ccs cases

CCS Cases

4-Step CCS Strategy?

• Stabilize, Dx, Rule Out, Tx, PPx
Step 1: H&P -> Rapid Dx
• Unstable: Focused Physical Exam -> MAVOCSZ + HY Dx Orders -> Advance Time
• Stable: Full Physical Exam -> MAVOCSZ + HY Dx Orders -> Advance Time
Step 2: Dx
• Location + L-MIPET-C
Step 3: Tx
• Treatment +/- NICE PTP
Step 4: Wrap-Up Orders
• Before Case-End: ETIOLOGIES + RULE OUT other causes of chief complaint
• Before Case-End: ABCDDEFG +/- Full Physical Exam
• Case-End: CV-RPN (Counsel, Vaccinate, Reassure, Pap Smear, Notify)
• *Always better to OVER order non-invasive diagnostic tests

General CCS Orders?

Stabilization Orders?
• Sick vs. Not Sick
• MAVOCSZ: Morphine/Tylenol/Ibuprofen, IV Access/NSS/NPO/Accucheck/Antibiotics, Vitals q1h, Oxygen/ABG/SaO2 q1h, Cardiac Monitor q1h, C-Spine Collar, Zofran
Common Diagnostic Orders?
• L-MIPET-C
• Labs: CBC, CMP, Magnesium, TSH, Troponin, Lipase, Urinalysis
• Micro: Culture (Blood, Urine, Sputum, Throat, Stool, Wound, Abscess, Cervix, CSF), STI (HIV, RPR, GC, HepB, HepC)
• Imaging: Abdominal X-ray/US/CT/MRI, Chest X-Ray
• Pregnancy (hCG)
• ECG
• The Others: LP (+ CSF), EEG, TTE, Biopsy
• Consults: Surgery, Gastroenterology
Common Treatment Orders?
• Antibiotics: Broad (Vanc/Zosyn OR Meropenem) or CTX/Flagyl [*Always Cultures First]
• Antiemetics: Zofran OR Metoclopramide OR Promethazine
• Antipyretics: Acetaminophen
• Procedures: Laparascopy, Laparotomy
Procedure Orders?
• NICE PTP: NPO/NSS, Informed Consent, Cefazolin (OR other ABx), ECG, PT/PTT, T&C (Type and Cross +/- Rh Type), PROCEDURE NAME
Admission Orders?
• ABCDDEFG: Ambulate or Bedrest, Stress Ulcer PPx, DVT PPx, Diet, Elevate HOB, Foley/Urine Output, Gastric Tube

Common Mistakes?

Fever. Symptomatic Relief?
• Acetaminophen (UNLESS liver damage)
Nauseous. Symptomatic Relief?
• Zofran (or Reglan/Promethazine)
Broadening Antibiotics?
• Vanc/Zosyn
• Meropenem
• *Always cultures first
Ordering Heparin?
• Heparin AND Warfarin
Ordering Intubation?
• Intubation AND Mechanical Ventilation
Suicide?
• Consult Psychiatry, Suicide Precautions, Activated Charcoal
Labs I keep forgetting to order?
• TSH, ESR/CRP/CK
• STI Panel (HIV, RPR, GC, HepB, HepC)
Part of strategy I always forget?
• Other etiologies and ruling out
• Solutions: Over-order, really try to remember this step (write on paper)

unresponsive

Unresponsive after life stressors with miosis and decreased respiratory rate. Likely diagnosis?

• Opioid Intoxication [10/29/22-45]
1. Dx
• Full PE + MAVOCSZ
• Accucheck, CMP, ABG, Urinalysis, Toxicology Urine, Toxicology Serum Lactate, CK, Carbon Monoxide, Methemoglobin, Acetaminophen Nomogram -> Advance Time
2. Tx
• Oxygen, Naloxone, Consult Psychiatry, Activated Charcoal, NSS, Suicide Precautions

Unresponsive after life stressor with cardiac arrhythmia. Likely diagnosis?

• TCA Intoxication [10/26/22-22]
1. Dx
• Full PE + MAVOCSZ
• Accucheck, ECG, ABG, Urinalysis, Urine Toxicology, Acetaminophen Nomogram, CT Head, Serum Toxicology, CK -> Advance Time
2. Tx
• Naloxone, Oxygen, Intubation, Sodium Bicarbonate, Activated Charcoal, NG Tube to Suction, NSS, Consult Psychiatry

syncope

Common Syncope Dx Tests?

• Labs: TSH
• Imaging: CT Head, MRI Brain, Carotid US, TTE
• ECG
• Consults: Neurology

Lightheadedness with one episode of LOC. Likely diagnosis?

• 3rd Degree AV Block [11/5/22-20]
1. Dx
• Full Physical Exam
• ECG, TSH, Lipid Panel, Lyme Serology, ESR -> Advance Time
2. Tx
• Cardiac Monitor, Cutaneous Pacemaker, Consult Cardiology (for PPM), NICE PTP, Atropine

altered mental status

Subacute AMS in elderly patient. Likely diagnosis?

• Subdural Hematoma [10/30/22-2]
1. Dx
• Full Physical Exam
• CT Head w/o Contrast -> Advance Time
2. Tx
• Consult Neurosurgeon, Craniotomy

headache

Headaches with blurry vision and n/v. Likely diagnosis?

• Hypertensive Emergency [11/5/22-34]
1. Dx
• Full Physical Exam
• CT Head TSH, Chest X-Ray, ECG, Troponin, Toxicology Screen, Urinalysis, Lipid Profile -> Advance Time
2. Tx
• Nicardipine, NPO, Zofran

Headaches and ataxia few weeks after hiking. Likely diagnosis?

• West Nile Virus Meningoencephalitis [11/5/22-5]
1. Dx
• Full Physical Exam
• CBC, CT/MRI Head, LP, CSF (All + West Nile Virus), Toxicology Screens -> Advance Time
2. Tx
• Supportive

Pregnant with blurry vision and increasing headaches. Likely diagnosis?

• Preeclampsia [11/4/22-14]
1. Dx
• Full Physical Exam
• Physical Exam, Urinalysis, Ultrasound Pelvis, 24-hour Urine Protein, Fetal Heart Rate -> Advance Time
2. Tx
• Labetalol/Hydralazine, Consult OB/Gyn, Dexamethasone, Magnesium Sulfate, Bedrest

Headache with nuchal rigidity. Likely diagnosis?

• Bacterial Meningitis [10/29/22-36]
1. Dx
• Full PE + MAVOCSZ
• CBC, Urinalysis, Blood Culture, CT Head w/o Contrast, LP CSF Studies, Toxicology Urine -> Advance Time
2. Tx
• NSS, Vanc/CTX, Dexamethasone, Antipyretic

Worsening headaches with nausea, intermittent diarrhea, and unintentional weight loss in adult who has multiple sexual partners. Likely diagnosis?

• Cryptococcal Meningitis [41]
1. Dx
• Full PE + MAVOCSZ
• CT Head, HIV, LP (+ CSF), Serum CrAg -> Advance Time
2. Tx
• Amphotericin B + Flucytosine, Fluconazole, HAART

Headache with fever, altered mental status, and impaired memory. Likely diagnosis?

• HSV Encephalitis [42]
1. Dx
• Full PE + MAVOCSZ
• CT Head, LP (+ CSF) -> Advance Time
2. Tx
• Acyclovir (+ NSS)

Headache over temples and fevers, fatigue, and unintentional weight loss. Likely diagnosis?

• Temporal GCA Arteritis [43]
1. Dx
• Full PE + MAVOCSZ
• ESR, CRP, CK, Head CT, Temporal Artery Biopsy -> Advance Time
2. Tx
• Dexamethasone/Prednisone, Aspirin, Pantoprazole, Calcium, Vitamin D

seizures

Alcoholic with seizures 30 hours after not drinking. Likely diagnosis?

• Alcohol Withdrawal Seizure [10/30/22-35]
1. Dx
• Full Physical Exam
• CMP, CT Head, Urine Toxicology -> Advance Time
2. Tx
• Lorazepam, Banana Bag (NSS, Thiamine, magnesium), Potassium, Consult Psychiatry, Consult Substance Abuse Unit Folic Acid, Vitamin B6

weakness or focal neurologic deficits

Weakness in lower extremities after recent infection. Likely diagnosis?

• Guillain-Barre Syndrome (GBS) [11/5/22-46]
1. Dx
• Full PE + MAVOCSZ
• LP + CSF Studies, PFTs, MRI Spine, EMG, TSH, ESR, CRP, CK, HIV, RPR -> Advance Time
2. Tx
• IVIG/Plasmapheresis, Avoid Steroids, Consult Neurology, Incentive Spirometry

Claudication on exertion and impotence. Likely diagnosis?

• Peripheral Arterial Disease (PAD) [11/5/22-10]
1. Dx
• Full PE + MAVOCSZ
• ABI, Lipid Panel, A1c, Microalbumin, AVOID Angiography -> Advance Time
2. Tx
• Aspirin, Atorvastatin, Metformin, Lisinopril

Child with volume overload 2 weeks after upper respiratory infection. Likely diagnosis?

• Poststreptococcal Glomerulonephritis (PSGN) [11/5/22-41]
1. Dx
• Full PE + MAVOCSZ
• Urinalysis, Complement, CXR, Antibodies (ASO, ANCA, GBM, Cryoglobulin, ANA), Abdominal US -> Advance Time
2. Tx
• Consult Nephrology, Furosemide

Generalized weakness with ptosis that improves with rest. Likely diagnosis?

• Myasthenia Gravis (MG) [11/5/22-7]
1. Dx
• Full PE + MAVOCSZ
• Acetylcholine Antibody, Tensilon Test, CXR, CT Chest, EMG -> Advance Time
2. Tx
• Pyridostigmine, Dexamethasone, Consult Surgery (for Thymectomy)

Focal neurologic deficits that resolve within 1 hour. Likely diagnosis?

• Transient Ischemic Attack (TIA) [10/29/22-51]
1. Dx
• Full PE + MAVOCSZ
• CT Head, MRI Head, Carotid US, Lipid Panel, A1c, TSH, ESR, PT/PTT, Urine Toxicology, Echo -> Advance Time
2. Tx
• Aspirin, Consult Neurology, Consult Vascular Surgery (for Carotid Endarterectomy + NICE PTP)

Generalized fatigue, anorexia, night sweats, and unintentional weight loss for weeks along with hematuria. Likely diagnosis?

• Renal Cell Carcinoma (RCC) [29]
1. Dx
• Full PE + MAVOCSZ
• Urinalysis, FOBT, CT Abdomen + Chest, Iron, TIBC, Ferritin, PT/PTT, Type and Cross -> Advance Time
2. Tx
• Consult Oncology, Consult Surgery (for Nephrectomy +/- NICE PTP)

chest pain

Chest pain with hypotension and bradycardia. Likely diagnosis?

• Right Ventricular Myocardial Infarction (RVMI) [11/5/22-125]
1. Dx
• Focused PE + MAVOCSZ
• ECG, Troponin, Cardiac Monitor -> Advance Time
2. Tx
• Aspirin, Atorvastatin, Clopidogrel, Consult Cardiology (for Angioplasty), AVOID Morphine + AVOID Metoprolol (in right ventricular MI)

Chest pain with palpitations and dizziness. Likely diagnosis?

• Atrial Fibrillation [11/5/22-77]
1. Dx
• Full PE + MAVOCSZ
• ECG, Troponin, TSH, CXR, TTE, Urine Toxicology Screen -> Advance Time
2. Tx
• Cardiac Monitor, Metoprolol, Consult Cardiology, Warfarin or DOAC, PT/PTT

African child with acute chest pain. Likely diagnosis?

• Acute Chest Syndrome 2/2 Sickle Cell Disease [11/5/22-25]
1. Dx
• Full PE + MAVOCSZ
• CBC, CXR, PT/PTT -> Advance Time
2. Tx
• Dilaudid, Hydroxyurea, CTX, Oxygen, NSS Transfusion + T&S, Penicillin V, Folic Acid, Consult Hematology/Oncology

Chest pain improving with leaning forward after recent viral respiratory illness. Likely diagnosis?

• Acute Pericarditis [11/3/22-15]
1. Dx
• Full PE + MAVOCSZ
• ECG, Chest X-ray, Troponin, Echo, ESR/CRP/CK, Blood Culture
2. Tx
• NSAID, Colchicine, AVOID Pericardiocentesis (small effusion) PPI

Chest pain radiating to shoulder. Likely diagnosis?

• ST-Elevation Myocardial Infarction (STEMI) [11/1/22-124]
1. Dx
• Full PE + MAVOCSZ
• ECG, Troponin -> Advance Time
2. Tx
• Aspirin, Stent, Atorvastatin, Metoprolol, Clopidogrel

Typical chest pain with diaphoresis at rest. Likely diagnosis?

• Unstable Angina [10/24/22-52]
1. Dx
• Full PE + MAVOCSZ
• Magnesium Serum, ECG, Troponin, CXR, Lipid Profile, A1c, Echo -> Advance Time
2. Tx
• Morphine, Oxygen, Nitroglycerin, Aspirin, Consult Cardiology (for Angioplasty + NICE PTP), Metoprolol, Lisinopril, Atorvastatin, Heparin, Clopidogrel

shortness of breath

Child with FTT, steatorrhea, and respiratory symptoms. Likely diagnosis?

• Cystic Fibrosis (CF) [11/5/22-26]
1. Dx
• Full PE + MAVOCSZ
• Full Exam, CF Sweat, Sputum Culture, Stool Fat, Respiratory Virus Antibody Panel -> Advance Time
2. Tx
• Oxygen, Pip/Tazo, Albuterol, Consult Pulmonary + Genetics + Nutrition

Shortness of breath after recent flight. Likely diagnosis?

• Pulmonary Embolism (PE) [10/31/22-55]
1. Dx
• Full PE + MAVOCSZ
• Doppler lower extremities, CT Angio Chest -> Advance Time
2. Tx
• Cardiac monitor, Heparin and Warfarin

Smoking COPD patient with worsening SOB and wheezing. Likely diagnosis?

• COPD Exacerbation [10/30/22-53]
1. Dx
• Full PE + MAVOCSZ
• ABG, CXR, PEFR -> Advance Time
2. Tx
• Oxygen, Albuterol, Ipratropium, Methylprednisolone, Ceftriaxone (OR Doxycycline outpt)

Progressively worsening SOB with orthopnea. Likely diagnosis?

• HFrEF [10/26/22-23]
1. Dx
• Full PE + MAVOCSZ
• CBC, ECG, Troponin, BNP, CXR, Echo TSH -> Advance Time
2. Tx
• Furosemide, Nitroglycerin, Metoprolol, Input and Output

Sudden onset SOB with unilateral hyperinflated chest. Likely diagnosis?

• Tension Pneumothorax [10/24/22-1]
1. Dx
• Focused PE + MAVOCSZ
• SaO2, CXR, Troponin, ECG -> Advance Time
2. Tx
• Needle Thoracostomy (with follow up CXR)

PMH asthma presenting with SOB, wheezing, and cough. Likely diagnosis?

• Asthma Exacerbation [10/24/22-1]
1. Dx
• Focused PE + MAVOCSZ
• ABG, CXR, PEFR, ECG -> Advance Time
2. Tx
• Oxygen, Albuterol, Ipratropium, Prednisone (OR methylprednisolone if PEFR less than 40% OR intubate if impending respiratory arrest)

cough

Febrile with worsening productive cough and SOB. Likely diagnosis?

• Community Acquired Pneumonia (CAP) [11/6/22-48]
1. Dx
• Full PE + MAVOCSZ
• CXR, Cultures (Sputum, Blood, Urine), ECG -> Advance Time
2. Tx
• Oxygen, NSS, CTX/Azithromycin

Immigrant with hemoptysis, fever, and night sweats. Likely diagnosis?

• Tuberculosis (TB) [11/5/22-66]
1. Dx
• Full PE + MAVOCSZ
• Sputum (Acid Fast), CXR, CT Chest, Interferon Gamma/PPD -> Advance Time
2. Tx
• RIPE, Isolation, Vitamin B6, Consult Ophthalmology (for Ethambutol)

Nonadherent HIV with progressive SOB, cough, and fever. Likely diagnosis?

• Pneumocystis pneumonia [10/30/22-16]
1. Dx
• Full PE + MAVOCSZ
• HIV (PCR, Viral Load, CD4), CXR, ABG, LDH, Sputum (Pneumocystis) -> Advance Time
2. Tx
• TMP-SMX, Oxygen, Dexamethasone (if PaO2 less than 70), NSS, Consult ID, HAART (Tenofovir, Emtricitabine, Raltegravir)

abdominal pain

Abdominal pain with unintentional weight loss and pencil-thin stools. Likely diagnosis?

• Colorectal Cancer [11/5/22-18]
1. Dx
• Full PE + MAVOCSZ
• CTAP, Colonoscopy, CEA, CXR + PET Scan (to check metastasis) -> Advance Time
2. Tx
• Consult Surgery (+ NICE PTP)

Abdominal pain and jaundice after traveling. Likely diagnosis?

• Viral Hepatitis [11/5/22-11]
1. Dx
• Full PE + MAVOCSZ
• Hepatitis Panel, RUQ US, CXR, Acetaminophen Nomogram -> Advance Time
2. Tx
• Morphine, NSS, Oxygen, Zosyn or Clindamycin, AVOID Acetaminophen

Abdominal pain with fever, n/v, vaginal discharge, and dyspareunia. Likely diagnosis?

• Pelvic Inflammatory Disease (PID) [11/5/22-28]
1. Dx
• Full PE + MAVOCSZ
• hCG, Urinalysis, Urine Culture, Cervix GC (DNA, GS Culture), Cervical Wet Mount, STI Panel (HIV/RPR/HepB/HepC, Pap Smear) -> Advance Time
2. Tx
• CTX/Flagyl, NSS, Zofran, Antipyretic

Acute abdominal pain with n/v and polyuria. Likely diagnosis?

• DKA/HHS [11/4/22-4]
1. Dx
• Full Physical Exam + MAVOCSZ
• Accucheck, CMP, Urinalysis, ABG -> Advance Time
• Location: ICU
2. Tx
• NSS, Insulin, Potassium

Abdominal pain few days after appendectomy. Likely diagnosis?

• Subphrenic Abscess [11/2/22-9]
1. Dx
• Full PE + MAVOCSZ
• CBC, CTAP, Abscess Bacterial Culture, Abscess Gram Stain -> Advance Time
2. Tx
• NSS, Morphine, Flagyl or Pip/Tazo, Zofran, Acetaminophen, Needle Drainage

LLQ abdominal pain with fever/nausea/vomiting. Likely diagnosis?

• Diverticulitis [10/31/22-19]
1. Dx
• Full PE + MAVOCSZ
• CBC, CT Abdomen with Contrast -> Advance Time
2. Tx
• NSS, NPO, Ceftriaxone/Flagyl, NO Surgery Consult (first stable episode)

Epigastric pain radiating to back w/ nausea and vomiting. Likely diagnosis?

• Acute Pancreatitis [10/30/22-39]
1. Dx
• Full PE + MAVOCSZ
• Lipase, CT Abdomen, Serum Ethanol, Abdominal X-ray-> Advance Time
2. Tx
• NPO, NSS, Morphine, ERCP, Consult Gastroenterology, Zofran

Abdominal pain with steatorrhea and weight loss. Likely diagnosis?

• Celiac Disease [10/29/22-71]
1. Dx
• Full PE + MAVOCSZ
• Gliadin Antibody, Fecal Fat, Bacterial Stool Culture, Gram Stain Stool Endomysial Antibody, EGD (+Small Bowel Biopsy), TSH, ESR, CRP, Iron, Ferritin, Vitamin B12, Folic Acid, Vitamin KADE, Zinc, Copper, PT/PTT, FOBT, Stool Ova and Parasites, Dexascan -> Advance Time
2. Tx
• Gluten Free Diet Vitamin D, Consult Nutrition

Abdominal pain after excess NSAID usage for OA. Likely diagnosis?

• Gastritis [10/26/22-13]
1. Dx
• Full PE + MAVOCSZ
• CBC, AVOID EGD, Helicobacter (Any Study) -> Advance Time
2. Tx
• Pantoprazole, Tylenol (or Diclofenac), Consult Orthopedic

RUQ abdominal pain radiating to R shoulder with n/v. Likely diagnosis?

• Acute Cholecystitis [10/24/22-32]
1. Dx
• Full PE + MAVOCSZ
• hCG, Abdomen US, AVOID CTAP, Urinalysis -> Advance Time
2. Tx
• Morphine, CTX, Consult Surgery (for Cholecystectomy + NICE PTP), Zofran

Colicky abdominal pain with hematochezia and brother with IBD. Likely diagnosis?

• Ulcerative Colitis (UC) [3]
1. Dx
• Full PE + MAVOCSZ
• CBC, CMP, ESR/CRP/CK, PT/PTT, Stool (Culture, O&P, White Cells), Colonoscopy -> Advance Time
2. Tx
• Mesalamine, Loperamide, Dicyclomine (antispasmodic), Consult Nutrition + Dexamethasone (if Flare)

Colicky abdominal pain relieved by defecation with alternative episodes of diarrhea/constipation. Likely diagnosis?

• Irritable Bowel Syndrome (IBS) [5]
1. Dx
• Full PE + MAVOCSZ
• ESR/CRP/CK, FOBT, Stool Studies (Culture, O&P, WBC, Fat) -> Advance Time
2. Tx
• High Fiber Diet, Lactose Free Diet, Loperamide, Dicyclomine (antispasmodic)

Abdominal distension after meals with several weeks of constipation. Likely diagnosis?

• Constipation [20]
1. Dx
• Full PE + MAVOCSZ
• Serum Mg/Phos, TSH, A1c, FOBT, Abdominal X-Ray, Colonoscopy -> Advance Time
2. Tx
• High Fiber Diet, Psyllium + Disimpaction (if Fecal Impaction)

Periumbilical abdominal pain with fever, n/v, and anorexia. Likely diagnosis?

• Appendicitis [21]
1. Dx
• Full PE + MAVOCSZ
• CBC, CMP, Abdominal X-Ray/US, FOBT, Urinalysis -> Advance Time
2. Tx
• Morphine, Ancef/Flagyl, Consult Surgery (for Appendectomy + NICE PTP)

Periumbilical abdominal pain with fever, n/v, and anorexia. Likely diagnosis?

• Blunt Abdominal Trauma (BAT) [25]
1. Dx
• C-Spine Collar BEFORE Full PE + MAVOCSZ
• CBC q6h, CMP, Lipase, ABG, Urinalysis, Toxicology, ECG, CXR, Spine X-Ray, CT Abdomen w/ Contrast (Abdomen US if unstable), Urine Output -> Advance Time
2. Tx
• Foley, Consult Surgery (for Possible Laparotomy + NICE PTP)

PMH OA with sudden onset epigastric pain with n/v. Likely diagnosis?

• Perforated Peptic Ulcer [30]
1. Dx
• Focused PE + MAVOCSZ
• CBC, CMP, Lipase, Abdominal X-Ray -> Advance Time
2. Tx
• Morphine, PPI, Consult Surgery (for Laparotomy + NICE PTP)

PMH OA with sudden onset epigastric pain with n/v. Likely diagnosis?

• Sigmoid Volvulus [47]
1. Dx
• Focused PE + MAVOCSZ
• Abdominal X-Ray -> Advance Time
2. Tx
• Consult Gastroenterology (for Sigmoidoscopy + NICE PTP)

Smoker with sudden-onset abdominal pain that radiates to his back with nausea and diaphoresis. Likely diagnosis?

• AAA Rupture [50]
1. Dx
• Focused PE + MAVOCSZ
• CT/US Abdomen -> Advance Time
2. Tx
• Consult Vascular (for Aneurysmectomy + NICE PTP)

fever

Child with dyspnea, drooling, and dysphagia. Likely diagnosis?

• Epiglottitis [11/5/22-101]
1. Dx
• Full PE + MAVOCSZ
• CBC, Blood Culture, Throat Culture, Neck X-Ray -> Advance Time
• Location: ICU
2. Tx
• Oxygen, Intubation + Ventilation, Ceftriaxone, Vancomycin, Acetaminophen

IVDU with altered mental status and hypotension. Likely diagnosis?

• Septic Shock [11/4/22-93]
1. Dx
• Focused PE + MAVOCSZ
• CBC, Bacterial Wound Culture, Blood Culture, TEE -> Advance Time
• Location: ICU
2. Tx
• NSS, Tylenol, Pip/Tazo AND Vanco, Consult ID, Consult Surgery

Febrile with pain and swelling in extremity after recent cut. Likely diagnosis?

• Cellulitis [26]
1. Dx
• Focused PE + MAVOCSZ
• CBC, Blood Culture, Extremity X-Ray -> Advance Time
2. Tx
• Augmentin/Doxy (OR Augmentin/Clinda)

Febrile with pain and swelling in extremity after recent cut. Likely diagnosis?

• Acute Bacterial Rhinosinusitis [49]
1. Dx
• Focused PE + MAVOCSZ
• AVOID Imaging unless CNS/Orbital Extension -> Advance Time
2. Tx
• Augmentin, Topical Glucocorticoids, Nasal Saline Irrigation

musculoskeletal and rheumatology

Painful, swollen knee with fever and chills. Likely diagnosis?

• Septic Arthritis [22]
1. Dx
• Focused PE + MAVOCSZ
• Blood Cultures, Knee X-ray, Synovial Fluid Analysis, Synovial Fluid (GS, Culture) -> Advance Time
2. Tx
• Morphine, Vanc/CTX, Consult Orthopedics (for Arthroscopy + NICE PTP)

Acutely painful, swollen big toe. Likely diagnosis?

• Gout [27]
1. Dx
• Focused PE + MAVOCSZ
• CBC, CMP, PT/PTT, Uric Acid, Foot X-Ray, Synovial Fluid Analysis -> Advance Time
2. Tx
• Indomethacin, Colchicine (OR Dexamethasone if PUD/Renal Dz), AVOID allopurinol

Elder with pain and stiffness in the shoulders and hips that lasts 1 hour in the mornings. Likely diagnosis?

• Polymyalgia Rheumatica [44]
1. Dx
• Focused PE + MAVOCSZ
• ESR, CRP, CK, ANA, RF, TSH, CXR -> Advance Time
2. Tx
• Prednisone, Calcium, Vitamin D

pediatrics

Child with severe cough and stridor. Likely diagnosis?

• Airway Obstruction (due to Foreign Body Aspiration) [12]
1. Dx
• Focused PE + MAVOCSZ
• Neck X-Ray, Chest X-Ray, Bronchoscopy
2. Tx
• Bronchoscopy

Child with continued bleeding 2 days after tooth extraction with FHx bleeding disorders. Likely diagnosis?

• Hemophilia [16]
1. Dx
• Focused PE + MAVOCSZ
• CBC, CMP, PT/PTT, Bleeding Time, Factor VIII, Factor IX, Factor XI
2. Tx
• Factor VIII Therapy (for Hemophilia A), No Aspirin

Child with progressive barking cough and noisy breathing. Likely diagnosis?

• Croup (Laryngotracheitis) [18]
1. Dx
• Focused PE + MAVOCSZ
• Neck X-Ray, Chest X-Ray
2. Tx
• Humidified Air, Dexamethasone, Epinephrine

Adolescent with primary amenorrhea and 5th percentile height. Likely diagnosis?

• Turner Syndrome [31]
1. Dx
• Full PE + MAVOCSZ
• Karyotype Analysis, FSH, LH, TSH, Lipid Profile, Renal US, Pelvic US, Echo, Skeletal Survey, Hearing Test
2. Tx
• Growth Hormone, Estrogen-Progestin Combination, Vitamin D, Calcium, Consult Nutrition, Consult Psychiatry, Consult Ophthalmology

Child s/p mGLF who is withdrawn, avoids eye contact, and has multiple bruises at different stages of healing. Likely diagnosis?

• Child Abuse [34]
1. Dx
• Full PE + MAVOCSZ
• Skeletal Survey, CBC, PT/PTT, Bleeding Time, CXR
2. Tx
• Consult Child Protective Service, Consult Psychiatry

Infant with episodes of sudden onset crying and drawing legs towards abdomen with n/v. Likely diagnosis?

• Intussusception [51]
1. Dx
• Full PE + MAVOCSZ
• Abdomen US/X-Ray
2. Tx
• Consult Surgery + NICE PTP for Air/Contrast Enema

ob/gyn

Afebrile pregnant patient with urinary urgency, frequency, and dysuria. Likely diagnosis?

• Cystitis [1]
1. Dx
• Full PE + MAVOCSZ
• hCG, Urinalysis, Urine Culture -> Advance Time
2. Tx
• Augmentin in all trimesters (Nitrofurantoin 2nd-3rd trimesters OR TMP-SMX if not pregnant), Prenatal Vitamins

Secondary amenorrhea with nausea/vomiting. Likely diagnosis?

• Pregnancy [2]
1. Dx
• Full PE + MAVOCSZ
• hCG, Ultrasound Pelvis, Prenatal Labs (CBC, CMP + Type & Screen, Atypical Antibodies + Urinalysis, Urine Culture + Pap Smear, HIV, RPR, HBs Antigen, Rubella) [US w/ 2-2-2-5] -> Advance Time
2. Tx
• Prenatal Vitamins, Iron Sulfate, Folic Acid
• Wrap-Up: Counsel (Prenatal), F/u 4 weeks

PMH PID p/w abdominal pain with LMP 7 weeks ago. Likely diagnosis?

• Ectopic Pregnancy [4]
1. Dx
• Focused PE + MAVOCSZ
• hCG, Ultrasound Transvaginal, GC Culture -> Advance Time
2. Tx
• MTX (OR Laparoscopy if stable with hCG >5k OR Laparotomy if unstable), Consult OB/Gyn, Bedrest

Vaginal discharge with vulvar pruritis. Likely diagnosis?

• Vaginitis [7]
1. Dx
• Focused PE + MAVOCSZ
• Wet Mount, Vaginal pH, GC Culture, Urinalysis, Urine Culture -> Advance Time
2. Tx
• Miconazole (Candida) OR Metronidazole (Trichomonas/BV)

40F with painless, mobile breast mass found on self-exam. Likely diagnosis?

• Fibroadenoma [10]
1. Dx
• Focused PE + MAVOCSZ
• Mammogram, Ultrasound, FNA -> Advance Time
2. Tx
• Reassure, Counsel

18F with heavy, irregular menstrual bleeding for the past 4 months. Likely diagnosis?

• Abnormal Uterine Bleeding (AUB) [23]
1. Dx
• Focused PE + MAVOCSZ
• hCG, TSH, Prolactin, PT/PTT, Ultrasound Pelvis -> Advance Time
2. Tx
• OCP (Combination), Iron Sulfate

55F with secondary amenorrhea and hot flashes, vaginal dryness, and insomnia. Likely diagnosis?

• Menopause [35]
1. Dx
• Focused PE + MAVOCSZ
• hCG, FSH -> Advance Time
2. Tx
• Estrogen-Progesterone Therapy

Acute RLQ abdominal pain with n/v with LMP 2 weeks ago. Likely diagnosis?

• Ovarian Torsion [45]
1. Dx
• Focused PE + MAVOCSZ
• hCG, Doppler Ovaries -> Advance Time
2. Tx
• Consult OB/Gyn (for Laparoscopic Detorsion + NICE PTP)

55F with abdominal distension, early satiety, anorexia, and fatigue for past 2 months. Likely diagnosis?

• Ovarian Cancer [46]
1. Dx
• Focused PE + MAVOCSZ
• hCG, Ultrasound Pelvis, CA 125, CTAP, CXR, Mammogram, Colonoscopy, Pap Smear -> Advance Time
2. Tx
• Consult Oncology, Consult OB/Gyn (for Laparotomy + NICE PTP)

psychiatry

Patient with SIGECAPS for >2 weeks. Likely diagnosis?

• MDD [6]
1. Dx
• Full PE + MAVOCSZ
• CBC, CMP, TSH, Vitamin B12 -> Advance Time
2. Tx
• SSRI, CBT

Elderly with gradual forgetfulness and difficult with ADLs. Likely diagnosis?

• Alzheimers [8]
1. Dx
• Full PE + MAVOCSZ
• CBC, CMP, TSH, Vitamin B12, CT/MRI Head -> Advance Time
2. Tx
• Donepezil, Vitamin E + Olanzapine (if Psychotic Sx)

Patient with palpitations, chest tightness, SOB, nausea, anxiety, and a fear of dying. Likely diagnosis?

• Panic Attack [13]
1. Dx
• Focused PE + MAVOCSZ
• TSH, ECG, Troponin, Urinalysis, Chest X-Ray -> Advance Time
2. Tx
• Lorazepam, Reassure
• PPx: Reassure, Counsel (No Caffeine, Nicotine, Alcohol)

Patient with palpitations, chest tightness, SOB, nausea, anxiety, and a fear of dying. Likely diagnosis?

• Bipolar I Disorder [39]
1. Dx
• Focused PE + MAVOCSZ
• TSH, Toxicology, AVOID Brain Imaging -> Advance Time
2. Tx
• Antipsychotic + Lithium, Consult Psychiatry, Psychotherapy

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