectomy and axiliary LN dissection,
no chemotherapy needed. She come to your office co of puffiness of her face, and body
swells.
Order complet PE >>> periorbital edema,
Order
CBC, stat
Bmp, stat,,>>>RFt all N
Ur/a , stat<>>> + 4 protinura, fat bodies, no cast.
Urine Sodium >>> 20
Total protein, stat>> N
Serum alabumin,
Lipid profile, >>>
Causes of nephrotic synd:
LFT, stat >>> N
1- Membranous, MPGN or
Order. Look for cause of nephrotic synd --- all will show N
minimal changes GN, or
some will order only nephrotic consultation to check for the cause .
FSGN GN.
but i would prefer to give some highlights on managment here.
2- SLE, DM, Amyloidosis,
ANA, complement for SLE.
Cryoglobulin.
HBsAg,
HCV, Ig
Order
renal biopsy >>> thick GBM with spikes, electrons microscope, subepithelia deposition. >>>
membranous GN ( idiopathic or due to tumor)
oral steroids,
Oral vit D oral Ca. omebrazol coz steroid predisbose to gastric ulcers
Dexa scan baseline
Lisinopril for protinura ip even if BP is N.
Renal diet, restricting Protien.
Order
Follow up after 6 wks, If the patient does not improved, order cyclosporine.
Monitor Bmp, u/a.
Mammography after months
Schedule colonoscopy after one month
Vaccine influenza,
17- 52 yo woman with type1 DM, comes to your ofce becuase of genralized weakness,
has difcult in clear thinking, she lost while she walk in the clinic to see you.
Order Complet PE>>> chest mild basilar rales, no murmurs, +2 edema, somewhat
confused. Order
CBC, stat>>>N
Bmp, stat>>> BUN, Cr, k (6), bicarbonate (15)
ABG, stat>>> Met acidosis
Acuecheck >>>140
Oliguric +
U/a, stat, >>>>3+ protinuria, 1+ glucose.
hyperkalemic+
Urine Sondium, stat
acidotic= D5W +
LFT, stat
bicarbonate to avoid
Renal ultrasound>>> bilateral large kidneys
overhydration and
24 hr urinary proteine collection,
Phosphorous,Mg,
if
bmp
shows
hypercalcemia
order
PTH
stat

correct

hyperkalemic and
acidosis

Order
Admit to ward
Bed rest
Diabetic diet
Acuecheck Q 8 hrs
Regular insulin, basale blous regimine
Serum uric acid, stat
Lipid profile, stat
Nephrologist consult cause Chronic renal failure.
EKG, STAT for K level.
IV regular insulin, and 50% glucose
Ca gluconate, stat
IV bicarbonate, if acidosis did not correct consider hemodialysis.
Pt, PTT, bleeding time, stat>>> cause uremia cause platelet disfunction
After improvement of chimestry lab,,..discharge home
Order
Oral Sodium polystyrene sulfonate or Kexylate, to get k out of body in stool,
Vit D
Oral Ca acetate, if Hi Ca in bmp, follow up ca level>> still hi >> sevelamir/calcitriol(vit-D).
PTH level, every month if high >> order cinacalcet in follow up visits.>> if not>>> thyroidectomy.
Patient education, medical compliance, no alcohol, renal diet, resitric Na, proteins.
Mammography, after 4 wks,
Colonoscopy, after 4 wks,
Dexa scan after 4 wks,
Schedule colonoscopy after one month
Vaccine influenza,
18- 57 yo with lung cancer history, comes to your office co of confusion. On
chemotherapy for lung cancer. Still has hemoptesis and perihilar LN. He is depressed
on SSRI. Diabetic on Glyburide.
Order complete PE>> weak, disoriented.
Order
Pulse oxy >>> 96%
CBC,>>>>N
Bmp, hyponatremia. N renal function, N Glucose.
U/a>>> N
EKG,>>> N
CXR, >>> peihilar Lymphadenopathy
Brain CT>>> N
Order
Plasma osmolarity >>>>200
Urine osmolarity >>> 600
Urine Sodium,>>> 40
Order>>>> this is hyponatremia secondary to SIADH
Water restriction
Oral frusemide
Stop SSRI, cause hyponatremia
Demeclocycline oral
Schedule colonoscopy after one month

 Vaccine influenza,
19- 27 yo woman in office with Continuos headache, she known Hypertensive and take
CCB. (headache is seems to be due to uncontroled blood pressure).
Order complete PE >>> high pitched sound on epigastric area
Order
CBC, >>> N
Bmp, >>>cr 1.2, BUN 36
U/a>>N
TSH >>>N
Abdominal ultrasound>>> bilateral small kidneys
MR Angiopgraphy>>> decrease up take of left kidney
MR Duplex Ultrasound of renal artery>>> left renal artery stenosis
MR arteriography ( gold standard) >>> stenosis of renal artery
Order
Balloon angiography of stenosis lesion>>> if fail repeat second time.
Operative repair
Control HTN by ACE inhibitors.
20- 32 yo man come in office co of painless gross hematuria after URTI. He has similar
episode from 3 years ago resolved by course of antibiotics. pH: HTN, Hyperlipidemia.
Order>> complete PE >>> BP155/92 ..otherwise N.
Order
CBC,
Bmp, >>> Cr 1.2,
U/a +3 protinuria, > 10 RBCS,
Serum albumin , N

24 hr urine protein
try to determine the cuase of nephrotic
COMPLEMENT C3. C4
HbSAg
HCV antibodies
ANA
Lipid profile

All are negative

Order
IVP to diagnose cause of hematuria >>> if negative in young so no further tests required
if negative in elderly next oder Cystoscope.
Order
Renal biopsy >>> mesangial hypercellularity, hyalinosis of arterioles, sclerosis, and intimal
fibrosis.
Electrons microscope: subendothelial immune type deposition. IgA deposition.
Order
ACE Inhibitor
Nephrologist consult
Prednisone oral

Vit D,
Calciam
Dexa scan
Patietn Education: avoid Blood product transfusion

Rhuematology
21- 35 yo woman in your office, she had joint pain and swelling for one year, pain began
in her right knee, left elbow, right wrist, bilateral MCP joint. Morning stiff for one hour.
Fatigue, weakness.
Complete physical exam>>> warm swelling, tender knee, wrists, elbow, MCP, PIP, & ankle.
No murmur but if there were murmurs you should order blood culture and echo to exclude
valve vegetation of endocarditis.
Order
CBC, Routine
Bmp, routine
LFT, routine,
BHCG, routine,
TSH, routine,
ESR, routine
ANA, routine
All are negative
Rheu factor,
Anticitrulinated peptide, routine
EBV titre
IgM parvovirus abs
Hepatitis panel...
Fobt, routine
X ray of hand, routine...erosion of MCP.
Order
Endomethacine,
Mxt, oral
Folenic acid, oral,
Pantoprazole,
Multivitamins,
Counsel, no smoke no, alcohol, safe sex, medication compliance
Avoid sick contacts.
Schedule after 4 wks.>>if does not improved order etanercept oral, with PPD test before use
etanercept.
Order CBC, LFT, fobt.
22- 48 yo woman in your office with history of brseat cancer co of proximal ms
weakness for 5 wks, general fatigue, rash on her eyelids, face, up chest from sun
exposure.
Order complete PE. >>> upper weakness of shoulder and thighs bilateral.
Order
CBC,routine
Bmp, routine
All are negative except
TSH,

 ESR, CRP,
CPK,>>> high
Serum ferritin>>> >>> mostly dermatomyocytis
EMG, to exclude Mythenia graves,>>>>repeatitive discharge positive sharp wave...N
Anti-Ro/ anti- La>>>
Anti-Jo,
Order >>> muscle biopsy >>> lymphocytic infiltration
Order
Oral prednisone,
Vit D
Calcium
Schedule after 6 wks
CBC, CPK level
Council,
Pap smear
Mammography .

23- 35 yo woman in office co of back pain after weekend vigorous athletic activity.

Order complete PE>>>sym, decrease ROM on lumbar spine planes as flextime, extension,
lateral bending, rotation, straight leg test is N,

DD, Muscke sprain, herniated disc, cuada equina, spinal stenosis, ankylosing spondiolitis.

Order
ESR
All are negative
X
ray
on
limbo
sacral
spin,

Oral Endomethacine (NSAIDs)

Pantobrazole,
Baclofen, muscle relaxant
24- 50 yo woman comes in office co of numbness of fingers after work as typist for
many hours, also she noticed weakness in hand.

Order complete PE exam >>> thenar eminence muscle atrophy.

Order
EMG, median nerve compression at wrist
TSH,
Lipid profile.
Fasting blood glucose
Mammography
Colonoscopy
Order
Splint at night
Decrease repetitive motion
physical therapy at wrist
If methods fails surgical release.
Consult surgeon.

25- 42 yo man come to the office co of joint pain for 5 month duration, associated with lower
back stiffness. Recent onset of left ankle join pain with several small joint that also become stiff
in morning for more than 2 hrs. PH psoriasis for 3 yrs.

Complete PE >>> well demarcated scaly skin rash on elbow knew, small punctuate lesion on
nail bed. Left ankle swollen painful. Tender sacroiliac spines.
Order
CBC,
LFT,
Bmp,
U/a
Ibuprofen,
MXT
Folenic acid
X ray of ankle and limbo sacral spine
ESR,
Pantobrazole,

26- 50 yo woman in office co of sand in her eyes, dry mouth, chronic bronchitis with Ms
pain.

Complete PE>>>> dry oral mucosa, enlarged parotid.

Order
CBC,
Bmp,
Schimer test>>> decrease lacrimal tears, ( wet area <5 mm, after > 5 min)
Ophthalmic consult>> rose Bengal dye slit lamb exam
Anti-Ro/anti/La>>>
Order
Artificial tears
Hydroxy urea
oral bilocarpin

26- 60 yo man in you office co of increase LFT knee pain that was chronic from 6 month
ago, and he recently notice pain in DIP of second and third finger of right hand too.

Order complete PE>>> no swelling, redness of knew or DIP, there is crepitation but no
tenderness.

Order
CBC,
Bmp,
Lipid profile
Fobt,
ESR,
Rheu factor
ANA
Plain X-ray of hand>>> loss of joint space, osteophytes

Order

All are negative except

Acetaminophen oral if not improve give

Oral NSAIDs if not improve pain order
Oral tramadol, if not improve order
Oral Ketorolac
Schedule colonoscopy after 4 wks
Vaccinate influenza
Vaccinate pneomcocal

27- 30 yo African American woman comes to office co of swollen hands for two mons,
with bluish red discoloration finger tips on exposed to cold.

Order complete PE>>> Raynaud phenomenon, thickened skin on hand and face with shiny
forehead.

Order
CBC,
Bmp
TSH
X-ray of hands
ESR
Anti topoisomerase test,,,

All are negative except

Anti centromere antibodies,,,

U/a
Order
Nifedipine,...
Enalapril,.....

28- 30 yo woman comes to office with intermittent joint pain, discrete swelling of the
joint recently of wrist, MCP, PIP. Mourning stiffness last more than 1 hr., intermittent
fever, wt loss.

Order complete PE>>> N

Order
CBC>>> pancytopenia
Bmp
U/a>> proteinuria
ESR>>
IgM antibodies of parvovirus
HBsAg
HCV
Lyme titer
ANA

Rheu Factor
X ray of hand
PPD
CXR >>>N
Lipid profile>>> SLE increase CV risk

Order
24 hrs Urine Protein measurement
Anti-dsDNA antibodies

Rheumatology consult reason ( 30 yo male with SLE for renal biopsy)

Order
Prednisone oral
Consider azathioprine and cyclophosphamide if refractory
Vit D
Calcium oral
Pap smear
Council, avoid sun, use Sun screen.
Respiratory
29- 39 YO man comes to your office for routine screening for new job. He is a
symptomatic. PH is HIV positive, PPD skin test ( CD4 < 550). He come for reading of PPD
test that was placed by nurse to him from 2 days ago.
Order complete PE>>> all N but PPD < 5 mm.>>> Latent TB.
Order
CBC, stat
Bmp, stat
CXR,
Sputum culture and gram stain, AFS
LFT, stat
Order
IZH + pyridoxine B6 oral.

All are negative except

30- 39 yo homeless man in your office co of productive cough for several months, fever
39.5, chilles, wt loss. Non smoker. PH was admitted with pneumonia for the past 4
month.
Order
complete PE>>> Vitally stable, fever 39, bitemporal wasting, poor dentation, 2cm cervical LN.
Order
Oxygen
Pulse oxy
Order
CBC,
CXR, >>>cavitation lesion in right upper lobe.>>> 1ry TB
U/a
Sputum gram stain, culture, AFS, >>>>TB
LFT,
Order
INH+ pyrazinamide+ ethambutol+ rifampin for 2 month
Reschedule after 2 wks order uric acid, LFT, examin your patient for neuropathy, do
ophthalmology exam on eye.
After 2 month stop Pyrazinamid & ethambutol. And continue INH + rifampin for 7 mons

31- 43 yo woman with persistent productive cough for the past 2 year with greenish
yellow sputum. Ph of bronchitis, on multiple antibiotic. Twice pneumonias in childhood.
Order complete PE>>> scattered rhonichi, bibasilar coarse crackles.
Order
CBC,
Bmp,
Sputum culture, gram stain, AFS.>>> non specific
CXR.>>> crowding bronchi ( tram trach)>>>> broncheictasis
Chest CT scan>>>> dilated medium and small bronchi though out the lung.
Order
Sweat Cl test>>N
Ciliary motion test>>N
All are negative
Serum Ig>>> specific IgG4 deficiency
Skin test for aspergillosis
Order
Monthly Ig therapy
Postural drainage exercise
Ampicillin or TMB/SMZ
B2 agonist albuterol MdI
32- 65 yo white man comes to office for SOB on exertion for several months. He co of
dry cough, he never smoke, no pets, no travel history,
Order complete PE >>> overweight augmented P2 Velcro rales at lung base bilateral,
clubbing.
Order
CBC,
Bmp,
CXR>> bibasilar interstitial infiltration with peripheral honey combing.
EKG,
Echo
Lipid profile, as screen
FBS, screen
Pulmonary function test>>> increase FEV1/FVC ratio, decrease DLco.>> restrictive
Order
Tracheobroncheal biopsy >>> fibrosis >>> diagnosis is Idiopatic Pulm fibrosis
Order
To confirm Diagnosis of IPF it is recommended to do
Corticosteroids, oral
open lung biopsy, bronchoscopic biopsy help to exclude
Vit D
other cause but not to confirm the diagnosis of IPF.
Calcium
Pantobrazole
Consider cyclophosphamide and azathioprine if refractory cases.
Vaccine influenza and pneumococcal,
Couple avoid smoke, alcohol. Exercise regularly.
33- 66 yo retired constructor worker comes to yr office co of SOB for the past 5 mons.
Associated with dry cough started from one month ago. He is walking 2 mile daily for many
years, recelty unable to walk for three blocks. He is smoker, 2 packs from 20 yrs. he quite 3
months ago.

Order complete PE >>> bibasilar coarse crackles, clubbing.

Order
CBC,
Bmp,
ABG,
CXR>> honey combing, pleural Plaques.. >>asbestosis
EKG,
Echo
Pulmonary function test>>> TLC, RV, DLco
Trans bronchial biopsy >>> fibrosis, asbestosis fiber.
Order
Annual chest radiography

All are negative except

32- 25 yo woman comes to office with productive cough on and off for one year.
Dyspnea on exertion, has lost 5 pounds, has occasional low grade fever. She has
intermittent pain in the shoulder and knees, worsen vision in last 2 weeks.
Order complete PE>>> mobile enlarged cervical LN, bilateral dry crackles, knee pain on
motion, painful red nodule on LL.
Order
CBC
Bmp,
EKG
Sputum culture and gram stain, AFS,
PPD
U/a
Blood culture
Urine culture
CXR>>> bilateral hilar LN === mostly will be sarcoidosis
Order
Cervical LN biopsy >>> non case aspiring granualoma.
Order>>> Oral steroid, vit D, calcium oral, pantoprazol, DEXA baseline,
34- 65 yo white man come to office with worsening Dypnea on exertion, recently was
treated for acute bronchitis with fever and productive cough, lost weight over last year.
Smoke one pack a day for 50 yrs.
Order complete PE>>thin, use accessory ms, tripod position. Scattered rhonchi, hyper
resonance chest, barrel shaped chest.
Order
CBC
Bmp
CXR>>>hyperinflation
Sputum culture and gram stain, AFS.
EKG
Echo
ABG>>>. pH < 7.42/40/74/94% in room air. Respiratory alkalosis
Pulmonary function test>>> FEV1, FEV1/FVC, FEF25-75%, DLco.
Order

 Oxygenation
Tiotropium
Antibiotic ( azithromycin)
Oral steroids,
Vit D, oral calcium
Mechanical ventilation if the PH < 7.2.
Order
Smoke cessation
Home oxygenation 24 hrs if the PaO2 < 55, or O2 sat 88%. Or PaO2 55-59, sat < 89 with
Pulm HTN, CHF, or Hct > 56 secondary erythrocytosis.
Tiotropium MDI is first line ttt of emphysema or COPD.
35- 28 yo woman comes to your office co of intermittent cough. She start running
several times a week, cough worsen after return from running.
Order complete PE>> N
Order
Pulm function test>>> Normal completely
Methacholine challenging test>> FEV1 drop to 48 of the predicted
Order
Inhaled Albuterol before exercise
Cromlyn is alternative
35- 72 yo immigrant comes to ER with persistent dry cough for I month, right sided
chest pain, Dypnea with exertion.lost wt, smoke 2 packs of cigarette per day for past 50
yrs. vitally stable.
Order complete PE >> tachycardia, decease breath sound on the right side from the base,
dull on percussion, no wheezes.
Order
Pulse oxy
Oxygen therapy
EKG
ABG>>> 7.48/30/65.
Order
CBC
Bmp
CXR>>> right large pleural effusion, right hilar mass
Order
Thoracoscentesis
Pleural fluid (LDH, Prtn, Glucose, AFS, cells count, culture, cytology).
Serum Protien
Serum LDH,
Serum Glucose
Lipid profile
Order
Admit to the hospital

 Chest tube with pleurodesis.>>> malignant cells in pleural effusion >> end stage
unrest table lung cancer
Chemo radiotherapy is ttt of choice
Oncology consult

Oncology
36- 40 yo man comes to your office co of persistent sore throat for the past 2 wks. He
completed 1 wk course of ampicillin without a change in symptoms, progressive malaise over
the past 2 wks, fever, to 38.9. Night sweat and easily bruising.
DD, AML, ALL,Leukemiod leukemia.
Order complete physical exam>> temp 38.9, palatal petechia, , tachycardia, petechia on ankle
Order
CBC>>> HB 7, platelet 20.000
PT, PTT,
Fibrinogen
DFP,
D-dimer
Bmp,
CXR,
Blood culture
U/a
Urine culture
37- 45 yo woman broguht to ED with altered mental status and hemiparesis of right side.
She was well until 2 wks earlier when she developed intermittent fever and sore throat.
She has suffered from several nosebleeds and gum bleed over the last week.
Order focused PE >> lethargic, confused, not moving right side, temp 38.3, BP 160/100,
withdraws her limbs to painful stimuli.
Order
Pulse oxy
Oxyg
Elevation of head
Suction airways
Iv access
NSS
Thiamine
Naloxone
Glucose IV
Order
CBC>>> 1500, Platlet 22000, Hb 7.>> .pancytopenia
Peripheral smear>> auer rod, immature myeloid cells.
PT/PTT >> high
BMP >>> N
TSH>> N
Vit B12>> N
LFT>> N
Head CT >> left intraparenchymal hemorrhage in parietal cells.>> hemorrhagic stroke
Fibrinogen >> N to exclude DIC that associated with M3.

 FDP >> N
Order
Platlet transfusion
Cytosine arabinosine ( ARA-C) and daunorobicin or idarubicin.
Allttrans-Retinoic acid (ATRA) only for M3 ( if there was associated DIC).
BMT for refracotry cases.
38- 22 yo man to clinic coz persistent sore for the past 2 wks. He recently completed
course of ampicillin without a change in symptomes, he note progressive malaise over
2 wks, fever 38.9, night sweats, easy brushing.
Order complete PE >> platal petechia, no LN, tachycardia.temp 38.3
Order
CBC>> WBCs 105.000, Hb 7.5, Platlet 20.000.
Peripheral smear >> blast cells.
BMP >>
Blood culture
U-a >> n
Urine culture >> N
Bone marrow aspirate: megakaryocyte, blast cells.
Order
Cell markers>>> CD 10, myeloperoxidase negative, terminal deoxynucleotidyle transferase
positive.
Cytogenetics>> N 46 xy
LP>> No for malignancy
Order>>>> acute lymphocytic leukemia
Vincristine/prednisone
Allopurinol + hydration.
Monitoring electrolyte for Tumor lysis syndrome
Intrathecal MXT prophylaxis CNS.

Gastroenterology

42- 48 yo woman in ER co of fever abd pain and distention. Last several mons, she
developed ascities, anorexia, progressive wasting, sever itching. PH drug abuser,
alcohol intoxication.
Focused PE>>> temp 38, poor dentation, enlarged parotid, scleral icterus. Abd, distended,
tympanic, tender, with shifting dullness. Palpable spleen, palmar erythema, spider angioma.
So diagnosis is alcoholic hepatitis>> fever + HS megaly + hi transaminases
Order
Pulse oxy
IV access

 IV ibuprofen
Order
CBC,
Bmp,
Any celiac dis or PBC
LFT>>> elevated transaminases
don't forget to add
Total protein>>>N
Vitamins A,D,K,E to
Albumin>>>2.8
treatment retiming.
PT, PTT>>> prolonged
Consult dietary. Celiac
GGT >>> high in alchoholic clever disease
use soya bean,rice,
Hepatitis C antibodies
potato. Add iron to celiac
HBsAg test
Disease.
HBsC antibodies
Order
paracentesis >>> WBC 50 >>> you exclude spontaneous
bacterial peritonitis
Abd USG>>>nodular fatty liver
Ceruloplasmin
Ferritin>>> N
Alpha-1 antitrypsin >>>
Antimitochondrial antibodies>> N to exclude PRIMARY BILIARY CIRRHOSIS
Schedule UGD to check esophygeal varices.
Order
Salt restriction
Diet enriched branched aa chain to avoid hepatic encephalopathy
Frusemide and spironolactone
Counsel against alcoholic ingestion
If UGD shows eosoph varices so give Proparnolol to decrease portal hypertension.
43- 72 yo man in ER vomiting blood. History of ethanol abuse, previous two UGI
bleeding in the past. He was drinking bing earlier today.
Focused PE>> BP 80 palpation, HR 125, stupor, reeks of alcohol, scleral icterus,
Gynecomastia, spider angioma,splenomegaly, non tender abdomen.
Order
Pulse oxy
Oxygen therapy
IV access
IV NSs
NG tube for gastric lavage>>> blood clots and coffee ground emesis
IV thiamine
Acue check..>> if hypoglycemia give glucose 50 % IV
Order
CBC>>> platelet 80,000 alcohol causes thrombocytopenia , HB 10
Bmp,
PT, PTT>>>
Fibrinogen >> N
LFT
Total protein
Total albumin

 Blood type and cross match

Repeat Hb and Hct every 4 hrs
Transfusion of packed RBCs becuase NG tube showed GI bleeding
FFP....coz coagulopathy
Order
Upper EGD >>> band ligation of eosoph. Varices
Admit to ICU
Bed rest
Pneumatic compression devise
NPO
IV Octeotides is mainstay ttt
Proparnolol, once BP stabilize
Omiprazole
Norfloxacin as prophylaxis against SBP
Order interval history and PE to check bleeding and vital signs
If the bleeding is not controlled next step is TIPs and blakemore tube is rarely used as
pride to prepare to TIPs.
44- 52- man cone to ER with 2 mons history of epigastric pain. Wake him up from
sleep. Antacid relieves him. Occasional smoke takes aspirin for back pain.
Complete PE. >>>> mild epigastric pain
Order
Pulse oxy
IV access
IV Morphine
IV omiprazole
Order
CBC
Bmp
Lipid profile
Abdominal x ray erect
Abdominal USG
LFT
Amylase/ lipase
Order
Upper EGD>>> ulcer on duodenum
Biopsy for H.pylori and exclude cancer
CLO- urease test >>>
H. Pylori serum titre>>>
Order
Oral amoxicillin + omiprazole tiwce daily + Clarithromycin for 14 day
Reschedule after 10 wks to do fecal ag test ...
Fecal antigen test after stop ttt by 8 wks
Avoid NSAID, alcohol, smoke,
Vaccine infeluenza.
45- 65 yo man come to ER with upper Abd pain, coffee ground vomitus, Pain started 2
mons ago, worsening by food ( direct us to Gastric ulcer) no wt loss, occasional use of
NSAIDs for back pain, smoker for 29 yrs. vitally stable

Complete PE >>> mild epigastric tenderness, rectal exam

brown guaiac positive stool, no hemorrhoids.

All are negative except

Order
CBC
Bmp
Abdominal x ray
Abdominal USG
LFT
PT PTT
Amylase/lipase
Order
Upper EGD >>> gastric ulcer
Biopsy >> no cancer
CLO- urease test
Order
As previous case
46- 45 yo man was admitted 2 days ago for an acute upper GI bleed, he is alcoholic, on
admission found to have duodenal ulcer that responded to PPI, and has been on
thiamin. Nurse noticed he became confused this morning.
Order neurological exam, Abd, chest, heart, general.
Order
Pulse oxy
Oxy therapy
Order
Cbc,
Bmp,
LFT
PT, PTT
Acuecheck
Ammonia ( N < 65)
U/a
Urine culture
Blood culture
CXR
Order
Correct infections or GI bleed or electrolyte disturbance ( m.c.c of Ppt hepatic
encephalopathy) ( do not give benzodiazepines to ttt alcohol withdrawal in HE)
Airway
protection>> incubate if necessary

Lactulose oral ( acidified colonic content, trap ammonia to the lumen, and prevent
its absorption)
Neomycine oral or rifaximin & ampicillin>> kill urease producing colonic bacteria
Restrict prtn diet.
47-27 yo woman come to office co of 8 mons diarrhea, wt loss, purritic skin rash.

Order complete PE >>> abdominal mild distended hyperactive sounds, diffuse

papulovesicular rash over elbow, knees, buttocks, back.
Order
CBC, iron studies if CBC shows Iron Def anemia
Bmp
Stool ( microscopic exam, G. stain, Culture, ova, parasite and fecal WBCs)
Stool fat collection, trypsinogen
HIV Eliza>>
Anti endomycial, anti transglutaminases, antiglydine antibodies >>
D xylose absorption test.>>> abn low < 5 g in 5 hrs.
Order
Lower endoscopy to take small Bowel biopsy ( to conrm diagnosis) >>>total villus
atrophy
Order
Gluten free diet
Eat rice, soya beans, potato, corn.
Ferrous Iron, oral, replace fat soluble vitamins by supplements of multivitamines
Folate, oral
48- 55 yo man in your office, co of progressive dysphasia over 3 months. Start by solid
food then became difficult to swallow fluids also. Smoke pack of cigarette per day.
Social drinker.
Complete PE >>> cachectic, rectal positive for blood in stool.
Order
CBC
Bmp, FOBT
Barium swallow>>

Circumferential mass in mideosophygus.

Send patient to
Emergency room

Order
PT PTT
Consent
Upper endoscope and biopsy >> SCC
Endoscopic Ultrasound >> to check the stage of invasion the esophageal wall >>
invade the wall.
Chest CT>>>
PET Scan for DM

Abdominal CT>>
Order
Surgical resection
RT + neoadjuvant chemo.

Consult Oncology
& General surgery

counsel cancer diagnosis

49- 78 yo African American woman in office co of progressive left lower abd pain for
past 24 hrs with low grade fever. She had the similar episode from 3 months ago.
Resolved spontaneous.
Order complete PE >>> temp 38.5, mild rebound tenderness on left lower quadrant.
Order

 CBC
Before any surgery:
Bmp,
Blood
culture

1-Cephazoline
CXR
2-Blood type &
U/a
3- Cross match
Urine culure
4- PT/PTT.
Abdominal X-ray >> N
5- Foly's catheter &
Abdominal CT>>> inflamed sigmoid colon, no masses.
Order
UOP.
Admit to hospital ( mild cases can be treated outpatient)
6- NPO.
NPO
7- DM: D/c Oral HG
IV access
& Start Insulin
IV NSS
infusion. Acue
Ciprofloxacin + metronidazole or pipracilline/Tazobactam
IV
Omiprazole

check /1hr
IV Morphine
IV acetaminofin
advance timer or do interval Hx & PE >> If improvment>>> send home>> Reschedule
after 4 wks for colonoscopy to diagnose diverticulosis & exclude cancer
If no improvement >> G. surgery consult for surgical exploration for abscess
drainage. If CT scan showed mass or abcess from the begining >> call of surgery first
50- 17 yo woman in office co of bright red blood per rectum and loose stool in past 2
wks. Associated with rectal bleeding 6 soft stool per day and lower Abd discomfort.
Order complete PE>> tender left lower quadrant, bright red blood in rectal ampulla.
Order
CBC>>> leucocytosis
Bmp
All are negative except
PT, PTT
Abdominal x ray
Abdominal USG
Stool culture, G stain, cytology, ova, parasite, WBCs>> leucocye in stool
Order
Unprepared flexible sigmoidoscopy >> petechia Enders hypermedia >> invasive
infectious enterocolitis on Biopsy>> Campylobacter jejuni Infection. Order
Azithromycine or ciprofloxacine.
51- 58 yo man is brought to ER co of painless blood per rectum. He noticed maroon
blood in stool yesterday. BP 120/80 on HR 80 but on standing BP 104/70 HR 105.
Complete PE. >>> tachycardia, rectal shows clotted blood but no masses or hemorrhoid
Order
IV access
Pulse oxy
NSS
BP monitoring
Cardiac monitoring
Foly's catheter,
NG tube >> for nasogastric lavage and to localize 90% of upper source if GI bleeding> no
blood, only bile.

Order
CBC,
Bmp, blood typing & cross matching
Transfused packed RBCS
PT, PTT
LFT
Flexible sigmoidoscopy >> if did not determined the source of the bleeding So next
step do colonoscopy, if the bleeding continue >>sulfur colloid bleeding scan if slow
rate bleeding ( 0.1ml/min) or angiography if fast rate bleeding ( 1ml/min) angiography
can be used in treatment by infusing Intra-arterial embolization or vasospastic agents
( vasopressin ). If the patient continue to bleed consult surgeon and do bowel
resection >>> colonoscopy was done and showed diverticulosis
Anoyscopy
H & H Q 2 hrs
Order
Transfer to ICU>> IVF , Omiprazole
Monitor further any sign of bleeding by ordering Vital /1 hr & UOP+ H & H/ 2hrs
In older pts or patients with CAD keep Hct > 30
High fiber diet
Multivitamins
Ferrous iron oral on discharger.
52-52 yo man co of diarrhea for a year. Several bowel movement. Recurrent
PUD. Despite the treatment of H.pylori.
Order complete PE >> thin, mild epigastric tenderness, no masses. Stool is yellowish brown
and guaic negative.
Order
CBC>> No megaloplastic anemia (X pernicious an)
Bmp> Normal calcium >X malabsorption causes
Stool(WBCs,ova,parasite,G. stain, 72hr fat culture).
Upper EGD, >> large mucosal folds.
Order
24 hr gastric pH >>> .
Serum Gastrin level

Chronic diahrreah
1. IBS
2. IBD
3. Malabsorption: sprue, bact.
Overgrowth & Celiec dis.
4. Chronic pancreatitis (72 hr
Fecal Fat).
5. Lactose intolerance
6. Pernicious anemia
7. Laxative abuse
8. Hypothyroid hyperparathyroid
9. Zollinger Ellison Syn
( gastrinoma)
10. Carcinoid

Secretin test >>>, Not suppressing gastrin

PTH >>>N
TSH>>
Order
Omiprazole
Abdominal CT to localize tumor
Somatostatin receptor scintigraphy
Endoscopic ultrasounds
Surgery consult reason: Pt with zollinger Ellison Syn for resection of the tumor.

53- 40 yo woman come to the office with history of progressive dysphasia to solid,
liquid, wt loss of 15 pounds. Food Regurgitation after meal.
Order complete PE>>> chronic ill, thin.
Order
CBC
Bmp
FOBT
ESR
Esophageal barium swallow>>> bird beak sign
Order
Esophageal manometry >>>confirm Achalesia pattern
Esophageal endoscopy and biopsy >>> no malignancy
Order >>> pneumatic dilatation of LES or Heller myotomy

Cardiology
54- 68 yo man come to ER co of one hour history of sever dull substernal chest pain
while moving furniture in his home, no radiation, there is SOB, but not diaphoretic. FH
father died from Heart trouble.
Order focused PE>>> vital stable, tachycardia, otherwise is normal.
Order
Pulse oxy >>>99% + Oxygen therapy
EKG>>> 2mm ST seg elevation in V2 V4
IV morphing
Aspirin
Metoprolol IV
NG SL
Lisinopril for all AMI

start ACE inhibitors

then stop after 6 wks for
normal EF...Continue
for dysfunctional lV with
low EF.

Order
CK-MB level every 2 hours >>> elevated >>> so diagnosis is ACUTE MI
admit to ICU
NPO
Bed rest
Pneumatic compression devise
clopidogril
IV Bivalorudin for 48 hrs better than Unfracnated Heparin
IV ebtifibatide IIb/IIIa Inhibitors
Consult cardiology>>> cardiac angiography after move the pateint to ICU>> RCA Stenosis
Cardiac angioplasty if <90 min but thrombolytics ( tPa or streptokinase) if >90 and <12
hours. if the angiography showed three vessels stenosis > 60% >> then order CABG.
Post PCI>>> Clopidogril for 4 wks and aspirin for year
For unstable MI you can use IntraAortic ballon until patient arrive to Cath lab if
you refer him to another hospital with available cath.lab. or give 1 dose of thrombolysis
then transfere him to closest facility with Cardiac Cath Lab.

55- 68 yo man admitted though ER to ICU for chest pain and EKG consistent with acute
inferior wall MI, resolved chest pain, and stable patient, nurse called you coz sudden
drop of HR and BP without any chest pain and the patient started to be confused.
Order focused PE>>> BP 70/50, pulse 40/min, cannon a wave, in confused patient.
Order
EKG >>> complete Heart Block
IV Atropine I mg
IV fluid
IV dopamine
transcutaneous Pacemaker
NB! All above labs should be ordered once in unstable patient
56- 72 yo man comes to ER co of chest pain < 1 hr with diaphoresis no radiation.
history of arrhythmia but not taking any meds. Similar episode in the past.
Order focused PE>> BP 80/60, pulse 180, RR 24, JV distention, breath sounds decrease
on the base, distant heart sounds.
Order
Pulse oxy
Oxygen
EKG>>> ventricular tachycardia
Cardiac monitoring
BP monitoring
NSS,
IV access
Order
DC cardioversion ( synchronized cardioversion, 100J, 200J, 360 J, 360 J).if persist
Amiodarone followed by lidocaine.
ABG
Bmp
CBC
Cardiology consult
Echocardiogram
For stable patients >> Amiodarone, 2nd is Lidocaine, 3rd is iptifibatide or Amiodarone
Treatment of underlying cause.
57- 65 yo man recently discharged from hospital after ttt for acute MI, he is brought to
ER coz of palpitation, while you examine him, he became unresponsive, and lose his
pulse.
Order
EKG>>> vent fibrillation
PULSE OXY
IV access
OXY Therapy
Cardiac monitoring
BP montoring

 ABG
Order. ( asyncronized cardioversion)
CPR (30/2 x 5 cycles) until defibrillator arrive
Defibrillation at 360 J continue CPR >>>360J + vasopressin 1mg >> 360 J + Epi
1mg>>360 J.
Intubation
Amiodarone or lidocaine ( in MCQ if both are given in choices choose Amiodarone)
Bicarbonate
58- 62 yo man with HTN, come to ER, with pressure like retrosternal chest pain, radiate
to neck, and left arm after claiming stair only two floors. He is on atenolol, carries SL
NG for occasional episodes he took NG with pain attack with subsequent relieving,
Order complete PE >> vitally stable, S4 HRT sound.
Order
EKG, >>> Normal >>> so no need for STESS EKG and no need for serial CK-MB.
Order
Admission to ward
Telemetry
Serial cardiac enzymes Q 8 hrs
Ambulate at well
Oral Propranolo,
Oral NG
Oral aspirin
CBC
Bmp
ECho
Lipid profile
Atorvastatin oral irrespective to lipid profile result
If there is a history of worsening Physical Function or more frequency of pain, >>
proceed for cardiac angiography >>> to determine if he needs CABG or not
If patient improved send patient home.
Order
Atenolol, NG, aspirin,
Statin oral.
Schedule for cardiac catheterization after 2 wks
59- 58 yo man with DM, HTN, is refered to you by vascular surgeon for clearance before
his femrolpopliteal bypass graft. He denies chest pain, non smoker, No FH of CAD.
Initial EkG was okay. You decided to do stress EKG which shows reversible inferior wall
Ischemia, surgeon was conserved because his LDL is 202.
Order complete PE>>> arcus senilis, lower legs are smooth and shiny
Order
Fasting Lipid profile>>> total cholesterol 212, LDL 138, TG 125, HDL 52.
Bmp
CBC

 TSH
LFT
Order
Statin forward the clock 6 month then reschadule your patient to check the lipid profile, Serum CK, LFT.
Life style modification
Stop the smoking if he smoke, priscribe nicotin patches for few months if not swich to
Exercise
Low
fat
diet
Buprobion or varinicline (CI in cardiovascular disease or depression)

60 - 68 yo woman is brought to ER by ambulance coz of SOB, PH of several MI, on

diuretics, digoxin, captopril, over the last days she became more dyspneic.
Order focused PE> vitally stable, edematous, JV distention, bilateral rales, tachypnia,
tachycardia, 3/6 systolic murmur, S3. Bilateral LL edema.
Order
Pulse oxy
Oxygen therapy Continous
Cardiac montoring
BP monitoring
NG SL, Continous
IV Morphine
EKG=== sinus tachy, Q wave in V2-V4
ABG===7.42/34/72.>> respiratory alkalosis
CXR===bilateral pleural effusion, kerley B lines, cardiomegaly >> pulmonary edema
Order
CK-MB Q 8 hrs >>>N
Echo >>> 30% EF
Brain natriuretic peptide >> high >>> acute HF lead to pulmonary edema
Order
Admit to ICU
Semi setting position ( upright position)
Bed rest
Pneumatic compression devise
NPO
swan-Ganz cath, to proper reading of intravascular volumes and pressure
IV frusemide Q 20 min
IV NG
IV Morphine
IV dobutamine >>> positive intotropic drug
IV Enalaprilat, after load reduction to allow increase SV or nitroprusside.
With EF < 30 %>>> IV spironolactone inhibit RA system and aldosterone water
retention effect.
Nesiritide>> synthetic atrial naturities peptide if not respond to above ttt.
After stabilization add digoxin oral, propranolol, Oral.
61- 47 yo man come to ER co of several hours of Dypnea, blurring of vision, difficulty
thinking, headache dizziness, mild palpitation. PH, HTN on thiazides,
Order focused PE >>> BP 230/150, eye exam arterial narrowing and AV nicking, S4. So
this is HTN emergency you should search for End organ damage to exclude HTN
Urgency.

Order
Pulse oxy
Oxygen therapy
EKG>> LVH ( S in V1 + R in V5 = 35 mm) and ST seg depression Hypertrophic
cardiomyopathy.
Cardiac monitoring
BP Monitoring
Bmp
U/a
Lipid profile
TSH
Order
Transfer patient to ICU
NPO
Bed rest
Pneumatic compression devise
Arterial line
IV Nitroprusside (Target to decrease diastole <95 ( or less 25% of the presented BP)
Interval history and monitoring vitals >> advance the clock to get BP
You can not give nitroprusside in ER, it has to be in ICU under Arterial line monitoring
Afte controlled >> ward & Dc arterial line and IV drugs to oral.
Oral thiazides, or atenolol, or ACE inhibitor according to your case.
62- 58 yo man comes to ER co of swelling of his LL, Exertional SOB, acutely
distressed. Drinks 2 bottles of pears every day.
Order focused PE >> BP 95/60, HR 110, lateral displaced maximum impulse, 2/6 systolic
radiate to axilla, bilateral bitting edema. H
Order
Pulse oxy
Oxygen therapy
EKG=== tachy, vent ectopy, decrease voltage and non specific T waves, and st seg
changes.
Cardiac montoring
BP monitoring
CXR >>> cardiomegaly full chambers, Kelly's lines on lung
Echo>> dilated all chamber insufficiency of MV, PV, TV. EF < 25%
Order
Ace inhibitor ( Enalapril)
Carvedolol
Frusemide
Digoxin
Spironolactone
LMWH (Dabigatran)for 24 hrs then start warfarin oral
Counsel stop alcohol
Diagnosis is alcoholic dilated cardiomyopathy
63- 36 yo come to office co of progressive Dypnea, coughing to blood daily,
palpitations.

Order complete PE >> vitally stable, JV distention, a wave, bibasilar rales, loud S1 and
snap after S2.
Order
CXR>> straight Left heart border,
EKG>>> biphasic P wave in V 1 ( large atrium)
Order >> Echo >> dilated left atrium and MS
Order cardiac catheterization >> valve size 1.3 cm outlet
( if < 1cm >>sever MS need
commissurotomy or
replacement )
Order
Salt restriction
Frusemide
Schedule follow up after 2 wks
If no improvement do balloon valvuloplasty.

Lower limb claudication is

very easy case, do Ankle
brachial index if < 1 so it is
diagnostic >> consult
vascular surgeon, order
cilostazol, physiotherapist
consult, aspirin also will help.

66- 59 yo Patient with h/o DM, HTN, CHF comes with complain of shortness of breath
and leg swelling.
Order focused PE>>> tachycardia, BP is low, JVP elevated, Diffuse or Basal crackles in
the lung field, lower extremity edema.
Order
O2 inhalation,
Pulse ox;
cardiac monitor;
IV access,
Order
CBC,
CHEM 8,
PT, PTT,
Cardiac enzymes every 8 hour,
Liver function test,
EKG 12 leads
Ttt (Nitroglycerine, sublingual and Aspirin can also be given here)
Chest x-ray portable;
Lasix IV, one time;
Morphine IV, one time bolus (Decreases anxiety and work of breathing, so will
decrease central sympathetic outflow and thus causes vasodilatation also);
Nitroglycerine, topical (Decreases preload). Note: If patient is hypertensive BP >150/90
can use IV Nitroglycerine, continuous; If hypotensive systolic BP <100 start Dopamine
IV continuous.
Move the clock to get report of most of the labs (LFT takes 2 hours, rest is available in
1 hour, so move clock for 1 hour).
Interval check
Order: vitals If stabilized,
order: Echocardiogram
Change location: Intensive care unit

Order
Fluid restriction, low salt diet,
monitor input/output,
lipid profile
Move the clock: Get Echocardiogram report
Move the clock for next day round at 9 AM
End of the case
Diagnosis: Acute decompensated heart failure.
Note: Management of acute decompensated heart failure of both systolic or diastolic
dysfunction is same. Statins can be added any time, after getting results of lipid
profile and liver function test. We dont add following drugs in an acutely
decompensated patient:
ACE inhibitor: once patient is stabilized, after 2 or 3 day,
repeat CHEM 8 and if renal function is stable, it can be added
Spironolactone: once patient is stabilized, can be added unless serum potassium >5.0
Beta blocker should be added prior to hospital discharge, or when patient comes back
to clinic for follow up.
67- 4 year old child with fever and rash for >5 days Vitals: febrile, rest are normal. HPI:
child is very irritable
Examine the child: Bilateral conjunctival injection, strawberry tongue, cervical
lymphadenopathy, maculopapular rash, erythema and swelling of hands and feet.
Order: IV line, CBC, BMP, LFT, Urine analysis, CRP, ESR, Blood culture, Urine culture,
CXR Note: Kawasaki is a clinical diagnosis, we dont have to wait for lab result
Order: stat of IV Immunoglobulins, Aspirin-oral-continuous,
order: Echocardiogram then Move the clock: Get all the report
Change location to Ward, if coronary artery aneurysm, call Pediatrics cardiology consult.

ENDOCRINOLOGY
67-28 yo man with IDDM, type 1, since age of 12 same dose of insulin ( 22NPH. 18
regular in AM) ( 18 NPH , 8 regular PM) for the last 8 months. He started new exercise
program wk ago. He noticed hypoglycemia s&s ( headache, diaphoresis, palpitation)
Glucose Diary: am ( 104,98,103) noon (85,92,91) Pm (62,40,35,37). Bedtime (88,82,89,93).
Order complete PE >> hypoglycemia is < 60
Order
CBC
Bmp>>>k 6 ( +++) , Na 130 ( low), BUN 60 ( +++), glucose 580...and no Renal failure
Hb A1c
ESR
Serum acito acitic acid and B-hydroxybutirate (ketone bodies)
LFT
Order >> decrease insulin ( NPH am), continue exercise. Counsel diabetic diet.

68- 49 yo obsess female is brought to ER co of drawsiness, not eating much for last 4
days. Urinate every hr, thirst, no fever, chills, nausea or vomiting. HTN for 10 yrs.
impaired diabetic ttt only by diet.
Order focused PE>> confused, vitally stable with orthostasis.
Order
Pulse oxy
EKG
IV access
IV NS bolus
ACUECHECK>> 990
ORDER
CBC
Bmp>> Na(130), K(5.2), BUN 58,
glucose 990!
U/a>>>
ketosis no WBCs

Uncontrolled type 2 DM on glipizide, add metformin

+glitazone+ insulin and ask for home glucose
monitoring ==> then order Hb A1c next visit to
check and home FBG ( should be < 126). Do
ophthalmology consult, check u-a for albumin give
ACE inhibitor for microalbuminuria.

Toxicology screen >>

ABG>>> metabolic acidosis pattern
IV NS continous
IV regular insulin >>>> acue check / hr>> Diagnosis is Hyperosmolar hyperglycemia

69- 30 yo man comes to office for evaluation of hypercalcemia. PH significant for

several episode or renal stone for 3 yrs. PE unremarkable
Order
Total serum ca >>> 11.3 >>> keep in your mind Indications for parathyroidectomy. And
also history of kidney stones is indicate this patient for resection.
Ionized ca
Total protein
Serum albumin.>>> normal coz it will affect level of total and isonised ca false reading
Immunoassay of PTH >> high
Mg
Serum level of 1,25 (OH)D, 25(OH)D
Phosphorus
CXR >> exclude sarcoidosis
Bmp
Order
Endocrinology consult
MRI of the neck to localize the PT adenoma or sestamimi scan
Surgery consult>> for parathyroidectomy after surgery check Ionized Ca/2hrs> IV Ca
gluconate if low.
70 -33 yo woman come to your office for evaluation of several hours of sever headache,
flushing, palpitation. She recall several similar episodes in the past. PH migraine.
Order complete PE: she is diaphoretic, anxious, BP 195/110. ( might be normal BP).
Tachycardia.
Order
Phenoxybenzamine for here HTN first
24 hr urine collection for catecholamine >> high

Plasma free metanephrines>>> high

Meta iodobenzaylguanidine scan (MIGA Scan)>>> no distal metastasis
Abd CT scan >>> left adrenal mass
Send patient home then schedule her visit after result come back
RET Oncogene >>> to exclude the association with MEN 2.

Order
Phentolamine or phenoxybenzamine for 2 wks before surgery ( avoid BB initially)
after stabilizing her BP you can add BB. Phentolamine IV >> if Pt present in Emergency room
Admit patient to ward
Ambulated at well
IV access, NPO, BMP, CBC, u/a,
Echo to assess for catecholamine cardiomyopathy.
PT, PTT, blood type and cross match, IV NS, IV cephazolin.
Consult surgery
Consult endocrinology
Advance the clock to get the procedure done.
71- 56 yo man in office co of one yr history of generalized headache, joint and muscle
aches, Skull enlargement, weight gain and coarsening and enlargement of facial feature.
He recently develope diabetes,no visual impairment.
Order complete PE>> normotensive, prognathism and macroglosia of face. S3.
Order
Measure serum insulting like Growth factor>> high
Give oral glucose 75 g and measure GH-2 hrs later. >>> high GH
MRI of brain>>> pituitary adenoma
Admit patient to ward
Consult surgery>> order tras-sphenoidal pitutary resection
Somatostatin analogue ( octreotide) oral >>> decrease size of the Tumors Preoperative
or if the surgery failed, or unfit patient for surgery.
Cabergolin for high prolactin.
72- 32 yo man comes to your office for routine physical exam. No significant medical
history or complaint. He excercise regularly. FH is significant for NIDDM type -2.
Order according to his age and FH
Fast lipid profile>>> LDL172, HDL52, TG 126.
Fast glucose test>>> 102.
Order
- LFT, CPK, TSH before prescribing statins
- Simivastatin
- Counsel life style modification> exercise program, no smokeing, limit alcohol.
- Low fat diet, balanced diet.
- Reschadule after 3 wks >> check CPK, LFT.

NEUROLOGY

70- 57 yo man come to ED coz increasing confusion, blurring vision, nausea, and
unsteady gait. Ex-Alcoholic, was on phenobarbital program. PH of seizures, repeated
head truma from intoxication. Only on phenytoin.
Order complete PE: obese, slurred speach. Both horizontal and vertical nystagmus are
present. Wide base unsteady wide based gait, daysmetric finger to Jose test.
Dysarthria on speach.
Order
Causes of horizontal
CBC
nystagmus:
Bmp
labyrinthitis, Menire
U/a
disease,cerebellar stroke,
Alcohol level
vasculitis of vestibular nerve.
Phenytoin level>>> high toxicity
Drug
toxicology
screen

Brain CT
TSH
Causes of vertical
SYPHYLIS
nystagmus:
Erythrocytes thiamine transketolase (ETKA) if >25% if
Meningitis,
diagnostic for thiamine deficiency.
Order
Hold phenytoin

barbiturate, alcohol,
phenytoin.

71- 55 yo woman with chronic back pain and History of breast cancer comes to office
becuase of worsening back pain. The pain recently begun to radiate around her body
like a tight belt. She take ibuprofen and acetaminophen.
Order PE>> spinal tenderness over the lower thoracic spine and poor effort on motor
examination due to pain. Tone in lower extremities is increased, there is sensory and
plantar response are extensor bilaterally.
Order
CBC
Bmp
Spinal MRI
CXR >> mass in right lung
Spinal x ray >> destruction of vertebral body at T10
Pelvic CT
Chest CT
Pet scan
Order
Steroid
Radiation therapy to spine
Morphine for pain.
ttt each cancer based on his type, add chemotherapy on lymphoma for example.
73- 54 yo man has noticed a drooping of his eyelids, double version later in day, difficult
finishing dinner coz of fatigue.

Order complete PE>> immobile mouth is turned down at the conrners. When smiling his
mouth resembles more of a snarl. There is marked weakness of elevator palpebrae and
eye closure.
Order
CBC
Bmp
Antiacetyle choline antibodies
Tension test >>
EMG>>> rapid reduction of amplitude of ms action after repeatitive movement, reverse
after edrophonium injection.
CXR
TSH
CPK
Order
Pyridostigmine, neostigmine
Steroids
Thymectomy
Azathioprine, cyclosporine
Plasmapheresis in refractory cases.
74- 65 yo man developes leg pain after walking 4 blocks. The pain started on left leg
then spread to right leg, numbness and tingling increase as he walks. PH mild lower
back pain, intact bowel and bladder function.
Order complete PE >> reflexes are absent on recumbent position, but reflexed regain on
stoop forward position. Mild decrease in vibration sens below the knee. Peripheral uses
are normal.
Order
API >>>. More than 1
MRI of spin >> hypertrophic of ligamenum flavum, osteaophytic overgrowth, spire
formation and narrowed lumber canal.
CT Mylography if patient cannot have MRI due to pacemaker.
Order
Rest
NSAIDs
Surgical decompression with laminectomy if symptomes did not resolve.
75- 54 yo African American with history of BP non insulting DM, hypercholesterolemia is
brought to ER because of hand weakness and grabled speach, onset sudden from 24
hrs. Tow wks earlier has lost vision in left eye with resolve after few hours.
Order focused PE >> frequent errors while speaking fluently, right visual defect, wide
palpebral fissure, flat nasolabial fold on right, brisk reflexes on right, babiniski sign in
right.
Order
Pulse oxy
Oxygen
EKG >> normal

 Cardiac montoring
Elevation of head
Mouth suction
Order
Brain CT without contrast >> negative >>> repeat it after 3 hrs if do LP
Aspirin ( do not order aspirin after excluding SAH)
Carotid Doppler >>>
Echo
If EKG and echo Normal >> order 24 hr holster monitoring.
Order
If present < 3 hrs, persistent, disabling, deficit, no bleeding >> tissue plasminogen
activator.
If arrhythmia >> digoxinm, bb, diltiazem, if there is AF > 48 hrs give warfarin.
Control HTN, DM,
Counsel smoke cessation.
Clopidogril used if stroke occurs while on aspirin.
76- 30 yo woman come to OFFICE with history of dipecrease vision on right eye from 5
yrs ago. Also had elisodes of blurring of vision in her right eye, that usually fade
quickly. Last wk she had ascending numbness and tingling in her legs, followed by
difficulty of walking.
Order complete PE>> pale optic disc, with color desaturation in right eye. Left inter
nuclear ophthalmoplegia, spastic LL. sensory level T4. Brisk reflexes in LL, positive
babiniski bilaterally.
Order
CBC
Bmp
U/a
TSH
Lipid profile
MRI of the brain >> hyper intense lesions on T2 weighted images in peri ventricular
white matter.
MRI of spin with gadolinium >> hyper intense lesions at T4 level on T2 weighted image
that enhance gadolinium.
LP if MRI was inconvenient >>> for oligoclonal band.
Order
INFb 1-a or INF-1b.
Azathioprine for eye symotomes,
copolymer ( galtiramer acetate).
Back often for spasticity
Vit D and calcium
Vaccinate infeunza and pneumococcal ( avoid live vac)
77- 25 yo man who has developed ascending weakness in LL and parasthesias after
event episode of Gstroenteritis comes to the office.

ORDRR complete PE >> Flaccid paralysis of Ll, loss of ankle reflex, symetic weakness
of LL.

Order
LP >> hi Protien
ABG
BMP
Mean inspiration pressure
EMG/ nerve conduction velocity >>> delay F wave response.
Vital capacity
Order
Admission
Bed rest
Respiratory support up to intubation if CASE need
Plasmapheresis
IV Ig daily for 2 weeks.

78- 28 yo man working on construction site had shaking arms then lost conscious, he
had no memory to this, but his friends told him.

Order complete PE >>> right visual field defect, right facial droop, right pronation drift,
increasingly tone, hyper reflexes on right.

Order
BMP
CBC
Toxicology screen
CXR >>
U/a
brain CT >> ring enhanced lesion

Order
HIV ELIZA >>>

Order
Lorazepam
Phenytoin
Prime thiamine + sulfasalazine + frolic acid

79- unconscious young man is brought by ambulance to emergency department. He has

no wallet and was found by peopel who were walking by. He is well dressed. Temp 35.8,
BP 90/60, RR 10/min.

Order focused PE >> pupils small equall, reactive to light, withdrawon his limb from
painful stimuli. Absent DTR. Several bullae are present on thighs. ( bullae are indicative
of barbiturate).
Order
Pulse oxy
Oxy
EKG
Cardiac montoring
HEAD ELEVATION
Airways suction
Intubation
Iva
NSS

If toxicology screen come back negative >>

order brain death work up:
Clinical diagnosis of BD
1-No response to painful stimulation
2- Positive apnea test.
Absent reflexes
3- core temp > 32, Negative toxicology screen,
no medical illnesses.
Confirm by
1- EEG
2- trans cranial Doppler USG
3- tech-99 brain scan
4- cerebral angiography
5- No somatosensory evoked potential ion
stimulation of median nerve.
6- consult neurology to declare BD.

Thiamine
Naloxone
Acuecheck>>> Hypoglycemia
Orde IV glucose

Order
CBC
Bmp
U/a
Head CT
ABG
LFT
Gastric lavage >> tablets present ( intubation is mandatory for Gastric lavage).
Charcoal in any intoxication
Urine toxicology screen
Order
Bicarbonate IV to alkalanize urine
Hemodialysis hemodialysis.
Infectious disease
80- 6 yo body is bought to office with rsh started as superficial accumulation of several
small vesicle on his legs below the knee. No fever or chills, ox honey down crusted
lesions on erythema tours base
Nothing to be done >> this is classical distribution of empetygo cursative organism
strep pyogenes
Topical Mopirocin if not oral dicloxacillin & nafcillin. Pen allergy erythromycin s or
azithromycin.
81- 32 yo man comes to ED room with 5 days of fever, productive cough, pleuritic chest
pain. He is active IV drug user and last used on the day before his presentation.

Order complete PE>>> Temp 39, thin, lying on stretcher, peteciae on his mouth and
conjunctiva. Bilateral clear.thin red lines on his fingernails.
Order
Pulse oxy
Oxygen
IV access >>> Norma saline
Cardiac monitoring
Order
CBC
BMP
Ua
Blood culture >>> MSSA >>>
Urine culture
IV Vancomycin + gentamycine
CXR >>> multiple modular lesion bilateral
Echo >>> vegetation
Order
Admition
Nafcillin+Genta for 6 wks coz vegetations.

82- 37 yo woman has 3 days of progressive joint pain in her ankle, knees, wrists. There
is also pain in the back of her hand and forearms as she flexes or extends her fingers.
Order complete PE >> temp 38.7, pharyngeal injection, skin peyechial rash. Swollen red
tender knee and ankles with decrease range or motion.
Order
CBC
Blood culture
PT, PTT
Ua
Urine culture
Swab rectal, oral, urethral.
Arthrocentesis
Joint fluid C&s, cells,
Thyer- Martin media culture
Vaginal C&S, DNA probe for chylamedia and Gonorrah,
Rpr, VDRL
HbsAg, anti Hbc Ab.
HIV
Order
IV Cephtriaxone 1 g Q day for 7 - 10 days is TOC for disseminated Gonorrhea.
83- 54 yo man with DM comes to your office, he began have RUQ pain, chills, fever. PH
known biliary tract disease.

Order complete PE>> 38.9 temp, vitally tachycardia , N. BP, mild icterus, RUQ Tenderness,
no masses. No peritoneal signs,
Order
CBC>> leucocytosis,
BMP
Abd ultrasound >> dilated common bile duct with stone and mass lesion in right lobe
of liver, consistent with hepatic abscess.
Abd xray acute series.
Alkaline phosphatase
LFT>>> total bilirubin 3.
PT,PTT
Ua
Blood culture
U culture
CXR>>> fluid in Right costophrenic angle,
Amylase
Lipase
Order
Send PT to ER
NPO
Iva
NSS
CT scan of the abdomen >> dilated CBD, 5X3 cm mass in right lobe of liver>> abscess.
Stool for (ova, parasite, culture, G stain)
IV ampicillin/ sulbactam + doxycycline or Cephtriaxone + metronidazole.
Surgical consult, reason : cholangitis for possible hepatic abscess.
Percutaneous drainage of liver.
83- 24 yo man had an painful ulcerative genital lesion for 33 days. The lesion began as a
papule with an erythematous base.
Order complete PE >> soft, tender ulcer on prepuse with inguinal LN.
Order
VDRL & RPR
HIV
Wight stain of scraping>> N to test for granuloma inguinale caused by Donnovanosis.
Gram stain>> peomorphic gram negative rod in "school of fish" pattern.
Dark field examination.
Chylamedial antibody testing of scraping.
Order
Culture of scrap>>> H. Duryi
Order
Azithromycin 1 g single oral dose or Cephtriaxone 250 IM single dose.
84- 24 yo man come to your office co of maculopapular rash all over his body, had mild
fever, headache, sore thoat. 2 wks ago he had painless genital ulcers that resolve on it
own.

Order>> complete PE >> alopecia, diffuse MP rash dark reddish, few pastules.
Generalized moderate adenopathy.
Order
CBC
BMP
Ua
VDRL & R&R>> high titre
HZV shingle cases order
HIV
Wright or giemsa stain of
HbsAg, anti HBc antibodies.
unroofed lesion (Tzanck prep)
Order
&Viral culture or PCR.
FTAA>>>
Culture of pustules. No growth
Order
LP normal
CSF VDRL, RPR, FTAA.>> all non reactive
Order
Penicillin G 2.4 million single IM dose.
85- 55 yo man comes to your office with almost 2 wks of progressive worsening
headache, fever, and 2 days of left hand and leg weakness. There has been nausea and
some vomiting.
Order complete PE >> temp 39, bulging red right tympanic members. Left Upper and lower
extremely weakness. Intact sensory exam.
Order
CBC
BMP
U-a
Urine culture
Blood culture
CXR
Brain CT with and without contrast >> hypodense area on right tempropariatal lobe.
Marked enhancement with contrast. >> consistent with brain abscess
Order
Send to ED
NPO
PT, PTT
Fibrinogen
FDP
Stereotactic CT guided needle biopsy of the lesion. >> G positive cocci in chain and G
negative rod >> culture >> strep viridans and bacteriodes melaninognicus.
Order
IV Penicillin + metronidazole for 8 wks, or phetriaxone + metro
Repeat CT after 3 wks.
Surgical drainage if resistant to antibiotic.
86- 25 yo man return from nicking trip with sever excruciate headache, fever, chills,
myalgia.

Order complete PE >> nuchal rigidity, right facial palsy. Temp 39.
Order
CBC
BMP
Fibrinogen
Blood culture
Brain CT
Lumbar puncture>> as usual add antibodies agaist Burrelia
burgedorferi ( ELIZA and western blot), bacterial and viral
culture.
Order
Burrelia burgedorferi Serum IgM level ( ELIZA )>> high titer
Serum Western blot
Order
Cephtriaxone for 3 wks.
87- 24 yo woman comes to your office co of several days of
fever, mayalgia, sore throat, malaise, headache, mild nasal
stuffiness. She had dry cough. She comes becuase the cough
worsening and become dyspneic. She do not have pets.

All are negative

If fungal infection
order KOH
preparation +
culture= hair/ nail
give itraconazole or
ketoconazole,
griseofulvin.
Otherwise topical
clotrimazole.

Order >> complete PE >> fever 38, mild enlarged cervical LN,
erythematous pharynx, scattered rahles bilaterally.

Otitis media culture

Order
or ear drainage & ttt
CBC>>
by topical polymyxin
BMP
B + neomycin.
Blood culture
Hydrocortisone
Urine analysis
drops in sever cases.
Urine culture
CXR>>
bilateral
interstitial
markings.

ABG >>> 7.48/30/70. O2 sat 93%.

Sputum G stain >> few leucocytes
Sputum culture for bacteria, viral, mycobacterium fungi >> viral ag detected.
Order
Admit to hospital
Respiratory support ( oxygen, humidified air) if her ABG deteriorating do intubation
Ozeltamivir/ zanamivir
Antibiotic if there is bacteria, infection detected in culture
88- 17 yo man comes to your office with 1 wk of increasing sever sore throat, fever,
fatigue, malaise, headache and myalgia. He was in ED from 2 days ago and received
ampicillin for his pharyngitis.
Order >> Complete PE >> temp 39, cervical LN, petechia over the trunk and oral
mucosa, liver enlarged 3 cm, splenogpmegaly.
Order
CBC>> leucocytosis, atypical lymphocytes, thrombocytopenia.
BMP
CXR

 LFT>> high bilirubin and ALT

Blood culture
Order
Heterophile antibodies/ monospot test.
Viral capsid antigen IgM
Order
Acetaminophen
Avoid contact sport
Prednisone if thrombocytopenia and hemolytic anemia is
sever

Dry scaly red indurated lesions

in interdigital area with pruritis
>>> is Tenia pedis and not
scapies. Do KOH exam, fungal
culture. Treat with topical
clotrimazole. Capitis &
onychomycosis give oral
griseofulvine,itraconazole ( not
in children).

89- 27 yo man comes to your office a weekafyer initial visit for ear pain and decrease
hearing. He was compliant with amoxicillin that you had prescribed it to him from week
ago. He comes now because the worsening pain and deterioration of hearing.
Order >> complete PE >> temp 38, bulging red tympanic membrane, intact membrane, tender
Pinna, which displaced inferiorly and laterally. Area abive the pinna is tender and Small
fluctuate mass.
Order
CBC
BMP
Plain x ray of mastoid process>>> obliteration of mastoid air cells and destruction of
trabecular mesh work.
CT of mastoid process >> massive destruction and subperiosteal collections.
Tympanocentesis and culture >> Strep. pneumonia.
Mastoid biopsy is the most sensitive test.
Order
IV penicillin only for pen sensitive pneumococcal infection
Pen resistant >> cefotaxime or Ceftriaxone
Vancomycine for one resistant.
90- 78 yo woman is brought to ED with fever, chills, RUQ pain, light stool color and
darker color of urine, HTN on beta blocker.
Order complete PE>> 38.6 temp, BP 90/60, HR100, scleral Icteric,RUQ tenderness, mild
rebound tenderness. Well healed scar in the RUQ.
Order
Oxy, Pulse oxy
IV access, NSS
NPO
Internal bleeding hemorrhoids
IV
ambicillin/
sulbactam
if
allergic
to
pen
use
azteronam
+

in vitally stable do office

Metronidazole cover G negative org.
sigmoidoscopy + colonoscopy
EKG
and barium enema. Add also
Cardiac monitoring
lft PT PTT. Schedule
Order
colonoscopy after month.
CBC
BMP>> BUN high,
Fibrinogen
Blood culture
Urine analysis

 Urine culture
LFT>> bilirubin 4 (hi) , alk 300 (hi), rest are N.
Abdominal USG >> dilated common bile duct >> no masses.
Order
admit to ward
Consult surgery
Order ERCP to review the stone from Bile duct if
failed >> exploratory laparotomy.
Pharyngitis picture in pediatric order
rapid antibody test, throat culture, ttt
Pediatric tips for CCS
by penicillin V BID for 10 days. If HS
megaly there order Monospot test, ttt
supportive.
Constipation in pediatrics
Functional constipation stool in rectal vault but
hirschsprung empty rectal vault.
Diarrhea in pediatrics: order stool
Hirschsprung do, anorectal manometery ( no sphincter
stuffs + enzyme immunoassay for
relaxation), first abd x ray, barium enema ( transitional
Rotavirus most it will be ttt
zone), rectal biopsy ( no ganglion cells). Surgical resection
by IV NS! Allow breast feed, Never to
and anastomosis.
use antidiahreal or antibiotic in viral
Functional constipation, asso with encorporesis (>4 YO)
diahrreah.
( overflow spill), rectal exam stool in vault, do Abd x ray
Bact diahrreah: salmonella < 1 year
( stool through out the colon), anorectal manometery
treat with TMB/SMZ or
( relaxed sph), barium rectal enema to evacuate the stool,
ciprofloxacin.cambylobacter
& shows no transition zone. Usually no need to do barium
( erythromycin). Yersina ( no
enema or USG or rectal biopsy to traditional cases of
antibiotic except if Yer. septicemia by
functiona constipation only do Abd x ray the start
blood culture metronidazole
treatment. Oder clean out enema if large collection, high
+cephazoline ), C. Difficile
fiber diet, postprandial toilet, drink a lot of water, don't use
( Metronidazole).
long term laxative.

Evaluation of limb cases: X-ray standing

AP & Frog leg on hip.
Legg-Calves-Perthes
( <12 Yo limping,

pain on groin & int. rotation), decrease

ROM on exam. Ttt bed rest, NSAIDs.
Slipped Capital epiphysis: obses child,
ice cream cone on X-ray, asso indocine
problem. Ttt surgical Pinning.

2 YO boy did not start walking by 18

months >> Cerebral palsy. Order spinal
MRI, Brain MRI, s. Creatine kinase.
Pancreatictherapy,
cancer physical

TTT: occupational
CBC,
BMP, Abd USG
and Ct
scan,
ERCP,
therapy,speech
therapy,
social
therapy,
CA-19.
Pancreaticoduodenectomy
(
whipple
surgery if need, pediatric neurology
orthopedic
consult. palliative
Procedure).
If non-resectable
ERCP with Stenting or surgical bypass.

CYSTIC FIBROSIS:
CXR , CBC, sweat Cl test, if -ve nasal
membrane potential ( )
Serum trypisongen ( ),DNA tests CFTR
gene. Ttt albuterol, piperacillin+ gentamycine
+ steroids+ recombinant Dnsase
( mucolytic), chest physio therapy. .

Congenital Rubella
Order Rubella IgM titer
Echo and hearing screen

Any recurrent infection pediatric case order

serum immunoglobulins and respiratory
burst test, flow cytometry.

Esophageal cancer
CBC, BMP, CXR, Upper gastrointestinal swallow,
UGD + biopsy, endoscopic USG to measure the
depth of tumor in esoph. Wall, Chest CT scan,
echo, PET scan for bone metastasis.

Colonic volvulus
CBC, BMP, Abd X-ray, rigid
sigmoidoscopy, rectal tube to
release the tention and untwist
bowel. Admit, NPO, IV NS.

Arterial embolization (of lower limb)

CBC, BMP, ABG, CXR, EKG look for AF, IV
LMWH, If abusless + motor function
preserved= IA thrombolytics (tpA) if the
motor weakness do emergent embolictomy,
if in addition there is total anaethesia so
this is irreversible ischemia need
amputation.


Obstetrics and gynecology

Vaginitis
Painless vaginal bleed
in 32 hydroxide
wks pregnant
Potassium
Iva, blood type & cross match,
NSS,
do not do
prep
genital exam in placental
case.
Do not
Vaginal prvia
secretion
KOH
order pelvic USG onlyCervical
do obstetric
USG,
NST
smear
after you stabilizeG&C
yourDNA
patient,
obstetrics
probe
test
consult, for Cesarean
section
if
unstable
or >37
Vulval itching in PMW
wks, don not forget to give
RoGam
for Rh -ve
Vulval
biopsy
women with Rh + husband.
(
no
kleinhaur
Gynecology consult test).

PG in 32 wks co of headache, BP 160/90.

Repeat BP after 15 min.
UA ( +3)
CBC, bmp, Uric acid, LFT, PT, PTT, urine toxicology ( all Normal)
Obstetric USG ,NST ( no BPP,AFI in CCS).
If result showed HELLP creiteria, NPO,
1st give MgSo4, IV Labetaol/ hydralazine, oxygen,pulse oxy, start
oxytocin to dleiver her if no CI for VD. If NST shows late non
reactive or late deceleration after induction of labor run to cesarean.

External fetal monitoring shows late deceleration in active

labour
Turn off the oxytocin
Give oxygen 10 L face mask
Give IVF, turn mom to her side, do genital exam to exclude cord
prolapse,do digital scalp stimulation & observe acceleration it should
be reassuring >> hyperstimulation is reason

Metreorragia in 32 Yo

1st Bhcg even if PH hasTubal

ligation.

2nd Pelvic USG

MPA (10 mgX7 days) oral
Continous. No change

Hysterogram ( saline us)

Hysteroscopy

Obstetrics consultation

High maternal serum AFP

Next do amniotic fluid chromosomal
analysis ( amniocentesis)
Genetic USG
Genetic counsel
Routine ANC

Uncontrolled GDM with

macrosomic EFW
Admit to ward to control sugar
Provide insulin therapy
Diabetic diet
Twice weekly NST, no AFI or BPP
in CCS soft ware .

2ry amenorrhea after labor from 15

mons
BHCG
Progesterone therapy once IMI ( NO
PCT in CCS Software). If -ve order P
+E oral Continous ( P&E CT) >> if -ve
order HSG ( obliteration of uterine
cavity)

Post date
Assure the dates by
USG& fundal height
NST
Fetal monitor ( external)

Nonvavrable cervix give

vaginal PGE2
Valve rabble cervix
admit, start induction by
oxytocin, consult
obstetrics.

Atonic PPH
Bimanual uterine
massage
IV oxytocin
IM methylergonovine
IV Prostaglandine E1
one time bolus.

Functional cyst (5 cm right

simple cyst in 25 yo mom)
BHCG
USG
Conservative follow up
after 6-8 wks

Pregnant with any

medical illness
Order weekly NST
Growth chart by fetal
USG

Septic abortion
CBC, BMP, urine, blood, cervical culture
Transvaginal USG ( do not wirte only USG)
Ampicillin + gentamycine+ clindamycine
Suction D&C